Name of Grant Program: Massachusetts 21st Century Community Learning Centers Exemplary Programs Grant
Fund Code: 647-B2
Part III - A Required Program Information –
Cover Sheet and District Summary Information
Cover Sheet
Applicant
Agency:
Program
Coordinator:
Address:
Phone:
Email:
Below please list the sites included in this
application in the corresponding level for
which they seek funding for FY17.
Site Name
Promising Expanded Learning Time (ELT)
FY14-Fund Code 647-B1A Grantee
Promising Out-of-School Time (OST)
FY14 Fund Code 647-B1B Grantee
Demonstration
FY14 Fund Code 647-B2 Grantee
Total FY17 21st CCLC Fund Code 647-B2 Funds Requested
% of Original Grant Award Funds that will be matched in FY17
(As noted in the RFP Funding section, applicants are required to demonstrate through a combination of
matching funds, in-kind resources, and/or collaborations/partnerships their ability to sustain their current
programming levels and/or enhance the amount and quality of services offered.)
Amount/Value ($) of FY17 Match
FY17 Fund Code 647-B2 Part III-A - Required Program Information - page 1
$
%
$
Name of Grant Program: Massachusetts 21st Century Community Learning Centers Exemplary Programs Grant
Fund Code: 647-B2
Instructions for completing this document:
 Please address each of the applicable questions below within the indicated page limits.
 Responses should be provided within this document leaving the questions above each response.
 Please do not delete questions that are not applicable – this will re-number questions and may lead
to confusion in responding to questions that reference earlier questions.
 Please do not change the font size or margins.
 All questions are shaded in gray and responses should be written in the white space below each
question.
 Narrative and/or bulleted responses are acceptable.
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 how the 21st CCLC ELT and/or OST grant(s) supports district goals and improvement efforts
in the applicant sites. Note: The response to this question should provide a general overview of the
district needs and strategies and specific details on added value. School-specific needs/priorities will
be described in the School/Site Implementation Plan.
2. Describe the planning process for developing this proposal. Include a list of the team members that
contributed to its development and their respective roles. Describe the process for gathering input
and “buy-in” from key stakeholders (including teachers/staff, parents, students, and community
partners).
3. Describe how the district (and lead applicant, if not the district) and the proposed school(s)/site(s)
have collaborated to support implementation of this grant. Please address the following in your
response:
 How the district (and lead applicant if not the district) and proposed school(s)/site(s) have
collaborated to support the goals described above.

How the district (and lead applicant if not the district) and proposed school(s)/site(s) have
collaborated on budgetary decisions.

How the 21st CCLC coordinator fits into the district organizational structure.

How leadership development for the district 21st CCLC coordinator (if applicable), school/site level
coordinator(s), and program staff including partners and contracted providers is encouraged and
supported.
4. Describe the lead applicant’s participation in the 21st CCLC regional networks, how the
program(s)/staff have benefitted, and any ideas for how the networks may be improved.
5. Describe how the district will ensure that students travel safely to and from the school/program.
Note: Federal regulations require that all 21st CCLC grantees describe a plan for transportation of
students. [ELT] Please describe how students travel to and from school as well as any OST or partner
programming.
FY17 Fund Code 647-B2 Part III-A - Required Program Information - page 2
Name of Grant Program: Massachusetts 21st Century Community Learning Centers Exemplary Programs Grant
Fund Code: 647-B2
6. Describe the additional resources, other than this grant, that demonstrate efforts to sustain the 21st
CCLC program and/or enhance the amount and quality of services offered. Be specific in describing
the actual dollar amount and/or in-kind value. Please note unless the applicant is a non-school district
use of school buildings and/or school equipment is not considered a sustainability strategy. Note: The
listing of additional resources may be provided in chart, bullet, or paragraph format.
In responding to this question please also include all of the following:
7.

Ways in which the lead applicant contributes financially and non-financially towards sustaining
the applicant site(s).

How this grant is/will be coordinated with other federal, state and local programs with
compatible/complementary services [e.g., McKinney-Vento, Title I, Title III, Adult Basic
Education, wrap around services, After-School and Out-of-School Time Quality (ASOST-Q)
grants, Department of Early Education and Care, etc.]

Planned/anticipated financial or other support from partners.

Other public or private financial and/or in-kind support.
If the applicant is not a 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 including completion of SAYO
surveys.
b. The system for sharing pertinent data including state and other school/student assessment data
(with appropriate confidentiality).
B. District Mentoring (2 pages maximum, not including chart)
1. OST Demonstration sites only- Use the Mentor/Exemplary Grant Requirements Log below to
document the required mentoring related activities conducted by the district coordinator during the
current/concluding funding cycle (that ends August 31, 2016).
MA 21st CCLC 2014-2015 Mentor/Exemplary Grant Requirements Log
Mentor Name(s)
Mentee Name
(if applicable):
District/Applicant Site(s)
Add additional rows as needed
Date of
conversation/peer APT
visit / training
conducted:-
Site visited (if applicable)
Was APT submitted
online
Yes/No
Topic of Conversation/Training
FY17 Fund Code 647-B2 Part III-A - Required Program Information - page 3
Name of Grant Program: Massachusetts 21st Century Community Learning Centers Exemplary Programs Grant
Fund Code: 647-B2
2. ALL APPLICANTS: Describe and provide specific examples of the ways in which the district can/will
serve as a resource and mentor. Refer to Addendum G - Mentoring Expectations which can be found
in the Funding Opportunity RFP’s Required Forms section.
Budget Notes/Reminders:

Complete the Part I Signature Page for school year (SY) and summer, and the Part II Budget and
Budget Narrative Pages - for SY expenditures that will occur September 1, 2016 through June 30,
2017 and for Summer for expenditures that will occur July 1, 2017 through August 31, 2017.

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 allowed with
approval from the Department’s 21st CCLC Coordinator for appropriate and reasonable requests
(such as a field trip a few miles away for grantees that live close to border states) or to attend the
U.S. Department of Education’s 21st CCLC Summer Institute typically held in July.

Programs may charge a nominal fee to help offset costs however; 21st CCLC funded 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.

Funded applicants requesting to subcontract funds through Line 5, Contractual Services, will be
required, upon awarding of the grant, to submit a detailed budget for each vendor that will receive
$5,000 or more. Vendors must follow the fund use requirements described in the Fund Code 647-B2
Grant RFP. Indirect Costs are not allowed for Fund Code 647-B2 applications. Costs normally
charged to indirect may be considered in-kind or an additional resource.
FY17 Fund Code 647-B2 Part III-A - Required Program Information - page 4