Site Status Report
Today’s Date:
Date of Sessions From:
To:
Site Name:
This form should
be filled out by
your Coordinator
Note any changes in the boxes below:
My Registered Director is:
Site Address:
City:
Is RAINBOWS included in your site’s annual budget?
YT - Yukon
No
Phone:
Did you obtain funding for RAINBOWS at your site?
Fax:
No
Email:
If YES, please give the name of the grantor/funder and the amount
of this award.
Site Coordinator:
Please let us know the details of your program using the following guidelines: Attribute only ONE type of loss per participant.
Supply information by LEVEL for each participant. See Facilitator Component Module for ages/grade breakdown.
Curricula Used
Level, etc.
Female
Male
Death
Separation
Divorce
Other
Loss
African
Canadian
Asian
Biracial
Caucasian
Hispanic
First
Nations
Other
Ethnic
Group
Total
# in
Level
SunBeams
Rainbows Level 1
Rainbows Level 2
Rainbows Level 3
Rainbows Level 4
Alumni Level 1
Alumni Level 2
Alumni Level 3
Alumni Level 4
Spectrum Level One
Spectrum Level Two
Total for each
category
ADULT CURRICULA INFORMATION – Prism/Kaleidoscope Coordinator Name
Level & Curricula
Female
Male
Death
Separation
Divorce
Other
Loss
African
Canadian
Asian
Biracial
Caucasian
Hispanic
First
Nations
Other
Ethnic
Group
Kaleidoscope
Prism
*Silver Linings
Total
*We used Silver Linings Level
two
Please check ALL the statements that apply to this site:
CURRICULA BEING USED:
Secular .. Religious
MATERIALS BEING USED:
Journal Sets
Storybooks
Activities (games) English
Activities Spanish
Keepsakes
Coordinator Manual
Facilitator Modules
We are additional resources:
(please explain)
for the following reason(s)
LAST DATE MATERIALS WERE ORDERED:
TELL US ABOUT YOUR PROGRRAM
Program is going well.
Program is in need of facilitators.
Community based/referrals accepted.
Never started program after training.
We are concerned about low enrollment.
We have trouble finding funds for reordering
consumables.
We are using the translated games.
Program is suspended at this time.
Date we plan to restart:
TOTAL NUMER OF FACILITATORS:
Do you anticipate a change in Coordinator next year?
If YES, please provide the new Coordinator’s name:
TYPE OF SITE
We have other concerns.
(Please attach another sheet with details.)
We have a summer program.
Please have someone call us.
We need your help to improve how we serve the children and to document your participation.
Please return ASAP to RAINBOWS Suite 545, 80 Bradford St., Barrie, Ontario L4N 6S7 or
FAX 705 7265805
1. Site Coordinator please return your report to your Registered Director
2. Registered Director please return a copy of the report before the end of May to: Director
of Development
Our Site is a
school
synagogue
agency
hospital
church
Our denomination is:
Submit by Email
Print Form
Revised May 07
Total
# in
Level