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Required Forms

TEESSEE 21st CETURY COMMUITY LEARIG CETERS PROGRAM


Application Cover Sheet

Applicant Agency (name of fiscal agent)


Building Families And Communities Missions Incorporated
Director of Agency: Grant Contact:
Rueben Y. Dockery, Sr., M.Ed. Rueben Y. Dockery, Sr., M.Ed.
Address: Address:
1715 10th Avenue North 1715 10th Avenue North
City: Zip: City: Zip:
Nashville 37208 Nashville 37208
Phone: FAX: Phone: FAX:
(615 ) 498-4669 (615 ) 876-8142 ( 615 ) 498-4669 ( 615 ) 876-8142
Email: Email:
bfcmissions@bellsouth.net bfcmissions@bellsouth.net

Program Summary

1. Total student enrollment in school district(s) served by this project: 70,000


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2. Total number of 21 Century Community Learning Centers program sites/locations: 6 (list below)
Y.C.H.G.P. Training Institute Greater Zion Baptist Church
Westwood Baptist Church University Center Greater Revelation M.B. Church
St. John AME Church Mt. Bethel Baptist Church
Participating School(s) Grade Level Free/Reduced % (RC)
Identify Month Used

Hillsboro High School 9-12 44.9%


Hillwood High School 9-12 59.9%
West End Middle School 5-8 56.9%

3. Total number of children/adults to be served by the 21st Century CLC Funds: 500 per year
Year 1 Year 2 Year 3

4. Total Amount of Grant Funds Requested: $ 706,690.00 $ 632,790.00 $ 505,590.00

Program Types:  all that apply


Academic Support/Enrichment Mathematics/Science Activities Music, Arts, and Drama
Entrepreneurial Programs Recreation Parent Involvement
Tutoring/Mentoring Technology and Communication
Family Literacy/Education Drug/Violence Prevention, Counseling, Character Education
GEERAL ASSURACES

Assurance is hereby provided that: 11. The grantee will use fiscal control and fund accounting procedures as will
1. The programs and services provided under this grant will be used to ensure proper disbursement of, and accounting for, federal funds received and
address the needs set forth in the application and fiscal related information distributed under this program.
will be provided within the fiscal year timelines established for new, 12. The grantee will (a) make reports to the Tennessee Department of
reapplying, and/or continuing programs. Education and the U.S. Secretary of Education as may be necessary to
2. The programs and services provided with federal funds under this grant enable the state and federal departments to perform their duties under this
will be operated so as not to discriminate on the basis of age, gender, race, program; and (b) maintain records, provide information, and afford access to
national origin, ancestry, religion, creed, pregnancy, marital or parental the records, as the department or the U.S. Secretary of Education may find
status, sexual orientation, or physical, mental, emotional, or learning necessary to carry out their duties
disabilities. 13. Each agency receiving funds under this grant shall use these funds only to
3. Administration of the program, activities, and services covered by this supplement, and not to supplant state and local funds that, in the absence of
application will be in accordance with all applicable state and federal such funds would otherwise be spent for activities under this section.
statutes, regulations, and the approved application. 14. The applicant will file financial reports and claims for reimbursement in
4. The activities and programs that will be performed under this grant will be accordance with procedures prescribed by the Tennessee Department of
used to supplement services and not supplant funds from non-federal Education.
sources. 15. No board or staff member of a grantee will participate in, or make
5. The grantee will require the entity and its principals involved in any subtier recommendations with respect to, an administrative decision regarding a
covered transaction paid through federal funds, that requires such program or project if such decision can be expected to result in any benefit or
certification, to ensure it/they are not debarred, suspended, proposed for remuneration, such as a royalty, commission, contingent fee, brokerage fee,
debarment, declared ineligible, or voluntarily excluded from participation by a consultant fee, or other benefit to him or her or any member of his/her
federal department or agency. {EDGAR-Part 85} immediate family.
6. The grantee will evaluate its program periodically to assess its progress 16. Before the plan was submitted, the grantee afforded a reasonable
toward achieving its goals and objectives and use its evaluation results to opportunity for public comment on the plan and has considered such
refine, improve, and strengthen its program and to refine its goals and comment.
objectives as appropriate. 17. Any printed (or other media) description of programs will state the total
7. The grantee will submit to the department such information, and at such amount being spent on the project or activity and will indicate the percentage
intervals, that the department requires to complete state and/or federal of funds from the federally funded programs.
reports. 18. The grantee will adopt and use proper methods of administering such
8. This program will be administered in accordance with all applicable program, including (a) the enforcement of any obligations imposed by law on
statutes, regulations, program plans, and applications. agencies, institutions, organizations, and other recipients responsible for
9. The grantee will cooperate in carrying out any evaluation of this program carrying out each program; or (b) the correction of deficiencies in program
conducted by or for the state educational agency, the secretary, or other operations that are identified through audits, monitoring, or evaluation.
federal officials. 19. The grantee will administer such funds and property to the extent required
10. The grantee will comply with civil rights and nondiscrimination by the authorizing statutes.
requirement provisions and equal opportunities to participate for all eligible
students, teachers, and other program beneficiaries.

