Name of Agency*Agency Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Program Name*DME Connection*Teaching & LearningFamily & Community PartnershipsOperational EffectivenessSchool Culture & ClimateProgram Director Name* First Last Program Director Email* Program Director Phone Number*School Name(s)*In which school(s) would this program be placed? Click the (+) button to add multiple schools. What type of on-site space does the program require?*(ie: classroom, gym, cafe)When would the program take place?*Select all that apply. After School programs serving students that end later than 6:00 pm are subject to a fee. Before School During School After School Do you need access to the building on weekends?*programs that take place on the weekends will incur a feeNoYesProgram Start Time* : HH MM AM PM Program End Time* : HH MM AM PM Which days will the program take place?* Monday Tuesday Wednesday Thursday Friday Saturday Sunday Program Duration*Please enter the duration of the program. For example: 8 weeks, or January to June.Grades Served*Select all that apply PreK K 1 2 3 4 5 6 7 8 9 10 11 12 Number of Students Served*Brief description of program*HPS ResponsibilitiesAgency ResponsibilitiesQuestions or CommentsLindsay Diaz will be in contact with you within one week of submission. Please note it can take up to four weeks for an MOU to be executed.