E-mail Address: Federal Employee ID #: Child Care License # (unless exempt school): Past Or Current 21st CCLC Subgrantee Yes No Program Director: Telephone Number: E-mail Address: Fax Number: Subgrant Start Date: Subgrant End Date: Amount Requested: May 1, 2019 November 30, 2020 $ Anticipated Enrollment: Anticipated Enrollment: School Year Summer Anticipated Average Daily School Year Anticipated Average Daily Summer Attendance: Attendance: Anticipated total unduplicated number of students to be served 2019 2020 (30 days or more): – Total Cost Per Student Per Year: $ List the school district(s) this program primarily Please check as many as apply: will serve: Establishment of a new program Expansion of an existing program Check the county(ies) this program primarily Current 21st CCLC Subgrantee will serve: New Castle Kent Sussex New 21st CCLC Subgrantee Activities will primarily serve students and/or their families Yes No attending schools with at least a 40% poverty rate Application reflects a partnership between school/school district Yes No and community agency Assurances have been signed as required Yes No Section 2: Application Information Center Information SCHOOL YEAR – School Building(s) Targeted Student School Building Center Name Number of Students and District Population - Principal (where services Served by of Target Grade Levels Printed Name and are provided) Center Site Student Population and Subgroups Signature* Enrollment: Building: Grade Levels: Subgroups: Average Daily District: Attendance: Average Daily Building: Levels: Enrollment: Subgroups: Average District: Attendance: Average Daily Building: Levels: Enrollment: Subgroups: Average Daily District: Attendance:
E-mail Address: Federal Employee ID #: Child Care License # (unless exempt school): Past Or Current 21st CCLC Subgrantee Yes No Program Director: Telephone Number: E-mail Address: Fax Number: Subgrant Start Date: May 1, 2019 Subgrant End Date: November 30, 2020 Amount Requested: $ Anticipated School Year Enrollment: Anticipated Summer Enrollment: Anticipated Average Daily School Year Attendance: Anticipated Average Daily Summer Attendance: Anticipated total unduplicated number of students to be served 2019 – 2020 (30 days or more): Total Cost Per Student Per Year: $ List the school district(s) this program primarily will serve: Please check as many as apply: Establishment of a new program Expansion of an existing program Check the county(ies) this program primarily will serve: New Castle Kent Sussex Current 21st CCLC Subgrantee New 21st CCLC Subgrantee Activities will primarily serve students and/or their families attending schools with at least a 40% poverty rate Yes No Application reflects a partnership between school/school district and community agency Yes No Assurances have been signed as required Yes No Section 2: Application Information Center Information – SCHOOL YEAR Center Name (where services are provided) Number of Students Served by Center Site School Building(s) and District of Target Student Population Targeted Student Population - Grade Levels and Subgroups School Building Principal Printed Name and Signature* Enrollment: Building: Grade Levels: Subgroups: Average Daily Attendance: District: Average Daily Enrollment: Building: Levels: Subgroups: Average Attendance: District: Average Daily Enrollment: Building: Levels: Subgroups: Average Daily Attendance: District: