Name of Grant Program: Massachusetts 21st Century Community Learning Centers Exemplary Programs Grant
Fund Code: 647-B2
PART III – REQUIRED PROGRAM INFORMATION
Cover Sheet
Applicant
Agency:
Program
Coordinator:
Address:
Phone:
(
)
Email:
Put an X in the appropriate box below for the category for which you are applying. REMINDER: A separate
application must be submitted for each category type, if entities are applying for sites in more than one category
Exemplary Site Applicants
Demonstration Site Applicants
(FY11-FY14 Fund Code 647-B1 sites)
(FY 12-14 Fund Code 647-B2 sites)
List the sites proposed through this application.
Site Name
Total number of children/youth served by the sites in this 21stCCLC proposal
during the following years:
FY11
FY12
FY13
FY14
(Projected)
FY15:
(Projected)
(If applicable)
(If applicable)
FY11
FY12
FY13
FY14
(Projected)
FY15:
(Projected)
FY12
FY13
FY14
(Projected)
FY15:
(Projected)
(If applicable)
FY11
(If applicable)
Total FY15 Fund Code 647-B2 Funds Requested
% Funds that will be matched in FY15
(As noted in the RFP Funding section, the minimum is 50% for Exemplary site applicants,
100% for Demonstration site applicants)
Amount/Value ($) of FY15 Match
$
%
$
Page 1 of 8
Name of Grant Program: Massachusetts 21st Century Community Learning Centers Exemplary Programs Grant
Fund Code: 647-B2
Instructions: Please address each of the following questions within the indicated page limits. Responses
should be provided within this document, without changing the format or font size, and leaving the questions
above each response.
District Summary- Please complete one (1) district summary for all schools/sites included in this application.
A. District Support and Sustainability (5 pages maximum):
1.
Describe the current district vision and goals for out-of-school time programming and how it connects
to and supports the proposed Exemplary/Demonstration site(s).
2.
Describe how the district/lead applicant supports and contributes towards sustaining the current
program model.
3.
Describe how the district/lead applicant will collaborate with the school(s)/site(s) to support
implementation of the 21st CCLC program(s) included in this application.
4.
Outline the districts leadership and staff development strategies related to this grant. Include the
following:

The process for ongoing program planning and monitoring of the schools/sites included in
this application.

How often were/are APT observations conducted and by whom, and the process for
providing feedback and ongoing TA to staff. How did/does APT observations help to inform
the TA and PD?

Describe the types of PD opportunities offered, how the PD supported identified needs, who
attended from the proposed sites; and the overall effects on program quality.
5.
Describe participation in the 21st CCLC regional networks; include how the program(s)/staff
benefitted.
6.
Describe current or potential partnerships as they relate to the implementation of this proposal
(Partners are defined as individuals or agencies that contribute back to the program and are able to
collaborate to achieve mutually beneficial goals.) Include how partners support the success and
sustainability of the proposed Exemplary/Demonstration site.
7.
Describe the additional resources, other than this grant, secured to support sustainability and the
required match [Exemplary site applicants - 50% match, and Demonstration site applicants - 100%
match of the site(s)] included in this application. Include all of the following:

How this grant will be coordinated with other federal, state and local programs with
compatible/complementary services (e.g., Academic Support, McKinney-Vento, Title I, Title III,
Adult Basic Education, Gateway Cities, Wrap Around Zones, Mass Grad, etc.); and

planned/anticipated support (financial and other) from municipalities, counties, school districts,
and/or private/community foundations.

Also complete the chart on the next page listing the amounts and sources that will be leveraged
to support the proposed Exemplary/Demonstration site(s). Be specific in noting funds dedicated
to specific sites if applying for more than one.
Page 2 of 8
Name of Grant Program: Massachusetts 21st Century Community Learning Centers Exemplary Programs Grant
Fund Code: 647-B2
A. District Support and Sustainability (continued)
Funding Category
Anticipated FY15
Costs (associated
with adding time)
Possible source(s) for supporting these
costs (federal, state, local, private, etc.)
Staffing (including, but not limited
to, instructional staff, planning time,
substitutes, etc.)
Professional Development
Vendors
Materials/Supplies
Transportation
Other: (please describe below)
Total Anticipated FY15 Costs
8.
If the applicant is not a school or school district describe the following:
a. The system that is used to establish effective means of communication and coordination between
the school, school day teachers, and the 21st CCLC program.
b. The system for sharing of pertinent data including state and other school assessment data (with
appropriate confidentiality). Include how the proposed program will ensure completion of SAYO
surveys.
Page 3 of 8
Name of Grant Program: Massachusetts 21st Century Community Learning Centers Exemplary Programs Grant
Fund Code: 647-B2
NOTE: This is the School/Site Summary Section. Complete a separate school/site summary for
each proposed site.
School/Site Name:
District/Applicant Entity:
B. EXEMPLARY PROGRAM NARRATIVE (5 pages max.)
1.
Provide a narrative describing the ways in which the school/site has evolved over the course of the
funding cycle (that ends August 31, 2014). Provide specific examples supported by data that clearly
demonstrate program growth and continuous program improvement. Describe the vision for the
program over the next three years including how it will continue to grow and improve. The vision
should include identifying the school’s/site’s specific needs and priorities related to student learning
(including academic, social-emotional, wellness, etc.) that will be addressed in the upcoming year.*
*Note: The school’s needs/priorities should be identified from existing school improvement,
turnaround, or other plans guiding current work. Schools should use the Conditions for School
Effectiveness as benchmarks against which to gauge practice in key areas.
C. PROGRAM INFORMATION – For each of the questions below provide specific examples that
support the responses. (12 pages max.)
1.
Based on the analysis of the SAYO and other school/district data, describe how the proposed sites
have contributed to academic achievement for the targeted students over the course of the funding
cycle that concludes this August 2014.
2.
If the program offers homework support, describe how the time has been or will be designed as a
strategy for supporting student academic needs. Cite any specific research, studies, or assessments
used to help inform the homework practices.
3.
Exemplary site applicants: Exemplary Elements
(Demonstration site applicants should skip to question 4.)
a. Provide at least two specific examples of the types of creative and innovative
programs/projects/activities offered at each proposed site. In describing the activities include the
following:




How they support the selected academic and intermediary outcomes;
How they effectively demonstrates student learning;
How they provided opportunities for the development of new skills; and
How they promote ownership, youth voice, and leadership opportunities.
b. Select two additional elements from Addendum D - Elements of Exemplary Programs in the
Funding Opportunities’ RFP’s Additional Information section that best demonstrate the areas in
which each proposed site is most exemplary. Provide information to support why and describe
how the elements may be replicated, adapted, or implemented at other sites across the state.
c.
Describe lessons learned over the funding cycle and how they will help to inform ways in which
each proposed site can serve as a mentor or resource.
1. Demonstration site applicants: Exemplary Elements
(Exemplary site applicants should skip to question 5.)
a. Provide at least two specific examples of the types of creative and
programs/projects/activities offered at each proposed site. Include the following;




