Name of Grant Program: Massachusetts 21st Century Community Learning
Centers Program - Continuation Grant
Fund Code: 647-A / 245-A
PART III - REQUIRED PROGRAM INFORMATION
FISCAL YEAR 2015-2016 (FY16)
In order to consolidate the continuation grant process for grantees that receive 21 st CCLC funds through multiple
fund codes, there is one application for recipients of any the following:
 Competitive new site grants through FY14 ELT, FY14 OST, and FY15 (ELT & OST) Fund Code (FC) 647-B1
 Competitive exemplary programs grants through FY14 and FY15 FC 647-B2
 Non-competitive enhanced programs for students with disabilities through FY14 and FY15 FC 245-B
INSTRUCTIONS FOR COMPLETING PART III:

All continuation applicants should respond to Sections I-VI below (in this document). Continuation applicants in
Exemplary status (awarded FY14 or FY15 FC 647-B2 grants) should also complete Section VII (in this document).

ELT sites DO NOT need to complete Section II SCHOOL/SITE DATA REPORTING (in this document).

FC 647-B1 OST sites funded competitively in FY13 that chose NOT to apply for a competitive FY16 FC 647B2 Exemplary Programs Grant only need to complete Sections I and II (in this document), and submit it along
with Parts I and II (signature and budget pages), and Addendum C – Program Components (see the RFP’s
Required Forms section).

FC 647-B1 OST sites funded competitively in FY13 that DID apply for an FY16 FC 647-B2 grant do not need
to complete this Part III document. They only need to submit Parts I and II (signature and budget pages) – see
the RFP’s Required Forms section.

Section VIII (in this document) provides additional details about completing budgets.

Section IX (in this document) is only required for applicants requesting FC 245-A; it requests information
regarding students served with these enhancement grant funds.
DUE DATE REMINDER: The Part I-II Excel Workbook (signature pages and budget/budget narratives) and a
scanned signed Part I page are due on or before August 17, 2015. This Part III document and all other required
forms are due on or before September 18, 2015. (See Funding Opportunity RFP Due Date and Submission
Instruction sections for more details.)
I.
PROGRAM SUMMARY INFORMATION
School District /
Applicant
Agency:
Program
Coordinator /
Contact:
Phone:
Email:
Total Number of
ELT FC647-A sites for
which you are applying
for continuation funding.
Total Number of
OST FC647-A sites for
which you are applying
for continuation funding.
Total Number of
FC 245-A sites for
which you are applying
for continuation funding.
For ELT FC 647-A sites:
Amount requested for 9/1/2015 - 6/31/2016:
$
For FY13 647-B1 OST sites with rollover funds:
Amount requested for 9/1/2015 - 12/31/2015
$
For all other OST FC 647-A sites:
Amount requested for 9/1/2015 - 6/31/2016:
$
Amount requested for 7/1/2016 - 8/31/2016:
$
TOTAL REQUESTED FOR FC 647-A (ELT + OST):
$
Amount requested for 9/1/2015-6/31/2016:
$
Amount requested for 7/1/2016-8/31/2016:
$
TOTAL REQUESTED FOR FC 245-A
$
1
Name of Grant Program: Massachusetts 21st Century Community Learning
Centers Program - Continuation Grant
Fund Code: 647-A / 245-A
II. SCHOOL/SITE DATA REPORTING (647-A) OST sites ONLY; ELT sites should skip to section III
question 2
(Please copy and paste this chart and then complete for each site for which you are applying for FY16 FC
647-A OST funds.)
Note: Please read instructions on page 1 before competing information below.
Is this site also
receiving
FC 245-A funds? (OST
only) (Y/N)
SITE NAME
If this is an Exemplary Site
indicate level (X in Appropriate Box)
Prac.
FY15
Number of
Students
Demo
FY15 %
SPED
FY16
Projected
Number of
Students
FY15
Mean
Hrs
FY15% Economically
Disadvantaged
FY15 % ELL
SAYO-Teacher
ELA
Math
H
W
Behavior
Initiative
Engage
-ment
Problem
Solving
Communication
Relations
Adults
# Students
Pre Mean
Post Mean
% Change
Pre to Post
SAYO-Staff
Learning
Skills
Behavior
Initiative
Engagement
Problem
Solving
Communication
Relations
Peers
Relations
Adults
# Students
Pre Mean
Post Mean
% Change
Pre to Post
2
Name of Grant Program: Massachusetts 21st Century Community Learning
Centers Program - Continuation Grant
Fund Code: 647-A / 245-A
III. ADDITIONAL PROGRAM AND DATA INFORMATION (647-A)
OST sites ONLY should respond; ELT sites should skip to question 2
REQUIREMENT
Indicate if these requirements were met. For any not
met, please provide a brief explanation as to why.
Utilize the chart on the next page under letter D
other to describe key strategies that will used to
address how you will meet this requirement
Served the projected number of participants?
Served higher than school-wide percentages of the targeted
students that this grant was intended to serve?
Offered the required minimum of 448 hours of operation for
the school year and summer?
(For each site that did not offer the required minimum, please
indicate in parentheses next to the site how many hours were
offered.)
Note ONLY OST sites need to respond to question 1 (ELT sites skip to question 2)
1.
(Data Analysis): What does data suggest about what may or may not be working at each funded site? Keep
the following in mind when crafting your response:

