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Appendix A FY 2021 WorkscopeProvider’s NameDYCD PIN: FORMTEXT ?????Executive DirectorEmail:Telephone:Program NameProgram Director/ Coordinator FORMTEXT ?????Email: FORMTEXT ?????Cell: FORMTEXT ?????Provider’s Main AddressCityStateZipDiscretionary Awards for this ContractMOCS ID (Ex. FY21 05210)Purpose of Funds(Use exact language as NYC’s Budget and Schedule C)Program Services Describe in detail program daily operations (Ex. After School Program servicing students from 5-12 yrs. Old. Daily scheduled activities include Homework Help for 1 hour, STEAM activities for 45 min and Basketball/Swimming for 45 min. We play organized sports on Fridays.) 1. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????INITIATIVESSelect Funding Initiative – (The initiative(s) provided by Program Manager)**Select all that apply, based on the initiative(s) approved on the latest cleared list FORMCHECKBOX A Greener NYC FORMCHECKBOX Access to Healthy Food and Nutritional Education FORMCHECKBOX Adult Literacy Initiative FORMCHECKBOX After School Enrichment Initiative FORMCHECKBOX Anti-Poverty FORMCHECKBOX Big Brothers/Big Sisters FORMCHECKBOX Boroughwide Needs Initiative FORMCHECKBOX CASA FORMCHECKBOX Census FORMCHECKBOX City’s First Readers FORMCHECKBOX Civic Education in New York City Schools FORMCHECKBOX Communities of Color FORMCHECKBOX Cultural Immigrant Initiatives FORMCHECKBOX CUNY Citizenship Now FORMCHECKBOX Digital Inclusion and Literacy FORMCHECKBOX Diversity, Inclusion and Equity in Tech Initiative FORMCHECKBOX Educational Program for Students FORMCHECKBOX Food Pantries FORMCHECKBOX Green Jobs FORMCHECKBOX Jill Chaifetz Helpline FORMCHECKBOX Job Training and Placement FORMCHECKBOX Key to the City FORMCHECKBOX LGBTQ Inclusive Curriculum FORMCHECKBOX Local FORMCHECKBOX NYC Clean Up FORMCHECKBOX Parks Equity FORMCHECKBOX Physical Ed and Fitness FORMCHECKBOX Speakers Initiative FORMCHECKBOX Sports Training and Role Models for Success (STARS) Initiative FORMCHECKBOX Step In and Stop It Initiative to Address Bystander Intervention FORMCHECKBOX Trans Equity Program FORMCHECKBOX Veteran’s Community Development FORMCHECKBOX Young Women’s Leadership Development FORMCHECKBOX Youth Build Project Initiative FORMCHECKBOX Youth FORMCHECKBOX Other (explain) FORMTEXT ?????Age Group FORMCHECKBOX Pre- K FORMCHECKBOX Kinder/ Elementary School FORMCHECKBOX Middle School FORMCHECKBOX High School FORMCHECKBOX Adult (18+) FORMCHECKBOX Senior (62+)Licenses FORMCHECKBOX SACC (School Age Child Care) Lic. # FORMTEXT ?????_________________________________List SACC License number for applicable programs (services to children), and any other applicable license and corresponding License # belowOther License: FORMTEXT ?????_______________________ Lic. # : FORMTEXT ?????____________________________Scope of Services FORMCHECKBOX Neighborhood Wide FORMCHECKBOX Borough Wide FORMCHECKBOX City WideIndicate Neighborhood If “Neighborhood Wide” was checked, list which neighborhood(s) your programs occur in. (Ex. Bushwick, Soho): _____________ONE DAY EVENTSEvent Date: ____________________ Time: ___________________Type of EventEvent Contact PersonContact Telephone / E-mailEvent Location / DescriptionEstimated ParticipantsEvent Date: ____________________ Time: ___________________Type of EventEvent Contact PersonContact Telephone / E-mailEvent Location / DescriptionEstimated ParticipantsEvent Date: ____________________ Time: ___________________Type of EventEvent Contact PersonContact Telephone / E-mailEvent Location / DescriptionEstimated Participants (Attach additional pages as needed)PROGRAM SCHEDULE Program Name FORMTEXT ?????Site Name (Ex. PS 128) FORMTEXT ?????Site Address FORMTEXT ?????Program Schedule Description(Brief description of program schedule) FORMTEXT ?????Projected Participant EnrollmentProjected Daily Participant Attendance (ADA)Volunteers in the program (Y/N) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Start & End Dates, Days of the Week and Hours the program is in session** If programs are FORMCHECKBOX drop-in, FORMCHECKBOX by appointment or FORMCHECKBOX irregular, ONLY indicate # of sessions/week and # of hours/weekProgram Start Date FORMTEXT ?????Program End Date FORMTEXT ?????