innovative
How they support the selected academic and intermediary outcomes;
How they effectively demonstrate student learning;
Opportunities provided for the development of new skills; and
How they promote ownership youth voice, and leadership opportunities.
Page 4 of 8
Name of Grant Program: Massachusetts 21st Century Community Learning Centers Exemplary Programs Grant
Fund Code: 647-B2
C. PROGRAM INFORMATION (continued)
b. Select four additional elements from Addendum D - Elements of Exemplary Programs in the
Funding Opportunity’s RFP’s Additional Information section that best demonstrate the areas in
which each proposed site is most exemplary. Provide information to support why and describe
how the elements may be replicated, adapted, or implemented at other sites across the state.
c.
Describe and provide specific examples of the ways in which each proposed site has served as a
resource or mentor over the last three years of funding (FY12-14). Describe lessons learned over
the entire funding cycle and how they will help to inform how the site will continue to serve in this
capacity.
2. Describe family involvement strategies the program has found to be effective and/or or plan to
implement. Note: Episodic, non-reoccurring, or special events while very beneficial to the program do
not as a stand-alone constitute ongoing family involvement. For example, an open house night for
parents of participating students that involves a meal or social activities would not in itself represent
ongoing family involvement.
3. Describe how the program supports social emotional learning (SEL) for the targeted population of
students.
PLEASE NOTE: SEL is a process that helps children to develop the fundamental skills for life
effectiveness. These skills include recognizing and managing emotions, developing caring and
concern for others, establishing positive relationships, making responsible decisions, and handling
challenging situations constructively. They are the skills that allow children to calm themselves when
angry, make friends, resolve conflicts respectfully, and make safe choices.
D. TARGET POPULATION (2 pages max.)
1. Over the grant period, how effective has the program been in reaching the targeted student
populations of this grant?
 Be specific in describing the target population (e.g. students that scored in the bottom half of
Needs Improvement).
 Describe the specific data elements (e.g., MCAS, Student Growth Percentiles, Early Warning
Indicator System, etc.) used to select targeted students.
 Describe the specific strategies that have been found to be the most effective in attracting hard to
reach students.
 Complete the chart below to provide information on students served in the targeted academic
are(s) for FY13 and FY14:
Notes: MCAS data for FY13 should be from the 2012 tests, and for FY14 from the 2013 tests. You only
need to provide MCAS data for the subject area(s) that match up with selected SAYO academic
outcomes.
FY13 (Winter/Spring 2012 MCAS data)
School (%)
21st
CCLC (%)
Scored below Proficient ELA (<240)
Scored below Proficient MATH (<240)
Scored below Proficient STE (<240)
Free and Reduced Lunch
Special Education
English Language Learners
Page 5 of 8
Name of Grant Program: Massachusetts 21st Century Community Learning Centers Exemplary Programs Grant
Fund Code: 647-B2
D. TARGET POPULATION (continued)
21st
CCLC (%)
FY14 (Winter/Spring 2013 MCAS data)
School (%)
Scored below Proficient ELA (<240)
Scored below Proficient MATH (<240)
Scored below Proficient STE (<240)
Free and Reduced Lunch
Special Education
English Language Learners
E. STUDENT ATTENDANCE (1 page max.)
1.
Describe the success rate the program has had in maintaining high and consistent attendance levels
over the three-year funding cycle. Describe the specific strategies that have been found to be the
most effective in maintaining high and consistent attendance levels.
2.
Did the school/site consistently meet the required average of the minimum required attendance hours
over the funding cycle (80 for high school, 90 for middle school, and 100 hours for elementary
school)? If not describe why and the plan to address this going forward. Additionally, complete the
appropriate chart below to provide information on students average attendance hours. Chart a is for
high school sites applying to be an Exemplary site and Chart b is for middle and elementary school
sites applying to be a Demonstration site.
a. For high school sites applying to be Exemplary sites, complete the boxes below.
Hours
Percentage of HS students that attended
FY 11
FY 12
FY13
FY14
≥ 80 hours
Percentage of HS students that attended
< 80 hours
b. For elementary and/or middle school sites applying to be Demonstration sites. Complete the
boxes below for the grade levels served by the proposed site.
Hours
Percentage of Elementary students that
attended ≥ 100 hours
FY 12
FY13
FY14
Percentage of Elementary students that
attended <100 hours
Percentage of MS students that attended
≥ 90 hours
Percentage of MS students that attended
< 90 hours
Page 6 of 8
Name of Grant Program: Massachusetts 21st Century Community Learning Centers Exemplary Programs Grant
Fund Code: 647-B2
F. TRAINING AND TECHNICAL ASSISTANCE (2 pages max.)
1.
Describe how the program has made effective use of the resources provided through the Department.
a. Indicate the specific trainings attended and how the resources or information provided was used
or implemented.
b. Has the program/staff utilized the Contextual Learning Portal? If yes, what types of projects have
you accessed? If no, please tell us why (e.g., projects do not connect to your focus, find the site
difficult to access, time constraints, etc.). Please provide any suggestions on how we may
improve the site.
c.
For Demonstration site applicants - Has program contributed to the Contextual Learning Portal? If
yes describe the activity(ies) submitted. If no, describe plans to contribute to the portal in the
upcoming year.
G. CONTRACTED PROVIDERS
1.
If the program contracts with any outside vendors/community-based agencies describe the criteria
and processes used to select them, the identified needs they meet, and how the services they
provide connect to and support SAYO outcomes. Complete a budget and budget narrative for each
contracted provider.
H. HOURS OF OPERATION (2 pages max.)
1.
Use the table below to provide information about the program schedule. NOTE: Please see top of
next page for important guidelines/requirements for program operation.
Anticipated
# Youth to
be Served
#
Hours /
week
#
Weeks
Total
#
Hours
Days of
Week
(e.g., M-F)
Program Times
Start Time:
School Year
(before school)
End Time:
Start Time:
School Year
(after school)
End Time:
Start Time:
Summer
End Time:
Total # of Hours Offered:
2.
Describe the student attendance policy for the school year and summer program. Include for both
(school year and summer) how often students are required to attend.
3.
Describe the location and space in which the program will take place. Describe how the space and
environment will be welcoming, have the necessary resources to fully implement program activities,
stimulate learning, and provide space to exhibit students' work and projects. Please refer to the
Addendum A: Administrative/Program Assurances document in the Required Forms section of the
Funding Opportunity RFP for more information regarding space requirements.
4.
Describe how the program will meet the United States Department of Agriculture (USDA) National
School Lunch Program requirements for meal supplements, in offering a daily nutritious snack and
breakfast (if offering a morning/before-school program).
5.
Summer Program Description: Provide a brief description of plans for implementing a summer
program.
Page 7 of 8
Name of Grant Program: Massachusetts 21st Century Community Learning Centers Exemplary Programs Grant
Fund Code: 647-B2
All FC 647-B2 grantees must adhere to the following guidelines:
 All programming must occur during out-of-school-time hours.
 Hours of Operation Options: In general, programs must offer a minimum of 8 hours per week during the
school year. The following are recommended options for program hours; however programs may also
propose something different, so long as the required minimum number of hours is offered.
School Year Minimum
Summer Minimum
384 Hours (12 hrs./wk. x 32 wks)
64 Hours [16 hrs./wk. (4 hrs./day for 4 days/wk.) x 4 wks.]
Includes before school
256 Hours (8 hrs./wk. x 32 wks.)
192 Hours [24 hrs./wk. (6 hrs./day x 4 days) x 8 wks.]



