Application - Fatherhood FLAME

User Account Information

Username*

Password*

Enter Password Confirm Password

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Email*

Enter Email Confirm Email

Name*

First Last

Title

Phone

Host Organization Information

Organization Name*

Mailing Address

Street Address Address Line 2 City State ZIP Code

Physical Address Checkbox

Physical Address is the same as the Mailing Address

Physical Address

Street Address Address Line 2 City State ZIP Code

Website

Social Media Handles (if applicable)

Twitter

Instagram

Facebook

Related Experience

Related Experience - Involvement Select

Select which describes your organization's involvement in the field of fatherhood (and, possibly, healthy marriage and/or employment services):

Provide direct service

Consultation

Support to social service organizations

Educational Services

Other

Related Experience - Involvement Select Other

If other, please explain.

Related Experience - Involvement Describe

Briefly describe your organization’s involvement in the field of fatherhood (and, possibly, healthy marriage and/or employment services):

Related Experience - Structure

Select which best describes your organization’s structure:

Public sector

Nonprofit

Private entity

Faith-based

Other

Related Experience - Structure Other

If other, please explain.

Note: Champion organizations cannot be partisan organizations.

Experience - Fatherhood Organizations You're Familar With

Please select the number of fatherhood organizations you are familiar with in your community.

0-1

2-3

4-5

Organizations and Fatherhood Involvement

Please list the organization(s) and their involvement in fatherhood efforts in the community.

Staff member Experienced in Meeting Facilitation

Do you have a staff member or volunteer experienced in meeting facilitation?

Yes

Meeting Facilitation Experience

If yes, please briefly describe their expertise and/or credentials in meeting facilitation.

Event Information

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Event - Month

My organization would like to host a FLAME event in 2021 during the month of:

February

March

April

May

June

My organization would like to host a FLAME event on:

MM slash DD slash YYYY

Event - Attendees

Anticipated number of attendees:

0-49

50-99

100-199

200-299

300+

Event - Why

Briefly describe why you want to hold a FLAME event:

Event - Target Audience

Briefly describe the target audience for your event:

Briefly describe what outcomes you envision as a result of holding your FLAME event.

Outcome 1*

Outcome 2

Outcome 3

Outcome 4

Outcome 5

Please list five organizations that will help execute your FLAME event (current partners, sources of recruitment for attendees, etc.):

Event - Organization 1*

Event - Organization 2*

Event - Organization 3*

Event - Organization 4

Event - Organization 5

Event - Collaborate

If another organization in your community applies, would you be willing to collaborate on a FLAME event?

Yes

How did you hear about FLAME?

Lastly, how did you hear about FLAME Community Conversations?

How did you hear about FLAME - Specify

Please specify

Agreements

Consent*

I understand that my organization is required to provide feedback to the office sponsoring the development of FLAME materials¹ at the completion of the event, including event information, photos, etc.

I agree that my organization will adhere to the following requirements:

I will identify and coordinate with a venue that meets event needs and is ADA²-compliant

All are welcome! No attendees will be turned away at the door.
HHS complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. HHS does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

I will follow the co-branding guidelines as laid out in the Champion Event Promotion Guide

I agree*

¹ U.S. Department of Health and Human Services, Administration for Children and Families, Office of Family Assistance.

² Americans with Disabilities Act

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