HomeMy WebLinkAboutPickleweed Advisory Committee 2022-04-13 Agenda PacketPICKLEWEED ADVISORY COMMITTEE
AGENDA
Wednesday, April 13, 2022
7:00 P.M.
Via Zoom
Watch Online (Public) Zoom Link:
https://tinyurl.com/PWAC-4-13-2022
Telephone: (669)900-9128
Meeting ID: 852 1560 3702
CALL TO ORDER
•Roll Call
AGENDA AMENDMENTS
MINUTES
1.Review and approve regular meeting minutes of February 2, 2022
MEETING OPEN TO THE PUBLIC
2.Public Comment from the audience regarding items not listed on the agenda. Speakers are
encouraged to limit comments to 3 minutes.
MATTERS BEFORE THE COMMITTEE
If necessary to assure completion of the following items, the Chairperson may establish time limits
for the presentations by individual speakers.
3.Summer Co-Sponsorship Application Committee Recommendations
A.Marin YMCA: YMCA Summer Camp @ Al Boro Community Center
B.Canal Alliance/Marin Football Club: Canal FC at Marin FC
4.Schoolyear Co-Sponsorship Application and Final Report Presentations
A.DrawBridge Weekly Expressive Art Groups
B.Tamalpais Adult School – English As A Second Language Classes
C.Troop 2000 Scouts BSA
D.Marin YMCA: YMCA 2022-2023 Afterschool Program
E.Parent Services Project: Aprendiendo Juntos
COMMITTEE REPORTS AND COMMENTS
5.Other brief reports on any meetings or community events attended by the Committee
members.
A.Parks & Recreation Master Plan Steering Committee Update – Sprague
B.Other Reports
STAFF COMMENTS
6. Updates and Events of Interest
NEXT REGULAR MEETING: June 1, 2022
ADJOURNMENT
Notice
Any records relating to an agenda item, received by a majority or more of the Council less than 72 hours
before the meeting, shall be available for inspection online. Sign Language interpreters may be requested by
calling (415) 485-3066 (voice), emailing Lindsay.lara@cityofsanrafael.org or using the California
Telecommunications Relay Service by dialing “711”, at least 72 hours in advance of the meeting. Copies of
documents are available in accessible formats upon request.. Public transportation is available through Marin
Transit. Paratransit is available by calling Marin Access Paratransit at (415) 454-0964. To allow individuals
with environmental illness or multiple chemical sensitivity to attend the meeting/hearing, individuals are
requested to refrain from wearing scented products.
PICKLEWEED ADVISORY COMMITTEE
AGENDA
Miércoles, 13 de Abril del 2022
7:00pm
Via Zoom
Ver en Linea (Publico):
https://tinyurl.com/PWAC-4-13-2022
Teléfono: (669)900-9128
ID de reunión: 852 1560 3702
Llamar a Orden
• Llamada de rol
ENMIENDAS DE AGENDA
MINUTOS
1. Revisar y aprobar los minutos de la reunion ordinara de 2 de Febrero, 2022
REUNIÓN ABIERTA AL PÚBLICO
2. Comentarios público de la audiencia sobre los temas que no estan incluidos en la agenda.
Se anima a los oradores a limitar los comentarios a 3 minutos.
ASUNTOS ANTE EL COMITÉ
Si es necesario para asegurar que se completen los siguientes puntos, el encargado puede
establecer límites de tiempo para las presentaciones de cada comentaristas individuales.
3. Recomendaciones del Comité de Solicitud de Co-Patrocinio de Verano.
A. YMCA de Marin: Campamento de Verano de YMCA @ Albert J Boro Centro
Comunitario
B. Canal Alliance/ Marin Football Club: Canal FC at Marin FC
4. Solicitud de co-patrocinio del año escolar y presentaciones del informe final
A. Grupos semanales de arte expresivo de DrawBridge
B. Tamalpais Adult School – Clases de inglés como segundo idioma
C. Troop 2000 Scouts BSA
D. Marin YMCA -YMCA 2022-2023 programa escolar después de escuela
E. Parent Services Project -Aprendiendo Juntos
REPORTES Y COMENTARIOS DEL COMITÉ
5. Otros informes breves sobre las reuniones o eventos comunitarios a los que haiga asistido
los miembros del Comité.
A. Actualización del Comité Directivo del Plan Maestro de Parques y Recreación –Sprague
B. Otros reportes
COMENTARIOS DEL PERSONAL
6. Actualizaciones y Eventos de interés
PRÓXIMA REUNIÓN: 1 de Junio,2022
APLAZAMIENTO
Aviso
Cualquier registro relacionado con un tema de la agenda, recibido por una mayoría o más del Consejo
menos de 72 horas antes de la reunión, estará disponible para su inspección en línea. Se pueden solicitar
intérpretes de lenguaje de señas llamando al (415) 485-3066 (voz), enviando un correo electrónico a
Lindsay.lara@cityofsanrafael.org o utilizando el Servicio de retransmisión de telecomunicaciones de
California marcando “711”, al menos 72 horas antes de la reunión. Las copias de los documentos están
disponibles en formatos accesibles a pedido. El transporte público está disponible a través de Marin Transit.
Paratransit está disponible llamando a Marin Access Paratransit al (415) 454-0964. Para permitir que las
personas con enfermedades ambientales o sensibilidad química múltiple asistan a la reunión / audiencia, se
solicita a las personas que se abstengan de usar productos con aroma.
Page 1 of 5
PICKLEWEED ADVISORY COMMITTEE
February 2, 2022 – 7:00 p.m.
DRAFT MINUTES
__________________________________________________________________
Watch on Zoom:
https://tinyurl.com/PWAC-2-2-2022
Telephone: (669) 900-9128
Meeting ID: 852 1560 3702
CALL TO ORDER
Chair Mason called the meeting to order at 7:04 p.m.
ROLL CALL
Present: Chair Mason
Member Hau-Gutierrez
Member Palacios
Member Sprague
Member Vasquez
Member Yost
Alternate Member Ceballos
Park & Recreation Commission Representative Gutierrez (left at 8:06 p.m)
Absent: Member Avalos
Member Tanchez
Also Present: Catherine Quffa, Assistant Library & Recreation Director
Becky Ordin, Senior Administrative Assistant
Torrey Kelly, Marin YMCA
Kelsey Roderer, Marin YMCA
Ryan Robinett, Marin FC
Omar Carrera, Canal Alliance
AGENDA AMENDMENTS
None
MINUTES
1. Approve regular meeting minutes of October 6, 2021
2
Member Sprague moved and Member Palacios seconded, to approve the incomplete
meetings minutes of October 6, 2021.
AYES: Members: Palacios, Sprague, Vasquez, Yost, Ceballos
NOES: Members: None
ABSENT: Members: Avalos, Tanchez
ABSTAINED: Members: None
Minutes approved as submitted.
MEETING OPEN TO THE PUBLIC
2. Public Comment from the audience regarding items not listed on the agenda
None.
MATTERS BEFORE THE COMMITTEE
If necessary, to assure completion of the following items, the Chairperson may establish time
limits for the presentations by individual speakers.
3. Co-Sponsorship Applications and Final Reports
A. Marin YMCA: YMCA Summer Camp @ Al Boro Community Center
Chair Mason presented the background of past summer camp programs.
Kelsea Roderer and Torrey Kelly presented an overview of the Marin YMCA Summer
Camp to support their application.
Staff and applicant responded to questions from Members.
B. Canal Alliance/Marin Football Club: Canal FC at Marin FC
Chair Mason presented the background of the Canal Mini Soccer League for youth
under 12 years of age and explained the void for Canal children above 12 to advance
their skills and play competitively within their community.
Omar Carrera from Canal Alliance, and Ryan Robinett from Marin FC presented an
overview of the Marin Football Club program to support their application.
Staff and applicant responded to questions from Members.
4. Review of Marin YMCA Afterschool Program Application – Informational Only
Chair Mason presented the staff approved application request for the Marin YMCA
Afterschool Program.
3
Staff responded to questions from Members.
5. Review of Thank You Letter – Informational Only
Chair Mason asked for comments regarding the thank you letter from the community
leaders in Voces del Canal.
Members shared their comments.
COMMITTEE REPORTS AND COMMENTS
6. Other brief reports on any meetings, conferences, and/or seminars attended by
the Commission members.
Member Sprague commented that she and her family were glad to see the Pickleweed
Library open again on Saturdays and have increased their hours.
Member Yost attended the annual Board and Commission Holiday Party.
Member Ceballos commented that it is a great opportunity to be a part of the meeting
and the opportunities that are arising as we return to normalcy.
STAFF COMMENTS
7. Events of Interest
Chair Mason commented on the success of the Día de los Muertos event. The Organizing
Committee received a lot of positive feedback.
He shared that Jennifer Godinez, the afternoon Clerical Aide, received a full-time benefited
position at another organization. Her last day was January 14th. They are hoping to be
recruiting soon to fill the vacant position.
Regarding the Community Center, there have been multiple facility leaks, and there has been
a shift in priorities to address the roof and Heating Ventilation and Air Conditioning problems
which are contributing to the leaks. The Facility Maintenance crew was already able to identify
and repair one of the major leaks in the Center.
We did not receive the Prop 68 grant, however, upon direction from the Mayor and City
Manager, Catherine has been applying for another State grant and the City has identified
funding to potentially use to convert the soccer fields to synthetic turf pending the outcome of
the other grant.
A representative of Canalart.org has been in contact with staff and want to expand their
projects to the community center. The City is currently drafting a Public Art Policy that would
provide guidelines for groups and individuals wanting to donate or create art for public space.
Previously, staff and public input had identified the back of the restrooms in the picnic area as
4
a possible area for a mural. The art hanging rails inside the center hallways is also another
area that could be expanded with the potential of rotating art exhibits to spotlight a variety of
local artists and groups. The other area, although not in City jurisdiction, are two transformers
near the parking lot that often get tagged and mig ht be ideal for an art project.