# of hours per week FORMTEXT ?????Sessions per week FORMTEXT ?????Program Hours** (ex. 3pm-6pm)SundayMondayTuesdayWednesdayThursdayFridaySaturday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????**Indicate program hours, and add ‘X’ underneath the days of the week that the program is in operation for those hours. Use additional lines as needed. PROGRAM SCHEDULEProgram Name FORMTEXT ?????Site Name (Ex. PS 128) FORMTEXT ?????Site Address FORMTEXT ?????Program Schedule Description(Brief description of program schedule) FORMTEXT ?????Projected Participant EnrollmentProjected Daily Participant Attendance (ADA)Volunteers in the program (Y/N) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Start & End Dates, Days of the Week and Hours the program is in session** If programs are FORMCHECKBOX drop-in, FORMCHECKBOX by appointment or FORMCHECKBOX irregular, ONLY indicate # of sessions/week and # of hours/weekProgram Start Date FORMTEXT ?????Program End Date FORMTEXT ?????# of hours per week FORMTEXT ?????Sessions per week FORMTEXT ?????Program Hours** (ex. 3pm-6pm)SundayMondayTuesdayWednesdayThursdayFridaySaturday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????**Indicate program hours, and add ‘x’ underneath the days of the week that the program is in operation for the hours indicated. Use additional lines as needed. DEMOGRAPHICSProvide unduplicated enrollment numbers for all activities excluding one day events. All ‘TOTAL’ rows should be equal. Ethnicity# Hispanic/Latino(a)Non- Hispanic/Latino(a)?TOTAL Race#White/Caucasian?Black/African American?Asian? FORMTEXT ?????Native Hawaiian / Other Pacific Islander? FORMTEXT ?????American Indian / Alaska Native? FORMTEXT ?????Other? TOTAL? FORMTEXT ?????Ages#Borough#Gender#0-4? FORMTEXT ?????Bronx? FORMTEXT ?????Male?5-9? FORMTEXT ?????Brooklyn? FORMTEXT ?????10-13? FORMTEXT ?????Manhattan?Female?14-16? FORMTEXT ?????Queens? FORMTEXT ?????17-24? FORMTEXT ?????Staten Island? FORMTEXT ?????Non-Conforming Gender FORMTEXT ??????24+?Citywide*? FORMTEXT ?????*Please do not include citywide totals in borough totalsTOTAL??TOTAL? FORMTEXT ??????TOTAL? FORMTEXT ?????BUDGET NARRATIVE OF HOW FUNDING/BUDGET WILL BE USED (Please include every line item that has funds allocated in your DISCRETIONARY budget.) Total Contract Amount: __________________________ Fill in total amount awarded in Discretionary fundingFunds will be used for:Personnel Services FORMCHECKBOX Salaries and Wages FORMCHECKBOX Fringe Benefits FORMCHECKBOX Central Insurance Program (CIP) Non-Staff Services FORMCHECKBOX Consultants FORMCHECKBOX Subcontractors FORMCHECKBOX Stipends FORMCHECKBOX Vendors FORMCHECKBOX Fiscal ConduitOther Than Personnel Services FORMCHECKBOX Consumable Supplies FORMCHECKBOX Equipment Purchase FORMCHECKBOX Equipment Other FORMCHECKBOX Space Cost FORMCHECKBOX Travel FORMCHECKBOX Utilities & Telephone FORMCHECKBOX Other Operational Costs FORMCHECKBOX Van Maintenance FORMCHECKBOX Fiscal Agent ServicesPERSONNEL *If you selected Salaries and Wages. List the names and titles of the salaried employees allocated to this contract. In case of staff change during FY, indicate name of currently employed staff. Full NameTitle (List Internal Title & DYCD Budget TitleFT/PTFull NameTitle (List Internal Title & DYCD Budget TitleFT/PT FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Detail of Other Operational Costs (Line 3710 in Budget) CategoryAmountCategoryAmountAdmissions Fees FORMTEXT ?????Participant T-Shirts/Uniforms FORMTEXT ?????Audit Fees FORMTEXT ?????Postage FORMTEXT ?????Awards FORMTEXT ?????Printing FORMTEXT ?????Bank Charges FORMTEXT ?????Publication Fees FORMTEXT ?????Computer Set Up/Wiring Costs FORMTEXT ?????Sporting/Recreational/Program Supplies FORMTEXT ?????General Liability Insurance FORMTEXT ?????Subscription Costs FORMTEXT ?????Food and Refreshments FORMTEXT ?????Other (list in detail): FORMTEXT ?????(Attach additional pages as needed) ................
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