2004-2005 21st Century Community Learning … · Web viewRefer to the January 14, 2014 Grant Announcement for the 2014-2015 21st Century Community Learning Centers Grants for specific

COMPETITIVE GRANT APPLICATION FOR 2014-201521st CENTURY COMMUNITY LEARNING CENTERS GRANTS

Instructions for Application Forms

Applications should be prepared simply and economically using the forms provided.

Refer to the January 14, 2014 Grant Announcement for the 2014-2015 21st Century Community Learning Centers Grants for specific rubrics detailing information that must be provided for each part of this application.

The forms provided are to be prepared using Microsoft Word 2003 or higher. It is recommended that the applicants save forms to their own computers

with the applicant’s name in the file description. Each form has fillable text fields that must be completed in the font size that

is set for that field. Additional page instructions may be found below the title of each page. In general all forms must be completed in Verdana 11 point font unless

otherwise noted on the form. Applicants MUST adhere to the page limits stated on each of the forms. Once the entire application is completed, the applicant must create a PDF

copy of the application in order to include an electronic copy of the application for submission.

All application pages must be securely bound with a binder clip. Do not use staples or other types of binding.

Supplementary materials, such as commercial publications and videotapes, are not reviewed and will be discarded.

Incomplete applications will not be accepted or reviewed.

02-65 Rev. 1/14AUTHORITY: No Child Left Behind Act of2001, Title IV, Part B.COMPLETION: Voluntary. (Consideration for funding will not be possible if form is not filed.)

Michigan Department of EducationMICHIGAN OFFICE OF GREAT START

EARLY CHILDHOOD EDUCATION AND FAMILY SERVICES

P.O. Box 30008, Lansing, Michigan 48909

Direct questions regarding this form to (517) 335-6528.

COMPETITIVE GRANT APPLICATION FOR 2014-201521st CENTURY COMMUNITY LEARNING CENTERS GRANTS

APPLICANTORGANIZATION

Legal Name of Applicant

Federal ID Number

Telephone (Area Code)( )

Address

City

Zip Code

CONTACTPERSON

Name of Contact Person


Fax Number (Area Code)( )

Address

City

Zip Code

E-Mail Address

County

CO-APPLICANT

Legal Name of Agency/District


Name of Contact Person

E-Mail

SCHOOL(S) TO BE SERVED GRADES TO BE SERVED

ISD CODE DISTRICTCODE

BUILDING CODE

ASSURANCES AND CERTIFICATIONS: By signing this assurances and certifications statement, the applicant certifies that it will agree to perform all actions and support all intentions stated in the Assurances and Certifications on pages 1a and 1b, and will comply with all state and federal regulations and requirements pertaining to this program. The applicant certifies further that the information submitted on this application is true and correct.

SIGNATURE OFSUPERINTENDENT ORAUTHORIZED OFFICIAL _____________________________________________________ DATE: _________________________

TYPED NAME/TITLE:

MAILING INSTRUCTIONS: The original, three (3) paper copies, and one electronic copy in PDF format (CD or USB drive) of this application must be RECEIVED by mail at the STATE address indicated above by February 24, 2014, no later than 5:00 p.m.

---STATE USE ONLY---Date Received

Project Number

02-65 Rev. 1/14(Page 1a)

ASSURANCES AND CERTIFICATIONS—FEDERAL PROGRAMS—

INSTRUCTIONS: Please attach ALL assurances to the application.

CERTIFICATION REGARDING LOBBYING FOR GRANTS AND COOPERATIVE AGREEMENTS

No federal, appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of a federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the making of any federal grant, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal grant or cooperative agreement. If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member Of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this federal grant or cooperative agreement, the undersigned shall complete and submit Standard Form – LL*Disclosure Form to Report Lobbying*, in accordance with its instructions. The undersigned shall require that the language of this certification be included in the awards documents for all subawards at all tiers (including subgrants, contracts under grants and cooperative agreements, and subcontracts) and that all subrecipients shall certify and disclose accordingly.

