HomeMy WebLinkAboutExhibit 20-en s u rust
ilication Forms
!livery Site Locations:
for applicants with more than one service delivery site location:
nation within the remaining sections of the Application Forms varies across site locations, specify within each section this variation by
applicable sites. If all details are identical across sites, there is no need to reference specific sites throughout the worksheet narratives.
Site Name:
Site Contact Person:
intact Person E-mail:
a school -based site?
❑ Summer Only
YES
NO
0 After -school Only
imber of Unduplicated
icipants to be Served:1 Numbers to be Served by Population Type (total should equal total number listed above):General Population
At -Risk Participants
Street Address:
City:
Fax Number:
Hours of Operation:
Zip Code:
Idren with Disabilities (
Phone Number:
Days of Operation:
0 Year -Round Program Start Date:
From age
(in years):
End Date:
Up to age
(in years):
Site Name:
Site Contact Person:
ontact Person E-mail:
a school -based site?
0 Summer Only
umber of Unduplicated
rticipants to be Served:
i Numbers to be Served by Population Type (total should equal total number lilted above):
Street Address:
City:
LJ YES U NO
0 After -school Only
Phone Number.
Days of Operation:
❑ Year -Round Program
iildren with Disabilities ( At -Risk Participants
Start Date:
From age
(in years):
Fax Number:
Hours of Operation:
Zip Code:
End Date:
Up to age
(in years):
General Population
Site Name:
Site Contact Person:
;ontact Person E-mail:
s a school -based site? 0 YES 0 NO ❑ Summer Only El After -school Only ❑year -Round Program
lumber of Unduplicated I
rticipants to be Served: I
d Numbers to be Served by Population Tye (total should equal total number listed above):
(
Street Address:
City:
Phone Number:
Days of Operation:
hildren with Disabiiitiest At -Risk Participants
Start Date:
From age
(in years):
Fax Number:
Hours of Operation:
Zip Code:
End Date:
Up to age
(in years):
General Population
ency Name in Footer
12/30/2005
Page 11 of 24
G1i a 1 1 Y.74.
ication Forms
ne
Instructions: If different service delivery
C terra column. If s serve different
primary serve the sametions, prima{ryteach participant group on a separate popula n, there is no need to reference specific note
erve each group in the Selection
worksheet.
PULATION ,HOW MANY ;CHARACTERISTICS of expected RECRUITMENT strategies and `SELECTION CRITERIA are factors
anticipate in the are expected ;participants, including age, gender, activities that will be used to inform :used to screen participant eligibility .
, children, parents, to participate ,race, ethnicity, income level, and engage the described participants for participation (e.g., attendance at
-ers, other
embers)
neighborhood, school performance, and into the program
'other risk factors that will be used to
'guide recruitment efforts. If serving
-children with disabilities, specify. types,
a particular school, residenc
e
particular neighborhood, income
below poverty level). If program is
;open to anyone, put NIA here.
_ncy Name in Tooter
12/30/2005
Page 12 of 24
3n s 1 rusl
ication Forms
Site instructions: If different service delivery sites have varying program goals, outcomes or activities, list each one on a separate line at
which each applies. if all sites follow the same goals, outcomes and activities, there is no need to reference specific sites on this worksh•
are statements of purpose or specific
tlining what the program expects to
ish in broad terms
V47C117 ■vVtl�Jll�.r+L
OUTCOMES are the realistic, measurable expected ACTIVITIES are what the staff will actually do for,
changes and benefits for the people served as a result of to or with participants to achieve the outcomes.
program participation List/name activities briefly in this column, as they
will be described in more detail in a later section.
Required Program Components are noted below.
List Literacy Component
List Physical Activity/Fitness Component
List Social Skills Development Component
List Family Involvement/Outreach Component
List Nutrition Services Component
List Additional Optional Progam Components
ancy Name in Footer
12/30/2005
Page 13 of 24
lication Forms
e Instructions: if different service delivery sites have varying outcome measures, list each one on a separate line and note the sites to which each applies.
collect the same outcome measures, there is no need to reference specific sites on this worksheet.
