High QualitySchool Readiness

Form 1:ApplicantInformation and Assurances

ApplicantEntity Name:

Private Providerspleasecheckone:Licensed ______LegallyLicense Exempt ______

Federal Tax ID#: ______

Address:

Street: City:

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State:

Zip:

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Name and contactinformation ofperson to becontacted on mattersinvolvingthisapplication:

Name: Title: OfficePhone: CellPhone: Email:

Name and contactinformation ofperson authorized tosignapplication on behalfofApplicant:Name: Title:

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Phone:

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Email:______

Information aboutcurrentprogram:Useextrasheet(s)ifnecessary(pageswillnotbecounted in pagetotal).

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Name of school/site where grant funding will be used / Total number of K-6/K-5 students/total number of economically disadvantaged in school/site / Total percentage of K-6/K-5 economically disadvantaged students in school/site / Anticipated number of 3- and 4-year old economically disadvantaged students / Anticipated percentage of 3- and 4-year old economically disadvantaged students
Example: Hansen Elem. / 500/300 / 60% / 9/20 / 45%

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Applicants must agree to prioritize enrollment of economically disadvantaged students. Applicant’s school readiness program must register and maintain a minimum of 25% of eligible3- and 4-year old students throughout the grant funding period.

List numberof studentsidentified ashaving adisability undertheIndividualswithDisabilitiesAct(IDEA):

Numberof licensed personnel:CDA_____AA_____ AS _____BA _____BS _____Other_____Total_____

Currentaverageclasssize:

Currentteacher/studentratio: _____

Program costperstudentper month: _____ How many days per week: _____ How many hours per day: _____

Identifyallotherfunding sourcesforthisprogram which servethesamepurposeasthisHQSRgrant.Foreach source,provideatotaldollaramountand detailhowthefundsareused intheprogram.Useextrasheet(s)ifnecessary(pageswillnotbecounted in pagetotal):

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By signingbelow,theApplicantassuresthe following:

  • Compliancewith allapplicablestatutesand regulations,in carrying outanyprojectactivitiessupported by thesefunds.
  • Continuing obligation tocomplywith termsand conditionsof governing statutesand grantdirections.
  • All studentswill begiven auniquestudentidentifier toenablelongitudinal datacollection.
  • Classsizes,ratios,and qualitywillbeobserved aspertherequirementsofthegoverningstatute(i.e.,classsizedoesnotexceed20 students,with oneadultforevery 10 studentsintheclass.Privateprovidersmustmeetstatelicensing ratios ataminimum).
  • Actively recruitand serveprimarily studentswho meet the definition of eligible students,asdefinedinUtahCode53F-6-301.
  • Applicants must agree to prioritize enrollment of eligible students. Program must maintain a minimum enrollment of 25percent of eligible3- and 4 year-old students throughout the grant funding period. Failure to maintain this percentage will result in ineligibility for the following grant cycle.
  • Provideinformation forreportsto theSchoolReadinessBoardand theUtah StateBoard ofEducation,including,butnotlimited to:(1)thenumber of studentsserved by theearlychildhood program,reported byeligible student status;(2)average dailyattendanceoverthegrantperiod; (3)thecostof theprogram perstudent; and (4)thepre‐mid‐and post‐assessmentresults,meeting allrequired timelines. Grant recipients will be required to report on progress and compliance with their grant proposal.

Maintain financialrecordsto ensure thatfundsawarded bythisgrantaresupplementingand notsupplantingthe existingprogram.

  • Cooperate with the independent evaluator. In addition, a minimum of 80 percent of the eligible students’ families must submit parent consent forms for data collection and tracking SSID number purposes.
  • Comply with allrequirements ofStudentFindundertheIndividualswithDisabilitiesEducation Act(IDEA).Pleaseseethe“AdditionalInformation” section forinformationonStudentFind.

Checkone:

Applicantagreesto useRiskFactorAssessment(Form 3) in studentrecruiting process.ApplicantdoesnotagreetouseRiskFactorAssessment (Form 3)in studentrecruiting process.

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SignatureofSuperintendent,CharterSchoolDirector,orPrivateProviderauthority*Date

Title

*OnlycharterschoolsthatfundtheirownpreschoolapplythroughUSBE.Charter schoolsthathave a privateproviderapplythroughtheDepartmentofWorkforceServices.

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