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY, AND VOLUNTARY EXCLUSION – LOWER TIER COVERED TRANSACTIONS

The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participating in this transaction by any Federal department or agency. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

ASSURANCE WITH P.L. 111-117 OF THE U.S. DEPARTMENT OF EDUCATION OMNIBUS APROPRIATIONS ACT OF 2010

When issuing statements, press releases, requests for proposals, solicitations, and other documents describing this project, the recipient shall state clearly: 1) the percentage of the total cost of the project that will be financed with federal funds, 2) the dollar amount of federal funds for the project, and 3) the percentage and dollar amount of the total cost of the project that will be financed by nongovernmental sources.

ASSURANCE CONCERNING MATERIALS DEVELOPED WITH FUNDS AWARDED UNDER THIS GRANT

The grantee assures that the following statement will be included on any publication or project materials developed with funds awarded under this program, including reports, films, brochures, and flyers: “These materials were developed under a grant awarded by the Michigan Department of Education.”

CERTIFICATION REGARDING NONDISCRIMINATION UNDER FEDERALLY AND STATE ASSISTED PROGRAMS

The applicant hereby agrees that it will comply with all federal and Michigan laws and regulations prohibiting discrimination and, in accordance therewith, no person, on the basis of race, color, religion, national origin or ancestry, age, sex, marital status or handicap, shall be discriminated against, excluded from participation in, denied the benefits of, or otherwise be subjected to discrimination in any program or activity for which it is responsible or for which it receives financial assistance from the U.S. Department of Education or the Michigan Department of Education.

CERTIFICATION REGARDING BOY SCOUTS OF AMERICA EQUAL ACCESS ACT, 20 U.S.C. 7905, 34 CFR PART 108.

A State or subgrantee that is a covered entity as defined in Sec. 108.3 of this title shall comply with the nondiscrimination requirements of the Boy Scouts of America Equal Access Act, 20 U.S.C. 7905, 34 CFR part 108.

PARTICIPATION OF NONPUBLIC SCHOOLS

The applicant assures that private nonprofit schools have been invited to participate in planning and implementing the activities of this application.

02-65 Rev. 1/14 (Page 1b)

ASSURANCES AND CERTIFICATIONS (Continued)—FEDERAL PROGRAMS—

ASSURANCE REGARDING ACCESS TO RECORDS AND FINANCIAL STATEMENTS

The applicant hereby assures that it will provide the pass-through entity, i.e., the Michigan Department of Education, and auditors with access to the records and financial statements as necessary for the pass-through entity to comply with Section 400 (d) (4) of the U.S. Department of Education Compliance Supplement for A-133.

ASSURANCE REGARDING COMPLIANCE WITH GRANT PROGRAM REQUIREMENTS

The grantee agrees to comply with all applicable requirements of all State statutes, Federal laws, executive orders, regulations, policies and award conditions governing this program. The grantee understands and agrees that if it materially fails to comply with the terms and conditions of the grant award, the Michigan Department of Education may withhold funds otherwise due to the grantee from this grant program, any other federal grant programs or the State School Aid Act of 1979 as amended, until the grantee comes into compliance or the matter has been adjudicated and the amount disallowed has been recaptured (forfeited). The Department may withhold up to 100% of any payment based on a monitoring finding, audit finding or pending final report.

CERTIFICATION REGARDING TITLE II OF THE AMERICANS WITH DISABILITIES ACT (A.D.A.), P.L. 101-336, STATE AND LOCAL GOVERNMENT SERVICES

The Americans with Disabilities Act (ADA) provides comprehensive civil rights protections for individuals with disabilities. Title II of the ADA covers programs, activities, and services of public entities. Title II requires that, “No qualified individual with a disability shall, by reason of such disability be excluded from participation in or be denied the benefits of the services, programs, or activities of a public entity, or be subjected to discrimination by such entity.” In accordance with Title II ADA provisions, the applicant has conducted a review of its employment and program/service delivery processes and has developed solutions to correcting barriers identified in the review.

