Attachments AA 1 Agency Program Logistics Summary 2013 Program Offering by IM5lOy

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									                         AGENCY PROGRAM LOGISTICS SUMMARY                        - Attachment A
Agency Name:
Program Name:

Site 1: Facility Name:
Address:
Program Offering/Component Name:
Operation Period:    /    /    to           /        /    Comments:
HOLIDAYS AND DATES COMPONENT WILL NOT OPERATE:
Days of Operation:                                          Times:       to
   M     T    W      Th    F   Sa    Su
Summer Schedule:                                            Times:       to
   M     T    W      Th    F   Sa    Su
Total Number of Youth:         AGE RANGE:       to              Average Attendance:

Site 2: Facility Name:
Address:
Program Offering/Component Name:
Operation Period:    /    /    to           /        /    Comments:
HOLIDAYS AND DATES COMPONENT WILL NOT OPERATE:
Days of Operation:                                          Times:       to
   M     T    W      Th    F   Sa    Su
Summer Schedule:                                            Times:       to
   M     T    W      Th    F   Sa    Su
Total Number of Youth:         AGE RANGE:       to              Average Attendance:

Site 3: Facility Name:
Address:
Program Offering/Component Name:
Operation Period:    /    /    to           /        /    Comments:
HOLIDAYS AND DATES COMPONENT WILL NOT OPERATE:
Days of Operation:                                          Times:       to
   M     T    W      Th    F   Sa    Su
Summer Schedule:                                            Times:       to
   M     T    W      Th    F   Sa    Su
Total Number of Youth:         AGE RANGE:       to              Average Attendance:

Site 4: Facility Name:
Address:
Program Offering/Component Name:
Operation Period:    /    /    to           /        /    Comments:
HOLIDAYS AND DATES COMPONENT WILL NOT OPERATE:
Days of Operation:                                          Times:       to
   M     T    W      Th    F   Sa    Su
Summer Schedule:                                            Times:       to
   M     T    W      Th    F   Sa    Su
Total Number of Youth:         AGE RANGE:       to              Average Attendance:

             Orange County Youth Bureau - Application for Funding               Revised 6.29.12   1
                                                          2013 Program Offering                                              - Attachment A-1
Agency:                                                                  Contact Person:
Program Name:
Address:
Staff and Program Quality: How well will we do it?                     Target NYS PQA Average Score:
 List of any additional quality measures for Staff and Program Quality:

How much?
Total # of Youth:             Gender: Male:           Female:           Age: 0-4:       5-9:       10-14:         15-17:       18-20:     21+:

Ethnicity:   White:        Black or African American:             Hispanic or Latino:           American Indian or Alaskan Native:

             Asian:         Native Hawaiian or Other Pacific Islander:               Two or More Races:
Target Population: (estimate projected whole numbers of youth for each category)
General Youth:                 Youth aging out of Foster Care:                          Children of Incarcerated Parents:
Youth in Juvenile Justice System who re-enter the community:                               Runaway and Homeless Youth:

Is anybody better off?       These refer to your Results Based Accountability Performance Measures.
    PARTICIPANT OUTCOMES                      STRATEGIES/ACTIVITIES                 PERFORMANCE TARGETS                    HOW YOU WILL MEASURE
(Refer to Performance Measures as             List all activities related to          FOR EACH OUTCOME                      THIS ACCOMPLISHMENT
based on Results Based Accountability)           Participant Outcome                What youth will achieve for each
Expected change, benefit or improvement                                                       Outcome?
          in condition or behavior
  (over the course of the program)




                                Orange County Youth Bureau - Application for Funding                             Revised 6.29.12                  2
                                                   2013 Program Offering                                      - Attachment A-1 continued

Is anybody better off?
    PARTICIPANT OUTCOMES                  STRATEGIES/ACTIVITIES            PERFORMANCE TARGETS                 HOW YOU WILL MEASURE
(Refer to Performance Measures as         List all activities related to     FOR EACH OUTCOME                   THIS ACCOMPLISHMENT
based on Results Based Accountability)       Participant Outcome           What youth will achieve for each
Expected change, benefit or                                                          Outcome?
improvement in condition or behavior
  (over the course of the program)




                                Orange County Youth Bureau - Application for Funding                    Revised 6.29.12                3

								
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