A.  BASIC INFORMATION ABOUT PROGRAM

  1. Name of Program___________________________________________
  1. Location: Rural____________________________________________
Address
  Urban ____________________________________________
Address
  1. Duration: Year Round Other
Specify
  1. Time Offered Full-time hours:__________________________________

         Part-time  hours: ________________________________________________
  1. Fee: Yes   How Much___________________Who pays?________________
  1. Cost of textbooks or materials for students
            Free  Deposit or Purchased Who pays?___________________________
          How much?_____________________________________________________
  1. Sponsors:_______________________________________________________
   ______________________________________________________________
  1. Funders_________________________________________________________
  1. Objectives of Program: (Please attach If available in printed form)
_________________________________________________________________
__________________________________________________________________
__________________________________________________________________
  1. For whom IS your program Intended?
__________________________________________________________________
__________________________________________________________________
  1. Entry Requirements of Students:________________________________________
__________________________________________________________________
  1. Is your program directly geared toward preparing your students for
    admission into other specific programs?
    Yes (please specify)________________________________________________
    No
  1. How does your program recruit students?
     Catalogue/Calendar TV Flyer/Community Boards
     Newspapers Agency referrals Word of Mouth
     No active recruitment
Other_________________________
    
  1. When and how did your program get started?
__________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________


B. SUPPLEMENTARY SERVICES

  1. Does your program provide anyone or more of the following services to students enrolled in your program?
 
Service Cost to Student Time Available FundlngSources
Day Evenlng

Child care _____________

________________
         
Career & Guidance Counselling _____________

________________
         
General Counselling & referrals (personal problems) _____________

________________
         
Orientation to social services in local & larger communities _____________

________________
         
Transportation _____________

________________
         
Other (specify) _____________

________________


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