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* 1. Enter the name of your organization 

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* 2. Enter the contact person for your organization

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* 3. Enter the contact person's phone number (work and cell)

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* 4. Enter the contact person's e-mail address

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* 5. Please select your organization's geographic reach

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* 6. Please select your organization type

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* 7. Please choose a virtual offering (if applicable)

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* 8. Please choose an in-person offering (if applicable)

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* 9. Please describe the neighborhood/community you currently serve/intend to serve (size, economic status, density, etc.)

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* 10. What is your community's strength(s)?

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* 11. Briefly describe your organization and partner organizations that will participate in the visit to the Harlem's Children's Zone

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* 12. Why does your organization want to visit?

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* 13. How many years has your organization been in existence?

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* 14. What is your organization's budget?

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* 15. What are your primary funding sources? Please list the percent of your funding that comes from private and public sources.

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* 16. How many employees (full-time and part-time) does your organization employ?

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* 17. What element(s) of the Harlem Children's Zone model most interest you and why?

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* 18. How did you hear about Harlem Children's Zone? (website, social media, news article/tv segment, book, friend or colleague, college, etc.)?

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* 19. Are you affiliated with any federal initiative (i.e., Promise Neighborhood, Choice Neighborhood, NRI, etc.)?

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