Data Collection Form

Agency Information

Agency name
Address
City, State, Zip
Phone
Website
Organization Type: / Corporation/For-profit Fiscally supported another 501(c)3Government Dept. or Entity
Nonprofit with 501(c)3 Nonprofit without 501(c)3 School District
Other: ______

Program Information(Please repeat this section for each program)

Program Name:

Program Description (2-3 Sentences Only)

Address
(If you have multiple sites feel free to attach a separate document with all the locations)
City, State, Zip
Program Contact Information
Program Contact name
Program Contact Phone
Program Contact E-mail

Program Type & Subtype

(check all that apply)

/ Afterschool
Standard: meets at least 12 hrs/week
or more during the school year
Enrichment: less than standard afterschool / Summer
Standard: meets at least 5 hrs/day for 5
days for at least 5 wks during the summer
Enrichment: meets less than standard

Program Focus

(check all that apply)

/ Academic or Educational Enrichment
Arts & Culture
Career, Employment, Workforce
Development
Civic Engagement, Activism, or Organizing
Leadership or Character Development
Mentoring
Recreation, Sports, Physical Fitness &
HealthyLifestyles / Service Learning or Community Service
Social, Emotional or Behavioral
Support/Modification
STEM
Environmental
Other ______

Program Details

Do you have any eligibility requirements?
(Check all that apply) / Age
Assessment scores
Ethnicity
Free-reduced lunch
Gender
Geographic / Grade level
Income level
Membership restriction
School or school district
Other ______
Are there fees to participate in your program? / Yes Donation No
Do you offer Scholarships or Subsidies / Yes No
Days of Operation / Sunday
Monday
Tuesday
Wednesday / Thursday
Friday
Saturday
Start Time / End Time / What is the capacity for this program?Maximum Number of Children or Youth you can serve.
Gender Served / Female Male / Age Served / Min Age:
Max Age: / Grade Served / Min Grade:
Max Grade:
Drop-in Available(Can kids just show up for your program without registration) / Yes No
Food Provided / Breakfast Lunch Dinner Snack
Must bring own snack/meals Other
Transportation Provided to the Site? / No Yes, without restrictions Yes, with restrictions
Transportation Provided from Site to Child’s Home? / No Yes, without restrictions Yes, with restrictions

Thank you for your participation.

Please email this document to to update the program finder on

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