SAYO: Did the sample size (e.g., number of youth sampled from each grade, number of
English Language Learners (ELL), free and reduced lunch, special education, etc. have any
effect on the results? Did any outcomes have zero or negative percentage changes? Did any
outcomes have particularly high percentage changes (> 25 percent)? Did results vary by
differing groups of students e.g., grade levels, students with high /low participation rates,
students with special needs, English language learners, etc.? If so, what might this suggest
about the data?

In addition to SAYO, did you look at district/student benchmark data, school attendance, state
assessment growth data, discipline data, etc. for students that participated in funded activities?

Were administrators and program staff engaged in data examination the process?
2.
(APT observations): Describe the process used to implement the APT (Assessment of Program Practices
Tool). Include the APT team members, number of observations conducted, and a synopsis of the findings
(strengths and areas for improvement) for each site.
3.
Based on information provided from Q.1: Data Analysis (If OST) and 2: APT observations (for all sites) as
well as information provided in the mid-year report, complete the following Action Planning Template on the
next page. Identify at least one priority under each category for improvement, and be sure to include specific
areas of ELA and/or mathematics that are prioritized.



State EACH specific priority in one to two sentences. Indicate whether it is a new or ongoing priority.
Briefly outline or bullet the key possible strategies to be implemented for each priority,
highlighting the type of programming/support.
Describe how the APT or other tools will be used to monitor progress
3
Name of Grant Program: Massachusetts 21st Century Community Learning
Fund Code: 647-A / 245-A
Centers Program - Continuation Grant
III.
ADDITIONAL PROGRAM AND DATA INFORMATION (647-A) - continued
Note: If different sites in the application will have different program priorities, copy and paste this page and
complete one for each site. If all sites have the same priorities, one form can be submitted.
Key strategies or program changes
to be implemented.
Specific priority
area(s) for
improvement:
New or
Ongoing
Priority
Please include the types of
programming/support to be offered
(e.g. service-learning, project-based
learning, social-emotional learning,
professional development, etc.)
How will you use APT
or other tools to assess
progress?
A. Academic Outcomes (MCAS/PARCC, Local Assessments, SAYO-T, etc.)
B. Intermediary Outcomes (SAYO-T and SAYO-S)
C. Youth Outcomes (SAYO-Y)
D. OTHER (if Applicable)
4.
Please describe the support program(s) will need from the MA 21st CCLC Program, 21st CCLC Regional
Networks, or other source(s) to help staff implement the above-identified strategies for improvement.
5.
If a site(s) offer blended learning, academic support, and/or homework support describe how the time was
used to assist students with a better understanding of content and any changes that will occur in FY16.
As you are aware Federal law mandates that private school administrators be consulted regarding programs and
services provided through the 21st CCLC grant.
6.
Indicate if your site(s) provided services to private schools or private school students/teachers in your
geographic vicinity. If yes, describe the service provided. If applicable, include the number of students
served from private schools.
4
Name of Grant Program: Massachusetts 21st Century Community Learning
Centers Program - Continuation Grant
III.
Fund Code: 647-A / 245-A
ADDITIONAL PROGRAM AND DATA INFORMATION (647-A) - continued
7. Complete the chart below describing one service-learning (SL) or project-based learning (PBL)
activity implemented in FY15 at each funded site and resulting impact. (Reminder: All grantees are
required to implement at least one SL or PBL activity at each funded site per year.) Insert rows if needed.
Site Name
8.
Activity
Type
(SL or PBL)
Provide a brief summary of one
SL or PBL activity implemented
Resulting FY15 successes (provide
evidence to support), or FY16
enhancements that will be made
For OST programs only, very briefly describe plans for providing a summer program. More detailed plans
will be required as part of the mid-year evaluation.
IV. STAFF/STAFF DEVELOPMENT (647-A)
1.
If there will be a new district or site level coordinator in FY16, describe his/her/their credentials, any