Staff has been working with the County and sponsored a Mobile Vaccine site in December and
have been discussing additional dates.
Staff is also working with Marin Sanitary on an annual Christmas tree drop in the parking lot in
January.
Program updates include the following:
Canal Karate is doing well. Gym rentals with CYO Basketball games on Saturday mornings
and various volleyball rentals. Still no Open Gym sports.
Recently there has been interest for party rentals later in the year such as August.
Senior Grab and Go Meals in partnership with the County.
Still hosting the SF/Marin Food Bank distribution on Tuesday mornings.
Currently holding a vote for Movie in the Park on Center’s Facebook site this week. The movie
will be shown in Spanish on Friday, September 23rd.
Bridge tried but decided not to come back at all this year, unless somehow interest resumes.
Drawbridge cancelled for the month will return on Valentine’s Day.
CYFC Canal Arts to resume February 12 with Valentine art program.
The long running Saturday morning dance program rental is going to do a test date in March,
two years after stopping due to COVID, to see if there is interest in returning.
Staff accepted comments and responded to questions from Members.
ADJOURNMENT
Chair Mason adjourned the meeting at 8:27 p.m.
___________________________________________
BECKY ORDIN, Senior Administrative Assistant
APPROVED THIS_____DAY OF___________, 2021
5
___________________________________________
SUSAN ANDRADE-WAX, Library & Recreation Director
PICKLEWEED ADVISORY COMMITTEE
AGENDA REPORT
April 13, 2022
Item # 3.A.
TITLE: YMCA Summer Camp @ Al Boro Community Center Co-Sponsorship
Recommendation
RECOMMENDATION
Staff recommends that the Pickleweed Advisory Committee consider granting the
YMCA a fee reduction or waiver for use of the rooms necessary to conduct a summer
camp program for Canal children at the Albert J. Boro Community Center and
Pickleweed Park, Monday through Friday, June 16 to July 29, 2022, with permission for
staff to grant additional space on a day-to-day basis, depending on availability.
BACKGROUND
At their February 2, 2022 regular meeting, the Pickleweed Advisory Committee received
an application and presentation from the YMCA requesting full co -sponsorship of rental
fees for their proposed YMCA Summer Camp @ Al Boro Community Center program.
The YMCA program, which is supported by San Rafael City Schools, plans to serve
over 75 school identified/referred/ELL/low-income students with a safe program that will
provide academic, social and emotional development, all free of charge to the
participants.
The application requests use of many of the Center’s rooms and amenities. As was
done in the past with both the Catholic Charities Kids Club program and previous YMCA
programs, in order to accommodate other programming in the facility, staff recommends
granting the YMCA enough rooms for them to successfully base daily activities. Should
the Committee agree, additional rooms could then be granted on a daily, space
available basis. Generally, the activity fits well in the Center’s schedule and is very
much needed in the community.
Page 2 of 2
DISCUSSION
As the Pickleweed Advisory Committee has had time to review the co -sponsorship
application, a recommendation is needed to grant a fee reduction (25%, 50%, 75%, or
other), grant a full fee-waiver, reject the application and ask applicant to resubmit with
additional information, or reject the co-sponsorship application all together. Members
must also consider the Committee’s annual total allocation of $140,000 in fees that can
be waived. Should the Advisory Committee approve co-sponsorship, their
recommendation should consider supporting staff’s recommendation of granting the
rooms necessary to conduct a summer camp with permission for staff to provide
additional space on a day-to-day basis, depending on availability.
FISCAL IMPACT
The non-profit value of a full co-sponsorship totals $23,560.00 while still retaining space
for other programs. A fee reduction or waiver would potentially result in lost revenue to
the City should a paying program be interested renting the facility at that time.
ALTERNATIVE ACTION
Any other action as determined by the Comm ittee.
Submitted by:
Steve Mason
Senior Recreation Supervisor
Attachments:
1. YMCA Summer 2022 Co-Sponsorship Application Packet
10/29/2021 Page 9 of 16
ALBERT J. BORO COMMUNITY CENTER
CO-SPONSORSHIP APPLICATION
Section I-About the Applicant Agency
Date Submitted: ________________ Revision Dates (if applicable) ___________________________
Title of Program: _____________________________________________________________________
Co-sponsoring agency or individual: _____________________________________________________
Address:________________________________
Telephone: Ext. _______________
Email: ____________________________________________________________
Website:________________________________
Non-Profit 501c3 Number: ____
Principal contacts:
Name: _________________________ Phone: __ Email: ____
Is this a first time program at Pickleweed? Yes No
If no, start date of original program: __________________ Location: ________________________
Most recently approved final report must be attached.
Section II-About the Program
General Statement about the Program. Provide a background statement or statement of the problem that
describes the challenges, behaviors or issues you hope to resolve or improve
01/10/2022
YMCA Summer Camp @ Al Boro Community Center
Marin YMCA
Torrey Kelly
Al Boro Community CenterWinter 2020
In partnership with San Rafael City Schools and the City of San Rafael, the YMCA hopes to
continue to serve the families of the Canal with summer programming. Overall, we hope to
serve 75+ school identified/referred/ELL/low income students in a safe and inclusive program
at Al Boro Community Center to support academic and social emotional development of San
Rafael/Canal youth.
10/29/2021 Page 11 of 16
Section III Outcomes and Measurements
List your expected outcome(s) for this program, and how you will measure your progress/success in meeting
each outcome. Refer to the applicant guidelines for samples of outcome and measurement statements.
Each outcome statement and measurement should be individually numbered.
Outcome Statement
Measurement for Outcome
Measurements:
How do you plan to track attendance? Attach a copy of your form.
As a direct result of their participation in our program, students will feel a sense of belonging,
physical and emotional safety, academic support, and enrichment. These outcomes are made
measurable through various means of impact surveys listed below.
1. YMCA surveys both parents and students on their YMCA program experience.
2.High attendance and engagement rates as evidenced by daily attendance.
3. As appropriate, SRCS will assess children via their usual means of academic/SEL
assessment.
Manual sign in and out sheet attendance sheets are used to track overall attendance, overall
attendance trends to be shared with the district- schedule to be determined.
10/29/2021 Page 13 of 16
Attach a program budget.
Section VI Attachments
List all attachments submitted with this application
YMCA of San Francisco Core and Holistic Health surveys(Attachment pg. 1 and 2)
10/29/2021 Page 16 of 16
Summer program Per 6 week session, assuming camp 9 hour/day operation
Summer program Payrate Hours Subtotal FICA WC UE Benefits Total weeks
Staff #1 $20.00 40 $800.00 $61.20 $18.00 $16.00 $895.20
Staff #2 $20.00 40 $800.00 $61.20 $18.00 $16.00 $895.20
Staff #3 $20.00 40 $800.00 $61.20 $18.00 $16.00 $895.20
Staff #4 $20.00 40 $800.00 $61.20 $18.00 $16.00 $895.20
Staff #5 $20.00 40 $800.00 $61.20 $18.00 $16.00 $895.20
Staff #6 $20.00 40 $800.00 $61.20 $18.00 $16.00 $895.20
Site Director $35.00 40 $1,400.00 $107.10 $31.50 $28.00 $700.00 $1,566.60
Site Coordinator $26.00 40 $1,040.00 $79.56 $23.40 $20.80 $700.00 $1,163.76
Executive Supervision/Support $555.00
$1,400.00 $8,656.56 6
Expense 6 week summer sessi #Per Youth
Staffing $53,339.36 75 $711.19
Supplies $15,000.00 75 $200.00
Admin $15,034.66 75 $200.46
TOTAL $83,374.02 $1,111.65
PICKLEWEED ADVISORY COMMITTEE
AGENDA REPORT
April 13, 2022
Item # 3.B.
TITLE: Canal FC at Marin FC Co-Sponsorship Recommendation
RECOMMENDATION
Staff recommends that the Pickleweed Advisory Committee consider granting Canal FC
at Marin FC a fee reduction or waiver for use of the Pickleweed Park Soccer Fields on
Tuesdays, Thursdays and Saturdays from August 1, 2022 to November 27, 2022.
BACKGROUND
At the February 2, 2022 regular meeting, the Pickleweed Advisory Committee received
an application and presentation from Marin FC and Canal Alliance representatives who
are partnering to provide instruction and competitive team soccer play in the Canal and
are requesting full co-sponsorship of rental fees for Pickleweed Soccer Fields for their
program.
The application requests use both of Pickleweed Park’s Soccer Fields on Tuesday,
Thursdays and Saturdays from August 1 to November 27,2022 . Addressing Committee
concerns regarding other field users, specifically San Rafael Soccer, the Center recently
received a rental application from longtime renter, San Rafael Soccer, requesting use of
Soccer Field #2 from 8:30 am to 2:30 pm on Saturdays from August 27 to October 29
and Monday through Fridays from 4:00 pm to 7:30 pm August 1 to November 4. The
revenue from San Rafael Soccer, beyond program value, would total $6,030. Marin FC,
who has also historically rented the other soccer field and is partnering in this Canal FC
proposal, cancelled their reservations in 2021 and did not utilize the Pickleweed Soccer
Fields. It should be noted that on September 3, 2021, all regular users of the
Pickleweed Fields, including the scheduler for San Rafael Soccer, were made aware of
a new City policy giving users the opportunity to receive priority use by submitting their
application for the 2022 season between September 1, 2021 and October 31, 202 1.
Out of all our users, we only received one application and that was from one of our
Page 2 of 2
regular Sunday adult leagues. As the Field Policy states, organizations can still apply
past the application deadline and be awarded use on a space available basis.
The Marin FC applicant has been made aware that there is the slight possibility that the
soccer fields may be closed in September should the City identify funds to convert the
fields to synthetic turf.
Additionally, Field 2 currently is not available on Saturday, August 6 and Tuesdays,
August 2,9, and 16 due to other preexisting programs.
