App Serving as FA

Application Information

Applicant Serving as Fiscal Agent (Applicant Agency):

App Serving as FA

County:

App Serving as FA County

Amount Requested:

App Serving as FA Amount requested

Director of Agency:

Contact Name:

DA Contact

Agency Name:

DA Agency

Phone:

DA Phone

Fax:

DA FAx

Email:

Grant Contact/Project Director: 

These fields will appear blank of the previous question was answered "Yes" and the Grant Contact/Project Director is the same as the Director of Agency. Adjust this language if the placeholders show up

Contact Name:

GC Contact

Agency Name:

GC Agency

Phone:

GC Phone

Fax:

GC FAx

Email:

DUNS Number:

Duns Number Entry

Is the Grant Contact/Project Director the same contact as the Director of Agency?

No

DA Address, DA City 11111

Address:

GC Address, GC City 22222

Address:

Data Collection and Evaluation Contact:

Contact Name:

DCEC Contact

Phone:

DCEC Phone

Fax:

DCEC Fax

Email:

DCEC Contract, DCEC City 33333

Address:

Fiscal Contact:

Contact Name:

FC Contact

Phone:

FC Phone

Fax:

FC FAx

Email:

FC Address, FC City 44444

Address:

Iowa 21st Century Community Learning Centers Request for Applications FY22

21CCLC logo Large_v_v.png

Past Grantee Supplemental Application Information

Have you ever been in non-compliance (received a letter notice from Iowa Department of Education stating non-compliance) with 21CCLC rules and regulations in the past three years? 

Yes

Did you meet your attendance goals for the past two years? (21CCLC funded sites are required to meet their attendance goals at a rate of 70% in year one and 80% by year three)

Yes

Please provide your enrollment numbers for the last three years of your previous 21CCLC grant.

PG Enrollment

Please provide your average daily attendance for the last threes years of your previous 21CCLC grant.

PG daily attendance

Did you meet your academic goals for the past two years?

Yes

How many of your local evaluation goals did you meet over the past two years?

100%

How much have office referrals been reduced over the past five years of your grant?

Over 50%

After 5 years, how many community partners for sustainability have been recruited?

50+

Have you exceeded the snack requirement, by providing a full meal?

Yes

Have you participated in required committee work in the last year? Attended:

All Meetings

Have you attended required Professional Development in the last year? Attended:

All Meetings

How many parent engagement meetings did you have in the last year of your most recent 21CCLC Grant?

1

How many field trips did you provide in the last year of your most recent 21CCLC Grant?

2

Have you provided children with the required snack?

Yes

Are you charging program fees to families?

Yes

Form Documentation

Legal Status of Applicant
Request for Competitive Priority
Minority Impact Statement
Private School Consultation Meeting Log
Sustainability Plan
Past Grantee Sustainability Form (if applicable)
Community Partner Official Notice
Assurances & Agreements Required of All Applicants
Collaborative Signatures

MOUs

Applicants were required to upload at least 5 and up to 10 MOUs. Not all buttons below will have an MOU attached. 

MOU Upload 1
MOU Upload 2
 MOU Upload 3
MOU Upload 4
MOU Upload 5
MOU Upload 6
MOU Upload 7
MOU Upload 8
MOU Upload 9
MOU Upload 10

Proposal Narrative

Abstract (Not scored)

The number of students served:

Abstract # served

The total amount requested per year:

Abstract total amount

The total amount per student:

Abstract total amount per student

abstract copy

Student Needs Assessments (20 possible points) 

student needs copy

Project (24 possible points) 

project copy

Research Base (5 possible points)  

research copy

Management and Sustainability Plan (20 points) 

managemnet copy

Communication Plan (5 possible points)

Partnerships (10 possible points) 

partnership copy

Evaluation (10 possible points) 

evaluation copy

Budget Narrative (10 possible points) 

budget narrative

Supplemental Materials

Before School (BS) Site Operations

Estimated Start Date:

August 1, 2021

Estimated End Date:

August 2, 2021

Total Number of Service Days:

BS Number

Total hours of Before School services per typical week:

BS Total Hours

Monday 

Tuesday

Wednesday

Thursday

Friday

Start Time 

End Time 

Hours 

1

1

1

1

1

2

2

2

2

2

3

3

3

3

3

Saturday

1

2

3

After School (AS) Site Operations

Total hours of After School services per typical week:

AS Total Hours

Total Number of Service Days:

AS Number

Estimated End Date:

August 4, 2021

Estimated Start Date:

August 3, 2021

Monday 

Tuesday

Wednesday

Thursday

Friday

Start Time 

End Time 

Hours 

4

4

4

4

4

5

5

5

5

5

6

6

6

6

6

Saturday

4

5

6

Summer (SUM) Site Operations

Monday 

Tuesday

Wednesday

Thursday

Friday

Start Time 

End Time 

Hours 

7

7

7

7

7

8

8

8

8

8

9

9

9

9

9

Saturday

7

8

9

Estimated Start Date:

August 5, 2021

Estimated End Date:

August 6, 2021

Total Number of Service Days:

Sum Number

Total hours of Summer services per typical week:

Summer Total Hours

Adult Family Member Services

All 21CCLC programs are required to host a minimum of four family-centered events each year. A general rule of thumb is one per quarter. Examples of events include back-to-school celebrations, literacy nights, family game nights, recreational events, guest speakers, and so on. 