CERTIFICATION REGARDING TITLE III OF THE AMERICANS WITH DISABILITIES ACT (A.D.A.), P.L. 101-336, PUBLIC ACCOMMODATIONS AND COMMERCIAL FACILITIES

The Americans with Disabilities Act (ADA) provides comprehensive civil rights protections for individuals with disabilities. Title III of the ADA covers public accommodations (private entities that affect commerce, such as museums, libraries, private schools and day care centers) and only addresses existing facilities and readily achievable barrier removal. In accordance with Title III provisions, the applicant has taken the necessary action to ensure that individuals with a disability are provided full and equal access to the goods, services, facilities, privileges, advantages, or accommodations offered by the applicant. In addition, a Title III entity, upon receiving a grant from the Michigan Department of Education, is required to meet the higher standards (i.e., program accessibility standards) as set forth in Title III of the ADA for the program or service for which they receive a grant.

CERTIFICATION REGARDING GUN-FREE SCHOOLS - Federal Programs (Section 4141, Part A, Title IV, NCLB)

The applicant assures that it has in effect a policy requiring the expulsion from school for a period of not less than one year of any student who is determined to have brought a weapon to school under the jurisdiction of the agency except such policy may allow the chief administering officer of the agency to modify such expulsion requirements for student on a case-by-case basis. (The term "weapon" means a firearm as such term is defined in Section 92` of Title 18, United States Code.)

The district has adopted, or is in the process of adopting, a policy requiring referral to the criminal or juvenile justice system of any student who brings a firearm or weapon to a school served by the agency.

AUDIT REQUIREMENTS All grant recipients who spend $500,000 or more in federal funds from one or more sources are required to have an audit performed in compliance with the Single Audit Act (effective July 1, 2003).

Further, the applicant hereby assures that it will direct its auditors to provide the Michigan Department of Education access to their audit work papers to upon the request of the Michigan Department of Education.

02-65 Rev. 1/14 (Page 1c)


ASSURANCE AGAINST TRAFFICKING IN PERSONS

The applicant assures that it adopts the requirements in the Code of Federal Regulations at 2 CFR 175 as a condition for this grant. You as a subrecipient under this award and your employees may not -- i. Engage in severe forms of trafficking in persons during the period of time that the award is in effect; ii. Procure a commercial sex act during the period of time that the award is in effect; or iii. Use forced labor in the performance of the award or subawards under the award. Under this condition, the Federal awarding agency may terminate this grant without penalty for any violation of these prohibitions by the grantee, its employees, or its subrecipients.

ASSURANCE REGARDING THE PROHIBITION OF TEXT MESSAGING AND EMAILING WHILE DRIVING DURING OFFICIAL FEDERAL GRANT BUSINESS

The applicant assures that it prohibits text messaging and emailing while driving during official grant business. Federal grant recipients, sub recipients and their grant personnel are prohibited from text messaging while driving a government owned vehicle, or while driving their own privately owned vehicle during official grant business, or from using government supplied electronic equipment to text message or email when driving.

Recipients must comply with these conditions under Executive Order 13513, “Federal Leadership on ‘Reducing Text Messaging While Driving,” October 1, 2009.

CERTIFICATION REGARDING UNIVERSAL IDENTIFIER REQUIREMENTS

The applicant or grant recipient certifies it will meet the requirement for supplying a Data Universal Numbering System (DUNS) number. As a condition of a subrecipient of a federal grant award, you must supply a DUNS number to MDE. No entity may receive a federal subaward without a DUNS number. MDE will not make a subaward to an entity unless that entity has provided its DUNS number.

ASSURANCE REGARDING REPORTING SUBAWARD DATA FOR SUBRECIPIENTS

The Federal Funding Accountability and Transparency Act (FFATA) is designed to increase transparency and improve the public’s access to Federal government information. To this end, FFATA requires that subaward data be reported for all new Federal grants funded at $25,000 or more with an award date on or after October 1, 2010.

An applicant or subrecipient assures that it will timely report data as needed to MDE for the purposes of federal reports for any subaward on a grant awarded by the U.S. Department of Education will be reported for each action or subaward that obligates $25,000 or more in Federal funds that does not include Recovery funds (as defined in section 1512(a)(2) of the American Recovery and Reinvestment Act of 2009, Pub. L. 111-5).

SPECIFIC PROGRAM ASSURANCES

Grantee agrees to comply with all applicable requirements of all State statutes, Federal laws, executive orders, regulations, policies and award conditions governing this program. Grantee understands and agrees that if it materially fails to comply with the terms and conditions of the grant award, the Michigan Department of Education may withhold funds otherwise due to the grantee from this grant program, any other federal grant programs or the State School Aid Act of 1979 as amended, until the grantee comes into compliance or the matter has been adjudicated and the amount disallowed has been recaptured (forfeited). The Department may withhold up to 100 percent of any payment based on a monitoring finding, audit finding or pending final report.

Funds made available under this section will be used to supplement, and to the extent practicable, increase the level of other federal, state, and local funds expended for the Federal 21st Century program. In no case shall Federal 21st Century funds be used to replace or supplant current federal, state, or local funding for existing programs.

02-65 Rev. 1/14 (Page 1d)


SPECIFIC PROGRAM ASSURANCES

The following provisions are understood by the recipients of the grants should it be awarded:

1. Grant award is approved and is not assignable to a third party without specific approval.

2. Funds shall be expended in conformity with budget. Line item changes and other deviations from the budget as attached to this grant agreement must have prior approval from the Michigan Office of Great Start/Early Childhood Education and Family Services Administrator of the Michigan Department of Education.

3. The Michigan Department of Education is not liable for any costs incurred by the grantee prior to the issuance of the grant award.

4. Payments made under the provision of this grant are subject to audit by the grantor.

5. The grant recipient hereby assures that it will provide access to student records and permission to survey teachers, students and parents for participants in this grant award program.

6. Each applicant acknowledges that any 21st CCLC programs may be selected to participate in national, regional and/or state-wide data collection efforts. Acceptance of 21st CCLC funds requires that if a program is selected to be a part of an evaluation project that it will cooperate fully with the state, its designated evaluation contractor, and any of the state’s other research partners.

______________________________________________________________________________ _ ___________________________________________________SIGNATURE OF SUPERINTENDENT OR AUTHORIZED OFFICIAL DATE

02-65 Rev. 1/14 (Page 2)

PART A. CERTIFICATION FOR PARTICIPATION IN CO-APPLICANT AGREEMENTDirections: For Co-Applicant Activities ONLY Page Limit: May be copied for additional co-applicants Font and Size: Verdana – 11 point.INSTRUCTIONS: Cooperative projects may be submitted by two or more eligible local education agencies (LEAs) or faith or community-based organizations. Each participating LEA or agency should take the following action:

Provide the name of each Superintendent /Public School Academy (PSA) Director or agency authorized official and signatures on the co-applicant agreement form.

Either accept administrative responsibility for the project or designate another LEA or agency as the administrative and fiscal agent.

Each of the undersigned certifies that, to the best of his or her knowledge, the information contained in this application is correct and complete; that the agency which he or she represents has authorized him or her to file this application; and that such authorization action is to be recorded in the minutes of the agency’s meeting. The administrative and fiscal agency named below has been designated as the administrative and fiscal agent for this project and is authorized to receive and expend funds to conduct this project.

CERTIFICATION OF LEA OR AGENCY DESIGNATED ADMINISTRATIVE AND FISCAL AGENT FOR THIS PROJECTName of LEA or Agency

Name of Superintendent or Authorized Official

Mailing Address (Street)

Signature

City

Zip Code

Date Signed

Telephone Number (Area Code/Local Number)( )

Name and Title of Contact Person

Mailing Address of Contact Person

E-mail Address of Contact Person

CERTIFICATION OF PARTICIPATING LEA OR AGENCYName of LEA or Agency



Signature

City

Zip Code

Date Signed





CERTIFICATION OF PARTICIPATING LEA OR AGENCYName of LEA or Agency



Signature

City

Zip Code

Date Signed





02-65 Rev. 1/14 (Page 3)

PART B. ACKNOWLEDGMENT OF INTENT TO COLLABORATE Directions: Use this form to show community coordination and collaboration.Page Limit: Duplicate this page for each agency or organization.Font and Size: Verdana - 11 point.

NAME OF APPLICANT:

NAME OF COLLABORATING AGENCY/ORGANIZATION: SECTOR(S) THIS AGENCY REPRESENTS:

Community-wide planning group; Education; Social Services; Health; Faith; Business; Other (explain)

USE THIS SPACE OR ATTACH A LETTER TO DESCRIBE HOW THIS AGENCY/ORGANIZATION WILL COORDINATE AND COLLABORATE IN THE IMPLEMENTATION OF THE PROPOSED 21ST CENTURY COMMUNITY LEARNING CENTERS PROJECT:

OR See attached letter

It is my understanding that the above-named applicant plans to submit a 21st Century Community Learning Centers application available through the Michigan Department of Education to provide comprehensive out-of-school time services. There is a need for such a program in this area, and a representative of my agency/organization/program will work with this program to ensure coordination and collaboration of services to these students and their families.

NOTE: Completion of this form does NOT in itself constitute an endorsement of the applicant’s plan.

_________________________________________________________________________ SIGNATURE OF AGENCY/ORGANIZATION/PROGRAM OFFICIAL DATE

NAME AND TITLE (Of Person Signing Above)---PRINT or TYPE

ADDRESS

CITY STATE ZIP CODE

02-65 Rev. 1/14(Page 4)

PART C. SCHOOL BUILDING VERIFICATION OF PARTICIPATIONDirections: Complete this page for each school to be served.Page Limit: One page for each school.Font and Size: Verdana - 11 point.

NAME OF APPLICANT:

SCHOOL TO BE SERVED

DISTRICT: SCHOOL NAME: SCHOOL ADDRESS: CITY: ZIP CODE:

It is my understanding that the above-named applicant plans to submit a 21st Century Community Learning Centers grant application available through the Michigan Department of Education to provide comprehensive out-of-school time services to students who attend this school. There is a need for such a program in this area, and the building principal will work with this program to ensure coordination and collaboration of services to these students and their families. This will include regular and effective communication with program staff to coordinate resources and use of school facilities.

Our district grants permission: for the release of student records data, including MEAP/MME scores, student grades, school attendance,

and disciplinary actions for participating students to the state evaluator, who will ensure the proper protections with the oversight of the Michigan State University Institutional Review Board.

to survey the students and parents participating in this program, school staff who provide services through the program, and teachers of students participating in the program.

No individual information will be released by the state evaluators; all data will be reported for groups only.

_________________________________________________________________________ SIGNATURE OF SUPERINTENDENT OR AUTHORIZED OFFICIAL DATE


Principal/Director: Only sign one collaboration form for this school. Multiple forms will disqualify this school from funding.

_________________________________________________________________________ SIGNATURE OF SCHOOL PRINCIPAL OR DIRECTOR DATE


EMAIL ADDRESS

( ) TELEPHONE NUMBER (Including Area Code)

02-65 Rev. 1/14(Page 5)

PART D. PROJECT ABSTRACTDirections: Use this form only.Page Limit: One (1) page ONLY. Do not refer to additional pages.Font and Size: Verdana – 10 point.

NAME OF APPLICANT:

PROJECT NAME:

STATEMENT OF NEEDS: Include target population(s).

DESCRIPTION OF THE PROJECT: Also serves as summary.

PROJECT OUTCOMES/EVALUATION PLAN: Summarize anticipated outcomes.

QUALIFICATIONS OF KEY PERSONNEL: Complete Part H. and summarize on this page.

02-65 Rev. 1/14 (Page 6)

PART E. ASSESSMENT OF NEEDDirections: Address the topics listed below.Page Limit: Two (2) pages total (6 and 6a).Font and Size: Verdana – 11 point.

