Family and Community Support Services

Annual Project Report Form

In an effort to best serve our broader community and to ensure accurate reporting to the province, please be aware that information in this report willbe shared with Council, regional FCSS and Government of Alberta

1. AGENCY INFORMATION
Agency Name
Project/Program Name
E-Mail Address
Address
Contact Person(s)
Phone Number(s)
2. PROJECT INFORMATION
2.1 Total Funding Received (from Town of Okotoks FCSS)
$
2.2 Have you received funds from any of the following? If so, please list amounts below and in your attached financial report)
Town of Black Diamond / $ / MD of Foothills / $
Town of High River / $ / Town of Turner Valley / $
Village of Longview / $
2.3 How did your agency use the funding from Okotoks FCSS? (a brief recap from your application - Max. 250 words)
2.4Please explain why this program is important. What outcomes are you looking to achieve?
2.5Please provide a brief explanation of the project/program activities undertaken to achieve outcomes?

Please use the Foothills Regional FCSS Program/Project Summary Report Form on page3 and 4 to report on one outcome and your total outputs. Use the Provincial Priority Measures Bank Outcomes and Indicators (Attachment 1).

Please note that an extra template of this form is attached if you wish to report on more than one outcome, (Attachment 2).

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3. PROJECT/PROGRAM OUTCOMES/OUTPUTS REPORT FORM
FOOTHILLS REGIONAL FCSS PROGRAM/PROJECT SUMMARY REPORT (One report per outcome)
Program/Project Name: / Date(s) of Program:
Total # in each category (Enter total number in each category for Okotoks)
Infants/Toddlers ______
(0-3 yrs) / Preschooler ______
(4-5 yrs) / Children ______
(6-12 yrs) / Youth ______
(13-18 yrs)
Adults ______/ Seniors ______/ Families ______/ Number of Okotoks
Community Presentations ______
Total # of Participants______
Outcome Measured as stated in your application
(One outcome per form) / Indicator(s) of Success: / Provincial Outcome & Provincial Indicator Alignment: / Measures Bank Measure Number: / Measure(s):
1. / 1. / 1.
# completing measure: _____
# experiencing a positive change:_____
2. (if more than one measure for this indicator)
# completing measure: _____
# experiencing a positive change:_____
2. (if more than one indicator for this outcome) / 1.
# completing measure: _____
# experiencing a positive change:_____
2. (if more than one measure for this indicator)
# completing measure: _____
# experiencing a positive change:_____

Note: Additional outcomes may be reported using Attachment 2.

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Additional Information
Identify Measurement Tool(s) Used:
Survey / Observation / Interview / Focus Groups
When Measurement
Tool(s) Used: / Pre-test/post-test: both before and after your activities / Post-Only :
After Activities / 
Other output information related to this program/project:
Volunteer involvement related to this program/project only: (if applicable)
# of volunteers: ______# of volunteer hours: ______
Stories - please share a story that describes the significant impact for the participants.
4. DOCUMENTATION REQUIREMENTS / Documents attached
4.1 Project/Program Financial Report – from January 1 to December 31 (include funding from other FCSS sources and value of in-kind support)
4.2 Most recent audited financial statement
4.3 List of current Board of Directors
5. Submit completed REPORT to:
Please
  1. Submit original signed copy of the report (via mail or drop-off at the office)
  2. Email a copy to: (scanned signatures will be accepted)
(Please note that if your report is not signed, it will be returned)
The deadline for submission is January 31, 2015.
DECLARATION:
This is to certify that to the best of my knowledge and belief, the information included in this Annual Project Report complies with the requirements and conditions set out in the Provincial FCSS Conditional Agreement Regulation Service Requirements.
______
Print Name Authorized Signature Date
By Mail: Attention: D. Posey
Town of Okotoks, FCSS
PO Box 20, Stn. Main,
Okotoks, AB T1S 1K1
For questions please contact:
Debbie Posey 403-938-8935 or email:

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