Outreach Opportunity Form Unified Champion Schools Outreach Opportunity Name of Applicant* First Last Phone*Email* Applicant Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is your Special Olympics Illinois Region?*ABCDEFGHIJKI Don't KnowSchool where project will take place School Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Select Applicant Type*TeacherStudentSO CollegePlease provide a brief description of the project that you wish to activate. (No more than 1-2 sentences)* List three goals for your project Have you received funding for this outreach project in the past? Yes No Goal 1 Goal 2 Goal 3 How will you measure your success?*If this is a multi-year initiative, how do you plan to sustain support beyond 2020?Amount of funds requested?* Please provide a budget for your project.*Which of the Unified Champion Schools core activities does your project support?*Unified SportsYouth LeadershipWhole School EnvolvementPlease enter the number of students with and without intellectual disabilities your project will serve.# with disability# of individuals with an intellectual disability# without disability# of individuals without an intellectual disability If my project is selected to receive an outreach opportunity, I understand that I will be required to do an online follow-up report after the project is complete. This report is due no later than the last day of the school year. Please note that funds will be reimbursed for expenses reported, they will not be provided in advance of the activity. If you do not agree to the above conditions please explain why.
