Advocacy Learning Center 
Class P Application Form
Before you complete this application please review the “Application Instruction Sheet” found on our How to Apply webpage. 

Submit your completed application package by 5:00 PM Central time on Monday, February 6, 2017 to genessis@praxisinternational.org

Please Note: Your application will not be reviewed unless all application components are complete.  
Applications will be considered based on the following criteria: 
•	Your program is a community-based, tribal or campus advocacy organization providing direct services to women/survivors of violence against women, or a state, tribal, territory or national coalition/network that focuses on violence against women (If your program fails to meet this criteria, please consider partnering with your local community-based advocacy program.)
•	Your program has the capacity to complete the 18-month course
•	Your program and team members are committed to reflecting on and strengthening how you and your organization does advocacy
•	Your proposed team includes a frontline advocate/crisis counselor and a manager/executive director
This project is supported by grant #2015-TA-AX-K004 awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinion, findings, conclusions or recommendations expressed are those of the author(s) and do not necessarily reflect the view of the U. S. Department of Justice. 

1.	We are applying as a:
☐ New applicant (our organization has never been involved in the ALC prior to this application).
☐Extended Placement Applicant (our organization was previously or currently* involved in the ALC in Class: A, B, C, D, E, F, G, H, I, J, K, L, M - highlight your response).
*Only current programs that have graduated before February 1, 2017 are eligible to apply for Class P

2.	Program Information:
Program Name: 	
Address: 	
City: 	
State: 	
Zip: 	

3.	Primary contact information (The person MUST be the same as Team Member #1 noted below; this is the person we will contact about your application):  
Name: 	
Email Address: 	
Phone Number: 	

Our organization (please check all those that apply):   

☐Receives funds directly from the following U.S. Department of Justice, Office on Violence Against Women (OVW) grant program(s): 

☐ Consolidated Grant Program to Address Children and Youth Experiencing Domestic and Sexual Assault and Engage Men and Boys as Allies
☐ Enhanced Training and Services to End Abuse in Later Life Program
☐ Improving Criminal Justice Responses (Formally Grants to Encourage Arrest Policies and Enforcement of Protection Orders Program)
☐ Grants to Enhance Culturally Specific Services for Victims of Sexual Assault, Domestic Violence, Dating Violence, and Stalking Program
☐ Grants for Outreach and Services to Underserved Populations
☐ Grants to Reduce Sexual Assault, Domestic Violence, Dating Violence, and Stalking on Campus Program
☐ Grants to Support Families in the Justice System
☐ Legal Assistance for Victims Grant Program
☐ Rural Sexual Assault, Domestic Violence, Dating Violence and Stalking Assistance Program
☐ Sexual Assault Services Culturally Specific Program
☐ Training and Services to End Violence Against Women with Disabilities Grant Program
☐ Transitional Housing Assistance Grants for Victims of Domestic Violence, Dating Violence, Stalking, or Sexual Assault Program
☐ Tribal Governments Program
☐ Tribal Sexual Assault Services Program

☐ Receives funds as a sub-grantee through the STOP Violence Against Women Formula Grants Program.
☐ Our organization is an advocacy partner of an OVW-funded project funded under the following grant program(s): 

☐ Consolidated Grant Program to Address Children and Youth Experiencing Domestic and Sexual Assault and Engage Men and Boys as Allies
☐ Enhanced Training and Services to End Abuse in Later Life Program
☐ Improving Criminal Justice Responses (Formally Grants to Encourage Arrest Policies and Enforcement of Protection Orders Program)
☐ Grants to Enhance Culturally Specific Services for Victims of Sexual Assault, Domestic Violence, Dating Violence, and Stalking Program
☐ Grants for Outreach and Services to Underserved Populations
☐ Grants to Reduce Sexual Assault, Domestic Violence, Dating Violence, and Stalking on Campus Program
☐ Grants to Support Families in the Justice System
☐ Legal Assistance for Victims Grant Program
☐ Rural Sexual Assault, Domestic Violence, Dating Violence and Stalking Assistance Program
☐ Sexual Assault Services Culturally Specific Program
☐ Training and Services to End Violence Against Women with Disabilities Grant Program
☐ Transitional Housing Assistance Grants for Victims of Domestic Violence, Dating Violence, Stalking, or Sexual Assault Program
☐ Tribal Governments Program
☐ Tribal Sexual Assault Services Program

☐ Our organization is NOT currently a grantee of the Office on Violence Against Women. 

Advocacy Program

Tell us about your advocacy program and how you provide advocacy (Please include BRIEF responses to each question):  

1.	What is your organization’s mission? 
Click here to enter text.

2.	Is your primary purpose to provide advocacy in a culturally specific community or communities?
☐ Yes
☐ No
If yes, which culturally specific communities do you work with?
	Click here to enter text.

