Name
Organization name
Email Address:
Telephone number
What type of organization are you?	School-based After-school Program Community Based Organization City Department (Example: Rec Program) Other (please describe in next question)
**Other type of organization
Please describe the program that you work for. (Examples: Education, sports & recreation, arts, health, etc.)
How many full-time employees do you have?
How many part-time employees do you have?
What is the age-range that your organization serves?
What type of service are you seeking?	Public training Agency-tailored training Organizational assessment/evaluation Organizational capacity building Other (Please describe in following question)
**Other type of service:
In a typical year, how much money do you spend on staff training?
How did you hear about CNYD?	Website Friend/Word of Mouth Direct mailing/e-mail Other

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