Scholastic Book Grants In Kind Donation Application Page 2
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3PROGRAM EVALUATION QUESTIONNAIRE
1)
What is the primary focus of your program?
___________________________________________________
___Tutoring/Mentoring
___Health Services
___Child Care
___Shelter
___Library
___Community Service
___Reading/Education
___
Other Describe_______________________
2)
How many children does your program serve? __________
3)
What percentage of children in your program are: __White (non-Hispanic)
__Hispanic
__African American __Asian American
__Native American
__Pacific Islander
4)
What are the ages and grade levels of the children you serve?
___________________________________
5)
What percentage of children in your program are from low-income households? __________________%
6)
What criteria does your program use to determine the economic need of the children you serve?
7)
What percentage of the children in your program speak English as their native language? _________%
8)
Are parents or primary caregivers actively encouraged to participate in your reading and literacy program? If yes,
please describe how you engage parent/caregiver participation.
9)
What percentage (estimate) of parents, primary caregivers, adult mentors, or tutors are involved in the
reading/literacy portion of your program?
_____________%
10)
Do you currently receive books from other book distribution organizations (i.e. Reading Is Fundamental, Reach
Out and Read, First Book, etc.). If so, how many books did your program receive, what time period did the
donation cover, and from whom and when did you last receive books?
11)
Is your program operated in partnership with other local or national reading, tutoring or mentoring program? If so,
please describe and list your partners.
12)
Detail the number of books you are requesting for your program, the time period over which the books will be
distributed and the frequency of the book distributions to children in your program.
13)
Briefly describe your specific plan for using books in your program.
14)
Please list the sources of funds that support your program (i.e., local, state or federal funds, the United Way,
corporate sponsors, foundation sponsors).
15)
Do you publicize your program in your community? If so, how?
16)
Please attach the following documents:
•
Proof your organization’s tax-exempt status
•
A list of your organization’s Board of Directors and/or management staff/leadership team
•
A description of your organization
•
A detailed description of your program’s literacy component
Please note: Organizations receiving in-kind gifts can only distribute the books at no-cost to recipients. Books
cannot be used for resale or fundraising purposes.
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