*Program Name:

*Activity Name:

*Contact Name (to verify information):

Facility:

Address:

State:

*Description of the Proposed Activity:

Number of Students Involved in the Activity:

Range of Student Ages:

Age of Groups Involved:

Duration of Activity (number of months, weeks, or days):

How many hours are students involved per week or day?

Is there any relevant contextual or demographic information you would like to share?

How does this activity foster engagement of the participants?

How does this activity help create capacity building?

How does this activity achieve continuity for participants?

How does this activity integrate other supportive factors—such as youth development principles, community support, and parent involvement—and build on human capital (are children and youth provided with a substantial quantity of resources)?