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* 1. Organization Name

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* 2. Program Name

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* 3. Address of Organization

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* 4. Contact Person

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* 5. Fiscal Agent (If applicable)

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* 6. Is your program located within the Park Heights area? (Park Circle to Northern Parkway and Greenspring to Wabash)

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* 7. IF you answered Yes to Question 6, please add how many Youth from the Park Heights Master Plan Area will your program serve?

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* 8. What best describes your program?

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* 9. What is the total amount of funding you are requesting for the 2018 - 2019 school year? (Please answer using a dollar amount format, e.g. $100,000)

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* 10. How many youth will your program serve during the 2018-19 year? (for specialized programs list the number of youth served during a cycle and the total number served over the year)

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* 11. Does your program partner with or serve students from a particular school?

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* 12. If you answered to Question 10, please list which school(s) does your program serve? (NOTE: If your program serves more than 4 schools select the schools with the largest number of students in your program first)

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* 13. Will your program continue during the Summer? If so, please describe how below.

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* 14. Does the program serve youth with other funding sources? If yes, please list the funding source indicate how many youth are served with that funding. (NOTE: If you reported match funding in your budget form
please explain it here.)

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* 15. What grades does your OST program serve? (check all that apply)

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* 16. Where do the youth in your program live? (NOTE: If your program serves youth from more than 3 neighborhoods select the 3 neighborhoods with the most students in your program first.)

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* 17. Do you serve any special populations? (check all that apply)

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* 18. How will you recruit students for your program?

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* 19. Describe your OST program; share successes from past years and goals for the coming year.

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* 20. How will your program partner with families to support youth?

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* 21. How will your program partner with community members to support youth?

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* 22. How will your program include students of all abilities?

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* 23. If your program serves older youth, do you offer any of the following activities? (check all that apply)

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* 24. Please describe the activities that you offer or how you support the focus areas you selected above.

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* 25. For programs serving elementary/middle school youth, do you offer any of the following activities?
(check all that apply)

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* 26. Please describe these activities or how your program supports the focus areas you listed above.

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* 27. How do you ensure that students receive a high quality experience at your program?

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* 28. Please answer the following questions about your staff:

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* 29. Budget

Be sure that the budget:

·         Does not exceed the category allocated award amount;

·         Does not include in-kind contributions;

·         Is consistent with the program design/plans outlined in the corresponding proposal narrative; and

·         Ensure administrative costs, if applicable, do not exceed 10% of total direct costs.

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* 30. Provide a copy of the organization’s independently audited financial statements for its fiscal year-end within the past 12 months

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* 31. Provide certificate of “Good Standing” for Organization or Fiscal Agent. Must provide a PDF copy of the certificate within the 2018 calendar year (January 1, 2018 to present).

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