2012-13MTSS GRANT

APPLICATION 1790 E. Packard Hwy., Charlotte, MI 48813 . Telephone: 517.543.5500 . Fax: 517.543.4870

General Information:District Name:Contact Person Name:Contact Person Email Address:School Address:City, State, Zip:Contact Person Telephone:Contact Person Fax:Oversight Contact:

The Eaton ISD has identified the following MTSS initiatives that meet the funding objectives. If the project is listed below (proceed to Part 3 of this application).

o Reading Streeto Intervention Programso Professional Development Specific to MTSSo Other (please explain) _______________________________

Part 1: Goals of the Program (One page maximum)a. Describe the goals for your proposed program. (As a result of this program, students will……..)b. Describe how your program will enhance the Districts MTSS Initiativec. Describe the target population and the grade levels the program will serve. Explain why you have

chosen this particular target populationd. Describe the need for this activity and how this need will be assessed

Part 2: Program/Project Specifics (One page maximum)a. Explain the program activities in one or two paragraphs emphasizing student learning and how the

program provides opportunity for studentsb. Indicate how many students will be impacted by this programc. Describe the anticipated positive effect on student attitude, behavior and achievement d. Describe how this program meets the criteria of being creative and innovative e. Include any research related to the programf. Include a timeline for the program g. Explain how you intend to sustain the program beyond the grant periodh. List any other organizations that will assist in the programi. Include a separate letter of support from your school district administrator

Part 3: Results and Evaluation (One page maximum)a. Briefly describe how you will evaluate whether the program is meeting its goals, including what data

will be used. Be specific about how you will evaluate changes in students’ interest and knowledgeb. Explain how progress will be monitored and measured on an on-going basis

Part 4: Program Budgeta. Time period of budget – From: ______________ To: ______________b. If you anticipate additional funding beyond this grant from your district, community or other sources,

please list these belowc. Indicate only the Expenses that apply to your project

ProgramExpenses

Total Requested from this Grant

Anticipated Funding From Other Sources

Total Expenses

SalariesFringe BenefitsInstructional MaterialsProgram Equipment – (Remains with the Program)SuppliesPrinting/CopyingOther (Explain Below)Totals

Part 5: Annual Grant Reporting RequirementsIf funded, you will be required to write a final report in a narrative format that addresses the following:

a. What you believe was the most important outcome of this program for your organization and the community it was meant to serve

b. What have you done, or do you plan to do, to insure that this program or activity continuesc. Share an example of how this grant made a difference to those you serve.d. Offer suggestions for how EISD can improve the grant application processe. Final budget report with receipts attached

Assurances StatementPrinciples: The overall goal of the MTSS Initiative is to define an integrated, multi-tiered system of instruction, assessment, and intervention designed to meet the achievement and behavioral needs of all learners. Eaton ISD has categorized the 11 essential components of MTSS into 5 Big Ideas: Leadership, Research & Evidence-Based Practices, Assessment and Data Collection, Problem-Solving and Data-Based Decision Making and Multi-Tier Service Delivery Model.

Certification: I certify that the information submitted on this report is true and correct to the best of my knowledge. This report was prepared in cooperation with the business staff and the costs reported are proper charges for the intended purpose of this Eaton ISD grant.

FOR THE DISTRICT FOR THE LEA/PSA

____________________________________ ________________________________________Signature Date Signature Date