ES are the realistic,
expected changes and
r the people served as a
ogram participation and
related to the described
characteristics and risks
in will be automatically
[he outcomes listed on the Documents section, in the order
indicated in Table of. Contents)
rksheet)
INDICATOR MEASUREME
the tools, tests and measures that will indicate where and how information
be used to specify the evidence to be will be collected (e.g., observations
collected to measure how well a by staff, school system data, self -
program is achieving its outcomes report surveys, etc.), managed,
(Attach copies of the proposed ,stored and analyzed
measures in the Supporting
0
0
0
0
0
0
0
0 .
0
0
0
0
0
0
0
0
0
0
0
0
0
a
0
0
0
0
0
0
NTS are DATA SOURCES & METHODS TIME OF MEASUREMENTS
indicates when measures will be
obtained (e.g., every 3 months, at
program completion, 6 weeks after
the program, etc.) & WITH WHOM
indicates who will complete each
measure (e.g., parent, child, teacher,
staff, etc.)
STAFF
position
responsible
for the
collection of
each indicator
measure
lency Name in Footer
12/30/2005
Page 14 of 24
:I I .0 1 I U01.
'cation Forms
Int+1.1V 11.166v.....
Instructions: If different service delivery sites have varying activity components this should be noted within the Goals worksheet, and will
Ily show up in the Activities column below.
are what the program staff will
ar, to or with participants (e.g.,
ents, interventions, etc.) to
h outcome for program
(this column will be automatically
e activities listed on the Goals
Component -
Activity/Fitness Component
;kills Development Component
nvolvementiOutreach Component
Services Component
ial Optional Progam Components
NUMBER
expected
to receive
each
.activity
0
0
0
0
0
0
0
0
0
a
0
0
a
0
a
0
0
a
a
0
0
0
ACTIVITY DESCRIPTION includes the details for each program activity, including the approach or model being
used (referencing evidence-based/best practices when applicable), how the activity will be provided in an engaging
manner, the materials to be used. how materials will be selected. and how participants will be assessed to ensure
activities are tailored to the appropriate ability levels. Activities should include all required components stated
within the bid solicitation.
Rows will expand with text to allow sufficient space to describe all activities.
ATTACH a Schedule of Daily Activities (and Field Trips if applicable) that details when activities will be conducted.
Include documents) in the Supporting Documents section, in order indicated by Table of Contents.
:ncy Name in Footer
12/30/2005
Page 15 of 24
en's Trust
lication Forms
Site Instructions If different service delivery sites have varying activity components this should be noted within the Goals worksheet, and will
cally show up in the Activities column below.
"IES are what the program
actually do for, to or with
rots (e.g., providing events,
lions, etc.) to achieve each
for program participants
umn will automatically be
the activities listed on the
Vorksheet)
:racy Component
isical Activity/Fitness
rnent
dal Skills Development
ment
mily Involvement/Outreach
anent
itrition Services Component
iditional Optional Progam
orients
INPUTS & RESOURCES required to
fully accomplish activities and
outcomes, including staffing (i.e.,
responsible parties) and other financial,
organizational, and community
resources (e.g., training, space,
equipment, etc.), as should be reflected
within the program budget
0
0
0
0
0
0
a
0
0
0
0
0
0
0
0
0
PLANNED
FREQUENCY of
how often the
activity will be
delivered (e.g.,
:daily, once a
week, 3 times a
year, etc.)
PLANNED
INTENSITY of
how long each
activity session
will last (e.g., 15
minute check -in,
2 hour class,
etc.)
PLANNED
DURATION
includes the total
time frame within
which
participants will
be involved in
the activity
(e.g.,1-time only,
6 weeks, all
school year)