Describe Frequency, Duration, and Dosage:

Family Engagement Describe

Estimated Total Number of Adult Family Members Served:*
Total Number of Family Events*
School Name

FE School1

FESch1Fmily

FESch1Adults

FE School2

FESch2Fmily

FESch2Adults

FE School3

FESch3Fmily

FESch3Adults

Form D1: 21CCLC Application Funding Request Summary
 

21CCLC TOTAL FUNDING REQUEST 

(Before and/or After School and Summer Program Funds) 

D1 Number prog

Number of program sites included in this application:

D1 Numbers served

Total number of students being served (all sites for one year):

D1 first year

Total first-year funding request (all sites):

Total three-year funding request (all sites):

D1 three year

FUNDING FOR EACH SITE INCLUDED IN THIS APPLICATION 

NOTE: A program site may serve students from many schools. For example, a location that serves students from three (3) different schools would be considered one Program Site. 

Name of Program Site(s) 
Year 1 Funding Request 
Year 2 Funding Request 
Year 3 Funding Request 
Total Funding Request 
(3-year total) 
Number of Students Served per site per year 

D1SchPro1

D1SchPro1Y1

D1SchPro1Y2

D1SchPro1Y3

D1SchPro1Y1-3

D1SchPro1NumServed

D1SchPro2

D1SchPro21

D1SchPro2Y2

D1SchPro2Y3

D1SchPro2Y1-3

D1SchPro2NumServed

D1SchPro3

D1SchPro3Y1

D1SchPro3Y2

D1SchPro3Y3

D1SchPro3Y1-3

D1SchPro3NumServed

School Year

Name of Program Site(s) 
Year 1 Funding Request 
Year 2 Funding Request 
Year 3 Funding Request 
Total Funding Request 
(3-year total) 
Number of Students Served per site per year 

D1SumPro1

D1SumPro1Y1

D1SumPro1Y2

D1SumPro1Y3

D1SumPro1Y1-3

D1SumPro1NumServ

D1SumPro2

D1SumPro2Y1

D1SumPro2Y2

D1SumPro2Y3

D1SumPro2Y1-3

D1SumPro2NumServ

D1SumPro3

D1SumPro3Y1

D1SumPro3Y2

D1SumPro3Y3

D1SumPro3Y1-3

D1SumPro3NumServ

Summer School

Form D4: Applicant Agency’s Fiscal Resource Information 

It is recommended that each applicant, including school districts, public entities, or government agencies, possess sufficient fiscal resources in order to start up and operate the program being requested for a period of up to three months. Please indicate if you are a public entity or a private/non-profit by checking the appropriate box below and then use the text box at the bottom of the page to answer the questions regarding fiscal resources for start-up costs and operational costs. 

Public Entity

In the textbox below, please describe your funding sources that can be used to start up and operate the program for up to three months. For example, public entities should include their budget line item number, account numbers, or any other applicable references. Private organizations should describe cash, lines of credit, emergency loans, etc. Fiscal resource information should be specific (e.g., bank or lender names; name of the holder of the account).

 

* Note: If you do not have the financial resources available equal to the amount of funding you are requesting, you do not have the financial capacity for this project. Agencies that do not have adequate fiscal resources on hand are eligible to participate in the application process. However, the applicant must describe in this section the agency’s plan to secure the necessary fiscal resources for this program application. 

D4 text

Basic Service Components

If location for the program is different from the school where children attend, list both below:

Basic school 2

School or Site/Building Name:

Basic school 1

School or Site/Building Name:

Basic school 3

School or Site/Building Name:
Do you plan to provide any of the following to meet the nutrition/food access needs of students?

Full meal (best practice)

Do you plan to follow best practices?

Yes, we will provide a free program to at-risk students in poverty as outlined in the guidance and consistent with the priority description in the application. All students on FRPL will attend for free. Only parents who can afford the program will pay a fee.Best Practice is that applicants serve a minimum of 50% of FRPL children at each school in the application to receive the bonus points.

 
 

Site Information 

2022-2025 Site Profile 

Site Info School Agency

School/Agency Name:

School Name
(can apply for up to 3 sites) 
School-Wide Information 

Grades Served by School 

Total Enrollment 

Free and Reduced Lunch Rate 

# Targeted Students 

Grades Served by Program 

BS

AS

SUM

Target Schools

Target School 1

TarSch1

TarSch1Enr

TarSch1FRLR

TarSch1Grades

TarBS1

TarAS1

TarSUM1

Target School 2

TarSch2

TarSch2Enr

TarSch2FRLR

TarSch2Grades

TarBS2

TarAS2

TarSUM2

Target School 3

TarSch3

TarSch3Enr

TarSch3FRLR

TarSch3Grades

TarBS3

TarAS3

TarSUM3

Total:

TarBSsum

TarASsum

TarSUMsum