DISCUSSION
Having reviewed the Canal FC at Marin FC co-sponsorship application, Pickleweed
Advisory Committee members have the opportunity to discuss and/or motion for a fee
reduction (25%, 50%, 75%, or other), grant a full fee-waiver, reject the application and
ask applicant to resubmit with additional information, or reject the co-sponsorship
application all together. Members must also consider the Committee’s annual total
allocation limit of $140,000 in fees that can be waived.
FISCAL IMPACT
The non-profit value of a full co-sponsorship totals $9,000. A fee reduction or waiver
would potentially result in lost revenue to the City, should a paying program be
interested renting the fields at that time.
ALTERNATIVE ACTION
Any other action as determined by the Comm ittee.
Submitted by:
Steve Mason
Senior Recreation Supervisor
Attachments:
1. Canal FC Use Agreement Application 2022 Packet
10/29/2021 Page 9 of 16
Section I-About the Applicant Agency
Date Submitted: ________________ Revision Dates (if applicable) ___________________________
Title of Program: _____________________________________________________________________
Co-sponsoring agency or individual: _____________________________________________________
Address: _________________________________________
Telephone: ________ Ext. _______________
Email: __________________________________________________________
Website: ____________________________________________________________
Non-Profit 501c3 Number: ________________
Principal contacts:
Name: _________________________ Phone: __ Email:
Is this a first time program at Pickleweed? Yes No
If no, start date of original program: __________________ Location: ________________________
Most recently approved final report must be attached.
Section II-About the Program
General Statement about the Program. Provide a background statement or statement of the problem that
describes the challenges, behaviors or issues you hope to resolve or improve
1/4/22 01/12/22 Rev 2
Canal FC at Marin FC
The Canal Alliance / The Marin Football Club
3
n/a
20-8903618
Ryan Robinett
Marin FC and The Canal Alliance are collaborating to extend soccer training, teams and competitive
play to underserved youth in the Canal / East San Rafael communities. Specifically there are
numerous young players who are new to the area and need both life structure activities and
comfortable socialization opportunities. Soccer provides both and the combination of the Canal
Alliance and Marin FC create outreach and a launching pad for youth through soccer.
Proposed Start Date: 8/1/22 • Proposed End Date: ______ 11 _/_27_/_2 _2 __ _
Number participants estimated: +/-60 Maximum number estimated: +/-100
Target age group: ____ 1 _2_-_1 _6 ___ _
Requested Rooms: □Classroom #□ □ Teen Activity Room □ □ Gymnasium
Days and Times Requested:
Community Room □Art Room
Computer Lab □Kitchen
II( Playing Field # 1 & 2 □Picnic Area
Day: Monday � Wednesday � Friday � Sunday
Time: Tuesday and Thursday afternoons (4-7pm) and Saturdays (Sam-1 pm)
Fee Reduction Request □25%□50%□75%� 100%
OFFICE USE ONLY: Monetary value of fee waiver request: $ 9,000
Will there be a charge to participants? Yes_X_ No __
If so, what will the fee be? $75 How will the proceeds be used?
The program consists of 32 sessions of professional coaching at 90 minutes per session with
games on the weekends. There are various costs for the program, eg. professional coaching,
insurance, medical items, and soccer equipment. The organizers propose to minimize fees
through cost savings, sponsorships and fundraising. Marin FC will donate $93 / player to reduce
the cost to $75 I player. In addition, we plan to have a scholarship program to help families who
can't afford the full amount. No player will be barred from playing due to the fee.
Describe your community outreach plan and how you will advertise:
Marin FC already has numerous players and families from the area in the club with whom we will
communicate this program. Additionally, the Canal Alliance has specific outreach mechanisms
specifically tailored to the youth to be served.
In what languages will your marketing materials be distributed?
)11 English )11 Spanish □ Vietnamese □Other
10/29/20 21 Page 10 of 16
10/29/2021 Page 11 of 16
Section III Outcomes and Measurements
List your expected outcome(s) for this program, and how you will measure your progress/success in meeting
each outcome. Refer to the applicant guidelines for samples of outcome and measurement statements.
Each outcome statement and measurement should be individually numbered.
Outcome Statement
Measurement for Outcome
Measurements:
How do you plan to track attendance? Attach a copy of your form.
The organizers hope to effect the following outcomes:
1. Enrollment
2. Retention
3. Satisfaction
4. Advancement
1. Enrollment - The first measure of success is actually engaging those youth who might enjoy
and benefit from the program.
2. Retention - Secondly, keeping the youth playing regularly represents a measurement of
affecting the stability of the lives of the youth.
3. Satisfaction - Like all Marin FC programs, feedback on satisfaction by the participants will be
tracked.
4. Advancement - Lastly, as Marin FC offers a tall ladder of possible levels of training, play and
competition, advancing youth from the initial program to these other levels will demonstrate
program success.
All teams maintain rosters in both Marin FC systems and league registration systems. Coaches
track attendance against these rosters for both trainings and games.
10/29/2021 Page 12 of 16
Client Satisfaction:
What evaluation or survey forms will you use for client satisfaction? Attach copy.
What other forms or measurement tools will you use? Attach copy.
Section IV Faculty/Leaders
Names, titles and contact information for key faculty/leaders other than listed in Section I
Section V Partners and Support
List partners and any cash or in-kind support for this project (Refer to the attached guidelines regarding
potential payment of user fees to the Albert J. Boro Community Center.)
Partners Dollar Amount Detail In-Kind
Marin FC uses online survey forms to both determine program success (and areas of needed
improvement) and personnel performance. In addition, we will have paper surveys in both
English and Spanish that will be given to the players and their parents.
Marin FC hosts a senior technical staff of age/gender leaders. Performance reviews are
generated twice annually using program observation and feedback from staff and participants.
Marin FC has approximately 40 professional coaches and 5 administrative staff members.
Admin staff will be involved constantly for equipment, scheduling and support needs. Coaching
slate will be determined at a date nearer the program start. Beyond the slated coaches, others
from our staff will be relied upon for assistance and cover duties. All staff at Marin FC are
background checked, concussion education verified and SafeSport certified.
ACCESS U Foundation and others to be
determined
Marin FC enjoys ongoing support from Fairview
Capital, Nike, Gatorade, and Bank of Marin.
10/29/2021 Page 13 of 16
Attach a program budget.
Section VI Attachments
List all attachments submitted with this application
Attached is Marin FC’s current insurance filing with the City of San Rafael
and the cost break down for an example U15 team.
PICKLEWEED ADVISORY COMMITTEE
AGENDA REPORT
April 13, 2022
Item #4.A.
TITLE: DrawBridge- Weekly Expressive Art Groups
RECOMMENDATION
It is recommended that the Pickleweed Advisory Committee grant a fee reduction or
waiver for use of the Albert J. Boro Community Center Art Room on Monday afternoons
from September 12, 2022 through August 28, 2023, excluding holidays and closures .
BACKGROUND
DrawBridge has been offering their Weekly Expressive Art Groups at the Albert J. Boro
Community Center since 2013. The City, through the Pickleweed Advisory Committee,
has been fully co-sponsoring the rental of the room for the program since 2017. The
activity fits well in the Center, especially in the Art Room, and appears to have a core
following of children that truly look forward to the program.
DrawBridge offers their Weekly Expressive Art Groups program for homeless, low -
income and underserved children at the Albert J. Boro Community Center. The
program provides children a safe, fun, supportive environment where youth ages five to
18 can use art to “build community, process stress, and explore difficult emotions
through creative expression.”
The term of the proposed art program is from September 12, 2022 through August 28,
2023. The applicant is requesting a full fee-waiver, valued at $1,410.00 for use of the
Art Room on Mondays from 3:30 pm to 5:30 pm, excluding holidays.
Per the Co-Sponsorship guidelines for renewal applications, a Final Report of the
program’s previous co-sponsored use is included with the application for the Pickleweed
Advisory Committee’s review.
Page 2 of 2
DISCUSSION
While the Pickleweed Advisory Committee reviews the Co-sponsorship Application and
Final Report, DrawBridge staff will be present to provide a program overview and
support their application which is before the Committee. Committee mem bers will then
have opportunity to ask questions of DrawBridge staff.
The Pickleweed Advisory Committee has the authority to grant a fee reduction (25%,
50%, 75%, or other), grant a full fee-waiver, reject the application and ask applicant to
resubmit with additional information, or reject the co-sponsorship application all
together.
The Committee will make their recommendation at their June 1, 2022 regular meeting.
FISCAL IMPACT
The resident/non-profit value of the rental totals $1,410.00. A fee reduction or waiver
would potentially result in lost revenue to the City should a paying program be
interested in using the Art Room at that time.
ALTERNATIVE ACTION
Any other action as determined by the Committee.
Submitted by:
Steve Mason
Senior Recreation Supervisor
Attachments:
1. Use Agreement Application
2. Final Program Report
3. Program Budget 2022
4. Attendance Form Sample
5. Program Evaluation Forms and Sample Responses
10/29/2021 Page 9 of 16
ALBERT J. BORO COMMUNITY CENTER
CO-SPONSORSHIP APPLICATION
Section I-About the Applicant Agency
Date Submitted: ________________ Revision Dates (if applicable) ___________________________
Title of Program: _____________________________________________________________________
Co-sponsoring agency or individual: _____________________________________________________
Address:
Telephone:_______ Ext. _______________
Email: ____________________________________
Website: ________________________________________________________
Non-Profit 501c3 Number: ____
Principal contacts:
Name: _________________________ Phone: __ Email: _
Is this a first time program at Pickleweed? Yes No
If no, start date of original program: __________________ Location: ________________________
Most recently approved final report must be attached.
Section II-About the Program
General Statement about the Program. Provide a background statement or statement of the problem that
describes the challenges, behaviors or issues you hope to resolve or improve
DrawBridge is a San Francisco Bay Area nonprofit that provides weekly expressive arts programs for
children who are underserved, low-income, or experiencing homelessness. Providing nurturing art
experiences and quality art supplies, DrawBridge’s programs are always free to the families we serve.
