Listen4Good Premium Registration Form

Thank you for your interest in participating in Listen4Good (L4G) Premium. Please review this page for more information about our participation guidelines and to help you determine whether L4G meets your needs. After we review your information, we may contact you for more details prior to finalizing your registration.

More details about what the L4G Premium program entails, including pricing and the program’s start and end dates, can be viewed here. Please read through those details.

If you have any questions regarding this form, please contact Rebecca Klein at rebecca@fundforsharedinsight.org.

This registration form has the following sections:

A. Organization Information

B. Contact Information

C. Organizational Mission and Learning Goals

D. Payer Information

E. Additional Organization Details

F. Wrap-Up

This form does not automatically save your progress. If you are not able to complete this form in one sitting, click on the “Save my progress and resume later” button on the top or bottom of the page you are on.

A. ORGANIZATION INFORMATION

Organization's legal name:

Publicly used name (doing business as) if different than above:

EIN# (#########):

Please only use numbers — do not include a dash.

Street address:

City:

State:

Zip code:

Website URL:

Is your organization a U.S. 501(c)3 public charity or government agency?

Yes, we are a 501(c)3 public charityYes, we are a government agencyNo, we are not a 501(c)3 public charity or government agency

Annual budget:

$

Please round to the nearest whole number and do not include commas.

Total number of full-time staff that work in your organization:

Does the head of your organization identify as BIPOC (Black, Indigenous, and/or a Person of Color)? (Optional)

YesNo I’m not sure

What percent of senior leaders at your organization identify as BIPOC (Black, Indigenous, and/or People of Color)? (Optional)

%

What percent of your organization’s board identifies as BIPOC (Black, Indigenous, and/or People of Color)? (Optional)

%

B. CONTACT INFORMATION

Project Champion The Project Champion, typically a senior leader or manager in the organization, will be responsible for change management and tying feedback to ongoing organizational initiatives.

Project Champion First Name:

Project Champion Last Name:

Project Champion Title:

Project Champion Email Address:

Project Champion Phone Number (###-###-#### ):

Project Manager for L4G Implementation The Project Manager will be responsible for overall project management and implementation of L4G, data analysis, and management of staff and client relationships to this work. If you don't know who will serve as the Project Manager yet, please include the primary contact for this registration.

Project Manager First Name:

Project Manager Last Name:

Project Manager Title:

Project Manager Email Address:

Project Manager Phone Number (###-###-####):

C. ORGANIZATIONAL MISSION AND LEARNING GOALS

The following questions help us understand your organization and how you will use L4G.

Please give a brief description of your organization's mission and activities. (150 words or less)

Which of the following issue areas best represents the core activities and services of your organization? (Click here for additional information about selecting your organization’s issue area.)

Issue Area Category:

Issue Area Sub-category:

Does your organization operate as a direct service organization?

L4G is designed for organizations that are “direct service”, which we define as organizations that interact with and/or provide services to individual clients. Organizations that provide services through a partner are considered direct service if the clients of the partner are the target of their survey efforts, and clients can realistically comment on the organization’s offerings.

Yes, we are a direct service organizationNo, we are not a direct service organizationI’m not sure

Does your organization intend to survey clients who use your programs through L4G?

The L4G question set is intended to capture feedback only from individuals who participate in programs. L4G is also not intended for gathering feedback from organizational partners, paid staff, or volunteers that you might depend on for implementation of your ultimate mission.

Yes, we will survey clients using L4GNo, we will not survey clients using L4GI’m not sure

Please describe the clients you serve. (150 words or less)

Do your clients represent “voices least heard”?

The phrase “voices least heard” refers to people who are the least heard in our broader society due to historic inequality and enduring structural barriers. (See here for additional background on voices least heard.)

Yes, our clients represent voices least heardNo, our clients do not represent voices least heardI’m not sure

Why are you interested in participating in L4G? What are the 2-3 things you hope to learn by gathering feedback through L4G? (200 words or less)

What program would you like to survey first? Tell us a bit about the program (what services are provided, how many clients you serve, how clients interact with the organization, etc.). (150 words or less)

D. PAYER INFORMATION

Please provide basic information on who will be paying for the $6,000 fee to fund your participation in L4G. Note that by listing a funder you are allowing us to directly contact the payer and solicit payment from them. If you plan to pay out-of-pocket, please note that below.

Who will be paying for your participation in L4G?

A funder will be paying on behalf of my organizationMy organization will pay out-of-pocket

Funder organization name (if your organization is paying out-of-pocket, enter "self-pay"):

First name of primary billing contact:

Last name of primary billing contact:

Primary contact title:

Primary contact email address:

Listen4Good Premium Registration Form

A. ORGANIZATION INFORMATION

B. CONTACT INFORMATION

C. ORGANIZATIONAL MISSION AND LEARNING GOALS

D. PAYER INFORMATION

E. ADDITIONAL ORGANIZATION DETAILS

F. WRAP-UP