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Program Submission Form

Please complete the online form below (an email of acknowledgement, including your below responses, will be sent to you.)
or print the Submission Form and scan/email or mail to Moira (mailing information included at bottom of printed form).

Name of Program:


Category:
Building Individual/Mutual Support
Building Community Support
Finding Meaningful Work and Economic Security
Expanding Lifelong Learning

PART 1: Description of the program

Program Overview (maximum 100 words):


Developed by (name of individual and/or organization):

Web Site:

Year Started:

Objectives:

Target Population:

Benefits/Outcomes:
 
 
Number of Volunteers:

Number of Paid Employees:

Total Hours per Month:

Program Guide:

Other Support Material:

Costs/Funding:

Training:

Promotion:

Policies for replicating:

Part 2: Description of the innovator of program (person and/or organization)

Individual's Name:

Organization's Name

Legal Form:

Date of Creation:

Mission:

Objectives:

Paid Staff:

Volunteer Staff:

Major Projects:

City:

Zip/Postal Code:

Country:

Contact Person (first and last name):

Function:

Telephone:

Email:

Mother Tongue:

Other Languages:

Additional Observations:

Please attach relevant support materials: (acceptable files types are jpg, png, gif, pdf, doc, docx, ppt)



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