DrawBridge’s trained facilitators provide children and youth ages 5 to 18 the safe space to build
community, process stress, and explore difficult emotions through creative expression. DrawBridge’s
programs offer children a fun, supportive environment to work at their own pace and explore playful
creativity that is so important to healthy development and emotional well-being.
3.11.22
DrawBridge Weekly Expressive Art Groups
Tracy Bays-Boothe
Art Room 2013
10/29/2021 Page 11 of 16
Section III Outcomes and Measurements
List your expected outcome(s) for this program, and how you will measure your progress/success in meeting
each outcome. Refer to the applicant guidelines for samples of outcome and measurement statements.
Each outcome statement and measurement should be individually numbered.
Outcome Statement
Measurement for Outcome
Measurements:
How do you plan to track attendance? Attach a copy of your form.
1. To provide a weekly art group that helps children develop a sense of group cohesiveness,
compassion, creativity, and self-worth.
2. To provide an outlet for the creative emotional expression for children which may not be
regularly available in other settings.
3. To serve 50 or more unduplicated young people from a variety of backgrounds, who will
attend the group 450 times or more per calendar year.
1. Children will be offered encouragement, non-judgmental respect, and compassion each time
they attend a group. Creative exploration will be fostered as well as their enjoyment of the
process, promoting feelings of self-worth. Collaborative learning and encouragement of others
will be modeled by facilitators and encouraged with the group. Qualitative feedback will be
gathered from children, facilitators, volunteers, and site staff around these outcomes.
2. Short and long-term qualitative measurements of wellbeing will be gathered including
anecdotal feedback, observations, and opportunities for self-reporting. DrawBridge will solicit
evaluations and document feedback from children and their caregivers.
3. Success will also be measured by the number of individual children served as well as the
number of child visits to DrawBridge groups at each site.
Participants sign in as they arrive, and facilitators check lists during each group. Attendance
information is submitted monthly to DrawBridge through an online attendance portal in which
facilitators upload information on each group. A screen shot of DrawBridge’s attendance form
and online facilitator portal is attached.
10/29/2021 Page 12 of 16
Client Satisfaction:
What evaluation or survey forms will you use for client satisfaction? Attach copy.
What other forms or measurement tools will you use? Attach copy.
Section IV Faculty/Leaders
Names, titles and contact information for key faculty/leaders other than listed in Section I
Section V Partners and Support
List partners and any cash or in-kind support for this project (Refer to the attached guidelines regarding
potential payment of user fees to the Albert J. Boro Community Center.)
Partners Dollar Amount Detail In-Kind
Children are asked about their experience and feelings about DrawBridge programs. Caregivers
are asked what they notice about their children after participating in DrawBridge programs.
Samples from the most recent caregiver and participant surveys are included as an attachment.
Observations, program feedback, and testimonials are also gathered from volunteers and
facilitators.
In addition, facilitators and partner site coordinators will be invited to participate in qualitative
post-program evaluations to identify successes, opportunities for improvement, and provide
testimonials. These surveys are in production and will be launched later in the year after on-site
programs have resumed.
Kathleen Keating, Art Group Facilitator,
We do not receive direct funds for this group.
10/29/2021 Page 13 of 16
Attach a program budget.
Section VI Attachments
List all attachments submitted with this application
- Application Form
- Program Budget
- Outcome Statement Form (included in application)
- Community Outreach Plan (included in application)
- Attendance Reporting Requirements
- Program Evaluation Form
- Final (or Interim) Report (Renewals Only – included in this application)
10/29/2021 Page 14 of 16
ALBERT J. BORO COMMUNITY CENTER
FINAL PROGRAM REPORT
FOR CO-SPONSORED PROGRAMS
(Use as many pages as necessary to address the required elements. Please number each one.)
Program Name:
Report prepared by:
Name _____________________________ Title ___________________________________________
Date submitted: __________________________________
Date program completed: __________________________
How many total people were served? _________________
A. Outcomes: List each numbered outcome from your application and describe your success in meeting
each outcome.
DrawBridge Weekly Expressive Art Groups
Tracy Bays-Boothe Executive Director
3.11.22
Ongoing
205
1. To provide a weekly art group that helps children develop a sense of group cohesiveness, compassion,
self-discipline, and self-worth.
2. To provide an outlet for emotional expression which may not be available to them in any other environment.
3. To serve 50 or more unduplicated young people from a variety of backgrounds, will attend the group 450
times or more.
DrawBridge in-person programs at the Albert J. Boro Community Center resumed in September of 2021 and
served 34 unduplicated children in a period of six months, with a total program attendance of 205 from
September 2021 to February 2022 (programs were paused in January due to the Omicron surge). During this
time, DrawBridge piloted a new visiting artist program to connect children with area artists including local Marin
artist Isidoro-Feldelfo Angeles who led DrawBridge art group participants in the creation of traditional shadow
boxes in celebration of Dia de los Muertos. In addition, as part of DrawBridge's holiday campaign, DrawBridge
youth artists received donations of backpacks filled with art supplies provided by the sport action brand Vans
and Flax Art and Design to wish program participants a creative new year. Despite the ongoing challenges of
the pandemic, the average attendance for DrawBridge programs at the Albert J. Boro Community Center has
been consistently strong and we anticipate meeting our annual attendance goals for the program by the end of
August as stated in our previous application.
10/29/2021 Page 15 of 16
B. Measurements: Describe the measurements and evaluation strategies you used for each outcome, and
provide a summary or actual data analysis. Attach relevant documents for each outcome and measurement
strategy.
C. Success: If you did not succeed in meeting your objectives, tell us why you think that happened, and
what strategies you employed to change the situation, or are planning to change in the future.
D. Summary: Briefly describe your overall satisfaction with your program and your reasoning, what
highlights you would like to bring to the Board’s attention, and any general comments about your program.
As DrawBridge resumes in-person programs at the Albert J. Boro Community Center and
across the community, DrawBridge staff will conduct surveys and a full evaluation of
experiences with participants and parents in Spring of 2022 to better inform ongoing program
offerings in the future. Results of these findings will be shared with key stakeholders.
Samples of past evaluations are included with this document to demonstrate impact of this
program.
DrawBridge’s trained facilitators provide children and youth the safe space to build community
and explore creative expression. As Bay Area communities begin to reopen, DrawBridge
programs are in demand more than ever. We are delighted to have almost hit our annual
attendance goals in just four months since resuming in-person programs at the Boro Center and
anticipate these numbers to grow in the coming year.
DrawBridge has offered expressive arts programs to the Canal community for over 25 years.
Working in collaboration with site directors and long-time artist and facilitator Kathleen Keating,
a San Rafael native, DrawBridge is looking forward to once again offering free expressive
on-site arts programs to children at the Albert J. Boro Community Center.
PROGRAM BUDGET, 2022
One site, based on 45 sessions per year
Facilitator Stipend $2250
Art Supplies and Materials $1450
Program Manager $1500
Executive Director $2000
Accounting $900
Insurance $175
Facilitator/Staff training $200
Storage space $75
Volunteer recruitment $100
Misc. $200
TOTAL $8,850
1
DrawBridge Online Attendance Forms
(completed weekly by Facilitators and DrawBridge Staff)
DrawBridge Program Evaluation Forms and Sample Responses 2020
Albert J. Boro Community Center
PICKLEWEED ADVISORY COMMITTEE
AGENDA REPORT
April 13, 2022
Item #4.B.
TITLE: Tamalpais Adult School/Bahia Vista Elementary School: English As
A Second Language Class
RECOMMENDATION
It is recommended that the Pickleweed Advisory Committee grant a fee reduction or
waiver for the use an Albert J. Boro Community Center Meeting Room on Monday and
Wednesday mornings to Tamalpais Adult School and Bahia Vista Elementary School.
BACKGROUND
Tamalpais Adult School and Bahia Vista Elementary School provide free English As A
Second Language class at the Albert J. Boro Community Center to “support adult
learners, many of whom have been under served in education , to thrive in their
community, learn English.” The program targets local parents, especially those whose
children attend nearby Bahia Vista Elementary School.
The term of the proposed adult program is from September 6, 2022 through May 18,
2023, with breaks during school holidays. Tamalpais Adult School and Bahia Vista
Elementary School are requesting a full fee-waiver valued at $2,057.00 for use of a
Meeting Room on Mondays and Wednesdays from 8:45 am to 10:45 am.
Per the Co-Sponsorship guidelines for renewal applications, a Final Report of the
program’s previous co-sponsored use is included with the application for the Pickleweed
Advisory Committee’s review.
The activity fits well in the Center’s schedule and purpose and is well received by the
community participants.
Page 2 of 2
DISCUSSION
While the Pickleweed Advisory Committee reviews the Co-sponsorship Application and
Final Report, Tamalpais Adult School staff will be present to provide a program
overview and support their application which is before the Committee. Committee
members will then have an opportunity to ask questions of Tamalpais Adult School staff.
The Pickleweed Advisory Committee has the authority to grant a fee reduction (25%,
50%, 75%, or other), grant a full fee-waiver, reject the application and ask applicant to
resubmit with additional information, or reject the co-sponsorship application all
together.
The Committee will make their recommendation at their June 1, 2022 regular meeting.
FISCAL IMPACT
The resident/non-profit value of the co-sponsorship totals $2,057.00. A fee reduction or
waiver would potentially result in lost revenue to the City should a paying program be
interested in using the Meeting Room at that time.
ALTERNATIVE ACTION
Any other action as determined by the Comm ittee.
Submitted by:
Steve Mason
Senior Recreation Supervisor
Attachments:
1. Use Agreement Application
2. Final/Interim Program Report
3. Program Expenses
4. Program Surveys and Attendance
10/29/2021 Page 9 of 16
ALBERT J. BORO COMMUNITY CENTER
CO-SPONSORSHIP APPLICATION
Section I-About the Applicant Agency
Date Submitted: 2/15/22 Revision Dates (if applicable)
Title of Program: Tamalpais Adult School, English As A Second Language Classes
Co-sponsoring agency or individual:
Address:
Telephone Ext.
