Please complete the following information to initiate the implementation of a new program within our organization.

If any of the fields below don’t apply simply mark “N/A”

Program Name

Description of Program (Objectives, Goals, Purpose)

Program Owner/Coordinator

First Name

Last Name

Email

Phone

(###)

###

####

Targeted age group

Website

http://

Proposed start date

MM

DD

YYYY

Expected Completion date

MM

DD

YYYY

Budget allocation

Personnel Needed (Roles, Responsibilities):

Equipment/Materials Needed:

How will this program integrate with existing processes or systems within the organization?

Will there be any training or orientation sessions required for staff?

Yes

No

If yes, please provide details

How will the success of the program be measured?

Who will be responsible for monitoring the progress and effectiveness of the program?

Identify potential risks associated with the implementation of the program and proposed mitigation strategies.

Insurance Provider

Policy Holder's Name

First Name

Last Name

Policy Number

Group Number (if applicable)

Effective Date

MM

DD

YYYY

Expiration Date

MM

DD

YYYY

Date Completed

MM

DD

YYYY

Additional comments

Please ensure all sections are completed accurately and thoroughly. Once submitted, this form will be reviewed by the appropriate Directors of BGCNCG for approval and further action.