Foster Grandparent Program

Civic Service Institute PO BOX 5063, Flagstaff, AZ 86011 (928)523-3560 or Toll Free at (866)856-3017 Foster Grandparent (FG) Program Child Assignment & Assessment Plan Foster Grandparent (Full Name): Does the Volunteer: Tutor Mentor Both

Name of Volunteer Station/Site: Station Location (City): . Please Check Station Type: K-12 Education Head Start/School Preparedness After School Programs Other: ______Instructions:  Please complete and return the initial assignment plan by October 31 to the FG volunteer.  The form will be returned to you at the beginning of April to complete end of year outcomes by April 30. Again, return the form to the FG volunteer. Service Activity: All FGs must have an assignment plan for the children they serve. Assigned children must have a special need as listed in special need codes below. FGs shouldPLEASE be assignedCHECK: at □ leastELEMENTARY 4 children, EDUCATIONand should spend □HEAD approximately START/ 30 minutes per day for a total of 2.5 hours per week per child in one-on-one or small group sessions. Objectives: By the end of the academic year, children assigned an FG volunteer will a) improve in SKILL area; and, b) will gain CONFIDENCE in SKILL area.

Check End Of Year End Of Year Check Check Special Need Skill If Outcome Outcome If If Student Name Grade Start Child Parent Parent Choose Exactly Choose Exactly Skill Improvement (First name & last initial) Level Date is in Confidence Improvement is in is a ONE To Track ONE To Track Foster Please Check Either: Please Check Either: Prison Veteran (See Codes Below) Care (See Codes Below) Improved Not Improved Improved Not Improved

RD Example: Sue K 3 9/1/11 X X J 4 Example: Amy J 3RD 9/1/11 X C 1 1. 2. 3. 4. 5. SPECIAL NEED CODES: J. Language Challenged A. Abused/Neglected K. Learning Challenged SKILL CODES: B. After School Care L. Low Income Challenged 1. Motor Skills: (Fine motor skills—cutting, drawing, tracing, coloring, writing, tying shoes, buttoning; Gross C. Developmentally Challenged Youth motor skills—crawling, balancing, walking, running, jumping, playground activities, etc.) D. Emotional/Social Challenged M. Physically Challenged 2. Intellectual Thinking Skills: (Problem solving, thinking learning, perceiving, memory, understanding, math, E. Hearing Challenged N. Runaway Youth F. Visually Challenged O. Medically Challenged word definition, comprehension, parenting/life skills) G. Speech Challenged P. Substance Abuse 3. Social/Emotional Skills: (Friendship, fairness, loyalty, respect for authority, rules/regulations, self-esteem, H. Homeless Youth Q. Teen Pregnancy/Parent depression, coping skills, controlling emotions, i.e., anger, anxiety, happiness) I. Adjudicated Youth R. Terminally Ill 4. Language Development Skills: (Speech and oral language, phonetics, reading, definitions, spelling, ELL) J.

Name: Signature: Date: Foster Grandparent:

Updated 8/2013 Teacher:

Updated 8/2013