Email:
Website:
Non-Profit 501c3 Number:
Principal contacts:
Name: Jaemi Naish Phone: Email:
Is this a first time program at Pickleweed? Yes No
If no, start date of original program: 2018-2019 Location: Albert J. Boro Community Center
Most recently approved final report must be attached.
Section II-About the Program
General Statement about the Program. Provide a background statement or statement of the problem that
describes the challenges, behaviors or issues you hope to resolve or improve
Tamalpais Adult School provides free ESL, GED, High School Diploma and Home Care
Aide classes to adults in Marin County. TAS partners with school districts, College of
Marin, Marin Adult Education Consortium and non-profit organizations to support adult
learners, many of whom have been under served in education, to thrive in their
community, learn English, attain high school equivalency, attend college and earn a
family-sustainable wage. Tam Adult School is a WASC accredited school and is
celebrating its 9oth year of service to adult learners in Marin County.
10/29/2021 Page 12 of 16
Client Satisfaction:
What evaluation or survey forms will you use for client satisfaction? Attach copy.
What other forms or measurement tools will you use? Attach copy.
Section IV Faculty/Leaders
Names, titles and contact information for key faculty/leaders other than listed in Section I
Section V Partners and Support
List partners and any cash or in-kind support for this project (Refer to the attached guidelines regarding
potential payment of user fees to the Albert J. Boro Community Center.)
Partners Dollar Amount Detail In-Kind
Sarah Galdano, Family Literacy Director
@ Bahia Vista Elementary School
Support marketing, enrollment,
parent communication
Students are provided a google survey 1 time per year to assess their satisfaction with the program,
provide a confidential voice for program improvement and to solicit feedback. It is a very useful and
valuable tool for program improvement.
Cindy Winship, ESL Teacher
Isabel Farga, Secretary @ Tam Adult School
Samuel Chavez, ParaEducator @ Tam Adult School
NA
10/29/2021 Page 13 of 16
Attach a program budget.
Section VI Attachments
List all attachments submitted with this application
End of year report, Attendance sample of the month of February, 2022, technology survey and
remote learning survey.
10/29/2021 Page 14 of 16
ALBERT J. BORO COMMUNITY CENTER
FINAL PROGRAM REPORT
FOR CO-SPONSORED PROGRAMS
(Use as many pages as necessary to address the required elements. Please number each one.)
Program Name:
Report prepared by:
Name Yasmine Peters-Knight Title Alternative School Secretary
Date submitted: 2/15/2022
Date program completed: May 19, 2022
How many total people were served? 21
A. Outcomes: List each numbered outcome from your application and describe your success in meeting
each outcome.
Tamalpais Adult School, English As A Second Language Class
Pandemic protocol did not allow for in-person morning class during the 2020-2021 school year.
Total served September 27, 2021 to February 15, 2022: 21 Students
The Spring semester ends on may 19, 2022
Level: Multilevel ESL of Basic and Level 1
Total attendance hours: 75.35
EL Civics Unit: Internet Safety 47.2: 8 students
CASAS level gain: 8 students
Pre-Post test: 10 Students
EL Civics Unit: Technology for communications 48.0 planned for March 2022
10/29/2021 Page 15 of 16
B.Measurements: Describe the measurements and evaluation strategies you used for each outcome, and
provide a summary or actual data analysis. Attach relevant documents for each outcome and measurement
strategy.
C.Success: If you did not succeed in meeting your objectives, tell us why you think that happened, and
what strategies you employed to change the situation, or are planning to change in the future.
D.Summary: Briefly describe your overall satisfaction with your program and your reasoning, what
highlights you would like to bring to the Board’s attention, and any general comments about your program.
We continue to compare student data in TAS ESL program by giving them surveys to complete while
they are attending and after the class ends. We use our CASAS pre-post reports, monthly attendance
reports, and student survey data and feedback to measure data. Attached is our technology survey,
remote learning surveys.
COVID19 pandemic parameters have made in-person classes complicated at times where
surges and community spread is high. There has been a steady stream of adult learners in
the morning ESL class at Albert J. Boro Community Center. This is a success!
Tam Adult School is thankful for the opportunity to partner with San Rafael City’s, Albert J. Boro
Community Center by providing adult learners access to free English classes. Providing a
location to access free education classes is vital in the Canal area. Tam Adult School
welcomes all students and provides equal access to a continuum of educational services to
support academic, career and personal goals. W e look forward to continuing a partnership with
Albert J. Boro Community Center to serve adult learners who lives primarily in the surrounding
neighborhood.
Tamalpais Adult School ESL Budget
Provided by Tamalpais Adult School:
· ESL instructor: $13,000
· ESL curriculum, textbook, eLearning student/staff accounts: $2,000
· Administrative Services: Supervision of instructor and program, data entry, program
evaluation report, fiscal oversight, program coordination, reports, marketing
· Direct Services: Instruction to students, registration, CASAS assessment of students,
daily attendance, distance learning homework, paraeducator support
2/14/2022 Student Technology Intake Survey - California Adult Education Program
https://caladulted.org/StudentTechnologyIntakeSurvey?agencyId=401 1/5
(/)
Student Technology Intake Survey
If you have filled out this survey already, you do not have to fill it out again.
A printable PDF version of this survey is available for download here: Student Technology Intake Survey
(/Content/Documents/StudentTechIntakeSurvey-r1-a11y.pdf)
To see this form in your language use the "Select Language" button in the top-right of the page and make your choice.
1. What school are you going to: *
Tamalpais Adult School
Monthly Attendance Report by Section For All Students by Date Range
TimePeriod: Full Year 2021-2022 From: 2/1/2022 To: 2/28/2022
Class Name: ESL Bahia Vista Multilevel . Class Code: 30002. Instructor: Winship, Cindy
Last Name First Name Customer
ID
02/01 02/02 02/03 02/04 02/05 02/06 02/07 02/08 02/09 02/10 02/11 02/12 02/13 02/14 02/15 02/16 02/17 02/18 02/19 02/20 02/21 02/22 02/23 02/24 02/25 02/26 02/27 02/28 Total
Hours
Sonia 9851503 02:00 02:00
Rosa 10241556 02:00 02:00
Sofia 9643512 02:00 02:00 04:00
Edwin 10241498 02:00 02:00 02:00 06:00
Dolores 9775224 02:00 02:00 02:00 06:00
Isabel 9382363 02:00 02:00
Irma 7273456 02:00 02:00 02:00 06:00
Erika 9865801 02:00 02:00 04:00
Maria 9854089 02:00 02:00 02:00 02:00 08:00
Karla 9849966 02:00 02:00
Guillermina 10241568 02:00 02:00
Total Students: 11
I affirm that attendance hours are accurate
______________________________________________ _____________________
Winship, Cindy Teacher Signature Date
PICKLEWEED ADVISORY COMMITTEE
AGENDA REPORT
April 13, 2022
Item #4.C.
TITLE: Scouts BSA: Troop 2000
RECOMMENDATION
It is recommended that the Pickleweed Advisory Committee grant a fee reduction or
waiver for use of the Albert J. Boro Community Center’s Multipurpose Room on Monday
evenings from September 12, 2022 through August 28, 2023, excluding holidays and
closures.
BACKGROUND
Troop 2000 has proudly called the Albert J. Boro Community Center and Pickleweed
Park home since forming in 2000. The City, through the Pickleweed Advisory
Committee, has been fully co-sponsoring the rental of the room for the program since
the troop’s formation. The activity fits in the Center’s schedule and the Scouts are
always agreeable to change rooms or move o utside if there is a pressing need to use
the Multipurpose Room for a special meeting or event. Troop 2000 regularly gives back
to the Center and the Canal community by volunteering and performing special projects
in support of an individual member’s Eagle Scout Project. In past years the Scouts
have repaired the Centers’ back deck, made improvements and repairs to Pickleweed
Playground, repaired park signboards, and performed projects in the Canal Community
Garden. We also call on Troop 2000 to support us with community events, such as
assisting with the Día de los Muertos procession by guiding participants safely in their
lane.
The term of the proposed Scout program co-sponsorship is from September 12, 2022
through August 28, 2023. The applicant is requesting a full fee-waiver, valued at
$4,140.00 for use of the Multipurpose Room on Mondays from 7:00 pm to 9:00 pm,
excluding holidays.
Page 2 of 2
Per the Co-Sponsorship guidelines for renewal applications, a Final Report of the
program’s previous co-sponsored use is included with the application for the Pickleweed
Advisory Committee’s review.
DISCUSSION
While the Pickleweed Advisory Committee reviews the Co-sponsorship Application and
Final Report, Troop 2000 leaders will be present to provide a program overview and
support their application which is before the Committee. Committee membe rs will then
have opportunity to ask questions of Scouts BSA leaders.
The Pickleweed Advisory Committee has the authority to grant a fee reduction (25%,
50%, 75%, or other), grant a full fee-waiver, reject the application and ask applicant to
resubmit with additional information, or reject the co-sponsorship application all
together.
The Committee will make their co-sponsorship recommendation at their June 1, 2022
regular meeting.
FISCAL IMPACT
The resident/non-profit value of the rental totals $4,140.00. A fee reduction or waiver
would potentially result in lost revenue to the City should a paying program be
interested in using the Multipurpose Room at that time.
ALTERNATIVE ACTION
Any other action as determined by the Committee.
Submitted by:
Steve Mason
Senior Recreation Supervisor
Attachments:
1. 2022 Use Agreement Application for Co-Sponsorship Programs
2. Evaluation 2021
3. BS Requirements
4. Troop 2000 Scouts BSA Attendance Sheet
10/29/2021 Page 11 of 16
Section III Outcomes and Measurements
List your expected outcome(s) for this program, and how you will measure your progress/success in meeting
each outcome. Refer to the applicant guidelines for samples of outcome and measurement statements.
Each outcome statement and measurement should be individually numbered.
Outcome Statement
Measurement for Outcome
Measurements:
How do you plan to track attendance? Attach a copy of your form.
