Tell us about the agency

Program Agency Name  

Address  

Phone Number  

Contact Person  

Website   If you have a website, please provide us with the URL

Can you assist families in Spanish?  

Yes
No

About the Program

Program Summary   Describe your program in a few sentences, including any special features you'd like to highlight.

Names of School(s) Served  

Type of Program / Service  

Before School
After School
Both: Before and After School

Days/Hours of Operation  

Cost  

Sliding Scale  

Yes
No

After School Programs   Do you provide snacks for your participants?

Yes
No
N/A: this is a before school program

Transportation

How do students get to your program after school?  

Program Bus

Chaperoned Walk

Program is on School Campus

Other (explain below)

Other - if you answered "other" above, please explain

How do students leave your program?  

Program Bus

Walk Home

Parent Pick-up

N/A: this is a before school program

Other (explain below)

Other - if you answered "other" above, please explain

Additional Information Provide any other important information you'd like to provide.

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