Program Replication Capacity Assessment

(1)

What organization (agency, non-profit, etc.) is planning to attend the program replication training?

*

Question - Required - Organization Address:

*

Question - Required - Website

Primary Contact Information

*

Name:

Title	First Required	Last Required

*

Email: Required

*

Phone Number: Required

Question - Not Required - Work Title:

* (2)

Please list the name, title, and email address for each person planning to attend the training, and indicate the program track (one only per person) in which they will participate.

Please note: Each individual may only indicate one program track; however, multiple people from an organization may participate in any one track, or several people from the same organization can participate in the training.

Attendee 1:

*

Question - Required - Name:

*

Question - Required - Work Title:

*

Question - Required - Email:

*

Question - Required - Phone:

*

Question - Required - Program track (select only one for each person)

Attendee 2:

Question - Not Required - Name:

Question - Not Required - Work Title:

Question - Not Required - Email:

Question - Not Required - Phone:

Question - Not Required - Program track (select only one for each person)

Attendee 3:

Question - Not Required - Name:

Question - Not Required - Work Title:

Question - Not Required - Email:

Question - Not Required - Phone:

Question - Not Required - Program track (select only one for each person)

Attendee 4:

Question - Not Required - Name:

Question - Not Required - Work Title:

Question - Not Required - Email:

Question - Not Required - Phone:

Question - Not Required - Program track (select only one for each person)

Attendee 5:

Question - Not Required - Name:

Question - Not Required - Work Title:

Question - Not Required - Email:

Question - Not Required - Phone:

Question - Not Required - Program track (select only one for each person)

* (3)

Question - Required -

Briefly describe the mission and the current programming of the entity planning to attend:

* (4)

Question - Required -

A strong connection with and knowledge of the community to be reached is necessary for the success of community-based projects. Please describe your entity's connection with the population and community to be reached.

(5)

It is vital that your entity have the staff and financial capacity, and the support of organizational leadership, to implement and sustain the project once the training is complete. The following page presents a brief outline of staff-time and costs associated with each program. Please review and then describe:

*

Question - Required -

(a) your staff capacity to carry out the project(s):

*

Question - Required -

(b) your plan for funding the project start-up:

*

Question - Required -

(c) how you intend to sustain the project in the long-term:

*

Question - Required - (d) how the organizational leadership, including board, executive staff, and other leaders, will support implementation and sustainability.

* (6)

Question - Required - What specific challenges do you anticipate in carrying out the planning, implementation, evaluation, and sustaining of the project (e.g. community outreach, fundraising, staffing, etc.)? This will be helpful for us in tailoring the training to your specific needs.

(7)

Question - Not Required -

Scholarships, both full and partial, are availability on a limited basis, and are issued according to interest and need. Please use the space below to indicate whether a full or a partial scholarship is needed, and to provide any additional information that may assist SFC staff in allocating the scholarships.

(8)

Question - Not Required - This year, SFC will add two optional evening sessions, in response to previous participant feedback. Please indicate your interest in these sessions:

	Community Organizing and Engagement: 6:00pm 7:30pm, Monday, June 8. Practical training and interactive activities to build skills for developing community-based leadership, plus community engagement planning tips and consultation.
	Grant Writing and Fund Development Strategies: 6:00pm 7:30pm, Tuesday, June 9. Successful strategies for organizational fundraising, including seeking out grant sources and writing successful proposals.

Program Replication Capacity Assessment

Program Replication Capacity Assessment Questionnaire