Maryland Afterschool and Summer Programming
Dear Out of School Program Provider-

The following survey consists of several questions and answers (multiple choice, fill in the blank and drop lists). The survey is relatively short and will take approximately 15 minutes to complete. All answer should be answered as completely as possible; if the question does not apply to your organization please answer with N/A.

This form must be filled out on a per site basis. In other words, if your program operates more than one site please fill out a form for each program.

Program Information
What is the name of your Agency/Organization? *
Maryland Out of School Time Network; YMCA
Your answer
What is the name of your program? *
Your answer
What is the current number of youth you have the capacity to serve? *
30; 50; 75
Your answer
When do you operate?
What days does your afterschool program operate?
Check all boxes that apply
What are your afterschool site program hours?
Ex. 3-5; 2-6; N/A
Your answer
What days does your summer program operate?
Check all boxes that apply
What are your summer site program hours?
Ex. N/A; 10-2; 2-4
Your answer
Please select the ages of the youths served at your site.
Select all that apply
Please select the program activities that apply to your site
Program Contact Information
Program Contact Name
Your answer
Contact Title
Your answer
Email Address
Your answer
Telephone Number
Your answer
Program Address
Your answer
City
Your answer
Zip Code
Your answer
What county is your program located?
Does your program provide meals to participants?
If so, how do you pay for meals?
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