Site Name Agency Number Email Person Filing Month - Select -JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year Today's Date Did you have a health department visit this month? Yes No Service Meals Served Snacks Served Days Open This Month Hours Open Each Day Days Open Each Week Weeks Open This Month Children Attending [A] Number of NEW Children This Month Ages of Children Attending This Month Ages → Number Ages 0-4 → Ages 0-4 Ages 5-10 → Ages 5-10 Ages 11-15 → Ages 11-15 Ages 16-18 → Ages 16-18 Ages Over 18 →Over 18, but still in high school. Ages Over 18 Total Number of Children Attending This Month →Add all fields above. This number should be the same as Children Attending [A]. Total Number of Children Attending This Month Race Race → Number African American → African American Asian → Asian Caucasian → Caucasian American Indian/Alaskan Native → American Indian/Alaskan Native Native Hawaiian/Pacific Islander → Native Hawaiian/Pacific Islander Latino/Hispanic → Latino/Hispanic Other → Other Total →Add all fields above. This number should be the same as Children Attending [A]. Total Backpack Program Did you operate a backpack program? Yes No Number of Days Backpacks Were Sent Home Backpacks filled? Children with a backpack? Count every child who took home a backpack this month. Support Total Number of Paid Staff (Including Site Director) Total # of Unpaid Staff Unpaid staff are regular helpers who play vital roles in the operation of your program but do not get paid. At some sites, the director is unpaid. This person would be considered an unpaid staff member. Number of paid staff who are parents of participating children (Including Site Director) Number of unpaid staff who are parents of participating children Total number of one-time or occasional volunteers, not including unpaid staff Number of volunteers who are parents of participating children Activities Planned Educational Activities Health? Yes No How many health events? Parents attending health events Hygiene? Yes No How many hygiene events? Parents attending hygiene events Nutrition? Yes No How many nutrition events? Parents attending nutrition events Job Training? Yes No How many job training events? Parents attending job training events Food Preparation? Yes No How many food preparation events? Parents attending food preparation events Life Skills? Yes No How many life skills events? Parents attending life skills events Community Service? Yes No How many community service events? Parents attending community service events Other? Yes No How many other events? Parents attending other events Special Activities Activity 1 Parents Attending Activity 1 Activity 2 Parents Attending Activity 2 Activity 3 Parents Attending Activity 3 Regular Activities Activity Questions Yes No Arts and Crafts Yes No Computer Yes No Homework Assistance Yes No Religion Yes No Game Room Yes No Recreation Yes No Gardening Yes No Mentoring Yes No Socialization Yes No Other Activities Miscellaneous Please describe any problems or needs. Stories about how your program is making a difference Any additional comments you wish to share? Leave this field blank