Host-Site Application LEWIS-CLARK SERVICE CORPS

2017-2018 Host-Site Application LEWIS-CLARK SERVICE CORPS Application Deadline: March 31, 2017 Applications received after the deadline date will not be considered in the first group of applicants. Please complete your portion of the application in Times New Roman 12 pt font. No handwritten applications will be accepted The mission of the Lewis-Clark Service Corps (LC Service Corps) is to improve school success for economically disadvantaged students and/or students with special or exceptional needs and to assist teachers, students and their families to plan a successful year. APPLICATION FOR: Enter # Full-Time Member(s) [1720 hrs] Enter # Part-Time Member(s) [920 hrs] Full-Time September July (11 months) Part-Time September June (10 months) I. HOST AGENCY INFORMATION Previous Host Site? Circle Yes No Name of applicant organization: Address: City: Zip: Phone: FAX: E-Mail: Contact Name: Title: Immediate Contact Information E-mail and Phone: Summer Contact Information E-mail and Phone: Please submit one original, one copy and one electronic copy of your completed and signed application by 5:00 p.m. Pacific time on March 31, 2017 to basyska@lcsc.edu. LC Service Corps / Lewis-Clark State College 500 8 th Avenue Lewiston, ID 83501

II. LC SERVICE CORPS PROGRAM DESIGN and MEASURABLE OUTCOMES A. NEEDS AND SERVICE ACTIVITIES 1. NEEDS: a. Provide a brief (this page only) explanation of your organization your overall mission and the population you serve: LC Service Corps 2017-2018 2

b. Describe the compelling community need your program will address with the assistance of LC Service Corps and why it is not presently being addressed within your current program (this page only). Provide sources of all statistics: LC Service Corps 2017-2018 3

1. SERVICES: Briefly address how your program will utilize one, some, or all of the following Service Activities through the direct service of your LC Service Corps AmeriCorps member. If a Service Activity does not apply to your site, please put N/A in the estimated number of students served for that measure. Tutor K-3 Reading to improve IRI or DIBELS scores Beneficiaries: Students K-3 Please estimate the number of students tutored over course of member's service: IRI Service Measure LC Service Corps' goal is that 50% of K-3 students tutored will improve reading skills by one IRI proficiency reading level. Out of those you will tutor, how will your organization measure academic success? Idaho Reading Indicator Other Standardized Test Used: DIBELS Service Measure LC Service Corps' goal is that 50% of K-3 students tutored will improve early literacy and reading skills proficiency. Out of those you will tutor, how will your organization measure academic success? DIBELS testing for early literacy and early reading skills Other Standardized Test Used: Tutor Math Beneficiaries: Please circle all that apply Students in Elementary School Middle School High School Please estimate the number of students tutored over course of member's service: Service Measure LC Service Corps' goal is that 68% of students tutored will demonstrate improved academic success in the tutored subject area. Out of those you will tutor, how will your organization measure academic success? Standardized Test Used: LC Service Corps 2017-2018 4

Tutor Literacy Beneficiaries: Please circle all that apply Students in Elementary School Middle School High School Please estimate the number of students tutored over course of member's service: Service Measure LC Service Corps' goal is that 68% of students tutored will demonstrate improved academic success in the tutored subject area. Out of those you will tutor, how will your organization measure academic success? Standardized Test Used: Mentor Beneficiaries: Please Circle all that apply Students in Elementary School Middle School High School Please estimate the number of students mentored over course of member's service: Service Measure LC Service Corps' goal is that 200 mentor/mentee matches will be established and of those, 150 mentees will continue the relationship for a minimum of 9 months. Out of those you will mentor, how will your organization measure improvement? Civic Engagement/Service-Learning Activities: Civic engagement means working to make a difference in the civic life of our communities and developing the combination of knowledge, skills, values and motivation to make that difference. It means promoting the quality of life in a community. Service-learning is a method of teaching, learning and reflecting that combines academic classroom curriculum with meaningful service throughout the community. Beneficiaries: Please circle all that apply Students in Elementary School Middle School High School Please estimate the number of students involved in Civic Engagement/Service-Learning activities: LC Service Corps 2017-2018 5

B. MEMBER DEVELOPMENT: Host sites must develop member position descriptions that provide for meaningful service activities and performance criteria that are appropriate to the skill level of the AmeriCorps members. The host site must ensure that each member has sufficient opportunity to complete the required number of hours to qualify for a post-service education award. In planning for the member s term of service, the host site must account for holidays, school breaks and other time off, and must provide each member with sufficient opportunity to make up missed hours. LC Service Corps program offices will work with host sites in regard to missed hours. 1. Describe how you will support the AmeriCorps member(s) on the job. a. How will you prevent member drop-out, or resolve problems that occur on the job? b. How will you establish professional protocol for your office with your LC Service Corps AmeriCorps Member? 2. Describe how you will introduce your AmeriCorps member within your agency; how you plan to familiarize your AmeriCorps member with your organization (for example taking them to staff meetings, etc...) LC SERVICE CORPS PROGRAM STAFF WILL PROVIDE THE FOLLOWING TRAINING: National service core skills training, program orientation, Serve Idaho Conference, monthly regional team meetings throughout the course of the AmeriCorps term and general and scientifically proven tutor/mentor skill training. LC Service Corps 2017-2018 6

