Program Information

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Title of Program:
Reporting Period:
  
We would like this program to be considered for an award: 
Is the program reported a single facet, integrated or umbrella program?
Note: To be considered an integrated program, at least three facets should be involved in implementation. To be considered an umbrella program, all five facets must be included.
If single, choose one facet; if integrated or umbrella, choose the lead facets: 
Select the lead program:
If other please specify:
  
_____________________________________________________________________________________________________________________________________
Program/Situation Addressed, Mission/Vision of Program, Objectives of Program
NOTE: Sections have character counts. Limits include spaces and punctuation
  
Using the Service Delivery Model developed by the chapter, please complete the following questions:
What was the problem or situation addressed?
 
2,000 characters or less, including spaces and punctuation.

What was the mission/vision of the chapter in implementing this program?
 
2,000 characters or less, including spaces and punctuation.

What were the goal(s)/objective(s) of the Program?
List no more than 5 goals/objectives that reflect the top priorities.
 
1,500 characters or less, including spaces and punctuation.What were the most outstanding qualities of this program? 

_____________________________________________________________________________________________________________________________________
Description of Program/Project, List Activities (Outputs) Implemented

Description of the Program:
If an umbrella program, state how each of the five facets were involved; If an integrated program describe how at least three facets were involved.

2,500 characters or less, including spaces and punctuation

List Activities (Outputs) Implemented:
Example We must clearly identify the clients served. In order to address our problem or asset, we will accomplish the following activities:
 
2,500 characters or less, including spaces and punctuation

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Targeted Groups
 (Example: a 15-year-old African American girl would count as one individual. and also be counted in the female, teen, and African American categories. Totals for each category should equal total individuals served.)
 Total individuals: 
  
 Gender Identity
Numbers should equal total individuals served		 
 Total males: 
 Total females: 
 Other: 
 Did not disclose/Unknown: 
  
 Age Range
Numbers should equal total individuals served		 
 Children (ages 0-12): 
 Teens (ages 13-19): 
 Young Adults (ages 20-24): 
 Adults (ages 25-65): 
 Seniors (ages 66+): 
 Did not close/Unknown: 
  
Groups 
 Families: 
 Disabled: 
 LGBTQIA+: 
 Veterans: 
 Homeless: 
 Others: 
 Please specify others: 
  
Ethnicities Served
Numbers should equal total individuals served		 
 American Indian or Alaska Native: 
 Asian: 
 Black, African American or of African Descent: 
 Native Hawaiian or Other Pacific Islander: 
 White (Non-Hispanic) 
 Hispanic or Latino: 
 Other: 
 Please specify other: 
 Did not disclose/Unknown: 
  
Average Household Income
Numbers should equal total individuals served		 
 Less then $25,000: 
 $25,000 to $49,999: 
 $50,000 to $74,999: 
 $75,000 to $99,999: 
 $100,000 or more: 
 Did not disclose/Unknown: 
  
_____________________________________________________________________________________________________________________________________
 Methods Used to Determine the Group(s)

Describe the methods used to determine the target groups served.
(e.g. Needs Assessment)
 
1,500 characters or less, including spaces and punctuation

 Total number of people who completed the entire program: 
 Did you collaborate with other community groups to plan
and/or implement this program?		 
 If yes, give names of groups and describe their involvement:
 
1,500 characters or less, including spaces and punctuation

_____________________________________________________________________________________________________________________________________
 Cost of the Program
  
 Projected Cost: 
 Actual Cost: 
 Was a grant or underwriting obtained? 
 Give name(s) of funding source(s): 
 Total Amount underwritten or Grant Amount Received: 
 Were any in-kind donations/services provided? 
 Give names(s) of in-kind donation/service: 
 Total monetary value of in-kind donations/services: 
 List items donated: 
 
500 characters or less, including spaces and punctuation
 
 _____________________________________________________________________________________________________________________________________
Operation and Sustainability
 
 How many years has the program been in operation?
 What year did the program start?
 If the program has been in operation five (5) years or more, please include specific modifications that you have implemented this program year.
 
1,000 characters or less, including spaces and punctuation

What were the most outstanding qualities of this program?
Up to three.
 
1,000 characters or less, including spaces and punctuation

 How will this program be sustained and/or institutionalized?
 
1,000 characters or less, including spaces and punctuation
 
  _____________________________________________________________________________________________________________________________________
Integrated Programming

 
 Describe how your integrated program was created. Please detail how your chapter's facets collaborated in the program's planning and execution.
 
2,000 characters or less, including spaces and punctuation

 
_____________________________________________________________________________________________________________________________________
Marketing and Evaluation

 
How did the chapter communicate and publicize the program?
 
1,000 characters or less, including spaces and punctuation

 How was the program evaluated?
Briefly describe how each goal/objective was met and describe the evaluation methods used.
 
2,500 characters or less, including spaces and punctuation

 List measurable outcomes, up to three: 
 
2,000 characters or less, including spaces and punctuation

 
 _____________________________________________________________________________________________________________________________________
Program Summary/Impact Statement

 
 Provide a summary of the chapter program that can be used for publication.
include information on how the program made an impact on your community.
 
2,500 characters or less, including spaces and punctuation

  _____________________________________________________________________________________________________________________________________
Testimonial
Provide up to three testimonials from program participants, if available.
 Testimonial #1:


  Testimonial #2:
 

  Testimonial #3:
 

 
  _____________________________________________________________________________________________________________________________________
Chapter Participation

 
 Number of members in chapter: 
 Number of active members in chapter: 
 Number of active members who participated in program: