Program Providers Form Program Provider Name* First Last Email* Phone*Organization Name* Website Brief Program Description/Mission*Grade Ranges Served* Pre-K K-5 6-8 9-12 How are most of your sites currently operating?* In-person Hybrid Virtual Not currently operating Are you planning on offering virtual programming during the summer of 2021?* Yes No Do you have the capacity to provide in-person summer programs in 2021?* Yes No How many sites could you operate?* How many children could you serve per site?* Do you have the capacity to provide in-person afterschool programs during the 2021-2022 school year?* Yes No How many sites could you operate?* How many children could you serve per site?* What counties are are you interested in working in? Check all that apply* Allegany Anne Arundel Baltimore Baltimore City Calvert Caroline Carroll Cecil Charles Dorchester Frederick Garrett Harford Howard Kent Montgomery Prince George's Queen Anne's St. Mary's Somerset Talbot Washington Wicomico Worcester What types of programming do you offer - check all that apply?* Tutoring Homework Support Math Science/STEM Literacy Arts Cultural Awareness Social-Emotional Learning 21st Century Skills Mentoring Service Learning Opportunities Career and College Readiness Physical Activity/Exercise Sports Field Trips Other Services Please list additional services you offer* Do you have ESSA approval in any county in Maryland?* Yes No Which Counties?* Do you provide transportation to your programs?* Yes No Are you interested in partnering with other program providers?* Yes No Briefly describe the kind of partnerships you may be looking for?*Additional notes/comments
