PROGENY: NGO Application
Fields marked with * are required.
Date of application:
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Name of your organization:
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Briefly describe the function of your organization:
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Street address 1:
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Street address 2:
City/Town:
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State/Region:
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Zip/Postal Code:
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Country:
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How many full-time staff members do you have?
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How many volunteers or part-time staff members do you have?
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How many children are resident at your facility?
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What is the age of the youngest child?
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What is the age of the oldest child?
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Number of boys:
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Number of girls:
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Does the number of children vary from month-to-month?
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Yes
No
If yes, by what percentage (%)?
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Do you expect an increase in the number of children at your facility over the next year?
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Yes
No
If yes, by what percentage (%)?
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Briefly describe the reasons for an expected increase:
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Do you expect a decrease in the number of children at your facility over the next year?
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Yes
No
If yes, by what percentage (%)?
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Briefly describe the reasons for an expected decrease:
What percentage of your children are true orphans?
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What percentage of your children have families but are unwanted or have been removed?
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What percentage of your children are endangered runaways?
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What percentage of your children are victims of conflict or war?
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What percentage of your children are victims of a natural disaster?
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How many of your children have been diagnosed as HIV Positive?
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How many of your children have been diagnosed with other sexually-transmitted diseases?
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How many of your children have been diagnosed with tuberculosis?
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How many of your children have been diagnosed with hepatitis?
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How many of your children have been diagnosed with cancer?
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How many of your children have serious eyesight disorders?
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How many of your children have serious hearing disorders?
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How many of your children are victims of severe physical trauma?
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How many of your children are suffering from severe mental trauma?
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Does your facility have a regular, attending doctor?
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Yes
No
If yes, how often does this doctor attend your children?
Describe the main medical problems and issues you are facing:
Describe in order of priority your 5 most important needs:
Are you under threat from organized crime or corrupt officials?
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Yes
No
If yes, describe in detail (we keep all this very confidential):
Do you consider your local police or government officials to be efficient and reliable?
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Yes
No
If no, describe in detail (we keep all this very confidential):
Describe your immediate short-term goals for your children?
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Any additional remarks:
Name of principal person at your facility:
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Telephone number (include country and area code):
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Telephone number (include country and area code):
FAX number (include country and area code):
Your e-mail address:
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Best time to contact you:
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Name of person completing this form:
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