PROGRAM SPECIFIC ASSURACES

Assurance is further provided that:


20. The program will take place in a safe and easily accessible facility.
21. The proposed program was developed and will be carried out in active collaboration with the schools the students attend.
22. The program will primarily target students who attend schools eligible for school-wide programs under Section 1114 and the
families of such students.
23. Funds under this part will be used to increase the level of state, local, and other non-federal funds that would, in the absence of
funds under this part, and in no case supplant federal, state, local, or other non-federal funds.
24. The community will be given notice of an intent to submit an application and that the application and any waiver request will be
available for public review after submission of the application.
25. The program will be provided in a manner that meets the minimum, basic requirements of state child care guidelines.

CERTIFICATIO/SIGATURES

I, THE UNDERSIGNED, CERTIFY that the information contained in this application is complete and accurate to the best of my
knowledge; that the necessary assurances of compliance with applicable state and federal statutes, rules, and regulations will be
met; and, that the indicated agency designated in this application is authorized to administer this grant.

I FURTHER CERTIFY that the assurances listed above have been satisfied and that all facts, figures, and representation in this
application are correct to the best of my knowledge.

Signature of Applicant Agency Administrator Date Signed (Mo./Day/Yr.)


MEMORANDUM of PARTNERSHIP AGREEMENT

Applicant Agency:Building Families and Communities Missions Incorporated

I understand that the above agency plans to submit a 21st Century Community Learning
Centers Program application to the TN Department of Education. Our school/district agrees
to the following responsibilities to ensure successful programming to our students and their
family members:

1. To provide on-going opportunities for meaningful communication between


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the school staff and the 21 CCLC program staff;
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2. To provide opportunities for school staff and 21 CCLC program staff to
plan, coordinate and integrate curricular needs within the afterschool
activities;
3. To assist in tracking student enrollment, academic and discipline information
via the Student Information System package (SIS). Assigned school/district
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staff will receive participant enrollment information from the 21 CCLC
program staff once per semester and will “flag” program participants in the
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SIS package for 21 CCLC under student classification; and,

4. To assist in obtaining all relevant student data including teacher surveys for
evaluating student progress and program effectiveness for mandatory state
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and federal reports. It will be the responsibility of the 21 CCLC program
staff to obtain parental/legal guardian consent for the sharing of student
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information. The school/district expects the 21 CCLC program staff to
maintain student confidentiality of records within the guidelines of state and
federal requirements.

Certification of Participation of School or District

Name of School or District:


Metropolitan Nashville Public School District
Mailing Address:
2601 Brandsford Avenue
Nashville, Tennessee 37204
Phone: Fax:
615 -259 - 3282 615 -
School or District Authorized Signature: Date:

School or District Authorized Signatory Name and Title:

Applicant Agency Authorized Signature: Date:

Applicant Agency Authorized Signatory Name and Title:


Rueben Y. Dockery, Sr., Executive Director
Abstract: Summarize the key elements and overall purpose of this grant. (Please limit to this page only.)

This Building Families and Communities Missions Incorporated - 21st Century Community Learning

Center grant proposal is prescriptive in nature. The scope of the proposal is multi-faceted. Several issues related to

the achievement gap in the Metropolitan Nashville Public School System are addressed simultaneously. Improved

academic performance, reduction in the school dropout rate, training in proper discipline and proactive parental

involvement in public education are hallmarks of the proposed programmatic structure. Perhaps the most significant

aspect of this proposal is its research oriented design.

This center functions as an "Urban Community Support Consortium". It is constructed to collaborate and

document effective outreach efforts among faith-based organizations directly located in high crime neighborhoods,

specifically located in council district 19, of Metropolitan Nashville-Davidson County. Additionally, it serves as a

liaison between local schools serving students living in the same council district and zoned to attend three Tennessee

Department of Education flagged high priority schools (Hillwood, Hillsboro High School and West End Middle

School clusters).