previous related experience, and the type of support that will be provided to assist them in the transition. If
not applicable indicate NA.
2.
Describe the make-up and credentials of the staffing used to support 21st CCLC projects/activities in FY15,
and any changes that will occur in FY16.
3. A. Will the district/program provide any of the following in FY16? Indicate with an “X” any/all that apply.
___ Staff planning time (If yes, how much time is provided?)
Please Note: The Department strongly recommends providing planning time. (Include how much
time is allotted.)
___ Collaborative planning time
___Staff meetings (Include how frequently they will be held.)
___ Professional development/technical assistance specific to supporting implementation of
the 21st CCLC program (For any PD/TA described, please indicate whether the local program is
providing it, or if it is desired from the state or regional networks.)
B. Do the contracted staff and or partners participate in any or all of the above?
5
Name of Grant Program: Massachusetts 21st Century Community Learning
Centers Program - Continuation Grant
Fund Code: 647-A / 245-A
IV. STAFF/STAFF DEVELOPMENT (647-A) - continued
4.
Please highlight any specific projects, programs or strategies that were implemented as a result of
participation in state, regional or local PD/training. Please cite the training(s) attended and if it was a
state, regional, or locally sponsored workshop (e.g. district sponsored, service-learning, promising
practices forum, FitMath, Scratch, etc.).
5.
If applicable, please describe the ways in which the coordinator and/or program staff benefitted from a peer
visit, mentoring, and/or peer support in from another 21st CCLC program. (If not applicable, please write NA.
V. PARTNERS/CONTRACTED PROVIDERS (647-A)
1.
If the program(s) partnered and/or contracted with outside vendors/community-based agencies, describe
any training or technical assistance provided and the process used to maintain ongoing planning and
communication.
2.
Use the chart below to list the Partners/Contracted providers utilized in FY15. *Partners are defined as
individuals or agencies that contribute back to the program and collaborate to achieve mutually beneficial
goals.) **Contractors are defined as individuals or agencies that primarily receive payment for services
provided.
PARTNERS/ CONTRACTORS
PARTNER*/CONTRACTOR** NAME
INDICATE IF
PARTNER (P) OR
CONTRACTOR (C)
BRIEFLY DESCRIBE PROGRAMMING PROVIDED AND
HOW IT CONNECTED TO AND SUPPORTED STUDENT
NEEDS AND SELECTED SAYO OUTCOMES.
WILL
CONTINUE
IN FY16
YES (Y)
NO (N)
VI. SUSTAINABILITY/ADDITIONAL SOURCES OF SUPPORT (647-A)
1. Describe strategies employed to sustain the program beyond the funding cycle.
6
Name of Grant Program: Massachusetts 21st Century Community Learning
Centers Program - Continuation Grant
Fund Code: 647-A / 245-A
VI. SUSTAINABILITY/ADDITIONAL SOURCES OF SUPPORT (647-A) - continued
2. Complete the chart below listing, by funding category, other (non-21st CCLC) grant funding and resources
maximized and leveraged to support 21st CCLC programming.
For each site list the source(s) and amount of additional resources secured or anticipated that will
support any or all of the categories below. NOTE: The funds listed below may be actual funding or
the value of in-kind contributions.
Funding
Category
Staffing (example)
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)
Title I $2,500
Title III $1,500
School Budget
$3,000
TOTAL Anticipated
Non-21st CCLC Funds
Site 4
(list site name below)
EEC
Vouchers/Reg.Fees
$5,000
TOTAL Anticipated
Non-21st CCLC
Funds
Site 5
(list site name
below)
McKinney Vento
$5,000
Staffing (including,
but not limited to,
administrators,
instructional staff,
planning time,
substitutes, etc.)
Professional
Development
Partners/Vendors
Materials/Supplies
Transportation
Other: (please
describe below)
Total Anticipated
Non 21st-CCLC
FY16 Costs
Note Regarding Registration Fees: OST PROGRAMS MAY CHARGE FEES PROVIDED THEY DO NOT PROHIBIT ANY FAMILY
FROM PARTICIPATING FOR FINANCIAL REASONS. 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.
3. If the OST program 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.
Programs must be equally accessible to all students targeted for services, regardless of their ability to pay.
7
Name of Grant Program: Massachusetts 21st Century Community Learning
Centers Program - Continuation Grant
Fund Code: 647-A / 245-A
VII. MENTORING / REGIONAL NETWORKS (647-A)
PROMISING, PRACTITONER (FORMERLY CALLED EXEMPLARY), AND DEMONSTRATION SITES ONLY