OUTPUTS are the direct
products and evidence of
service delivery and the work
of the program, including the
volume of work accomplished
(i.e., # participants,
attendance, # classes offered,
# brochures distributed, etc.)
12/301200;
Page 16 of 2i
ency Name in Footer
en's Trust
Iication Forms
ERAL
Mon Name:
Person:
:NCY BUDGET
0
0
0
0
Source of Funding
ildren s Trust Requested Grant Amount far Program
ievelopment Services Funds
Dade County Grants(Local)
Agency Fiscal Year Begins: 0
Fax: 0
Funding/Grant Period
Agency and Program nuageL
Areas in Blue to be completed by the Agency
E-mail: 0
Program Budget Agency Budget
0.00
0.00
0.00
. Services Coalition
0.00
0.00
r! Grants (Specify Source)
f Education
wants (Sped Source)
)f Education
clarions/Charitable Funds (Sped Source)
JFees/Other Revenue (Specify Source)
"ind Contributions
BUDGET SUMMARY FOR PROPOSED PROJECT/PROGRAM
TEGORY
sonnet
ngc Benefits
crating
lirect/Administrahive Costs TOTAL REQUESTED
REQUESTED AMOUNT DESCRIPTION
0.00 Salaries
S0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
12/30/2005
Page 17 of 24
,gency Name in Footer
Budget Summary Tor rroposru
an's Trust
ication Forms
d:
4EOF FUNDING SOURCE:
.ARIES.
Full -Time Employees 0. t t CPA 0.00
is Name Annual Salary 0 0.00 ° t' 0.00 0% 0.00
0. 0.tt
O. � t 0.00 0.00 D.00 0% 0.00
0.00 0.00 0.00 0.000.00 0.00 0.00 0% 0.00
O. 0.00 0.00 O. 0% 000
0.00 0.00 0.00„ 0., + 0% 0. t +
Ott 0.00 0.00 O.0.,, 0.'' 0% 0.00
u t, 0.00 0.00 0-00aoo at � 0.00 O. t 0.00 O.
t
Full -Time Total a 0.00
O. 0.00 0.00 0.00
0 00 0.00 0° 0.00
;t Part -Time Employees O. t t 0.00 0.00 u+ 0.00 0% 0.00
O. t t 0.00 0.00 0.O t t t t % 0.00
fl 00 0.00 0.00 0- 0
t t O. 0% 0.00
0.'r 0.00 0.00 O.0.00 O. 0% 0.00
0. � � 0.00 0.00 a
0.00 0.00 0-00 0.00 0. 0.00 0. 0.00 D. 0.00 o. � , aoo ..oD so. � _op sa., � .Do SO.
Part -Time Total50. " .00 50.00 .00 s0.OD
TOTAL FTEs/SAl..ARI .00
Areas in Blue to be completed by the Agency
••1•••120•• to ••!••120•' 0 months
Requested Funding Other Funding Requested or Received
Chidren's Trust Amour
% Amount % Amount
% Amour+
Matching Funds Total
Amour
%
Amour
RINGE BENEFITS
ia/Mica Rate: 7.65%
V-Comp's Rate:
lnemploy Rate:
iealth lns. Cost per Staff
,ife inc. Cosi per Stall
tenement Rate.
3ther Specify & provide calculations
Rate:
Rate.
Rate:
Rate
TOTAL FRINGE BENEFITS
D DO 0.000
0.00 0.00 0.00 0.00
0.00 0.,
0.00 D.00 0.00 0
0.00 0.00 0.00 ,00 0.00 0.00 .
0.00
0.00 0.00 0.00 .00
0.00 0.00 6.00
0.00 0.00 0.00 0.00 0.00 O.t t
0.00
0.00 0.00
0.00 Q.DO
0.00 0.00 0.00 - 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 SO.O50.00 50.00 50.' '
t1
50.00 S0.00
npnr-v Name In Footer
112/30/2005
Page 18 of 24
an's Trust
ication Forms
in Blue to be compkted by the A
IE OF FUNDING SOURCE:
gency
RATING EXPENSES_ Annual Cost
el (other than clients)
1 mileage. tolls, parking
of -town
,eI (clients)
pass/tokens
1 nips?BusesNans
its (clients)
;Is (after school)
Lis (full days)
ce
se/Rent
ntenance
minty
nmunications
1pl'hes
ice Supplies
gram Supplies
sting/reproduction
FpmgFP0stage
n-Capital Equipment (<5750) (List
th)
rpital Equipment (>S750) (List
eh)
rnrasiooal services (List each)
ither (List each)
OTAL OPERATING EXPENSES:
�dministrativdlodircct Costs
Can not exceed 10%)
TOTAL BUDGET
r
Requested Funding
Ch0dren's Trust
Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
S0.00
50.00
Budget Summary for Proposed Program
Other Funding Requested or Received Matching Funds
% Amount % Amount °% Amount
.00 0.00 0.00
.00 0.00 0.00
0.00
0.00
0.00 0.00
0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
000
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00 0.00 0.00
0.00 0.00 0.00
Amount
0.00
0.00'
0.00
0.001
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00.
