ORGANIZATION and/or ACTIVITY NAME: SITE:

AMOUNT OF TIME PROVIDED:
Total number of weeks provided:
Typical Number of days per week:
Typical Number of Hours Provided Per Day:

AVERAGE NUMBER OF STUDENTS ATTENDING ACTIVITY:

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It's common for a given activity to be offered in multiple sessions concurrently or at multiple times to different groups of participants during the course of a week. If either of these circumstances were true for this activity, please select the appropriate option.

Was this activity in multiple sessions that occurred concurrently on the same day serving different groups of students? (e.g., there were two session of the activity that met from 4-5 on Tuesdays, with no one session for students in grade 4 and a second session for students in grade 5)

Was this activity offered multiple times during the course of the typical week but to different groups of students on a given day? (e.g., the activity was offered on Tuesdays to students in grade 4 and Thursdays to students in grade 5)

Was the activity typically offered less frequently than weekly during the period it was offered (e.g., was the activity provided every other Saturday or one Saturday a month?) Select the most appropriate.

Yes, this activity was typically offered 1-3 times a month.
Yes, this activity was typically offered less than once a month.
No, this activity was typically offered every week during the period it was offered.

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ACTIVITY TARGETED YOUTH - Select up to two options.
Academic Enrichment
Tutoring
Homework Help
Mentoring
Recreational
Career/Job Training
Drug/Violence Prevention/Counseling/Character Education
Expanded Library Service Hours
Supplemental Education Services
Community Service/Service Learning

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TARGETED SPECIFIC STUDENT SUBJECT AREAS - Select one option.
Students not performing at grade level
Limited English Proficient Students
Students who have been suspended or expelled
Students with special needs
Other:
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ACTIVITY ADDRESSED SPECIFIC SUBJECT AREAS - Select all options that apply.
Reading/Literacy
Mathematics
Science
Arts and Music
Entrepreneurial Education
Technology/Telecommunications
Cultural Activities/Social Studies
Health/Nutrition
Other:

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DESCRIPTION OF THE ACTIVITY.


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