Start-Up Form EYPC Start-Up Form Are you ready to start making a difference in your community? Fill out this start-up form and we will be in contact with you about the next steps! * Organization Name * Implementation Site, if different Implementation Site (e.g.,Local School, Community Office) * Address Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State ZIP Code * Phone Number Project Coordinator Fill in information for the project coordinator below. * Name First Last * Email Project Faciltator Fill in information for the project facilitator below, if Project Coordinator and Facilitator will be different. Name First Last Email * Have you attented a Facilitator Training? Yes No * If YES, when? Let us know what date you attended a Facilitator Training. Program Information Fill our the below information about your potential EYPC program * What is your anticipated start date? * What is your anticipated end date? * Do you wish to administer the online survey or the paper survey? Online Paper * What local policy will this EYPC effort work to advance? * Is EYPC the only initiative this group will be working on during this time frame? Yes No * What is the name of the government, or the decision makers, that will be the focus of this EYPC effort? Government (e.g., County Board, City Council, Township Board, Village Board, School District Board, Park Board) * How often do you plan to meet with this EYPC group? (e.g., weekly, bi-weekly, monthly) * How many youth have commited to be apart of the project? * What is the age range of these students? * What is the community problem the youth are planning to address?