Thank you for applying to be a part of the first cohort of the Underserved Populations Learning Collaborative.  Please complete all of the questions that follow.  Should you have any questions as you complete this application, you can reach Katie Moffitt or Quan Williams, UPLC Coaches, at 804-377-0335 for additional information.

* 1. First and last name of SDVA Lead Contact for this application.

* 2. Agency

* 3. Are you public or non-profit?

* 4. Number of FTEs in SDVA programs (full-time equivalent staff positions)

* 6. Are you a DV, SV, or dual agency

* 7. Please indicate all of the eligibility criteria met by your SDVA: (check all that apply)

* 8. I understand the expectation of the UPLC is that:

* 9. Who are some of the specific populations your agency serves?

* 10. Describe the outcomes you are hoping your agency will achieve as a result of participation in the UPLC.

* 11. What support do you have (community partners, funding, connections to other agencies, staff and/or Board buy-in) to participate in this project?

* 12. What barriers do you anticipate you may face that will inhibit you from participating in this project?

* 13. Please provide the name and position/agency role of each UPLC team member 

* 14. Please provide the email address of each UPLC team member

* 15. When building this team, we assessed the aspects of leadership and diversity provided in the RFA and Project Overview document and believe these are the right people to serve on this team.