New Hampshire Family Resource Centers of Quality

Designation Application

Cover Sheet

Family Resource Center Name: Click or tap here to enter text.

Address: Click or tap here to enter text.

Person completing this application: Click or tap here to enter text.

Role at Family Resource Center: Click or tap here to enter text.

Email address: Click or tap here to enter text. Phone number: Click or tap here to enter text.

Parent Agency: Click or tap here to enter text.

☐None, FRC is free-standing.

Address if Different: Click or tap here to enter text.

Website: Click or tap here to enter text.

Has your Center provided services to families for more than 12 consecutive months? ☐ Yes	☐No

A complete application includes:

☐ This cover sheet

☐ Center Narrative (recommended maximum length – 4 pages, double spaced, 12 font)

including:

Family Resource Center Mission

Organizational history

Program Descriptions (based on 5 core services as stated in Standard SP2 of NH Operational Standards)

Number of Participants served

Summary of Center’s Self-Assessments and Participant Surveys

Strengths identified in process

Areas for Improvement

Priority Steps for Improvement

Pertinent “takeaways” learned through self-assessment process, if any

This narrative should summarize your application and illustrate to reviewers your rationale for applying for designation – you do not need to repeat details of this narrative throughout the application. In responses you may note “refer to narrative” if an adequate description of fulfillment of a standard can be found there. The narrative should provide details of your process assessing and determining that your program meets the criteria for designation as an FRC-Q. It is your opportunity to present your program to the Wellness and Primary Prevention Council. It may be helpful to consider the other application elements being exhibits to what you present in your narrative.

☐ National Standards of Quality for Family Strengthening and Support Programs Self-Assessment

Most recently completed Program Self-Assessment (completed w/in 3 months of application date)

Participant Surveys – Applicants should strive for a representative sample of their participants in the surveys returned as part of their application. Surveys returned should be ideally completed within the 3 months before application and represent at least 15-20% of program participants.

☐Completed NH Family Resource Centers of Quality Operational Standards Self-Assessment

☐FRC Organizational Chart

☐Staff list form (name, position, FTE, education, years of experience, relevant certification)

☐Previous Fiscal Year financial report (990, audit)

☐Current Fiscal Year Budget Year-to-Date

☐NH Non-profit Certificate of Good Standing

☐Certificate of Insurance indicating liability and workers’ compensation insurance

☐ Report from Guidestar

☐Three letters of recommendation for designation from local community agencies/organizations.

Affirmation:

My signature below affirms that all materials and responses included in this application is, to the best of my knowledge a true reflection of the program(s) and services described. (electronic signature acceptable)

Enter name here

Signature

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Date