50.00 50.00 50.00 50.00
0.00
0.00 0.00
0.00
S0.00 50.00 S0.00 50.00
Total
0% 0.00
0°% 0.00
0.00
0.00
0.00
0.00
0% 0.00
0% 0.00
0% 0.00
0% 0.00
0°% 0.00
0°% 0.00
0% 0.00
0°% 0.00
0.00
0°% 0.00
0°% 0.00
0% 0.00
0°% 0.00
0°% 0.00
0% 0.00
0% 0.00
0°% 0.00
0°% 0.00
0% 0.00
so.00
0.00
so.00t
0%
0%
0%
0%
Amount
ency Name in Footer
12/30/2005
Page 19 of 24
ication Forms
.n0..
Name
playas
Ailment
Arms in Blue to be rrnnpleted by the Agony
Detailed Justification for Each line item Credentials -describe staff education
training and key experience
0
0
0
0
0
0%
0
0
npin7ees
0
0%
0%
Foil -Time Total
0.00
0.00
0
0
0
0
0
0
0 09
0 0%
TOTAL
:BENEFITS
•NSES
Part -Time Total
0 0%
0.00 0.00
50.00 0.00
50.00
e clients)
e. Parkin
0.00
0.00
0.00
0.00
1)
0.00
0.00
0.00
0.06
0.00
0.00
0.00
=an
VI UMW (4750} (Last nth
0.00
0.00
0.00
0.00
0.00
3eet (>050)
(List
th
0.00
0.00
0.00
rviers (List each)
0.00
0.00
0.00
0.00
1)
0.00
tATWC EXPENSES:
And Beet Costs
0.00
50.00
1 10%) 1
TOTAL BUDGET
0.00
S0.00
sncv Name in Footer
12/30/2005
Page 20 of 24
'.rl b. 1 IliwI
'cation Forms
20•• to ••I••R0'• 0months
OF SITE LOCATION;
Site Location
1
Site Location 2
Site Location 3
Arras in Blue to be completed by the Agency
Site Location 4
Site Location 5
Total
RIES:
uI1-Time Employees
n Name Annual Salary
O 0 0
O 0 0
O 0 0
0 0 0
O 0 0
O 0 0
O 0 0
Fall -Time Total 0.00
'art -Tune Employees
0 0 0
O 0 0
O 0 0
O 0 0
O 0 0
Fart -Time Total 0.00
" GE BENEFITS
TOTAL FTEsISALARIES
0.00
0.00
+Mica Rate: 7.65%
:omp's Rate: .00%
mploy Rate: .00%
lth Ins. Cost per Staff 300.00
Inc. Cost per Staff 0.00
maent Rate: 0 00
rr Specify & provide calculations
O Rate: 0
0 Rate: 0
O Rate: 0
O Rate: 0
TOTAL FRINGE BENEFITS
Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
.00 S0.00
1'. Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00 0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
.00 S0.00
'h Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00 : 0.00
0.00
0.00
0.00
0.00
0.00
0.00 0.00
.00 50.00
% Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
.0.00 0.00
.00 S0.00
0.00
Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
.00 54001
Amount
0% 0.0G
0% 0.00
0% • 0.00
0% _0.00
0% 0.00
0% 0.00
o% 0.00
0.00 0.00
0% 0.00
0'h 0.00
0% 0.00
0% 0.00
0% 0.00
0.00 0.00
.00 50.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
S0.00
0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00
0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00
0.000.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00
0.00
0.00 0.00 0.00 0.00
S0.00 S0.00 50.00 S0.00 50.00
ency Name in Footer
12/30/2005
Page 21 of 24
ell M. 1 'via'.
lication Forms
m Bute to be completed by the agency.
E OF SITE LOCATION:
ATTT1G EXPENSES:
I (other than clients)
toils, parking
(-town
1 (clients)
nssPokens
trips BusesrVans
s (clients)
ks (after school)
s (lull days)
elRent
tricity
nnrtnications
plim
ae
gram Supplies
ltingkvproduction
pPingfPostage
a -Capital Equipment (. 750) (List
h)
Site Location 1
Site Location 2
Site Location 3 'Site Location 4
Annual Cost
0.
0.
00
00
0.
00
00
0.00
o.
D0
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0 0.00
0 0.00
0 0.00
rpital Equipment (}5750) (List each)
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
00
rafasional Services (List each)
)ther (Litt each)
Administrative/Indirect Costs
Can not exceed 10Y
)
0 0.
0
TOTAL BUDGET
Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
S0.00
% Amount
Site Location 5 Total
0.00
0.00
0,00
D_00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
% Amount
0.00
0.00
0.00
0.00'
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00•
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
o.00'
0.00
50.00 50.00
% Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
• 0.00
0.00
0.00
0.00
% Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0,00
0.00
0.00
0.00
D.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
50.00 SO OD o.Da41 0.00 a.�
1
0.001 1 0.001 S0.00 S0.00 SOA4�
50.00 S0.00 50.00
Amount
0% 0.00
0% 0.00
0% 0.00
0% 0.00
0%
0°%
0.00
0.00
0% 0.00
0% 0.00
0% 0.00
0%
0% - 0.00
0% 0.00
0% 0.00
0% 0.00
0% 0.00-
0% 0.00
0% 0.00
0% 0.00
0% OD0
a% 0.00
0% 0.00
0% 0.00
0% 0.00
0% 0.00
0% 0.00
S0.00
gency Name in Foote(
12/30/2005
Page 22 of 24
ildren's Trust
.pplication Forms
Areas in Blue to be completed by the agency
)verall Program
Jnit Cost (per youth) - General Population
mice Name students # of days otal ho . - U # of Total Cost SO.OD
;unmet Camp
.tmatter After -School
Ho
teacher Planning
h1 k grmtg/Winter/SpringBreaks
'.fur School Days
'Saturdays
Total
Site Location 1
Unit Cost (per youth) - General Population
# of
students Of of days
Sets Name
Summer Camp
Summer After -School
Legal Holiday
Teacher Planning
Thanksgiving/Winterf Breaks
After School Days
Saturdays
Total
Site Location 2
Unit Cost (per youth) - General Population
# of
students # of days otal ho Unit Cost
Service Name
Summer Camp
Summer After -School
Legal Holiday
archer Planning
Thanksgivinelinter/Spring Breaks
After School Days
Saturdays
Total
oral ho
S0.00
- S0.00
S0.00
S0.00
S0.00
S0.00
SO.
Unit Cost 1 Total
50.00
50.
S0_00
SO.
50.00
S0.00
= S0.00
SO
Site Location 3
Unit Cost (per youth) - General Population
# of
students # of days
Unit Cost (per youth)"-: Children with disabilities
#of
Name students # of days Total hours Unit Cost Total
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urruner Camp
ummer After -School
Legal Holidays
cachet Planning
glWittier1Sprmg BTeaks
School Days
aturdays
Total
50.
50.
S0.
S0.00
S0.00
SO.00
S0.00
50.00
otal host Unit Cost Total
50.00
Tarot
Unit Cost (per youth) - Children with disabilities
* of
utudeats j # of days Total hours Unit Cost
'cc Name"
Summer Camp
ummer After -School
Holidays
etcher Planning
inter/Spring Breaks
School Days
Saturdays
Tonal
nit Cost (per youth) - Children with disabilities
#of
erviex Name students # of days otal hours
Stamper Camp
ummer After -School
gal Holidays
richer Planting
Inter/Spring Bomb
fter School Days
rs
Total
Unit Cost
50.00
50.00
S0.00
S0.00
S0.00
S0.00
50.00
50.00
Total
$0.00
50.00
$0.00
S0.00
50.00
50.00
S0-00
50.00
Total
50.00
$0.00
S0.00
50.00
$O 00
S0.00
50.00
50.00
Areas in Blue to be completed by the agency
Unit Cost (per youth) = Children with disabilities
#or
studeau # of days Total hours
Service Name
Summer Camp
Summer After -School
Legal Holidays
After School Days
Unit Cost
Total
$0.00
50.00
50.00
50.00
50.00
S0.00
50.00
50.00
Total
S0.00
50.00
S0.00
S0.00
12/30/200!
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