NAME OF APPLICANT:

POVERTY INFORMATION FOR THE STUDENTS AND COMMUNITY TO BE SERVED:

ACHIEVEMENT LEVELS OF STUDENTS TO BE SERVED:

02-65 Rev. 1/14 (Page 6a)

PART E. ASSESSMENT OF NEED (continued)Directions: Address the topics listed below.Page Limit: Two (2) pages total (6 and 6a).Font and Size: Verdana – 11 point

NAME OF APPLICANT:

COMMUNITY NEEDS ASSESSMENT:

PROCESS FOR STUDENT REFERRAL AND SELECTION:

02-65 Rev. 1/14 (Page 7)

PART F. QUALITY OF PROJECT MODELDirections: Address the topic listed below.Page Limit: Nine (9) pages total (7 – 7h)Font and Size: Verdana – 11 point

NAME OF APPLICANT:

the connection between the 21st CCLC program and the curriculum and goals of the school as it relates to the State Board of Education’s Mission and Priorities.

02-65 Rev. 1/14 (Page 7a)

PART F. QUALITY OF PROJECT MODEL (continued)Directions: Address the topic listed below.Page Limit: Nine (9) pages total (7 – 7h)Font and Size: Verdana – 11 point

NAME OF APPLICANT:

a description of the services to be provided to students and their families, including opportunities for academic enrichment (such as providing personalized instruction to help students, particularly students who attend “Priority” or “Focus” schools, to meet state and local student performance standards in core academic subjects).

02-65 Rev. 1/14 (Page 7b)


NAME OF APPLICANT:

the extent to which the design of the proposed project is appropriate to, and will successfully address, the needs of the target population, including plans to include very high-need populations, homeless students, students with limited English-speaking ability, and students with disabilities.

02-65 Rev. 1/14 (Page 7c)

PART F. QUALITY OF PROJECT MODEL(continued) Directions: Address the topic listed below.Page Limit: Nine (9) pages total (7 – 7h)Font and Size: Verdana – 11 point

NAME OF APPLICANT:

a description of the formal structures and processes for school day teacher input into the 21st CCLC program to provide individualized assistance for students in academic areas.

02-65 Rev. 1/14 (Page 7d)


NAME OF APPLICANT:

how students and parents will be involved in planning implementation, program evaluation, and decision making in the program.

02-65 Rev. 1/14 (Page 7e)


NAME OF APPLICANT:

a diverse array of additional services, programs, and activities, such as youth development activities, drug and violence prevention programs, nutrition and health programs, character education, and counseling programs that are aligned with the needs of the particular population to be served.

02-65 Rev. 1/14 (Page 7f)

PART F. QUALITY OF PROJECT MODEL (continued) Directions: Address the topic listed below.Page Limit: Nine (9) pages total (7 – 7h)Font and Size: Verdana – 11 point

NAME OF APPLICANT:

a diverse array of art, music, recreation, and technology education programs, that are designed to reinforce and complement the regular academic program of participating students.

02-65 Rev. 1/14 (Page 7g)


NAME OF APPLICANT:

opportunities for literacy and related educational development for students’ families.

02-65 Rev. 1/14 (Page 7h)


NAME OF APPLICANT:

a plan to provide snacks and supper free to students, according to the United States Department of Agriculture (USDA) national standards.

02-65 Rev. 1/14(Page 8 )

PART G. FACILITY DESCRIPTIONDirections: Complete the form.Page Limit: Form plus required attachments.Font and Size: Verdana – 11 point

NAME OF APPLICANT: EXISTING SITE(S) VERIFICATION OF LICENSE: List complete name and address for each facility that will be used. Indicate license number, effective and expiration dates, capacity, and age range on the license. Attach copy(ies) of license(s).NEW SITE(S) VERIFICATION OF LICENSE APPLICATION: If a site is not currently licensed, list the name and address and write “TBD” in the License Number column. Attach a copy of the first page of the completed license application for each new site. HIGH SCHOOL (HS) SITES: Enter “none” for License Number column and attach assurance they will meet MOST Standards of Quality.SITE THAT IS NOT THE HOME SCHOOL OF STUDENTS TO BE SERVED: Complete column seven (7) to describe plans for transporting or escorting students to any sites in which they do not attend school.

