Program Dashboard Form Welcome! We are so excited that you have a new program to tell us about. Please fill out this form with all of the program details. If you have any questions, please feel free to reach out to your Regional Coordinator or info@prisonyoga.org. Section 1: Location DetailsIs this a new program at a facility where there are existing programs?(Required) Yes No Select Your Program(Required) RegionInternationalUS – CaliforniaUS – East CoastUS – Midwest – West CoastUS – South State/Territory Organization Facility Program Name Organizationex. San Diego County Sheriff’s Department, Indiana Department of CorrectionsFacility Name(Required)ex. East Mesa Detention Facility, Pendleton Correctional FacilityAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Program Location in Facility(Required)ex. yard (Delta Yard), room (Classroom A, gym), etc.Facility ContactFirst NameLast NameEmail AddressPhone NumberSection 2: Program OverviewProgram Type(Required) Trauma-informed yoga class Yoga and Mindfulness Immersion (YMI) Peer Facilitation Youth Correctional Staff In-Facility YTT Program Start Date(Required) MM slash DD slash YYYY Program Cycle(Required) Open-Ended Close-Ended Program End Date(Required) MM slash DD slash YYYY Section 3: Schedule & LogisticsFrequency(Required) Weekly Multiple times a week Monthly Twice per month Occasional How many times a week does this program run?(Required)1234567What day or days of the week does this program happen?(Required) Monday Tuesday Wednesday Thursday Friday Saturday Sunday What time or times does this program happen? (if you have multiple sessions a week, separate the times with a comma)(Required)Please use 24-hour time, ex. 14:00 for a class at 2 pm.What is the length of the session (in minutes)?(Required)What is the maximum number of people this program can accommodate?(Required)Section 4: Participant InfoGender of Participants(Required) Female Male Both Transgender/Nonbinary Does this program have a waitlist?(Required) Yes No What is the participation type of this program?(Required) Voluntary Mandatory Section 5: Funding & ContractsWhat type of funding does this program have?(Required) Volunteer Contract with Facility Other Funding Contract Start Date(Required) MM slash DD slash YYYY Contract End Date(Required) MM slash DD slash YYYY Financial NotesWho is funding this program?(Required)Funding Start Date(Required) MM slash DD slash YYYY Funding End Date (leave blank if there is no end date). MM slash DD slash YYYY Financial NotesSection 6: Facilitator InformationHow many facilitators are facilitating this program?(Required)12345678910Name(Required) First Last Email(Required) Name(Required) First Last Email(Required) Name(Required) First Last Email(Required) Name(Required) First Last Email(Required) Name(Required) First Last Email(Required) Name(Required) First Last Email(Required) Name(Required) First Last Email(Required) Name(Required) First Last Email(Required) Name(Required) First Last Email(Required) Name(Required) First Last Email(Required) Section 7: Additional InformationDo you have additional information you would like to share about this program?