The program offers to expose the participant to three aims: one is growth in moral strength and
character, second is participating in citizenship and the third aim is development in the
physical, mental and emotional fitness
The fundamental goals of the scouts BSA are Adventure, learning, challenges, responsibility,
developing self-potential, relating to others, developing values and contributing to family and
society. All these goals are related to the advancement program that the scout needs to
achieve his goals. The measurement would be the earned badges all oriented towards the
maximum goal of achieving the highest rank: Eagle Award. (see attached)
see attached sample attendance form
10/29/2021 Page 13 of 16
Attach a program budget.
Section VI Attachments
List all attachments submitted with this application
1. copy of attendance spread sheet
2. copy of evaluation plan
3. copy of measurement tools for rank advancement and list of activities and service project
done
10/29/2021 Page 14 of 16
ALBERT J. BORO COMMUNITY CENTER
FINAL PROGRAM REPORT
FOR CO-SPONSORED PROGRAMS
(Use as many pages as necessary to address the required elements. Please number each one.)
Program Name:
Report prepared by:
Name _____________________________ Title ___________________________________________
Date submitted: __________________________________
Date program completed: __________________________
How many total people were served? _________________
A. Outcomes: List each numbered outcome from your application and describe your success in meeting
each outcome.
Troop 2000 scouts BSA
Oscar Guardado Assistant Scout Master
3/9/2022
ongoing
13
We have provided and continue to provide services to boys in Marin County that want to joint
scouting.
The Scouts BSA is an international organization with a program based in the Scouting Promise
and Law, sharing the common goals of adventure, learning personal challenges and
responsibility. The program is carried out with adult volunteer leadership and provides a wide
range of activities including: planning outings and activities, making new friends from different
economic and social backgrounds, prepare the youth with active involvement with community
and the nation.
10/29/2021 Page 15 of 16
B. Measurements: Describe the measurements and evaluation strategies you used for each outcome, and
provide a summary or actual data analysis. Attach relevant documents for each outcome and measurement
strategy.
C. Success: If you did not succeed in meeting your objectives, tell us why you think that happened, and
what strategies you employed to change the situation, or are planning to change in the future.
D. Summary: Briefly describe your overall satisfaction with your program and your reasoning, what
highlights you would like to bring to the Board’s attention, and any general comments about your program.
Evaluation 2022
Outcome Statement
The program offers to expose the participant to three aims: one is
growth in moral strength and character, second is participating in
citizenship and the third aim is development in the physical, mental and
emotional fitness.
Measurement of outcome
We believe we have made a lot of progress in the community with our
troop. The fundamental goals of the Boys Scouts are Adventure,
learning, challenges, responsibility, developing self-potential, relating
to others, developing values and contributing to family and society.
The Troop serves boys from 11 to 18 years old in the primarily Hispanic
Canal neighborhood of San Rafael. We provide leadership, values,
outdoor activities, training, and opportunities otherwise unavailable to
our boys. We are making a difference in the community to provide
service projects in different areas of Marin. We have made extra
efforts to keep the troop united and thru the COVID 19 emergency
contacting members to check how they are doing. Recruiting parent
leaders has been a challenge for some years, more outreach is needed
in this area.
TROOP 2000 Scouts BSA ATTENDANCE SHEET
***Please return to Willy Coronado/Oscar Guardado Thank you***
Date: Activity:
SCOUT NAME PARENT
PICKLEWEED ADVISORY COMMITTEE
AGENDA REPORT
April 13, 2022
Item # 4.D.
TITLE: Marin YMCA 2022/2023 Afterschool Program
RECOMMENDATION
It is recommended that the Pickleweed Advisory Committee grant the YMCA a fee
reduction or waiver for use of the rooms necessary to conduct a 2022/2023 afterschool
program for Canal children at the Albert J. Boro Community Center and Pickleweed Park
Monday through Friday, August 15, 2022 through June 9, 2023, excluding holidays and
closures, with permission for City staff to grant additional space on a day-to-day basis,
depending on availability.
BACKGROUND
The Albert J. Boro Community Center & Pickleweed Park has hosted YMCA learning
hubs, summer camps and afterschool programs, supported by the San Rafael City School
District, since the pandemic to support Canal youth, and their families.
The program is free to all participants who are identified and referred to the YMCA by the
student’s school.
The application requested use of many of the Center’s rooms and amenities. As was
done in the past with both the Kids Club program and YMCA programs, in order to
accommodate other offerings in the facility, the City co-sponsored and provided the
YMCA with three meeting rooms and the picnic area daily. Additional rooms are granted
on a daily, space available, basis. The listed fiscal impact of the program, therefore,
reflects the base fees and not the extras that will be added during the period of use.
A Final Report was not provided for their Winter/Spring 2022 program that is currently
being held at the Center. YMCA staff have been encouraged to provide that information
during their presentation at the meeting.
Page 2 of 2
DISCUSSION
While the Pickleweed Advisory Committee reviews the Co-sponsorship Application and
Final Report, YMCA staff will be present to provide a program overview and support their
application which is before the Committee. Committee mem bers will then have
opportunity to ask questions of YMCA staff.
The Pickleweed Advisory Committee has the authority to grant a fee reduction (25%,
50%, 75%, or other), grant a full fee-waiver, reject the application and ask applicant to
resubmit with additional information, or reject the co-sponsorship application all together.
The Committee will make their recommendation at their June 1, 2022 regular meeting.
FISCAL IMPACT
The non-profit value of the granted full co-sponsorship for the meeting rooms and picnic
area total $61,020.00, while still retaining space for other programs. The fee waiver
potentially results in lost revenue to the City should a paying program be interested renting
the facilities at that time. The co-sponsorship amount will also be charged against the
$140,000 available annually for co-sponsorship.
ALTERNATIVE ACTION
No action is required by the Committee.
Submitted by:
Steve Mason
Senior Recreation Supervisor
Attachments:
1. Use Agreement Application 2022/2023
2. Sign In-Out Template
3. 2020-11-20-School-Age-PQA-Fillable-Version
4. Core+HHcombo_3-5_PAPER_Eng
5. YMCA of San Francisco Youth Core Survey
6. 22-23 Al Boro Rough Budget
10/29/2021 Page 9 of 16
ALBERT J. BORO COMMUNITY CENTER
CO-SPONSORSHIP APPLICATION
Section I-About the Applicant Agency
Date Submitted: ________________ Revision Dates (if applicable) ___________________________
Title of Program: _____________________________________________________________________
Co-sponsoring agency or individual: _____________________________________________________
Address:________________________________
Telephone: ________ Ext. _______________
Email: __________________________________________________________
Website: ___________________________________________________________________________
Non-Profit 501c3 Number: ____
Principal contacts:
Name: _________________________ Phone: ___ Email: __
Is this a first time program at Pickleweed? Yes No
If no, start date of original program: __________________ Location: ________________________
Most recently approved final report must be attached.
Section II-About the Program
General Statement about the Program. Provide a background statement or statement of the problem that
describes the challenges, behaviors or issues you hope to resolve or improve
3/28/2022 (Received 3/31 -Updated 4/1)
YMCA - Al Boro Afterschool Program
YMCA of San Fransisco, Marin Branch
Marissa Williams
Albert J. Boro Community Center1/4/2022
In partnership with the SRCS we will provide a safe and enriching environment for the students. We provide academic support, enrichment activities and social-emotional support to the students.
10/29/2021 Page 11 of 16
Section III Outcomes and Measurements
List your expected outcome(s) for this program, and how you will measure your progress/success in meeting
each outcome. Refer to the applicant guidelines for samples of outcome and measurement statements.
Each outcome statement and measurement should be individually numbered.
Outcome Statement
Measurement for Outcome
Measurements:
How do you plan to track attendance? Attach a copy of your form.
1. Children will have a safe space - emotionally and physically
2. Children will have a supportive environment where they can explore, learn and grow
3. Children will interact positively with the staff and each other
4. Children will engage in with new ideas and experiences
Program Quality Assessment (PQA) - measures the overall quality of the program through Safe
Environment, Supportive Environment, Interaction and Engagement
Program Measurement Quality Index (PMQI) - is a survey completed by participants and their
families for direct feedback on their program experience
Aries - School Software system
See attached YMCA sign in/out Template
10/29/2021 Page 12 of 16
Client Satisfaction:
What evaluation or survey forms will you use for client satisfaction? Attach copy.
What other forms or measurement tools will you use? Attach copy.
Section IV Faculty/Leaders
Names, titles and contact information for key faculty/leaders other than listed in Section I
Section V Partners and Support
List partners and any cash or in-kind support for this project (Refer to the attached guidelines regarding
potential payment of user fees to the Albert J. Boro Community Center.)
Partners Dollar Amount Detail In-Kind
See attached:
2020-11-20-School-Age-PQA-Fillable-Version
Core+HHcombo_3-5_PAPER_Eng
YMCA of San Fransisco Youth Core Survey
none - all attached
Torrey Kelly - Associate Executive Director;
Jordan James - Senior Director of Youth Development;
Kelsey Roderer - Senior Director of Camp Programs;
Marissa Williams - Community Programs Director;
Anahi Sanchez - Al Boro Site Coordinator;
San Rafael City Schools $262,768.50 see attached 22-23 al boro
rough budget
10/29/2021 Page 13 of 16
Attach a program budget.
Section VI Attachments
List all attachments submitted with this application
Sign In-Out Template
2020-11-20-School-Age-PQA-Fillable-Version
Core+HHcombo_3-5_PAPER_Eng
YMCA of San Fransisco Youth Core Survey
22-23 Al Boro rough budget
10/29/2021 Page 14 of 16
ALBERT J. BORO COMMUNITY CENTER
FINAL PROGRAM REPORT
FOR CO-SPONSORED PROGRAMS
(Use as many pages as necessary to address the required elements. Please number each one.)
Program Name:
Report prepared by:
Name _____________________________ Title ___________________________________________
Date submitted: __________________________________
Date program completed: __________________________
How many total people were served? _________________
A. Outcomes: List each numbered outcome from your application and describe your success in meeting
each outcome.