SITE NAME AND COMPLETE ADDRESS

HOME SCHOOL OF STUDENTS

TO BE SERVED

LICENSENUMBER

For HS enter “none”

EFFECTIVEDATE

EXPIRATIONDATE

LICENSEDCAPACITY

APPROVEDAGE RANGEON LICENSE

TRANSPORTATION PLANS

1. Yes

No

2. Yes

No

3. Yes

No

4. Yes

No

5. Yes

No

02-65 Rev. 1/14(Page 9)

PART H. PROGRAM PERSONNELDirections: Complete the form to identify personnel/service vendors who will be working in this 21st CCLC program.Page Limit: Use additional sheets as needed.Font and Size: Verdana – 10 point

NAME OF APPLICANT:

POSITION/TITLE NAME/SERVICE TIME: # OF HRS/DAY

TIME: # OF DAYS/WEEK

TIME:# OF WEEKS/YR.

DEGREE(S)/CERTIFICATION AND SUMMARY OF EXPERIENCE

PROJECT DIRECTOR/ADMINISTRATOR

SITE COORDINATORS

FRONTLINE STAFF/VENDORS

02-65 Rev. 1/14 (Page 10)

PART I. PROFESSIONAL DEVELOPMENTDirections: Describe plans for professional development that meet/exceed DHS licensing requirements. Address how

partners, vendors, and volunteers will participate in staff development. Page Limit: One (1) page.Font and Size: Verdana – 11 point

NAME OF APPLICANT:

02-65 Rev. 1/14(Page 11)

PART J. PROGRAM MANAGEMENTDirections: Describe the plan for program and management staff to meet to plan and evaluate curriculum and align with the

school-day staff for the individual needs of students.Page Limit: One (1) page.Font and Size: Verdana – 11 point

NAME OF APPLICANT:

02-65 Rev. 1/14 (Page 12)

PART K. EVALUATION OF PROJECT Directions: Describe all components for the evaluation of the project. Page Limit: Two (2) pages.Font and Size: Verdana – 11 point

NAME OF APPLICANT:

02-65 Rev. 1/14 (Page 13)

PART L. PROJECT PLAN – FEDERAL TARGET GOALS Directions: Complete column three (3) to describe the specific activities/tasks/staff that will be used to meet each of the stated federal target objectives for the

identified goals listed on this form.Page Limit: Use additional sheets as needed.Font and Size: Verdana – 9 point

NAME OF APPLICANT:

STUDENT OUTCOMES

TARGETGOALS OBJECTIVES ACTIVITIES/TASKS/STAFF TIMELINES ANTICIPATED

OUTCOMESMEASUREMENT

STRATEGIES

Increase academic achievement

48.5% of regularly participating students will improve by a ½ grade in reading/ language arts

48.5% of regularly participating students will improve by a ½ grade in math

45% of MEAP/MME reading scores will improve for regularly participating elementary school students

25% of MEAP/MME math scores will improve for regularly participating middle school students

75% of regularly participating students will improve in teacher-rated classroom behavior

77% of regularly participating students will improve in teacher-rated homework completion and class participation

Yearly: Data provided at end of school year

48.5% of regularly participating students improved by ½ grade in reading/language arts

48.5% of regularly participating students improved by ½ grade in math

45% MEAP/MME reading scores improved for regularly participating elementary school students

25% MEAP/MME math scores improved for regularly participating middle school students

75% of regularly participating students improved in teacher-rated classroom behavior

77% of regularly participating students improved in teacher-rated homework completion and class participation.

Reading and math grades reported for all participating students for all marking periods (provided to state evaluators)

MEAP/MME reading and math scores reported for all participating students (provided to state evaluators)

Teacher surveys completed by teachers of regularly attending students (coordinated by state evaluators)

02-65 Rev. 1/14 (Page 13a)

PART L. PROJECT PLAN – FEDERAL TARGET GOALS (continued)

NAME OF APPLICANT:

TARGETGOALS OBJECTIVES ACTIVITIES/TASKS/STAFF TIMELINES ANTICIPATED

OUTCOMESMEASUREMENT

STRATEGIES

Increase student academic learning

Increase student learning in non-academic areas

85% of regularly participating students with room for improvement report that the program helped them in reading, math, or other school subjects

85% of regularly participating students with room for improvement report that the program helped them in non-academic areas (e.g., leadership, peer relations, community service, sports skills, computer skills, drug/alcohol resistance, etc.)



