2018 ACS QUARTERLY REPORT FORM

Select Quarter *

Name of Church/ACS Center *

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of ACS Leader/Director *

Name of ACS Leader/Director

First Name

Last Name

Email Address of ACS Leader/Director *

Phone Number of ACS Leader/Director *

Phone Number of ACS Leader/Director

(###)

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Fax Number of ACS Leader/Director

(###)

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This Report is submitted for the following activity/activities (Please check all applicable boxes) *

A copy of completed Report should be sent to your Pastor(s), Personal Ministries Leader, ACS Federation President and ACS Federation Coordinator. Please also keep a copy for your files.

Adventist Community Services Agency

Adventist Disaster Response

Crisis Care

Inner City - Community Development

Local Church Ministries

Medical/Dental Clinic

Tutoring/Mentoring

Youth Empowered to Serve (YES)

Other

Do you provide service other than at the church/center? *

If Yes, where and when?

OPERATIONS

What is the regular schedule your Center/ Program/Church is open to the public (days and hours of the week)? *

Is an intake interview completed with each client?

Do the intake workers have access to a copy of the current human resources directory for your community? *

Are case records kept on file? *

If Yes, are they kept under lock and key?

What percentage of the clients served in the year received a follow-up visit or telephone call? *

To what agencies do you make referrals? *

Which agencies make regular referrals to your center or program? *

PROGRAM STATISTICS

Total number of Active Volunteers *

Total number of Volunteer Hours *

Total number of Clients Served *

Total number of Agency Referrals *

Total number of Job Placements made *

Total number of Meals Delivered *

Total number of clothing items distributed *

Total number of bedding items distributed *

Total number of furniture pieces distributed *

Total pieces of literature distributed *

Total cash value of food distributed *

Total cash value of grants distributed *

Total cash value of vouchers distributed *

Did you provide any type of emotional care? *

If Yes, total number served

Total number of Dental Clinics offered *

Total number of Eye Clinics offered *

Total number of Health Screenings offered *

Total number of people screened *

Total number of Health Classes offered *

Total number of Health Class enrollees *

Did you provide any Other Health Services? *

If Yes, total number served

Total number of Job Training Classes offered *

Total number of Job Training Classes enrollees *

Total number of Parenting Classes offered *

Total number of Parenting Classes enrollees *

Total number of Tutoring/Mentoring programs offered *

Total number of Tutoring/Mentoring programs enrollees *

Total number of Financial Planning classes offered *

Total number of Financial Planning classes enrollees *

Total number of Retirement Planning classes offered *

Total number of Retirement Planning classes enrollees *

Total number of Literacy (ESL) or other classes offered *

Total number of Literacy (ESL) or other classes enrollees *

Did you provide any Other Ministries? *

If Yes, total number served

Total number of Bible class/study Groups offered *

Total number of Bible class/study Groups enrollees *

Please list any Other Services offered

CLIENT DEMOGRAPHICS (numerical values only)

Total number of Asians served *

Total number of African Americans served *

Total number of Caucasians served *

Total number of Latinos served *

Total number of Others served *

Total number of Females served *

Total number of Males served *

Total number of clients aged 0 - 17 served *

Total number of clients aged 18 - 62 served *

Total number of clients aged 63+ served *

Total number of clients served living up to 1 mile from your service location *

Total number of clients served living 1 to 10 miles from your service location *

Total number of clients served living more than 10 miles from your service location *

ANY OTHER COMMENTS

2018 ACS QUARTERLY REPORT FORM

Allegheny East Conference Corp of Seventh-day Adventists

767 Douglass Drive | Boyertown, PA 19512

Local 610.326.4610 | Toll-free 800.830.0224 | Fax 610.326.3946