Agency/Contractor Name: *

Agency/Contractor Contact: *

Agency/Contractor Phone: *

Agency/Contractor E-mail: *

Total number of unduplicated youth served? *

Select all grade level groups served: *

Total Elementary youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Total Middle School youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Total High School youth served (if selected): *

Select all races served: *

American Indian or Alaskan Native

Asian

Black Multiracial

Native Hawaiian

Other Pacific Islander

White

Other/Unknown

Number of American Indian or Alaskan Native youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Number of Asian youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Number of Black youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Number of Multiracial youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Number of Native Hawaiian or Other Pacific Islander youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Number of White youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Number of Other youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Number of Unknown Race youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Select all ethnic groups served: *

Hispanic/Latinx

Non-Hispanic

Other

Number of Hispanic/Latinx youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Number of Non-Hispanic/Latinx youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Number of Unknown youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Select all gender groups served: *

Male

Female

Gender Non-conforming

Non-binary

Unknown

Number of Male youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Number of Female youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Number of Gender non-conforming youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Number of non-binary or Other gender youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Number of unknown gender of youth served (if selected): *

 please ensure that the total for the groups selected equal the unduplicated youth served.

Current BOOST Operation *

In a short paragraph (150 words or less), please describe the current operation(activities, early successes and challenges, etc) of your BOOST program.

ASP- How many days per week may a single youth attend your program? *

1-2 days

3-5 days

6 days or more

N/A - Summer Only

ASP - How many hours per day may a single youth participate in your program? *

1 hour or less

2-4 hours

5 hours or more

N/A - Summer Only

ASP - # of Weeks your Program Operates in a School year? *

34+ weeks

13-33 weeks

28-30 weeks

24-27 weeks

N/A - Summer Only

Summer - What is the Number of days per week program operates ? *

5 days

4 days

3 days

N/A - Afterschool Only

Summer: What is the numbers of hours per day program operates? *

8 or more

6-8

5 or fewer

N/A - Afterschool Only

Summer: what is the number of weeks your program operates during the Summer? *

8+ weeks

7 weeks

6 weeks

5 weeks

4 weeks

N/A - Afterschool Only

Please update a list of your current BOOST sites using BOOST Site List form below: *

***SHOULD INCLUDE AFTERSCHOOL AND SUMMER SITE LOCATIONS***

BOOST Site Form

If you have any problems with this document, email admin@grpa.org

20MB max

How Many Boost Sites are you currently operating? *

Please select the priority service areas your program currently provides. *

Workforce Development

Literacy Based on the Science of Reading Numeracy

My program does not provide services in these areas

What are your current workforce development program services and activities? *

What are your current literacy program services and activities? *

What are your current numeracy program services and activities? *

Specific Need Strategies- Part 1: *

Are strategies in place to recruit, serve, and/or address specific needs of the following populations (select all that apply):

Youth receiving free or reduced-price lunch Youth with disabilities and/or special needs

Youth experiencing homelessness

Youth in foster care English language learners

Youth impacted by the juvenile justice system

Youth who are or are at risk of becoming chronically absent from school

No strategies in place

# of Youth receiving free or reduced-price lunch Youth with disabilities and/or special needs served *

# of Youth experiencing homelessness served: *

# of Youth in foster care English language learners served *

# of Youth impacted by the juvenile justice system served *

# of Youth who are or are at risk of becoming chronically absent from school served *