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MO 500-2288 (Rev. 3-17) DUE NO LATER THAN 1:00 P.M. ON MAY 15, 2017
STATE OF MISSOURI
DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION MISSOURI PRESCHOOL PROGRAM - RENEWAL APPLICATION
IFG NO.: HB1519R CONTACT PERSON: Angie Koetting TITLE: Missouri Preschool Program PHONE NUMBER: 573-751-2095 ISSUE DATE: April 1, 2017 Email: [email protected]
RETURN APPLICATION NO LATER THAN: 1:00 p.m. on May 15, 2017
RETURN APPLICATION TO:
MAILING ADDRESS DELIVERY ADDRESS
Department of Elementary and Department of Elementary and Secondary Education Secondary Education Early Learning Section Early Learning Section PO Box 480 Jefferson State Office Bldg., 7
th Floor
Jefferson City, MO 65102-0480 205 Jefferson Street Jefferson City, MO 65101
CONTRACT PERIOD: July 1, 2017 through June 30, 2018 The grantee hereby declares understanding, agreement and certification of compliance to provide the items and/or services in
accordance with all requirements and specifications contained herein and the Terms and Conditions Invitation for Grant. The grantee further agrees that the language of this IFG shall govern in the event of a conflict with his/her proposal. The grantee further agrees that upon receipt of an authorized purchase order from the DESE or when this IFG is countersigned by an authorized official of the
State of Missouri, a binding agreement shall exist between the grantee and the DESE.
SIGNATURE REQUIRED
AUTHORIZED REPRESENTATIVE SIGNATURE
DATE
PRINTED NAME
TITLE
LEAD AGENCY NAME
FEDERAL EMPLOYER ID NO. (EIN) / SOCIAL SECURITY NO. (SSN)
MAILING ADDRESS
CITY STATE ZIP
PHONE NUMBER
FAX NUMBER EMAIL ADDRESS
NOTICE OF AWARD (STATE USE ONLY)
ACCEPTED BY STATE OF MISSOURI AS FOLLOWS:
TITLE
Commissioner of Education DATE
CONTRACT AMOUNT NOT TO EXCEED: $____________________
The Department of Elementary and Secondary Education does not discriminate on the basis of race, color, religion, gender, national origin, age, or disability in its programs and activities. Inquiries related to Department programs and to the location of services, activities, and facilities that are accessible by persons with disabilities may be directed to the Jefferson State Office Building, Office of the General Counsel, Coordinator – Civil Rights Compliance (Title VI/Title IX/504/ADA/Age Act), 6
th Floor,
205 Jefferson Street, P.O. Box 480, Jefferson City, MO 65102-0480; telephone number 573-526-4757 or TTY 800-735-2966; email [email protected].
MO 500-2288 (Rev. 3-17) DUE NO LATER THAN 1:00 P.M. ON MAY 15, 2017
MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION OFFICE OF QUALITY SCHOOLS – EARLY LEARNING
MISSOURI PRESCHOOL PROGRAM (MPP) RENEWAL APPLICATION
SECTION I - SITE INFORMATION
LEAD AGENCY SCHOOL DISTRICT COUNTY-DISTRICT CODE
-
MPP AWARD NUMBER
PLEASE CHECK ONE
PUBLIC SCHOOL PRIVATE PRESCHOOL NON-PROFIT AGENCY RENEWAL YEAR
1ST RENEWAL 2
nd RENEWAL 3
rd RENEWAL 4
th RENEWAL
LEAD EDUCATION AGENCY AUTHORIZED REPRESENTATIVE
AUTHORIZED REPRESENTATIVE EMAIL ADDRESS
STREET ADDRESS CITY STATE
MO
ZIP
INDIVIDUAL RESPONSIBLE FOR COMMUNICATING WITH THE DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION (DESE) REGARDING PROGRAM ACTIVITES
CONTACT PERSON TITLE ORGANIZATION/ENTITY NAME
STREET ADDRESS CITY STATE
MO
ZIP
TELEPHONE NUMBER FAX NUMBER EMAIL ADDRESS
SECTION II – SITE BUDGET INFORMATION
MPP Funds will be pooled into an Early Learning Blended Funding Program (available only to Public Schools). Continue on to Section III, the budget grid and Attachment A are not applicable for programs applying as an Early Learning Blended Funding Program.