1. Use the Mentor/Exemplary Grant Requirements Log below to document the required mentoring related
activities.
MA 21st CCLC 2014-2015 Mentor/Exemplary Grant Requirements Log
Mentor Name(s)
District/Program
Site(s)
Mentee Name
(if applicable):
District/Site(s)
Add additional rows if needed
Date of
conversation/training
conducted:
If applicable, type of
conversation (meeting,
phone, email, etc.):
How long (in 1/4 hour
increments):
Topic of Conversation/Training:
8
Name of Grant Program: Massachusetts 21st Century Community Learning
Centers Program - Continuation Grant
Fund Code: 647-A / 245-A
VIII. BUDGET (647-A and 245-A)
1. If you have used grant funds to purchase any type of electronic equipment such as laptops, hand held devices
(iPads, Nooks, etc.), camera’s, printers or other type of media equipment it is now required that you have a
process in place to inventory and track these items. Describe the process you currently use, or will be using, to
inventory and track electronics purchased with grant funds.
2. Each Part II Budget Workbook (Excel file) is four pages and includes a budget and an associated budget
narrative. Submit one (School Year) Part IIA/IIB Budget/Budget Narrative Excel file for expenditures that will
occur September 1, 2015 - June 30, 2016. Summer budgets (for OST and FC 245-A sites) for expenditures
that will occur July 1, 2016 - August 31, 2016 do not need to be submitted until mid-year reports are due
(details to be sent later in the year to grantees).
BUDGET RELATED REMINDERS:
1. For FC 245-A enhancement grant applicants, submit separate budget files for the enhancement grant funds,
and submit at this time for school year expenses only.
2. In constructing the budgets, please make sure for all stipend positions and contracted providers to provide the
rate (hourly or flat fee) or number of staff and Full Time Equivalent (FTE) information on the budget pages.
3. All costs must be reasonable and necessary to implement program activities. Additionally, budget narratives
must demonstrate clear and specific links to the project activity plan. Please be as specific as possible
describing budgeted materials and supplies.
4. Out of state travel to attend conferences is not allowed, other than for the U.S Department of Education’s 21st
CCLC Summer Institute.
5. Field trips are an allowable expense provided they connect to and support program activities and outcomes.
Out of state student field trips beyond the local region must be approved in advance by the Department’s 21 st
CCLC program Coordinator. Field tip expenses should be budgeted under line 8 other costs
Memberships/Subscriptions/Computer Licenses.
6. 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 typically part of the school day are not allowable expenses under this grant.
7. If the budget includes contracts with any outside vendors/community-based agencies you must attach a
budget/budget narrative for each contracted provider. Contracted providers must be held to the same budget
requirements as the grantee.
8. No more than 10% of the budget may be used on materials and supplies; and no more than 22.5% of the total
budget may be used for program coordination and administration.
9. For non-public school districts to take indirect, (non-exemplary sites only) you must have applied for and
received an approved FY16 indirect rate. Indirect is capped at 5% for those whose approved rates are
higher.
(See next page for IX. FOR APPLICANTS REQUESTING FC 245-A CONTINUATION GRANTS FOR
ENHANCED PROGRAMS FOR STUDENTS WITH DISABILITIES SECTION)
9
Name of Grant Program: Massachusetts 21st Century Community Learning
Centers Program - Continuation Grant
Fund Code: 647-A / 245-A
IX. FOR APPLICANTS REQUESTING FC 245-A CONTINUATION GRANTS FOR ENHANCED PROGRAMS
FOR STUDENTS WITH DISABILITIES (245-A)
Please respond to all of the questions below, regarding students served with these funds.
A. PROGRAM INFORMATION (FC 245-A)For each funded site:
1. Where you able to reach the projected number of participants on Individualized Education Programs
(IEPs)? If not, explain why and how this will be addressed in the coming year.
2. Describe the following:
 Programmatically what worked well this year? Provide evidence that supports how the enhancements
contributed to increased achievement, healthy development, and socialization for students on an IEP.
Describe the process used to ensure activities were fully inclusive and students with disabilities were
engaged with peers without disabilities.