There are six components of the project's paradigm; they are as follow:

 An urban consortium of faith-based organizations hosting satellite classrooms

 Six satellite locations strategically located for community accessibility

 Targeted parental involvement training and support services

 Supplemental educational services for failing students

 Family health services and information dissemination

 A specific partnership with the Metropolitan Nashville Public School District for the sake of neighborhood

and school collaboration

The projected outcomes of full implementation of this project are as follows:

 Modeling of how all populations of Metropolitan Nashville-Davidson County can become connected to

civic pride and values and receive a quality public education

 Modeling of how to strengthen ties between the public school system and all neighborhoods comprising the

greater Nashville community

 Sustaining of proactive measures for neighborhood based control of criminal activity and civic progress

economically, socially and educationally


STATEMET OF COLLABORATIO & PARTERSHIP
I/We have participated in the planning and design of this project and agree to support and participate in the
activities outlined in this application.

*Copy form as needed.


Name of Partner Group/Organization: Description of Services and/or Support to be provided.
Y.C.H.G.P. Building & Training Institute The Y. C. H. G. P. Training Institute will serve as the
Address: primary training center for adult participants in the 21st
1808 Buchanan Street, Nashville, TN 37208 CCLC. It will house the entrepreneurial satellite classroom
Phone: Fax: and act as a hub for community service projects.
615-256-7171 N/A
Email:
N/A
Printed Name:
Rev. Floyd Stone
Signature:

Name of Partner Group/Organization: Description of Services and/or Support to be provided.


Greater Zion Primitive Baptist Church Greater Zion Baptist Church agrees to offer its facilaties as a
Address: satellite classrom for the 21st. Century Community Learning
1817 Morena Street, Nashville, TN 37208 Center. This faith-based organization will follow the
Phone: Fax: programmatic protocol of Building Families and
615-327-2865 N/A Commnuities Missions Inc., in order to meet the stated goals
Email: and objectives of the project. A lead (trained volunteer)
N/A person will be provided to ensure the implementation of
Printed Name: designed program activities and the classromm environment
Rev. Robert L. Howse will be available to qualified participants for a minimum of
Signature: twelve hours per week.

Name of Partner Group/Organization: Description of Services and/or Support to be provided.


Westwood Baptist Church University Center Westwood Baptist Church University Center agrees to offer
Address: its facilaties as a satellite classrom for the 21st. Century
2510 Albion Street, Nashville, TN 37208 Community Learning Center. This faith-based organization
Phone: Fax: will follow the programmatic protocol of Building Families
615-327-3897 N/A and Commnuities Missions Inc., in order to meet the stated
Email: goals and objectives of the project. A lead (trained volunteer)
N/A person will be provided to ensure the implementation of
Printed Name: designed program activities and the classromm environment
Rev. Marvin Neal will be available to qualified participants for a minimum of
Signature: twelve hours per week.
Name of Partner Group/Organization: Description of Services and/or Support to be provided.
Greater Revelation M.B. Church Greater Revelation M.B. Church agrees to offer its facilaties
Address: as a satellite classrom for the 21st. Century Community
1027 12th Avenue North, Nashville, TN 37208 Learning Center. This faith-based organization will follow
Phone: Fax: the programmatic protocol of Building Families and
N/A Commnuities Missions Inc., in order to meet the stated goals
Email: and objectives of the project. A lead (trained volunteer)
N/A person will be provided to ensure the implementation of
Printed Name: designed program activities and the classromm environment
Rev. Adric Lane will be available to qualified participants for a minimum of
Signature: twelve hours per week.

Name of Partner Group/Organization: Description of Services and/or Support to be provided.


St. John AME Church St. John AME Church agrees to offer its facilaties as a
Address satellite classrom for the 21st. Century Community Learning
1822 Formosa Street, Nashville, TN 37208 Center. This faith-based organization will follow the
Phone: Fax: programmatic protocol of Building Families and
615- 320-1026 N/A Commnuities Missions Inc., in order to meet the stated goals
Email: and objectives of the project. A lead (trained volunteer)
N/A person will be provided to ensure the implementation of
Printed Name: designed program activities and the classromm environment
Rev. Antoni Sinkfield will be available to qualified participants for a minimum of
Signature: twelve hours per week.

Name of Partner Group/Organization: Description of Services and/or Support to be provided.


Mt. Bethel Baptist Church Mt. Bethel Baptist Church agrees to offer its facilaties as a
Address: satellite classrom for the 21st. Century Community Learning
1501 Arthur Avenue, Nashville, TN 37208 Center. This faith-based organization will follow the
Phone: Fax: programmatic protocol of Building Families and
615-256-2069 N/A Commnuities Missions Inc., in order to meet the stated goals
Email: and objectives of the project. A lead (trained volunteer)
N/A person will be provided to ensure the implementation of
Printed Name: designed program activities and the classromm environment
Rev. Benjamin Sweat will be available to qualified participants for a minimum of
Signature: twelve hours per week.
BUDGET SUMMARY T 21st CETURY COMMUITY LEARIG CETERS FUDS
Please attach a Budget arrative describing the expenditures listed below. Although matching funds are not required, applicants should include a brief description of the contribution of resources
being provided towards the implementation of this project. OTE: Line item definitions can be found in the Appendix.