3.	Number of years your organization/program has been providing advocacy:
Click here to enter text.

4.	Organizational/program development (when/how it came about):
Click here to enter text.

5.	Program size and structure (describe, e.g. staff/volunteer levels, one site/multiple sites, regional safe-home network, tribal program, state or tribal coalition/number of members, etc.).    
  		Click here to enter text.

6.	Do you consider your organization/program to be (check all that apply):
☐ Primarily a domestic violence organization
☐ Primarily a sexual assault organization
☐ Primarily a dual domestic violence/sexual assault organization
☐ Primarily a transitional housing program
☐ Primarily a campus-based program
☐ Primarily a program for victims of prostitution or trafficking
☐ Primarily a program for immigrant victims
☐ Primarily a program for victims of abuse in later life
☐ Primarily a program for American Indian/Alaska Native victims
☐ Other, please state:  Click here to enter text.

7.	The percentage of the advocacy you provide includes:
Click here to enter text. % Individual advocacy 
(assist an individual coming to your program)
Click here to enter text. % Institutional advocacy 
(change institutional responses that impact many who experience a similar problem)
Click here to enter text. % Community advocacy 
(change cultural and social norms that contribute to violence against women)

8.	Our organization/program would like to participate in the course because (list 3 reasons specific to strengthening your advocacy):
1.	Click here to enter text.
2.	Click here to enter text.
3.	Click here to enter text. 

9.	We have the organizational capacity to participate in the full 18-month program because (provide 3 reasons): 
1.	Click here to enter text.
2.	Click here to enter text.
3.	Click here to enter text.

10.	Our organization/program will support the participation of each team member in the 18-month course by (2-3 ways): 
1.	Click here to enter text.
2.	Click here to enter text.
3.	Click here to enter text.

Team Member Information
   
If applying for 1 or 4 team members, please explain why this is necessary (please remember subsidies will be limited to up to 3 team members):

Click here to enter text.

Name and role of each team member: (your team must include a frontline advocate or crisis counselor currently doing direct advocacy and a manager/executive director).

Name:	Role and whether they are a frontline advocate/crisis counselor, or manager/executive director:
__________________________________________________________ 

1.	Click here to enter text.	Click here to enter text.
2.	Click here to enter text.	Click here to enter text.
3.	Click here to enter text.	Click here to enter text.
4.	Click here to enter text.	Click here to enter text.

Team Member #1 (This must be the same as the main contact noted above.)  
Name: 	
Program Name: 	
Role: 	
Address: 	
Email Address: 	
Phone Number: 	

Describe your key job responsibilities as a front line advocate/crisis counselor or manager/executive director:
Click here to enter text.

Length of time as a frontline advocate/crisis counselor or manager/executive director:
Click here to enter text.  

I would like to participate in the 18-month course because (3 specific reasons that relate to your desire to strengthen how you do advocacy):   
    
1.	Click here to enter text. 
2.	Click here to enter text.
3.	Click here to enter text. 

  Team Member #2  
Name: 	
Program Name: 	
Role: 	
Address: 	
Email Address: 	
Phone Number: 	

Describe your key job responsibilities as a front line advocate/crisis counselor or manager/executive director:
Click here to enter text.

Length of time as a frontline advocate/crisis counselor or manager/executive director:
Click here to enter text. 
 
I would like to participate in the 18-month course because (3 specific reasons that relate to your desire to strengthen how you do advocacy):   
    
1.	Click here to enter text.
2.	Click here to enter text.
3.	Click here to enter text. 

  Team Member #3 
Name: 	
Program Name: 	
Role: 	
Address: 	
Email Address: 	
Phone Number: 	

Describe your key job responsibilities as a front line advocate/crisis counselor or manager/executive director:
Click here to enter text.

Length of time as a frontline advocate/crisis counselor or manager/executive director:
Click here to enter text.

I would like to participate in the 18-month course because (3 specific reasons that relate to your desire to strengthen how you do advocacy):   
    
1.	Click here to enter text. 
2.	Click here to enter text.
3.	Click here to enter text.

Team Member #4 (please remember subsidies will be limited to up to 3 team members)
Name: 	
Program Name: 	
Role: 	
Address: 	
Email Address: 	
Phone Number: 	

Describe your key job responsibilities as a front line advocate/crisis counselor or manager/executive director:
Click here to enter text.

Length of time as a frontline advocate/crisis counselor or manager/executive director:
Click here to enter text.  
 
