SAIL Program Engagement Agreement

Program Engagement Agreement

Stay Active & Independent for Life [SAIL] Program
Part 1 of the two-part Program Engagement process.

The purpose of this Program Engagement Agreement is to provide clear expectations for the host organization (named here) in implementing the evidence-based SAIL program within the host organization's community - as part of the grant awarded to the Northern Virginia Falls Prevention Alliance.

This form is to be completed by the Primary Point of Contact of the Host Organization.
HOST ORGANIZATION
Organization's Name: *
Organization hosting the SAIL Program
Organization Type: *

Educational Faith-based Health Care Government Recreational Residential
Organization Size: *

0 - 50 51 - 100 101 - 250 251 - 500 500+
PRIMARY CONTACT: *

First Name Last Name
Primary Contact's Role: *
Primary Contact's Email Address: *
Primary Contact's Phone Number: *
Exercise programs currently offered by host organization: *
PROGRAM IMPLEMENTATION SITE
Program Site's Name: *
Location the SAIL Program will be held
Site Type: *

Educational Faith-based Health Care Government Recreational Residential

Site Address: *

PROGRAM SCHEDULING
START Date (first class): *

/ Month / Day Year
Date
END Date (last class): *

/ Month / Day Year
Date
Proposed Weekly Schedule: *
(Example: Mon & Wed, 10am - 11am)
What is the registration process for this program? *
If not yet decided - insert TBD
Is this program open to the public? *
If only open to organization members please specify
Is there a COST to take this program? *
If YES - please include the amount
PROGRAM LEADERS

Those who will be leading the SAIL program
SAIL Leader's Full Name: *
Proposed Training Date *

- Month - Day Year
If already trained, please inset date
SAIL Leader's Full Name:
Proposed Training Date

- Month - Day Year
If already trained, please insert date
Are program leaders part of the host organization? *
If not part of the host organization - what organization(s) (if any) are they affiliated with?
Part 2 of the SAIL Engagement process consists of:

(A) Supplies/equipment provided by the grant for the SAIL program at this site.

(B) Expected implementation process dates and timelines.

After submitting this form, we will get in touch with you for next steps.

Thank you for completing this SAIL Program Engagement Agreement!
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Program Engagement Agreement