Updating or Adding Your Agency Information

Please answer for your SITE only.
Your Name
Your Title
Email
Agency/ Site Name
Executive Director
E.D. Email
Site Address City State Zip Code
Mailing Address City State Zip
Agency Phone Agency Fax Agency Email Agency Website


1. What types of afterschool programs does your site offer? (CHECK ALL THAT APPLY)
Advocacy SAT Prep & College Counciling
Arts & Cultural Parent Involvement
Community Service Journalism
Recreation & Sports Job Training & Career Prep
Intergenerational Computer Training & Support
Homework Help & Tutoring GED
Conflict Resolution ESOL
Literacy & Reading enrichment Youth Leadership & Peer Education
Immigrant Services Health Education (HIV/AIDS/Substance Abbuse/Pregnancy Prevention)
Counseling & Group Work Special Needs
Math & Science Main Site
Mentoring No Direct Service At This Site
Foster Care    
Other Services

2. Which of the following best represents your site? (CHECK ONE FROM EACH COLUMN)

Program Specialty
Program Location
Arts School-Based
Literacy Faith-Based
Youth Leadership Community-Based
Multi-Service Sub-Contractor (e.g., "programs for hire"
Other Other

3. What times of the day, days of the week and times of the year does your site operate afterschool & youth programs? (CHECK ALL THAT APPLY)

School Year
Summer
Day Afternoon Evening Day Afternoon Evening
Monday Monday
Tuesday Tuesday
Wednesday Wednesday
Thursday Thursday
Friday Friday
Saturday Saturday
Sunday Sunday

4. a) On average, how many youth does your site serve per day? (CHOOSE ONE FROM EACH GROUP and ONLY FOR YOUR SITE)

Elementary Age
Middle School Age
High School Age
1-24 1-24 1-24
25-49 25-49 25-49
50-74 50-74 50-74
75-99 75-99 75-99
100-149 100-149 100-149
150-199 150-199 150-199
200-250 200-250 200-250

4. b) Under present conditions, can you serve more youth at your SITE?

Yes No
If yes, how many?

4. c) Do you have any youth on a waiting list?

Yes No
If yes, how many?

5. What is the annual budget size of your agency? (ANSWER FOR YOUR ENTIRE AGNECY)

Under $100,000 $500,001 - $1,000,000
$100,001 - $250,000 $1,000,001 - $2,500,000
$250,001 - $500,000 $2,500,001 or more

6. Do you charge fees for service? If yes, how much?

7. What is your staff to student ratio AT YOUR SITE?

1 Staff for every
Students

8. Does your AGENCY operate afterschool programs in MULTIPLE SITES?

Yes No
If yes, how many?

Please list the names of those sites:

9. Who is the person PASE should contact for more information at your site?

Name Title Email