85% of regularly participating students with room for improvement reported that the program helped them in reading, math, or other school subjects

85% of regularly participating students with room for improvement reported that the program helped them in non-academic areas (e.g., leadership, peer relations, community service, sports skills, computer skills, drug/alcohol resistance, etc.)

Student surveys (coordinated by state evaluators)

Student surveys (coordinated by state evaluators)

02-65 Rev. 1/14 (Page 14)

PART L2. PROJECT PLAN – LOCAL GOALSDirections: Complete all columns to describe any additional project goals and describe the plan for achieving these goals. State the project goals, objectives,

activities/tasks/staff planned to meet the goals, provide a timeline for completion, and anticipated outcomes of the objective as well as how the outcomes will be measured.

Page Limit: Use additional sheets as needed.Font and Size: Verdana – 9 point

NAME OF APPLICANT:

LOCALGOALS OBJECTIVES ACTIVITIES/TASKS/STAFF TIMELINES ANTICIPATED

OUTCOMESMEASUREMENT

STRATEGIES

02-65 Rev. 1/14(Page 15)

PART M. SUSTAINABILITY PLANDirections: Describe a plan to sustain the project beyond the funding cycle.Page Limit: One (1) page.Font and Size: Verdana – 11 point

NAME OF APPLICANT:

02-65 Rev. 1/14(Page 16)

PART N. BUDGET - SUMMARYINSTRUCTIONS: The Budget Summary (1) and the Budget Detail (2) must be prepared by or with the cooperation of the Business Office, using the School District Accounting Manual (Bulletin 1022).

1. BUDGET SUMMARY CFDA NUMBER: 84.287NAME OF APPLICANT

DISTRICT/RECIPIENT CODE GRANT NUMBER152110

PROJECT NUMBER PROJECT TYPE Regular Carry-over

ENDING DATE (mm/dd/yy) 0 6 / 30 / 2015

FY of Approved Activity 2 0 1 5

FUNCTIONCODE FUNCTION TITLE SALARIES

(1000)BENEFITS

(2000)PURCHASED

SERVICES(3000, 4000)

SUPPLIES &MATERIALS

(5000)

CAPITALOUTLAY(6000)

OTHEREXPENDITURES(7000, 8000)

TOTAL

110 Instruction --- Basic Needs

120 Instruction --- Added Needs

210 Pupil Support Services

220 Instructional Staff Services

230 General Administration

240 School Administration

250 Business Services

260 Operation and Maintenance

270 Pupil Transportation Services

280 Central Support Services

290 Other Support Services

300 Community Services SUBTOTALS (Sum of ALL lines above)

400 Outgoing Transfers & Other Transactions

999 INDIRECT CHARGES

TOTAL EXPENDITURES A)

FUNDING: Department of Education Share of Expenditures

Local Share of Expenditures (Block A Minus Block B)

B)

C)

_______________________________ _______________________________ DATE BUSINESS OFFICE REPRESENTATIVE (Type or Print) SIGNATURE

_______________________________ _______________________________ DATE PROJECT CONTACT PERSON (Type or Print) SIGNATURE

__________________________ LORRAINE THORESON, JOHN TAYLOR OR PAT HENNESSEY _______________________________ DATE MDE CONTACT PERSON (Type or Print) SIGNATURE

02-65 Rev. 1/14(Page 16a)

PART N2. BUDGET – DETAILDirections: Complete all columns to describe the project expenditures. Enter each Function Code as many times as necessary to give a clear description of each

expenditure type. Page Limit: Use additional sheets as needed.Font and Size: Verdana – 11 point.

2. BUDGET DETAIL FUNCTION

CODE TYPE DESCRIPTION OF EXPENDITURES AMOUNT Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One Choose One

Documents

2004-2005 21st Century Community Learning … · Web viewRefer to the January 14, 2014 Grant Announcement for the 2014-2015 21st Century Community Learning Centers Grants for specific