ame of Applicant Agency/Organization: Building Families and Communities Missions Incorporated (BFC)
Project Year 1 Project Year 2 Project Year 3 Total
Budget Categories (a) (b) (c) (d)

1. Personnel $273,000.00 $273,000.00 $273,000.00 $819,000.00

2. Fringe Benefits13% $35,490.00 $35,490.00 $35,490.00 $106,470.00

3. Professional Fees $108,200.00 $108,200.00 $65,000.00 $281,400.00

4. Supplies $50,000.00 $50,000.00 $50,000.00 $150,000.00

5. Telephone $12,600.00 $12,600.00 $12,600.00 $37,800.00

6. Postage/Shipping $1,500.00 $1,500.00 $1,500.00 $4,500.00

7. Occupancy $84,000.00 $84,000.00 $0.00 $168,000.00

8. Equipment Rental &


$6,000.00 $6,000.00 $6,000.00 $18,000.00
Maintenance

9. Printing/Publications $7,000.00 $7,000.00 $7,000.00 $21,000.00

10. Travel/Conferences &


$45,000.00 $45,000.00 $45,000.00 $135,000.00
Meetings

11. Insurance $10,000.00 $10,000.00 $10,000.00 $30,000.00

$30,000.00
12. Other Non-Personnel $30,000.00 $0.00 $0.00

13. Total Direct Costs


$662,790.00 $632,790.00 $505,590.00 $1,801,170.00
(lines 1-12)

14. Indirect Cost _____% $0.00 $0.00 $0.00 $0.00

15. Reimbursable Capital


$43,900.00 $0.00 $0.00 $43,900.00
Purchases

GRAND TOTAL $706,690.00 $632,790.00 $505,590.00 $1,845,070.00


Grant Budget Line-Item Definitions
(source: F&A Policy 03 available at www.state.tn.us/finance/act/policy3.pdf )

Line 1 — Salaries and Wages (Personnel) — expense for compensation, fees, salaries, and
wages paid to officers, directors, trustees, and employees
Line 2 — Employee Benefits & Payroll Taxes — expenses for contributions to pension plans
and to employee benefit programs (such as health, life, and disability insurance) and for payroll
taxes (such as social security and Medicare taxes and unemployment and workers’ compensation
insurance)
Line 3 — Professional Fees / Grants & Awards — expense for fees to outside professionals,
consultants, and personal-service contractors and for awards, grants, subsidies, and other pass-
through expenditures to individuals and to other organizations (including allocations to affiliated
organizations, in-kind grants to individuals and organizations, scholarships, tuition payments,
travel allowances, and equipment allowances to clients and individual beneficiaries)
Line 4 — Supplies — expense for office supplies, housekeeping supplies, food and beverages,
and other supplies
Line 5 — Telephone — expense for telephone, cellular phones, beepers, telegram, FAX, E-mail,
telephone equipment maintenance, and other related expenses
Line 6 — Postage & Shipping — expense for postage, messenger services, overnight delivery,
outside mailing service fees, freight and trucking, and maintenance of delivery and shipping
vehicles
Line 7 — Occupancy — expense for use of office space and other facilities, heat, light, power,
other utilities, outside janitorial services, mortgage interest, real estate taxes, and similar expenses
Line 8 — Equipment Rental And Maintenance — expense for renting and maintaining
computers, copiers, postage meters, other office equipment, and other equipment (except for
telephone, truck, and automobile expenses)
Line 9 — printing And Publications — expense for producing printed materials, purchasing
books and publications, and buying subscriptions to publications
Line 10 — Travel / Conferences And Meetings — expense for travel, including transportation,
meals and lodging, and per diem payments (including gas and oil, repairs, licenses and permits,
and leasing costs for vehicles) and for conducting or attending meetings, conferences, and
conventions (including facility rental, speakers' fees and expenses, printed materials, and
registration fees
Line 11 — Insurance — expense for liability insurance, property and vehicle insurance, fidelity
bonds, and other insurance except include employee-related insurance
Line 12 — Other on-personnel Expenses — allowable expense for advertising, bad debts,
contingency provisions, fines and penalties, independent research and development, recruiting,
taxes, membership dues in associations and professional societies other fees for licenses, permits,
registrations, etc. (NOTE: DO NOT include any expense that should be detailed in other line-
items)
Line 14 — Indirect Cost — expense distribution made in accordance with an allocation plan
approved by the cognizant state agency.
Line 15 — Reimbursable Capital Purchases — expense for equipment purchases