Reporting to Motheread® Arizona

Name of site (Enter the name of your site, not its location.):

Name of sponsoring agency (Enter the name of the agency that financially supports your site. If this support comes from a combination of agencies, please list all of them.):

Type of site (Enter the type of program at your location, i.e. Even Start Comprehensive Family Literacy Program, Library, Mental Health Agency, Other-please specify.):

Number of years site has had Motheread® Arizona programming (This number applies to your individual site, not your sponsoring agency or Motheread® Arizona.):

How many cycles of classes are offered at this site each year? (If your Motheread® Arizona classes are not offered continuously throughout your program year, please list how many cycles are provided. If you do offer classes continuously throughout the program year, just enter "continuous."):

Implementation strategy (select one)
Indicate which of the two options represents most accurately the structure of your Motheread® Arizona program:
Integrated into larger instructional program (Ex: Even Start, Basic Skills)
Stand-alone program (Ex: Community-based program, Mental Health Agency)

Trained Motheread® Arizona facilitator(s) at this site

Name(s):

Job Title(s):

Address:

City:

State:

Zip Code:

Phone(s):

Fax:

E-Mail(s):

Discussion Series Dates (List each date, in "1/1/05" format.):

How long did this series last in weeks? (Indicate how many weeks it took for a student to complete this class if he/she signed up for this series of classes.):

How many instructional hours did this class series include? (Indicate how many hours of actual instruction a student received if he/she signed up for this series of classes and attended every class session.):

Community Partners (note contribution of partner):