CENTER INFORMATION

School District:  
Center Type:   FRC
  YSC
  FRYSC
 Center Name:
FRYSC Region: Coordinator Name:
Coordinator Email: Phone Number:

DATA COLLECTION EFFORTS
Please indicate which of the following data collection tools you currently USE in your center on a regular basis. Check all that apply.
  Large Group Activity Sheets   Daily Log   Referral Forms
  STI   FRYSC Tracker Software (Buchanan)   The Ultimate FRYSC Toolkit (Cooper)
Other:  

SERVICES AND ACTIVITIES

Please indicate which of the following services or programs your center either provides solely or takes an active role to provide. Please indicate both the unduplicated number of students and/or parents AND the total number of student/parent contacts (See "Tip Sheet" for detailed explanation).
  Unduplicated Total Contacts
  # of Students # of Parents Total Student Contacts Total Parent Contacts
Health Services/Referrals
Dental Health
Obesity: Nutrition
Obesity: Physical Activity
Family Crisis/Mental Health/Referrals
Drug/Alcohol Counseling, Referrals
(now Substance Abuse Education and Counseling)
Summer/Part-Time Job Development
Employment Counseling, Training, Placement
(now Career Exploration and Development)
Educational Support
Character Education
Basic Needs
Parenting Classes
Holiday Assistance
Reading Programs/Activities
Grandparent Support Group
Tobacco Prevention
Families in Training (new and expectant parents)
Summer Program/Camp
Peer Mediation
Conflict Resolution
Service Learning
Job Shadowing
Mentoring
Tutoring
Reality Store
Transitioning
Pregnancy Prevention
Back to School Event
Bullying Education
Newsletters (not flyers/brochures)

SERVICES AND ACTIVITIES (CONTINUED)
Please help us to understand more about the services and activities your center provides by answering the following questions. If a question does not apply to your center, please check NO. Please do not leave any questions blank.
How many home visits has your center conducted this year?
How many individual families does that number represent?
How many of those home visits were Parents as Teachers (PAT) home visits?
 
Please indicate the total number of volunteer hours this year:
 
Do you have an AmeriCorps worker? Yes    No
If yes, how many?
 
Does your center provide training for child care providers? Yes    No
If yes, how many trainings did your center provide this year?
How many child care providers received training (unduplicated)?
 
Does your center provide licensed day care (pre-K)? Yes    No
If yes, how many are you licensed to serve?
 
Does your center provide licensed day care for infants under age 2? Yes    No
If yes, how many are you licensed to serve?
 
Does your center have a before school, after school, or summer program? Yes    No
How many children do you serve?
BEFORE:
AFTER:
SUMMER:
Is it licensed? Yes    No
 
If your center has a licensed child care center, do you participate in the STARS (rating system for child care centers) program?
Yes
No
Don't Know
 
Does your center have a family literacy program? Yes    No
(Note: Reading Activity/Program participants reported in table above)
Please check the Family Literacy components utilized:
Adult Education
Parent time
Children's Education
Parent and Child Together (PACT) Time
 
List up to three reading programs or activities your center uses or provides:


FAMILY TEAM MEETINGS
(Formerly Comprehensive Family Services)
How many Family Team Meetings has your center participated in during this fiscal year?
How many different families did those meetings represent?
How many meetings did your center staff chair?

ADDITIONAL INFORMATION
Approximately how much of your FRYSC allocation goes toward the provision of the following services?
  Onsite Offsite
Health Services by a licensed provider $ $
Mental Health Counseling by a licensed provider $ $
Drug/Alcohol Abuse Counseling by a licensed provider $ $

CASH AND IN-KIND CONTRIBUTIONS and FUNDRAISERS
  School Board Community Total
Salary Supplement $ $ $
Donations (cash) $ $ $
Donations (goods, time, space, etc) $ $ $
Fundraisers $
Child Care Parent Fees $

ADDITIONAL GRANTS (excluding FRYSC allocation)
Total Grant Dollars $
Please list name of grant and amount received. If more than four were received within the year, please list the largest four here.
Name of Grant Amount Received
1) $
2) $
3) $
4) $
If you want a printed copy of this form for your records click here before you submit the form.