Attachment 6 - Affirmation of Support from LHD and Community Partners FINAL LOCKED.docx

Attachment 6

Affirmation of Support Form: Local Health Department(s) and Community Partners

Targeted Healthy Families New York (HFNY) Program with Healthy Families America (HFA) Child Welfare Protocols New York State Office of Children and Family Services Request for Proposals (RFP)

Instructions:

· Applicants – If you identified community partners in your proposal, such as local department(s) of health, prenatal clinic, birthing hospital(s), and Women Infant and Children (WIC) programs, it is recommended that you include this Attachment 6 from them and any applicable MOUs with your proposal.

· Local Health Department Commissioners and community partners may complete this form for multiple organizations proposing to serve the county they operate in.

Name of entity applying for HFNY funding:

Name of community partner organization or the local health department:

Name of County the community partner or local health department serves:

Does the organization/health department support the proposal from the entity above to provide HFNY services? Yes No Identify any specific action(s) the organization/local health department will take to support the proposed HFNY program such as: referrals to the program, providing services to HFNY families, providing funding, providing space for HFNY staff or services, screening of families for possible eligibility, participating in an advisory capacity, serving on a committee, activities to foster relationships between their staff and that of the HFNY program.

Name of organization/health department representative [first and last name]:

Title of representative:

Signature of representative [inked or electronic]:

Email address and phone number of representative: