OCFS-5003 (11/2015) Page 1 of 3 NEW YORK STATE IMPLEMENTING AGENCY: OFFICE OF CHILDREN AND FAMILY SERVICES INDIVIDUAL PROGRAM APPLICATION PROGRAM TITLE: Program Summary-Program Components Life Area: GOAL: (Enter Code) (Enter Code) Performance Measures: OBJECTIVE: SOS: (Enter Code) Code) (Enter Code) How much: How well: Better off: Use whole numbers when entering information for Gender, Ethnicity, Ages, and Target Population areas, NOT percentages. Gender of program Participants: (Enter number participants per gender) MALE FEMALE BLACK OR AFRICAN HISPANIC OR LATINO ETHNICITY: WHITE AMERICAN (Enter number of participants AMERICAN INDIAN OR ALASKAN NATIVE ASIAN per ethnic TWO OR group) NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER MORE RACES AGES 0-4 5-9 10-14 15-17 18-20 21+ Is Target Population serving Disconnected Youth: No Yes (Enter number of participants per population described) If aging out of foster care Children of incarcerated parents “Yes”, Youth in the juvenile justice system who re-enter the community Runaway and Homeless Youth If Applicable Performance Measures: OBJECTIVE: SOS: (Enter Code) (Enter Code) (Enter Code) How much: How well: Better off: Use whole numbers when entering information for Gender, Ethnicity, Ages, and Target Population areas, NOT percentages. Gender of program Participants: (Enter number participants per gender) MALE FEMALE BLACK OR AFRICAN HISPANIC OR LATINO ETHNICITY: WHITE AMERICAN (Enter number of participants AMERICAN INDIAN OR ALASKAN NATIVE ASIAN per ethnic TWO OR group) NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER MORE RACES AGES 0-4 5-9 10-14 15-17 18-20 21+ Is Target Population serving Disconnected No Yes (Enter number of participants per population described) If Youth aging out of foster care Children of incarcerated parents “Yes”, Youth in the juvenile justice system who re-enter the community Runaway and Homeless Youth
OCFS-5003 (11/2015) Page 1 of 3 NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES INDIVIDUAL PROGRAM APPLICATION Program Summary-Program Components IMPLEMENTING AGENCY: PROGRAM TITLE: Life Area: (Enter Code) GOAL: (Enter Code) OBJECTIVE: Code) SOS: (Enter Code) Performance Measures: (Enter Code) How much: How well: Better off: Use whole numbers when entering information for Gender, Ethnicity, Ages, and Target Population areas, NOT percentages. Gender of program Participants: (Enter number participants per gender) MALE FEMALE ETHNICITY: (Enter number of participants per ethnic group) WHITE BLACK OR AFRICAN AMERICAN HISPANIC OR LATINO AMERICAN INDIAN OR ALASKAN NATIVE ASIAN NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER TWO OR MORE RACES AGES 0-4 5-9 10-14 15-17 18-20 21+ Is Target Population serving Disconnected Youth: (Enter number of participants per population described) No Yes If “Yes”, aging out of foster care Children of incarcerated parents Youth in the juvenile justice system who re-enter the community Runaway and Homeless Youth If Applicable OBJECTIVE: (Enter Code) SOS: (Enter Code) Performance Measures: (Enter Code) How much: How well: Better off: Use whole numbers when entering information for Gender, Ethnicity, Ages, and Target Population areas, NOT percentages. Gender of program Participants: (Enter number participants per gender) MALE FEMALE ETHNICITY: (Enter number of participants per ethnic group) WHITE BLACK OR AFRICAN AMERICAN HISPANIC OR LATINO AMERICAN INDIAN OR ALASKAN NATIVE ASIAN NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER TWO OR MORE RACES AGES 0-4 5-9 10-14 15-17 18-20 21+ Is Target Population serving Disconnected (Enter number of participants per population described) No Yes If “Yes”, Youth aging out of foster care Children of incarcerated parents Youth in the juvenile justice system who re-enter the community Runaway and Homeless Youth
OCFS-5003.docx