Name of Grant Program: Massachusetts 21st Century Community
Learning Centers – Enhanced Programs for
Students with Disabilities
Fund Code: 245-B
PART III – REQUIRED PROGRAM INFORMATION
A. GENERAL INFORMATION
21st CCLC Program
Coordinator:
District:
Email Address:
Phone:
In the chart below please list the names of all the sites for which you are applying for funding through Fund
Code: 245-B and the year in which they were originally funded.
21st CCLC OST Site
Name
FY15 Fund Code
(put an X in the
appropriate box)
647-A:
647-B2:
647-A:
647-B2:
647-A:
647-B2:
Total number
of
unduplicated
students on
IEPs
currently
enrolled.
Proposed
number of
additional
students
on IEPs to
be
enrolled.
School Year
(enhanced programming)
Start Date
End date
School Year
Total number of weeks of
enhanced programming
School Year only
Summer
(if proposed)
Start Date
End date
Summer
(if proposed)
Total weeks of enhanced
programming
School Year
and Summer
Site Name
Funds
Requested
per Site
Total Funds Requested
Total number
of students on
IEPs proposed
to be served.
SY
Summer
Total
$
$
$
$
$
$
$
$
$
$
$
Total Value of Match
(Reminder: Must be at least 10% in FY15, 15% in FY16, and 25% in FY17)
$
$
Name of Grant Program: Massachusetts 21st Century Community
Learning Centers – Enhanced Programs for
Students with Disabilities
Fund Code: 245-B
B. PROJECT SUMMARY (50 word maximum)
Describe how these funds will be used to enhance the current 21 st CCLC program at proposed each site
to increase the number and better serve students on IEPs.
C. LESSONS LEARNED (1 page maximum)
If you are a previous or current recipient of a Fund Code 245 grant (for other sites) respond to the
questions below if not skip to D.
1. Describe lessons learned in implementing the Fund Code 245 grant and how those lessons have
been applied to this application.
2. Provide evidence of previous success in providing services and programming to students on
Individual education plans (IEP). Include the number of students targeted and actual number served.
D. PLANNING AND IMPLEMENTATION (8 pages maximum)
For each site proposed address the questions in the same order as they are listed below.
1. Describe the composition of the planning team and the resources and/or expertise they brought to
the development of this grant application.
2. Describe the target population for this grant. Be very specific in describing the particular disabilities
of the students to be served, their areas of greatest need and how that need was determined (e.g.,
IEPs, MCAS scores, school/district measures). Include the following:
 Why additional funds are needed; and
 Barriers the program has experienced in serving this population.
3. Complete the chart below indicating background and qualifications of current program staff:
Indicate the number of teachers/educators/instructors in each of the following areas:
(count dual/multi-certified teachers in all applicable categories)
School/Site :
Cert.
Math
Cert.
ELA
Cert.
Science
Cert.
Art
Cert.
Social
Sci.
Cert.
Health
/PE
Cert.
SPED
Other (List
Licensure if
applicable)
4. If you plan to hire additional staff describe the number of additional staff that will be hired and their
special education credentials. Please note that if these funds are being used to hire additional para
professions they must be directly supervised by a certified special education teacher. If you plan to
hire additional para professionals describe the process for providing appropriate supervision.
5. Describe how current activities and/or proposed new activities will be designed to be fully inclusive
and ensure students with disabilities are fully engaged with peers without disabilities. Describe the
specific strategies that will be used to address areas of need described above in question 2.
6. Provide specific examples of either the types of activities to be offered or ways in which students will
be fully included in current activities. Include the following
 Describe how the enhancements will contribute to increased achievement, healthy development,
and increased socialization for students with disabilities.
 Provide the student-to-staff ratios.
7. If applicable describe plans for summer programming.
8. Describe the process that will be used to maintain ongoing communication and collaboration with the
IEP Team chair and/or classroom teacher(s) regarding students with IEPs served by the program.
Name of Grant Program: Massachusetts 21st Century Community
Learning Centers – Enhanced Programs for
Students with Disabilities
Fund Code: 245-B
D. PLANNING AND IMPLEMENTATION (continued
9. If the proposal includes contracting with additional partners or providers describe their experience
working with the targeted population, how you will ensure that staff have appropriate experience and
support, and the added enhancements they will provide.
10. If the proposal includes providing professional development, technical assistance, and/or
consultations provide the names of the individuals and/or organizations providing the service, their
background and experience, the specific topics and/or services to be provided and timeframe for
implementation.
11. If students to be served currently utilize, or the applicant is proposing to purchase, specialized
materials and/or equipment, including augmentative and alternative communication aids or devices or
other assistive technology, provide the follow:

Describe the training that will be provided to ensure that staff has the necessary knowledge to
appropriately use the items; and

Describe the rationale for purchasing the particular materials and/or equipment.
E. EVALUATION (1 page maximum)
Recipients will be required to utilize the Survey of Academic Youth Outcomes for all students served by
these funds.
1. If an IEP calls for assessment modifications or accommodations describe what, if any,
accommodations may be needed in the administration of the SAYO (Teacher, Staff and/or Youth
versions).
2. Describe any efforts that will be used in addition to the SAYO to evaluate the impact of these
additional resources and enhancements on students served by these funds.
F. SUSTAINABILITY
1. Use the chart below to list financial resources and in-kind contributions that have been cultivated to support
programmatic efforts. Be specific about the actual match secured in relation to the total amount of your
budget request. Include the value of both dollar and in- kind contributions. Please note: the only
transportation costs allowed are for the purpose of including students served by these funds on field trips.
These funds cannot be used to transport students to or from the school based program.
Funding Category
Staffing
Professional Development
Contracted Providers/Vendors
Materials/Supplies
Transportation
Other: (please describe)
Total Anticipated FY15 Costs
FY15 FC245-B
Funds
Additional source(s)
including in-kind
(list actual source e.g.,
SPED, Title I, etc.)
Dollar amts/
value in-kind
that will be
leveraged
Total