Form - GSAN

Program Name

Program Contact

Program Contact Email

Address

City

State

ZIP Code

Counties Served (For multiple selection use Ctrl + Select)

Phone

Website URL

Hours of Operation

Total Hours of Youth Programming Offered Per Week( Put only two digit number. )

Food Served

Breakfast Lunch Supper Snack

*Please select all that apply

Select the Options that Best Describes Your Program

YMCA Boys & Girls Club Community-Based School-Based Faith-Based Based in an Institution of Higher Education

Other:

Program Fees

Set Fee Sliding Scale Free

Other:

Do you accept CAPS

Yes No

Please check all that apply based on the transportation your programs offer

Program provides transportation options Program does not provide transportation Program is near public transportation

Current Enrollment ( Put only two digit number. )

Staff : Student Ratio

Less than 1:10 1:11-1:20 1:21-1:30 1:31 or more

Do you currently have a waitlist for any of your youth programs?

Yes No

License Status

Exempt Licensed by the Department of Early Care and Learning

Funding Sources

Fees 21st Century Community Learning Center DFCS Afterschool Care Program United Way Corporate/Business Local Government

Other:

*Please check all that apply

Do you want your program to be considered to be highlighted on GSAN's website?

Yes No