OCFS 5003 – County of Saratoga, New York

Aging OCFS-5003

IMPLEMENTING AGENCY:

PROGRAM TITLE:

LIFE AREA:

GOAL:

OBJECTIVE:

SOS:

PERFORMANCE MEASURES:

How much:

How well:

Better off:

Use whole numbers, when entering information for Sex, Race/Ethnicity, Ages, and Target Population areas, NOT percentages. Please note, residential programs may only serve young adults ages 21-24 if certified to do so and such services have been documented.

SEX: (Enter number of participants per sex)

Male

Transgender Boy/Man

Female

Transgender Girl/Woman

GNC/Non-binary

Other

RACE/ETHNICITY OF PROGRAM PARTICIPANTS: (Enter number of participants per race or ethnic group)

Asian/Bangladeshi

Asian/Korean

Asian/Other

White

Asian/Burmese

Asian/Japanese

Pacific Islander/Guamanian and Chamorro

Black or African American

Asian/Chinese

Asian/Nepalese

Pacific Islander/Native Hawaiian

Hispanic or Latino

Asian/Filipino

Asian/Pakistani

Pacific Islander/Samoan

American Indian or Alaskan Native

Asian/Indian

Asian/Vietnamese

Pacific Islander/Other

Two or more Races

Other (specify):

PRIMARY LANGUAGES SPOKEN AT HOME

Other Language

AGES

0-4

5-9

10-14

15-17

18-20

21+

DOES TARGET POPULATION INCLUDE DISCONNECTED YOUTH?

Radio Field

Yes

Enter number of participants per population described

Youth aging out of foster care

Youth in the juvenile justice system who re-enter the community

Children of incarcerated parents

Runaway and homeless youth

Text Input

Disclaimer: This form will be submitted to the Saratoga County Department of Aging & Youth Services. Please note that submission of these forms to the County Department of Aging and Youth Services does NOT guarantee funding will be allocated to your program.