I would like to participate in the 18-month course because (3 specific reasons that relate to your desire to strengthen how you do advocacy):   
    
1.	Click here to enter text. 
2.	Click here to enter text.
3.	Click here to enter text. 
  
Additional REQUIRED Application Components

1.	Your Organizational chart:

Please attach a copy of your organizational chart (identifying where each team member fits in your organization) to the same email when you submit your completed application. 

2.	Organizational and Team Member Commitment Statements to the ALC:   

On the final page of this application packet you will find the Organizational and Team Member Commitment Statements to the ALC. Please print this page, complete it and scan it to your computer – attach a scanned copy to the same email when you submit your application.

The ALC 18-month course is intended to help advocacy programs and individual advocates reflect on their advocacy practices and change policies and practices, if necessary, in order to strengthen individual, systems and community advocacy. The course requires time, energy and resources from both the organization and each team member. We ask each applicant organization and team member to make a commitment to fully participate in the course and to anticipate, in good faith, that each proposed team member will remain with the organization for the duration of the 18-month course.   

For Extended Placement Applicants ONLY
1.	Previous ALC team members AND indicate whether they are still engaged with the organization or not:
1.	Name: Click here to enter text.
	☐Still with organization
	☐No longer with organization 
2.	Name: Click here to enter text.
	☐Still with organization
	☐No longer with organization 
3.	Name: Click here to enter text.
	☐Still with organization
	☐No longer with organization 
4.	Name: Click here to enter text.
	☐Still with organization
	☐No longer with organization 	
2.	Briefly describe how your advocacy has been strengthened as a result of participating in the ALC. 
  
Click here to enter text.

3.	Prior to your programs participation in the ALC, what percentage of the advocacy you provide included:
Click here to enter text. % Individual advocacy 
(Assist an individual coming to your program)
Click here to enter text. % Institutional advocacy 
(Change institutional responses that impact many who experience a similar problem)
Click here to enter text. % Community advocacy 
(Change cultural and social norms that contribute to violence against women)

4.	After completing the ALC course, what percentage of the advocacy you provide includes:
Click here to enter text. % Individual advocacy 
(Assist an individual coming to your program)
Click here to enter text. % Institutional advocacy 
(Change institutional responses that impact many who experience a similar problem)
Click here to enter text. % Community advocacy 
(Change cultural and social norms that contribute to violence against women)

5.	Please describe at least one programmatic change you have implemented as a result of participating in the ALC (and/or other changes you are starting):
   
1. Click here to enter text.
2. Click here to enter text.  
3. Click here to enter text. 

6.	Tell us why your organization would like to extend this course work to additional staff (list 3 specific reasons):

1. Click here to enter text.
2. Click here to enter text.  
3. Click here to enter text.

 Organizational and Team Member Commitment Statements to the ALC

☐ Our organization and each team member understand that this course requires time, energy and resources from both the organization and each team member. If our program is selected for Class P, each team member will be available to participate in each of the following: 

•	Introductory webinar/audio conference sessions on June 28 & 29, 2017 from 2:00-3:30 PM Central time,
•	A four-day in-person advocacy immersion event on July 11-14, 2017,
•	A three-day in-person institute on November 28-30, 2017,
•	A two-day in-person training on June 19-20, 2018,
•	A minimum of monthly meetings as a team to discuss coursework and complete homework assignments prior to webinars,
•	Monthly webinar/audio conference calls,
•	Quarterly keynote webinars,
•	On-line self- study course and required reading, 
•	One in-person site visit to a model advocacy organization (only 1 member of your team will participate) *Note we do not offer the site visit component of the ALC course to extended placement participants since their program has already benefited from this offering. 
•	A graduation webinar on November 13, 2018 from 1:00-2:00 PM Central time, to celebrate the completion of your coursework,   
•	And we agree to complete evaluations after events, and to provide regular updates to ALC staff about our team's participation, reflection, impact and adaptation. 

☐ Our organization and each team member, in good faith, agree that each proposed team member will remain with the organization for the duration of the 18-month course.

☐ Our organization and each team member will use course materials to facilitate an organizational process of assessing and improving our advocacy.    

☐ Our organization and each team member understand that team members will be asked to give updates to ALC staff on their reflection and adaptation process. 

☐ Our organization and each team member understand that we will not be invited to participate in the in-person site visit to a model advocacy organization if our team is not fully participating in the coursework.
  
I understand the requirements of the ALC and commit to actively and fully participate in all activities of the ALC.

________________________________     
Signature of Board President       Date

________________________________    
Signature of Executive Director     Date

	I understand the requirements of the ALC and commit to actively and fully participate in all activities of the ALC.
________________________________     
Signature, Team Member #1     Date

________________________________   
Signature, Team Member #2     Date

________________________________   
Signature, Team Member #3     Date

________________________________   
Signature, Team Member #4     Date