Funds cannot be used to support only before school and/or summer programs.
If proposed, before-school services must run for at least one (1) hour each morning offered, and conclude
before the school day begins.
Students must attend the offered school year programming for, on average, a minimum of 100 hours
(elementary), 90 (middle) and 80 (high).* Drop-in programs are not allowed.
*Required average hours are based on MA 21st CCLC statewide data. Vacation week programs may not be
counted towards total hours unless serving the same students that attend the OST program.
I. BUDGET

As noted in the Funding Opportunity RFP’s Required Forms section, submit two complete Part I-II
Budget Workbooks. Complete the School Year Part I Signature Page (prints to one page) and the
School Year Part II Budget and Budget Narrative Pages (prints to four pages) for expenditures that
will occur September 1, 2014 through June 30, 2015. Similarly, complete the Summer Part I
Signature Page and the Summer Part II Budget and Budget Narrative Forms for expenditures that will
occur July 1, 2015 through August 31, 2015.

In constructing the budgets, please note that all costs must be reasonable and necessary to
implement program activities. Additionally, applicants must complete a budget narrative that
demonstrates clear and specific links to the project activity plan. Out of state travel is not allowed,
other than for approved conferences.

Programs must be equally accessible to all students targeted for services, regardless of their ability to
pay. Income generated from fees, services, or other public or private funds must be used to fund
additional costs consistent with the grant application and cannot be carried over beyond the three
year grant cycle. Append to this application a description of any projected revenues and how they will
be used to support additional costs consistent with implementing the proposed program.

Funds allocated under this program may be used only to supplement, not supplant, funds that local
schools and community-based organizations would otherwise expend for programs of this type.
Rental of space, cash stipends to students to attend the program, cell phones, telephone and utilities,
overhead costs and the purchase of materials that are used during the school day are not allowable
expenses under this grant.

If the applicant plans to contract with any outside vendors/community-based agencies please attach a
budget and budget narrative for each contracted provider. Contracted providers must be held to the
same budget requirements as the applicant agency.
1.
Registration Fees
If the 21st CCLC program charges or plans to charge a registration fee, provide a narrative explaining
the fee structure and the process that will be used to ensure that income and/or ability to pay will not
deter families from enrolling their children in the program. Additionally, describe the how the funds will
be administered and managed.
Note: Programs may charge fees provided they do not prohibit any family from participating for
financial reasons.
J. ADDITIONAL INFORMATION – OPTIONAL (1 page max.)
1. (OPTIONAL) Provide any additional information, not already addressed above, that supports why the
proposed site is exemplary (e.g. any changes to the program since the site visit).
Page 8 of 8