SWSD 2013 Program Handbook November 2013 | Page 142

Exhibit A: SAMPLE
JACK AND JILL OF AMERICA, INC.
ACTIVITY REPORT AND EVALUATION
ACTIVITY REPORT
Age Group

_______

Date of Activity: _______

Activity: ________________________
Type (Circle One): Civic/Service ? Cultural ? Educational ? Health Awareness ? Recreational ? Social
Place of Activity: _____________
Total Cost: $

Cost per Member: $

Youth Attended
1.
2.
3.
4.
5.

Child’s Name
___________
__________
__________
___________

6.
7.
8.
9.
10.

___________

EVALUATION
Recommend:

___________________________________________

Recommend with the following changes:
________________________

Do not recommend for the following reasons:
___________________

Activity Sponsor(s) Signature
1.

Date

___

2.
3.
Attachments: ? Announcement

B-47

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