10/29/2021 Page 15 of 16
B. Measurements: Describe the measurements and evaluation strategies you used for each outcome, and
provide a summary or actual data analysis. Attach relevant documents for each outcome and measurement
strategy.
C. Success: If you did not succeed in meeting your objectives, tell us why you think that happened, and
what strategies you employed to change the situation, or are planning to change in the future.
D. Summary: Briefly describe your overall satisfaction with your program and your reasoning, what
highlights you would like to bring to the Board’s attention, and any general comments about your program.
Program Sign-In/Out
Printed on 4/1/2022
Location: &=Master.TREX1__COURSE_OPTION_TREX1__LOCATION_NAME
Course Option: &=Master.TREX1__COURSE_OPTION_NAME
Start Date: End Date: &=Master.TREX1__COURSE_OPTION_END_DATE
Start Time: End T me: &=Master.TREX1__COURSE_OPTION_END_TIME
#Time Time Signature Time Signature Time Signature Time Signature
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
OUT
IN
&=Master.TREX1__COU OPT ON START DATE
&=Master.TREX1__COU OP ON START TIME
1
2
Signature
5
11
9
10
7
8
6
3
4
Thursday Friday
&=ProgramEnro
llmentExp.TREX
&=ProgramEnro
llmentExp TREX
Participant Name
Monday Tuesday Wednesday
PAPER ENGLISH - YSF Youth Core & HH Survey Grades 3-5 Adapted for In-Person Programs
Are you...?
Afr can Amer can/B ack
A askan Nat ve
As an/Pac f c Is ander
Caucas an/Wh te
H span c
Nat ve Amer can
Other
Unspec f ed
Are you...?
Ma e
Transgender
I prefer to dent fy n a d fferent way
Fema e
Non-b nary
I prefer not to state
Month
Date
Year
Your birthday...
Thank you!!
Al Boro ASP 2022/2023 10 MONTH
Budget based on serving 75
School year program Per 4 week session, assuming ASP hours 2-6pm
School year program Payrate Hours Subtotal FICA WC UE Benefits Total Session
Staff #1 20.00$ 20 400.00$ 30.60$ 9.00$ 8.00$ 447.60$
Staff #2 20.00$ 20 400.00$ 30.60$ 9.00$ 8.00$ 447.60$
Staff #3 20.00$ 20 400.00$ 30.60$ 9.00$ 8.00$ 447.60$
Staff #4 20.00$ 20 400.00$ 30.60$ 9.00$ 8.00$ 447.60$
Staff #5 20.00$ 20 400.00$ 30.60$ 9.00$ 8.00$ 447.60$
Site Director 35.00$ 40 1 400.00$ 107.10$ 31.50$ 28.00$ 350.00$ 1 566.60$ oversight of all SRCS school year and summer camp programs $68 000 plus benefits
-$ -$ -$ -$ -$ school year and summer camp in ratio staff
Executive Supervision/Support 555.00$
350.00$ 4 359.60$ 4 17 788.40$ per 4 weeks for school year January- June
Expense per month #Per Youth Al Boro ASP 2022/2023 10 MONTH
Staffing 17 788.40$ 75 237.18$ $177 884
Supplies 3 750.00$ 75 50.00$ $37 500
Admin 4 738.45$ 75 63.18$ $47 385
TOTAL 26,276.85$ 350.36$ $262,768.50
Summer program Per 6 week session, assuming camp 9 hour/day operation
Summer program Payrate Hours Subtotal FICA WC UE Benefits Total weeks Session
Staff #1 20.00$ 40 800.00$ 61.20$ 18.00$ 16.00$ 895.20$
Staff #2 20.00$ 40 800.00$ 61.20$ 18.00$ 16.00$ 895.20$
Staff #3 20.00$ 40 800.00$ 61.20$ 18.00$ 16.00$ 895.20$
Staff #4 20.00$ 40 800.00$ 61.20$ 18.00$ 16.00$ 895.20$
Staff #5 20.00$ 40 800.00$ 61.20$ 18.00$ 16.00$ 895.20$
Staff #6 20.00$ 40 800.00$ 61.20$ 18.00$ 16.00$ 895.20$
Site Director 35.00$ 40 1 400.00$ 107.10$ 31.50$ 28.00$ 700.00$ 1 566.60$ oversight of all SRCS school year and summer camp programs $68 000 plus benefits
Site Coordinator 26.00$ 40 1 040.00$ 79.56$ 23.40$ 20.80$ 700.00$ 1 163.76$ school year and summer camp in ratio staff
Executive Supervision/Support 555.00$
1 400.00$ 8 656.56$ 6 53 339.36$ per 6 weeks of camp
Expense 6 week summer session #Per Youth
Staffing 53 339.36$ 75 711.19$
Supplies 15 000.00$ 75 200.00$
Admin 15 034.66$ 75 200.46$
TOTAL 83,374.02$ 1,111.65$
Total for Jan-June and summer 2022
Total for ASP(Jan-June) = $157,661.09
Total for Summer 6 weeks= 83,374.02$
Grand total for Jan-June and Summer 2 241,035.11$
Questions about costs associated with these/ who pays? Not currently included in budget
PPE & Janitorial?
Facility City of SR cost (Staff open/close)
Facility Rental
PICKLEWEED ADVISORY COMMITTEE
AGENDA REPORT
April 13, 2022
Item #4.E.
TITLE: Aprendiendo Juntos, Parent Services Project
RECOMMENDATION
It is recommended that the Pickleweed Advisory Committee grant a fee reduction or
waiver for use of the Albert J. Boro Community Center on Wednesdays and Thursdays
to Parent Services Project from September 8, 2022 through June 2, 2023, excluding
holidays and closures.
BACKGROUND
Parent Services Project has utilized the Albert J. Boro Community Center for their
Aprendiendo Juntos (Learning Together) program since 2007. The program has been
co-sponsored by the Pickleweed Advisory Committee and has been popular in
attendance over the years, thus reflecting community interest and need.
The developmental playgroup for children 0-5 years old and their parents teaches
parenting skills and helps parents strengthen their relationship with their child. In
addition to encouraging the healthy development of infants and young children, the
program helps build a support network in the community and provides connections to
community resources, organizations and programs.
The term of the proposed pre-school age program is from September 8, 2022 through
June 2, 2023. Although listed on the co-sponsorship application, the applicant is aware
that the Multipurpose Room is not available for co-sponsorship on Fridays and is
prepared to pay for the room on that day through the City’s traditional rental application
process. Parent Services Project is therefore requesting a full fee-waiver, valued at
$10,260.00 for use of Meeting Room 3 on Wednesdays from 9:30 am to 12:00 pm and
the Multipurpose Room on Thursdays from 9:00 am to 2:30 pm, excluding holidays and
closures.
Page 2 of 3
Per the Co-Sponsorship guidelines for renewal applications, a Final Report of the
program’s previous co-sponsored use is included with the application for the Pickleweed
Advisory Committee’s review. The applicant noted that due to the application timeline,
specific 2021-2022 program data has not yet been compiled and can report back to the
Committee at a later date.
DISCUSSION
While the Pickleweed Advisory Committee reviews the Co-sponsorship Application and
Final Report, Parent Services Project staff will be present to provide a program
overview and support their application which is before the Committee. Committee
members will then have opportunity to ask questions of Parent Services Project staff.
The Pickleweed Advisory Committee has the authority to grant a fee reduction (25%,
50%, 75%, or other), grant a full fee-waiver, reject the application and ask applicant to
resubmit with additional information, or reject the co-sponsorship application all
together.
The Committee will make their recommendation at their June 1, 2022 regular meeting.
FISCAL IMPACT
The resident/non-profit value of the co-sponsorship totals $10,260.00 ($1,350.00 for
Meeting Room 3 and $8,910.00 for Multipurpose Room). A fee reduction or waiver
would potentially result in lost revenue to the City should a paying program be
interested in using either the Meeting Room and the Multipurpose Room at that time.
However, being that Parent Services Project conducts the program all three days at the
Albert J. Boro Community Center, the City realizes an estimated $8,662.50 in revenue
for the rental of the Multipurpose Room to the program on Fridays.
ALTERNATIVE ACTION
Any other action as determined by the Comm ittee.
Submitted by:
Steve Mason
Senior Recreation Supervisor
Attachments:
Page 3 of 3
1. Use Agreement Application 2022
2. Final/Interim Program Report
3. Project Budget
4. Agency Intake Form
5. AJ and Baby Gym Post Survey
10/29/2021 Page 9 of 16
ALBERT J. BORO COMMUNITY CENTER
CO-SPONSORSHIP APPLICATION
Section I-About the Applicant Agency
Date Submitted: ________________ Revision Dates (if applicable) ___________________________
Title of Program: _____________________________________________________________________
Co-sponsoring agency or individual: _____________________________________________________
Address: _____________________________
Telephone: ________ Ext. _______________
Email: __________________________________________________
Website: ___________________________________________________________________________
Non-Profit 501c3 Number: ____
Principal contacts:
Name: _________________________ Phone: _ Email: _
Is this a first time program at Pickleweed? Yes No
If no, start date of original program: __________________ Location: ________________________
Most recently approved final report must be attached.
Section II-About the Program
General Statement about the Program. Provide a background statement or statement of the problem that
describes the challenges, behaviors or issues you hope to resolve or improve
3-29-22
Aprendiendo Juntos
Parent Services Proejct
Balandra Fregoso
Pickleweed2012
Aprendiendo Juntos (Learning Together) is a developmental playgroup for children ages 0-5 years old and their
parents. The playgroup teaches parenting skills and helps parents strengthen their relationship with their child
(ren). Aprendiendo Juntos (AJ) helps parents, family members and caregivers by providing high quality early
experiences for children that are crucial for their development. The playgroup includes developmentally rich play
activities, parent support and education that encourages the healthy development of infants and young children.