OR
6100 Certified Staff
6150 Noncertified
Staff
6200 Employee Benefits
6300 Purchased Services
6400 Materials &
Supplies
6500 Capital Outlay
Total
3512 Early Childhood
Instruction
4000 Facilities
Acquisition & Construction
Administrative Costs
Grand Total
DESE COMMENTS - (FOR DESE USE ONLY)
SIGNATURE OF AUTHORIZED DESE OFFICAL FUNDS AWARDED DATE APPROVED
FY 18
MO 500-2288 (Rev. 3-17) DUE NO LATER THAN 1:00 P.M. ON MAY 15, 2017
ATTACHMENT A – ITEMIZED BUDGET: Not applicable for programs applying as a Blended Funding Program.
REQUIRED FORMAT: http://dese.mo.gov/early-extended-learning/early-learning/missouri-preschool-program
MO 500-2288 (Rev. 3-17) DUE NO LATER THAN 1:00 P.M. ON MAY 15, 2017
SECTION III – SITE INFORMATION PROGRAM NAME
STREET ADDRESS CITY STATE
MO
ZIP
REFER TO CHILD CARE LICENSE
CHILD CARE LICENSE NUMBER _________________________
LICENSED CAPACITY __________________________________
LICENSE IS EFFECTIVE THROUGH _______/_______/________
ACCREDITING SOURCE
MISSOURI ACCREDITATION
NATIONAL ASSOCIATION FOR THE EDUCATION OF YOUNG CHILDREN
INITIAL ACCREDITATION
ACCREDITED THROUGH ______/_______/________
WORKING ON RENEWAL ACCREDITATION/REVISION
TOTAL NUMBER OF CONTRACTED MPP SLOTS IN THE MPP CLASSROOM
10 or 10AM/10PM (20)
15 or 15AM/15PM (30)
20 or 20AM/20PM (40)
CURRICULUM MODEL
CREATIVE CURRICULUM
EMERGING LANGUAGE & LITERACY CURRICULUM
HIGH/SCOPE®
PROJECT CONSTRUCT
LENGTH OF PROGRAM YEAR 12 MONTHS OR SCHOOL YEAR
LENGTH OF PROGRAM DAY AND DESIGNATED MPP TIME
HALF DAY _____ A.M. - _____ A.M. (MUST BE 3 HOURS)
_____ P.M. - _____ P.M. (MUST BE 3 HOURS)
FULL DAY _____ A.M. - _____ P.M. (MUST BE 6.5 HOURS)
EXTENDED DAY SERVICES OFFERED YES OR NO
TRANSPORTATION OFFERED YES OR NO
FEE OR SCHOLARSHIP SYSTEM FOR PRESCHOOL SERVICES IS IMPLEMENTED
YES OR NO
MEALS/SNACKS DURING MPP HOURS PROVIDED BREAKFAST AM SNACK
LUNCH PM SNACK
SECTION IV – CLASSROOM INFORMATION
CLASSROOM CODE: __ __ __ - __ __ __ - __ __ - __ __ - __ AGE 3 BEFORE AUGUST 1, 2017
AGE 4 BEFORE AUGUST 1, 2017
TOTAL NUMBER OF SLOTS
LEAD TEACHER NAME:
QUALIFICATIONS: EARLY CHILDHOOD EARLY CHILDHOOD SPECIAL EDUCATION 4 YEAR CHILD DEVELOPMENT
(NOT AN OPTION FOR BLENDED PROGRAMS)
COMPLETED TRAINING IN THE SELECTED CURRICULUM MODEL: YES NO
COMPLETED DESIRED RESULTS DEVELOPMENTAL PROFILE TRAINING: YES NO
ASSISTANT TEACHER NAME:
QUALIFICATIONS: CDA ACC 60 HRS
COMPLETED TRAINING IN THE SELECTED CURRICULUM MODEL: YES NO
COMPLETED DESIRED RESULTS DEVELOPMENTAL PROFILE TRAINING: YES NO
MO 500-2288 (Rev. 3-17) DUE NO LATER THAN 1:00 P.M. ON MAY 15, 2017
SECTION IV – CLASSROOM INFORMATION CON’T (REPORT ADDITIONAL CLASSROOMS AS NEEDED)
CLASSROOM CODE: __ __ __ - __ __ __ - __ __ - __ __ - __ AGE 3 BEFORE
AUGUST 1, 2017
AGE 4 BEFORE
AUGUST 1, 2017
TOTAL NUMBER OF SLOTS
LEAD TEACHER NAME:
QUALIFICATIONS: EARLY CHILDHOOD EARLY CHILDHOOD SPECIAL EDUCATION 4 YEAR CHILD DEVELOPMENT
(NOT AN OPTION FOR BLENDED PROGRAMS)
COMPLETED TRAINING IN THE SELECTED CURRICULUM MODEL: YES NO
COMPLETED DESIRED RESULTS DEVELOPMENTAL PROFILE TRAINING: YES NO
ASSISTANT TEACHER NAME:
QUALIFICATIONS: CDA ACC 60 HRS
COMPLETED TRAINING IN THE SELECTED CURRICULUM MODEL: YES NO
COMPLETED DESIRED RESULTS DEVELOPMENTAL PROFILE TRAINING: YES NO
CLASSROOM CODE: __ __ __ - __ __ __ - __ __ - __ __ - __ AGE 3 BEFORE AUGUST 1, 2017
AGE 4 BEFORE AUGUST 1, 2017
TOTAL NUMBER OF SLOTS
LEAD TEACHER NAME:
QUALIFICATIONS: EARLY CHILDHOOD EARLY CHILDHOOD SPECIAL EDUCATION 4 YEAR CHILD DEVELOPMENT
(NOT AN OPTION FOR BLENDED PROGRAMS)
COMPLETED TRAINING IN THE SELECTED CURRICULUM MODEL: YES NO
COMPLETED DESIRED RESULTS DEVELOPMENTAL PROFILE TRAINING: YES NO
ASSISTANT TEACHER NAME:
QUALIFICATIONS: CDA ACC 60 HRS
COMPLETED TRAINING IN THE SELECTED CURRICULUM MODEL: YES NO
COMPLETED DESIRED RESULTS DEVELOPMENTAL PROFILE TRAINING: YES NO
CLASSROOM CODE: __ __ __ - __ __ __ - __ __ - __ __ - __ AGE 3 BEFORE AUGUST 1, 2017
AGE 4 BEFORE AUGUST 1, 2017
TOTAL NUMBER OF SLOTS
LEAD TEACHER NAME:
QUALIFICATIONS: EARLY CHILDHOOD EARLY CHILDHOOD SPECIAL EDUCATION 4 YEAR CHILD DEVELOPMENT
(NOT AN OPTION FOR BLENDED PROGRAMS)
COMPLETED TRAINING IN THE SELECTED CURRICULUM MODEL: YES NO
COMPLETED DESIRED RESULTS DEVELOPMENTAL PROFILE TRAINING: YES NO
ASSISTANT TEACHER NAME:
QUALIFICATIONS: CDA ACC 60 HRS
COMPLETED TRAINING IN THE SELECTED CURRICULUM MODEL: YES NO
COMPLETED DESIRED RESULTS DEVELOPMENTAL PROFILE TRAINING: YES NO
MAKE ADDITIONAL COPIES AS NEEDED FOR EARLY LEARNING BLENDED CLASSROOMS.
MO 500-2288 (Rev. 3-17) DUE NO LATER THAN 1:00 P.M. ON MAY 15, 2017
ATTACHMENT B: Replace this page with a copy of the accreditation certificate or a narrative explaining where the program is in attaining
ATTACHMENT B: Replace this page with a copy of the child care license.
MO 500-2288 (Rev. 3-17) DUE NO LATER THAN 1:00 P.M. ON MAY 15, 2017
ATTACHMENT C: Replace this page with a copy of the accreditation certificate or a narrative explaining where the program is in attaining accreditation.
MO 500-2288 (Rev. 3-17) DUE NO LATER THAN 1:00 P.M. ON MAY 15, 2017
SECTION V - PROGRAM IMPLEMENTATION DESCRIPTION FOR THE RENEWAL YEAR
PROVIDE A NARRATIVE DESCRIPTION OF THE PROGRAM FOR THIS YEAR.
USE ONLY SPACE PROVIDED.
MO 500-2288 (Rev. 3-17) DUE NO LATER THAN 1:00 P.M. ON MAY 15, 2017
SECTION VI - FUNDING PLAN: Must include a sliding fee schedule or tiered scholarship system to ensure all children regardless of income have
access to services:
FOOD SERVICES:
LOCAL GRANTS:
FUNDRAISING:
CHILD CARE SUBSIDY:
OTHER SOURCES:
MO 500-2288 (Rev. 3-17) DUE NO LATER THAN 1:00 P.M. ON MAY 15, 2017
ATTACHMENT D: Replace this with a copy of the sliding fee schedule or sliding scale scholarship system.
MO 500-2288 (Rev. 3-17) DUE NO LATER THAN 1:00 P.M. ON MAY 15, 2017
SECTION VII – PLAN UPDATE
Provide a narrative description of the changes made as a result of the previous year’s Early Childhood Environmental Ratings Scale-3 (ECERS-3) Summary.
Provide a narrative description of the changes made to the program plans. Parent Advisory Committee Plan: Child Development, Education and Care Plan: Professional Development Plan: Parent Education/Involvement/Communication Plan: Community Plan: