Children and Youth Programs and Services Community Inventory

Person Completing the Form

Contact Information

Program Name

Program Description Briefly describe the program.

Program Category Please select the appropriate category or categories associated with your program.

Early Learning

Outdoor Adventures

Health & Fitness

Fun & Education

The Arts

Cultural & Community Engagement

Services Provided

Type of Services Provided Identify the type of service provided.

Direct
Contract
Other

Time and Season Services Provided Please select all that apply

Before school

After school

Summer

Spring break

Internship

Mentorship

Income Requirement Is there an income requirement to participate?

Yes
No

Other Eligibility Requirements Briefly describe additional eligibility requirements

Number of Children/Youth Served

Ages of Children/Youth Served Please select the ages of children/youth served:

Birth to three

Three to five

Elementary school age

Middle school age

High school age

Post-secondary

Primary Zip Code Served

Location of Services

Waiting List Is there a waiting list?

Yes
No

Length of Waiting List

Opportunity for Expansion Is there opportunity for expansion?

Yes
No