Name of Grant Program: Massachusetts 21st Century Community Learning Centers –
Enhanced Programs for Students on an IEP
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 are currently funded.
FY16 Fund Code
(put an X in the
21 CCLC OST Site
Name appropriate box)
Total number of
unduplicated
students on IEPs
currently
enrolled.
Proposed number of
additional students on
IEPs to be enrolled.
Start Date
End date
Total number of weeks of
enhanced programming
Start Date
End date
Total number of weeks of
enhanced programming
Site Name
SY $
st
647-A:
647-B2:
647-A:
647-B2:
647-A:
647-B2:
School Year
Summer
(if applicable)
Funds Requested
per Site
Summer $
Total $
$
$
$
$
$
$
$
$
$
Total Funds Requested
Total Value of Match
(Reminder: Must be at least 10%)
$
Name of Grant Program: Massachusetts 21st Century Community Learning Centers –
Enhanced Programs for Students on an IEP
Fund Code: 245-B
B. PROJECT SUMMARY (50 word maximum)
1. Describe how these funds will be used to enhance the current 21 st CCLC program in order to
increase the number of and better serve students on Individual Education Plans (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 IEPs.
Include the number of students targeted and actual number served.
D. PLANNING AND IMPLEMENTATION (8 pages maximum)
For each site proposed copy, paste, and respond to the following 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 area(s) of greatest need, and how that need was determined (e.g.,
IEPs). Describe the barriers the program has experienced in serving this population. (Please note
these grant funds cannot serve students on a 540 plan.)
3. Describe how current activities and/or proposed new activities will be designed to ensure students
with disabilities are fully engaged with peers without disabilities. Include the following:

Provide specific examples of either the types of activities to be offered or ways in which students
will be fully included in current activities.

Describe how the enhancements will contribute to increased achievement, healthy development,
and increased socialization for students with disabilities.

Provide the student-to-staff ratios.
4. If you are a community based agency (CBO) or currently contract with a CBO to operate the
program, describe your (their) experience working with students on an IEP and the process for
providing professional development and appropriate supervision. Please note that if these funds are
being used to hire additional staff they must be directly supervised by a certified special education
teacher. If not applicable indicate NA.
5. If you plan to hire additional teaching staff describe the number of additional staff that will be hired
and their special education credentials. If not applicable indicate NA.
Name of Grant Program: Massachusetts 21st Century Community Learning Centers –
Enhanced Programs for Students on an IEP
Fund Code: 245-B
6. If you plan to hire additional paraprofessionals describe their qualifications and the process for
providing appropriate supervision. Please note that if these funds are being used to hire additional
paraprofessionals they must be directly supervised by a certified special education teacher. If not
applicable indicate NA.
7. If you plan to contract for additional services with an outside agency or CBO, describe their
experience working with the targeted population, and describe how you will ensure that staff have
appropriate experience, support, and supervision. Additionally, describe the added enhancements
they will provide. If not applicable indicate NA.
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.
9. 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.
10. 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 (SAYO) 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.
Name of Grant Program: Massachusetts 21st Century Community Learning Centers –
Enhanced Programs for Students on an IEP
Fund Code: 245-B
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 21st CCLC program. These funds may be
used to provide specialized transportation for the purpose of including targeted students served by these
grant funds on field trips.
Funding
Category
Transportation
(example)
Staffing (including,
but not limited to,
administrators,
instructional staff,
planning time,
supervision, etc.)
Professional
Development
Partners/Vendors
Materials/Supplies
Transportation
Other: (please
describe below)*
Total Anticipated
Non 21st CCLC
FY16 Funds
*Other:
TOTAL Anticipated
Non-21st CCLC
Funds
Site 1
TOTAL Anticipated
Non-21st CCLC
Funds
Site 2
TOTAL Anticipated
Non-21st CCLC
Funds
Site 3
(list site name
below)
(list site name
below)
(list site name
below)
Special
Education Funds
$5,000