APPLICATION FOR LOCAL PROGRAM ACCREDITATION
Program Name *
THIS APPLICATION WAS PREPARED BY:
First Name * Last Name * Title/Position on Local Program Committee Address * City * State * Zip * Work Phone * Home Phone * Cell Phone * Email * Fax
ACCREDITATION STANDARDS ACKNOWLEDGMENT
As Local Coordinator of Special Olympics Connecticut, Inc., I acknowledge that I have reviewed this Application for Accreditation and all statements made herein are true. I further acknowledge that I have reviewed and understand the rules, policies and procedures established by Special Olympics, Inc., Special Olympics Connecticut, Inc., the Official Special Olympics General Rules, and the Official Special Olympics Sports Rules. I understand that Accredited Programs are committed to abide by all rules, policies and procedures established by Special Olympics, Inc., Special Olympics Connecticut, Inc., the Official Special Olympics General Rules and the Official Special Olympics Sports Rules and that non-compliance may result in loss of accreditation at any time and loss of the right to use the Special Olympics name for any purpose whatsoever. I acknowledge that I serve in a voluntary capacity as Local Coordinator for Special Olympics, Inc., and Special Olympics Connecticut, Inc., and may be removed at any time for any reason.
Local Coordinator’s Signature * Date *
If Local Coordinator information is different than above
First Name Last Name Address City State Zip Telephone (Daytime) Telephone (Evening) Email Fax
PLEASE SUBMIT THIS APPLICATION TO SOCT BY JANUARY 20, 2017
Information provided here will assist in our 2017 Program Planning and help direct needed resources to your local program.
Local Program Committee (Include Co-local Coordinators)
Please List Members of your Local Program Committee and the Position they hold:
Name & Position *
Local Program Budget - 2017
Please upload and complete the 2017 Budget of Revenue and Expenses Excel Form listed below the Accreditation Application link. It designed to auto tally your budget line $ amounts and you may use the notes section to list a breakdown of events/projects the monies would be coming from. . It is important you save the completed budget in your local programs name and send a copy to Marc Mercadante at email@example.com. This is a new format; please contact Marc if you have any questions.
Please list 2 goals that your Local Program will achieve for 2017. Include completion dates. Please identify your goals in areas of fund raising, new sports or volunteer/coaches training.
Program Name * Goal #1 * Completion Date * Goal #2 * Completion Date *
Sports and Organization Information
If yes, what team or sport? What age group?
2. In what sports can your program use:
Coaches Unified Partners Age Groups Athletes Age Groups
3. Please indicate the Social Media Outlets your Local Program uses
Select Outlet (CTRL+Click) * Group Facebook for your Local Program Twitter Instagram Other Local Program Facebook URL Address Is a Public or Private Facebook Group?
5. If yes, what health and wellness topics below would your program be interested in learning more about?
Select Multiple (CTRL+Click) Nutrition Hydration Stretching techniques Warm up/Cool down Exercises Asthma Awareness Your Suggestion
Susan Saint James Endowment Request
This endowment was established by Susan Saint James for Local Programs. Annual funding is based on the average fair market value of the endowment over the past three years and the amount of local programs who submit this grant by the deadline. The Endowment will be dispersed as follows:
- 50 % of fund divided equally to all eligible accredited local programs - 50 % based on the # of athletes and partners registered in these eligible accredited local programs. This total will come from the previous year’s Athlete Census submitted to SOI. To Be Eligible to Receive This Endowment Funding, you must: Complete and submit your Local Accreditation Form via SOCT website to the SOCT by the January 20, 2017 deadline. Complete and submit your Susan Saint James Endowment Request via SOCT website to the SOCT by the January 20, 2017 deadline. Complete your Local Coordinator Survey by January 20, 2017 (will be e-mailed to you, one survey required per Local Program) Local Programs in the New London area who are eligible for funding through the Eunice Murtha Endowment are not eligible for this funding
Please indicate how you will use the funding by checking off the categories from the approved listing of expenses:
Select Outlet (CTRL+Click) * Sports Equipment Transportation for Games/Training Stipends for Administrative Support Games Assessment Fees Sports Facility Usage Awards Banquet for Athletes/Volunteers Uniforms Health & Wellness Program Please describe how this funding will help your local program * Local Program Name *
Any questions regarding this can go to Rich Kalcznski, Local Coordinator Representative at
or (203) 509-5243.