Office of Higher Education
National Direct State Commission Consultation Form
Form must be submitted by January 1
|[pic] | |
| |Serve Connecticut |
| |Connecticut Commission on Community Service |
| |Kate Scheuritzel, Senior Program Officer |
|Legal Applicant Information | |
|Organization | |
|Contact Person | |
|Email | |
|Phone | |
|Type of AmeriCorps Grant Request |National Direct |
|Please check ( one: |Education Award |
| |Professional Corps |
| |Indian Tribe |
|AmeriCorps Program Model (check one) |National (members at local organizations directly controlled by |
| |parent) |
| |Affiliates (members at affiliates of parent – limited direct |
| |control) |
| |Consortium (members at independent organizations that interact on|
| |activities beyond AmeriCorps) |
| |Intermediary (members at unrelated organizations) |
|Type of Application |New Application |
| |Re-compete |
| |Continuation (Year __ of 3 Year Cycle) |
|Proposed National Program Overview | |
|Program Name | |
|Start Date | |
|End Date | |
|Number of AmeriCorps Slots |Minimum Time |Quarter Time |Reduced Half |2 Year Half Time |Half Time |Full Time |
| | | |Time | | | |
| | | | | | | |
|Total for Application | | | | | | |
| | | | | | | |
|Total in Connecticut | | | | | | |
| | | | | | | |
| | | | | | | |
|Total CNCS Budget Request within Connecticut | |
|Number of MSYs | |
|Cost per MSY | |
|AmeriCorps Program Focus (brief narrative; community need being | |
|addressed) | |
| | |
| | |
|Description of Primary AmeriCorps Program Activities (Brief succinct | |
|description of how members will achieve the result. Explain exactly what | |
|members will be doing. Give a clear picture of member activity. ) | |
|Beneficiaries within the state | |
|Proposed Primary Outcome Target | |
|Prior Year Member Enrollment Rate | |
|Prior Year Member Retention Rate | |
|AmeriCorps Program Staff (How many staff in state to oversee the program? |Number of FTEs ______ |
|If none in state, what staff will oversee?) | |
|Role of Parent in Administration of Program at state level; (i.e. site | |
|monitoring; background checks; training and development) | |
|Skills and Resources to share | |
| | |
|Overview of Proposed Service Site(s) | |
|Location of site | |
|Number of members: | |
|Does this site oversee members from any other AmeriCorps program? If so, | |
|please name. | |
|Location of site | |
|Number of members: | |
|Does this site oversee members from any other AmeriCorps program? If so, | |
|please name. | |
|Location of site | |
|Number of members: | |
|Does this site oversee members from any other AmeriCorps program? If so, | |
|please name. | |
|SUBMISSION INSTRUCTONS | |
|Complete and save this consultation form. | |
|Submit to Kate Scheuritzel, kscheuritzel@ prior to January 1. | |
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