Add Program

General Information

Program name*

Host organization name

Host organization program website link

Provide a brief program description. Please include the goal(s) or objective(s) of the program.

Program logo (optional)

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Picture file of the program’s logo (JPG or PNG work best).

Program Duration and Location

What is the program duration/length?

Generally, when do program activities take place? Select all that apply.

After school weekday hours

Weekends

Summer

During the academic year

Other (please specify):

(Other) Please specify

Is the program offered in-person, virtual, or hybrid?

In-person program location(s). Please include the address, name of building, etc.

In what county is the program offered?

Eligibility Criteria and How to Apply

Please briefly describe any programs that this program articulates with (i.e., participants are able to flow into the program from another program and/or enter another program after completing this one).

Description of affiliations

Please briefly describe umbrella organization(s) and/or program network(s) with which this program is affliated at the regional, state, or national level (e.g. AHEC, HRSA HCOP programs, etc.).

Program Components

Program Costs

How much is the program participation fee?

Brief description of participant costs.

Is financial assistance available to support program participation?

Funding

FTE paid program staff

Number of full-time-equivalent paid program staff

Approximate annual budget

Approximate annual program budget (excluding in-kind donations).

Sources of funding

Program’s host organization (e.g. university)

Grants

Donations

Program revenue

Endowment

Other (please describe):

Please list any recent sources of funding for this program.

(Other) Please describe

Grants funding organizations

Please list name(s) of funding organizations

Program revenue

Please describe program revenue

In-kind resources

Does this program receive any in-kind resources that support its operation (e.g., donated office space, volunteers, tuition waivers for participants)?

Description of in-kind resources

Please briefly describe in-kind support received by the program.

Contact Information

Program contact person’s first name

Program contact person’s last name

Program contact person’s job title

Program contact person’s email. This will be visible in the Inventory.

Program contact person’s phone number. This will be visible in the Inventory.

If you are not the program contact person updating the program entry, please enter your first and last name, job title, and email. Your information will not be shared publicly.

Other Information

Additional information

Please share any additional information about the program or other comments.