STATE OF NEW JERSEY

DEPARTMENT OF CHIDREN AND FAMILIES

Contract # ______

Division of Family and Community Partnerships

Office of School Linked Services

Annex A

LEVEL OF SERVICE

Section 2.5 a. School Based Youth Services (SBYSP) – Elementary/High School Programs

Note: This form is to be completed for each separately funded SBYSP located in an elementary or high school.

School Based Site: ______Date ______

Individual/Group
Unduplicated / Events/Recreation
Duplicated
DCF Expected LOS: ELM / 100 / 200
ELM: Actual # served during most recent complete fiscal year.*
ELM: Estimated # to be served during this new fiscal year.
DCF Expected LOS: HS / 300 / 700
HS: Actual # served during most recent complete fiscal year.*
HS: Estimated # to be served during this new fiscal year

* The DCF contracted MIS database, Youth Services Net must be used to report this level of service.


School Based Site: ______Date ______

Events

SBYSPs are expected to plan a minimum of 4 activities/events each school year to promote student, family and community engagement and education.

o  An event to promote father engagement (i.e. September--Dads Take Your Child to School Day)

o  Three additional events/activities, such as: dinner and movie night; family game night; volunteer appreciation; spring cleaning; workshops (e.g. community safety, social media, and employment), etc. Programs can certainly develop events/activities not listed.

Provide a brief description of the expected minimum of 4 activities/events that will take place to promote student, family and community engagement and education.

Anticipated Date/Month (e.g. May 2017) / Event/Activity (e.g. social media safety) / Target Audience (e.g. students, family, community) / Anticipated # of participants

Effective July 1, 2017

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