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* Name of organization:
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* Name of contact person:
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Address:
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City:
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State:
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Zip:
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Phone number:
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Fax number:
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E-mail:
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* Which best describes your organization:
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Mission of organization:
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* Name of program:
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* Topic area program addresses:
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Other:
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Goals of program:
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Brief description of program (100 words or less):
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How long has this program been in existence?
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* Target population:
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How many people does the program reach each year?
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* In which county(ies) is the program available?
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How is the effectiveness of the program measured?
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Funding source:
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Funding amount per year:
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Is there a fee to participate in the program?
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If so, how much?
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Program beginning date:
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Program end date (if there is one):
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Collaborators on this program:
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Website address for information on program:
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Other information about this program:
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