Summarize at least two of the program’s most successful accomplishments, over the past year with
regards to FC 245. At least one should be programmatic and include a project that highlights the
accomplishments of the program and provides specific examples of ways in which the learning and
developmental needs of the participants were supported. Samples of lesson plan templates, etc. may
be attached to the proposal. Include plans for continuing to support the academic and developmental
needs of students on IEP’s in FY16. Please note these accomplishments will be share with the
Department’s Office of Special Education Policy and Planning.
3. Programmatically what did not work well this year, or did not work as well as intended?
 Describe any changes or enhancements that will be made in FY16 to better support students on IEPs.
4. Describe the process 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.
B. STAFF/STAFF DEVELOPMENT (FC 245-A)
1. Describe the following:
 If additional staff were hired to support the students on an IEP describe their credentials and role in the
program (e.g., inclusion specialist, 1:1, etc.).
 Any professional development that was provided to all staff, specific to including students on IEP’s.
Include by whom the PD/training was provided, who attended, and the overall effects on program
quality.
 Any changes to staffing that will occur in FY16.
C. SUSTAINABILITY (FC 245-A)
As noted in the FY15 continuation and non-competitive Funding Opportunity RFP documents, continued funding,
pending budget appropriations, will be available through the 21 st CCLC grantee site's final year within its FC 647-A
funding cycle (for a maximum of 3 years). FY16 FC 245-A grant entities may request up to 85% of their FY15 FC
245 award (with a 15% match expected), and/or up to 75% of their FY14 award (with a 25% match expected),
whichever is applicable.
1. Describe additional financial resources and in-kind contributions secured to support sustainability efforts
and ensure that each site will continue to meet the requirements of the FC 245-A grant.
2. COMPLETE THE CHART ON THE NEXT PAGE LISTING THE GRANT FUNDS AND THE OTHER SOURCES DESCRIBED IN #1
ABOVE THAT WILL BE LEVERAGED TO SUPPORT THE SPECIFIC FUNDING CATEGORY.
10
Name of Grant Program: Massachusetts 21st Century Community Learning
Centers Program - Continuation Grant
Fund Code: 647-A / 245-A
IX. FOR APPLICANTS REQUESTING FC 245-A CONTINUATION GRANTS FOR ENHANCED PROGRAMS
FOR STUDENTS WITH DISABILITIES (245-A) - continued
C. SUSTAINABILITY (FC 245-A) – (continued)
For each site list the source(s) and amount of additional resources (non FC 647 and non FC 245)
secured or anticipated that will support any or all of the categories below. NOTE: The funds
listed below should be specific to supporting the FC 245 grant (e.g. district support for
transporting students on an IEP that requires a specialized bus) and may be actual funding or
the value of in-kind contributions.
Funding
Category
Staffing (example)
TOTAL Anticipated
Non-21st CCLC
Funds
For FC 245-A Site 1
(list site name below)
TOTAL Anticipated Non-21st
CCLC Funds
For FC 245-A Site 2
TOTAL Anticipated Non-21st
CCLC Funds
For FC 245-A Site 3
(list site name below)
(list site name below)
$1,000 Special Education
Funds
Staffing (including, but not limited
to, administrators, instructional staff,
planning time, substitutes, etc.)
Professional Development
Partners/Vendors
Materials/Supplies
Transportation
Other: (please describe below)
Total Anticipated Non 21stCCLC FY16 Costs
11