We help isolated families to build a support network in the community and we connect them with community
resources, organizations and programs according to their needs and interests
10,260.00
10/29/2021 Page 11 of 16
Section III Outcomes and Measurements
List your expected outcome(s) for this program, and how you will measure your progress/success in meeting
each outcome. Refer to the applicant guidelines for samples of outcome and measurement statements.
Each outcome statement and measurement should be individually numbered.
Outcome Statement
Measurement for Outcome
Measurements:
How do you plan to track attendance? Attach a copy of your form.
1. Coordinate 5 interactive developmental playgroups for children ages 0-5 and their
caregivers, five times per week, 1.5 hours per group.
2. The interactive playgroup will provide school readiness activities that are developmentally
appropriate to the children's ages and will provide caregivers with information and resources to
support raising children.
3. Families must live in San Rafael and have limited to no access to preschool.
1. 60 families per year are engaged in weekly developmentally appropriate playgroups including bilingual
socialization and learning opportunities for children and families.
2. 100% of children identified without insurance will be connected to resources to become insured by year end.
3. 75% of parents will report new knowledge gained about community resources.
4. 75% of parents will indicate that they have seen improvement in their children's readiness for school.
5. 75% of parents will report that they have built knowledge and skills related to parenting and their children's
development.
6. 75% of parents will report increased connection with their child(ren).
7. 75% of parents will report increased connection with other parents.
8. 100% of parent participants mental health will be assessed on an ongoing basis.
9. Quality, bi-lingual and culturally competent mental health services will be available for all playgroup families who
seek support
The attendance will be tracked by a weekly sign in sheet per playgroup.
10/29/2021 Page 13 of 16
Attach a program budget.
Section VI Attachments
List all attachments submitted with this application
Intake Form
Pre and Post Survey
10/29/2021 Page 14 of 16
ALBERT J. BORO COMMUNITY CENTER
FINAL PROGRAM REPORT
FOR CO-SPONSORED PROGRAMS
(Use as many pages as necessary to address the required elements. Please number each one.)
Program Name:
Report prepared by:
Name _____________________________ Title ___________________________________________
Date submitted: __________________________________
Date program completed: __________________________
How many total people were served? _________________
A. Outcomes: List each numbered outcome from your application and describe your success in meeting
each outcome.
Aprendiendo Juntos, Parent Services Project
Balandra Fregoso Executive Director
3-29-22
June 3, 2022
65 families
The results of our goals and outcomes will not be determined until June/July once the program has been completed
for the year. We will distribut the post surveys mid to late May, 2022.
As of this point in time, we believe that 100% of our outcomes will have been met by June 2022.
65 families are participating regularly in Aprendiendo Juntos this year. We will have held over 100 developmental
playgroup sessions Sept 2021-June 2022. Playgroup includes developmentally rich play activities, parent support
and education that encourages the healthy development of infants and young children.
Aprendiendo Juntos has a positive reputation in the Canal and families know and trust Parent Services Project. We
meet parents where they are at and challenge them to learn new ways of engaging with the community and with
their families. They are deeply committed to giving their children a better life. We hire culturally competent staff that
have a history of working with families and a passion for social justice. The staff/client connection is a critical
component of our success.
10/29/2021 Page 15 of 16
B. Measurements: Describe the measurements and evaluation strategies you used for each outcome, and
provide a summary or actual data analysis. Attach relevant documents for each outcome and measurement
strategy.
C. Success: If you did not succeed in meeting your objectives, tell us why you think that happened, and
what strategies you employed to change the situation, or are planning to change in the future.
D. Summary: Briefly describe your overall satisfaction with your program and your reasoning, what
highlights you would like to bring to the Board’s attention, and any general comments about your program.
PSP conducts pre and post surveys in order to evaluate Aprendiendo Juntos. There are
informal parent-coordinator meetings as well as parent-child activities, presentations,
workshops and referrals throughout the year to help and support families.
We firmly bellieve that we will reach all of our performance measures this year. We are thrilled
to be able to offer safe in-person programming, even through Omicron, and we continue to go
above and beyond to support our playgroup families and deepen our work despite the
challenges of the pandemic. In June/July 2022 we will offer a four week in person summer
program for families with children entering TK and kindergarten in August. We will continue to
offer behavioral health support and early childhood mental health consultation through the
partnership with JFCS and well as individual brief case management for all playgroup families
in need. We are excited to share that Parent Services Project is coordinating a Playgroup
Collaborative so that we can improve our efforts county wide and align where appropriate.
PSP is also part of the Canal Community Response efforts and through support from Canal
Alliance, we have distributed over 200 at home test kits to Aprendiendo Junto families.
Aprendiendo Juntos/ Learning Together
Parent Services Project
2021-2022 Budget
Revenues
Bella Vista Foundation 50,000 50,000
Marin First 5 (Secured) 102,733 102,733
TOTAL INCOME 50,000 102,733 152,733
Expenses
Project Personnel
Program Director/ Direct Supervision 10,500 3,058 13,558
Family Engagement Specialist 9,000 54,000 63,000
Assistant Coordinator 3,800 3,800 7,600
Subtotal personnel 23,300 60,858 84,158
Fringe/benefits x24% 5,592 14,606 20,198
Total Personnel Costs 28,892 75,464 104,356
Project Operating Expenses
Rent/Utilities/Janitorial: total program staff/ total
agency staff X total agency overhead
7,120
9,043
16,163
Playgroup associated cost to include space rental
childcare and props and video equipment for virtual
play groups per week 3,673
3,673
Supplies/ Playgroup activities, art supplies, games &
materials and refreshments at $50 per weekly meeting 3,873
3,873
Mental Health Care / intern fee and support
7,200 7,200
Promotores Stipends
1,500 360 1,860
Travel- (Project Personnel)
288 320 608
Subtotal Operating Expenses 16,108 17,269 33,377
Total Personnel & Operating Expenses 45,000 92,733 137,733
Indirect, not to exceed 10% of budget 5,000 10,000 15,000
TOTAL EXPENSES 50,000 102,733 152,733
First 5 MarinBella Vista
Foundation Total Budget
Initials: _______________ Date: ________________ Age: __________
Staff Initials : _____________________
Intake Form
Thank you for answering the questions below. Your honest answers are important to us and will
be kept confidential.
Type of service/program requested: _______________________________________________
1. What is your race or ethnicity? _____________________________________________
2. What language is spoken most often in your home? _____________________________
3. How many people live in your house? ________ Adults _____Children
Age of child: School:
Age of child: School:
Age of child: School:
Age of child: School:
4. Do your children have medical insurance? Yes or No
5. Are you able to access reliable internet at home? Yes or No
6. Do you have access to a computer device or tablet at home? (not including a phone or a
school issued device) Yes or No
7. Are you interested in introductory-level technology support or technology workshops?
Yes or No
8. Staff Notes:
Initials: _______________ Date: ________________ Age: __________
Staff Initials : _____________________
Forma de Registro
Gracias por responder a las siguientes preguntas. Sus respuestas son importantes para nosotros
y serán confidenciales.
Tipo de Servicio/Programa Requerido:
______________________________________________________
1. ¿Cuál es su Raza/origen étnico?: ___________________________________________
2. ¿Qué idioma se hable más a menudo en su casa?________________________________
3. Número de personas que viven en su hogar: ______ Adultos _______ Niños
Edad del niño/a Escuela
Edad del niño/a Escuela
Edad del niño/a Escuela
Edad del niño/a Escuela
4. ¿Tu hijo/hija tiene seguro médico? Si o No
5. ¿Tiene servicio internet confiable en la casa? Si o No
6. ¿Aparte del aparato que ha prestado la escuela, mi hijo/a tenemos una computadora o
tableta en casa? Si o No
7. ¿Está interesado en el apoyo tecnológico o en los talleres de tecnología? Si o No
8. Cometarios del Personal:
¡GRACIAS!
Thank you for participating
in AJ and Baby Gym this
year. Please help us
improve our program by
filling out this short survey
Gracias por participar en AJ y
Baby Gym este año. Ayúdenos
a mejorar nuestro programa
por completando esta breve
encuesta.
Playgroup Pre-Survey August/September 2021
1. In general, do you feel like you know what your child should be doing and saying at his or her
age? De forma general sientes que sabes lo que tu hijo debería hacer y decir a su edad?
Yes/Si
No
2. Are you interested in resources to help you feel better, happier or less stressed?
Esta interesada en recursos que te ayudo a sentirme mejor, feliz o menos estresado?
Yes/Si
No
3. Does your child have health insurance? Tu hijo/hija tiene seguro medico?
Yes/Si
No
4. Are you able to access reliable internet at home? ¿Tiene servicio internet confiable en la casa?
Yes/ Si
No
5. Do you have access to a computer device or tablet at home? (not including a phone or a school
issued device) ¿Aparte del aparato que ha prestado la escuela, mi hijo/a tenemos una
computadora o tableta en casa?
Yes/Si
No
6. Are you interested in introductory-level technology support or technology workshops? ¿Está
interesado en el apoyo tecnológico o en los talleres de tecnología?
Yes/Si
No
7. What is your race or ethnicity? ¿Cuál es su Raza/origen étnico?:
______________________________________________________________________________
8. What language is spoken most often in your home? ¿Qué idioma se hable más a menudo en su
casa? _________________________________________________________________________
Thank you for participating
in AJ and Baby Gym this
year. Please help us
improve our program by
filling out this short survey
Gracias por participar en AJ y
Baby Gym este año. Ayúdenos
a mejorar nuestro programa
por completando esta breve
encuesta.
9. How many people live in your house? ________ Adults _____Children
Age of child: School:
Age of child: School:
Age of child: School:
Age of child: School:
Número de personas que viven en su hogar: ______ Adultos _______ Niños
Edad del niño/a Escuela
Edad del niño/a Escuela
Edad del niño/a Escuela
Edad del niño/a Escuela
10. Is there anything else you would like to share with us? Hay algo que te gustaria compartir con
nosotros?
THANK YOU
GRACIAS