HOST SITES WILL PROVIDE THE FOLLOWING TRAINING: 1. Ongoing, site managed tutor and/or mentor skill training. Please describe: 2. Briefly describe what additional type of training you plan to provide for your member(s) throughout the year of service Tutoring Practices Mentoring Practices Testing Skills (IRI, SBAC, etc.) Other: 3. If resources allow, your site plans to send your AmeriCorps member(s) to the following conferences and training opportunities: 4. Please describe how you will document the member's increased confidence developed through training provided at your site. Member Performance Evaluations Self-reports by members following training session / conference Other C. STRENGTHENING COMMUNITIES: VOLUNTEER RECRUITMENT: A requirement of our grant from the Corporation for National and Community Service is that all AmeriCorps members are to recruit and train volunteers to serve their communities such as with required community service projects. Some of our sites utilize AmeriCorps members to recruit and train community members to serve as volunteer tutors and mentors at their sites. Host sites are asked to find some way of involving their AmeriCorps member in a volunteer recruitment process at the host site, perhaps by training volunteers in tutoring methods or enlisting them in planning service-learning activities, and / or service project activities. 1. Member(s) will recruit, train and facilitate community volunteers to tutor students Estimated number of tutors to be recruited over course of member's service: Estimated number of students served by community volunteers: Estimated number of hours per week community volunteers will serve: LC Service Corps 2017-2018 7

How will your organization record volunteer service hours and number of students served by community volunteers? Volunteer time records Member Service Logs (required) Other 2. Member(s) will recruit, train and facilitate community volunteers to mentor students Estimated number of mentors to be recruited over course of member's service: Estimated number of students served by community volunteers: Estimated number of hours per week community volunteers will serve: How will your organization record volunteer service hours and number of students served by community volunteers? Volunteer time records Member Service Logs (required) Other 3. Member(s) will recruit, train and engage community volunteers by enlisting them in planning service-learning activities, and / or service project activities. Estimated number of volunteers to be recruited over course of member s service: Es Estimated number of hours per project community volunteers will serve: Community Service: A requirement of our grant from the Corporation for National and Community Service is that all AmeriCorps members are involved in developing community resources by planning and facilitating a minimum of three community service projects during the year. Will your site participate in the required community service activities Yes No If yes, please describe how your site plans to participate? 4. List potential and/or current partnerships within your community with which your member may develop contacts and collaboration on projects. Please list agencies name(s) LC Service Corps 2017-2018 8

III. ORGANIZATIONAL CAPACITY A. MEMBER SUPERVISION: 1. Based on site requirements for the LC Service Corps AmeriCorps Program, describe a typical week between the supervisor/americorps member. 2. List the supervisor s name and his/her capacity within your organization. It is very important that this individual has the time to supervise the member and the commitment to the member and program including attendance at required supervisor trainings / meetings. If your site is a school, we highly recommend the direct supervisor be a teacher who is working with the member on a day-to-day basis: B. FINANCIAL RESPONSIBILITIES IN-KIND MATCH CONTRIBUTIONS: In order to emphasize partnership and community support of AmeriCorps programs, the Corporation for National Service requires programs to obtain a certain percentage of in-kind contributions toward members' service. This is in addition to the non-federal cash match described in the following section. We require each site to commit to: A minimum of $3,000 total in-kind per AmeriCorps member position which can be broken down within each of the categories outlined below ~ AND~ A minimum of 3-5 hours per week of supervisor / other staff time toward working with your LC Service Corps AmeriCorps member We are allowed to count in-kind contributions as those expenses a site incurs in support of the member's service. Those categories include: REPORTED ANNUALLY: The cost of room space and utilities Equipment use (computers, copiers, fax machines, etc.) REPORTED MONTHLY on MEMBERS MONTHLY DATA REPORT: Copies, postage, other incidentals Purchase of curriculum related to a member's service Travel and training your site provides for the member Hours your supervisor and other staff/teachers spend with the member During the course of the year, these in-kind contributions are tracked on member service logs and on an annual in-kind contribution form, which covers equipment and facilities. Some sites inherently provide much more than these minimums. (Thank you!) LC Service Corps 2017-2018 9

Please indicate your organization s ability to meet the in-kind match requirements: Yes, we are willing to commit to providing a minimum of $3,000 in-kind match toward the support of hosting an LC Service Corps AmeriCorps member Yes, we are also willing to commit to a minimum of 3-5 hours per week supervisor and staff time toward the support of hosting an LC Service Corps AmeriCorps member No, we are unable to meet this in-kind match requirement. Please explain below: CASH MATCH CONTRIBUTION: A non-federal cash match is required to host a LC Service Corps Member. Please indicate your organization s ability to meet the following match requirements and funding source: $7,500 per Full-Time Member Full time members serve a minimum 1720 hours $4,100 per Part-Time Member Part time members serve a minimum 920 hours Please check if you are obligating these funds Pending Funding for your site. ARE THESE FUNDS? Local or state public funds Source? Private funds Source? Other (please describe) It is required that we document all sources of cash match funding. Please provide the source of your cash match, including a list of community partners who may be providing cash or in-kind contributions toward this position(s): Some federal agencies allow their funds to be used as match for AmeriCorps positions. If you are utilizing a federal financial source, please provide documentation from the federal agency indicating that their funding can be used. The Department of Education and Department of Interior have authorized the use of their funds for the AmeriCorps cash match. Cash match must be paid within the first 60 days of the program year, no later than November 1, 2017. If a member is terminated or leaves within the first 60 days of his/her program year, a site will be partially reimbursed by a pro-rated formula. If a member leaves or is terminated after January 1, sites will not be reimbursed. LC Service Corps 2017-2018 10

IV. RECRUITMENT Recruiting a member who fits the needs of the site is crucial to a successful year. Recruitment is an ongoing endeavor for both the site and Lewis-Clark Service Corps. Please provide a description of member recruitment activities. For example: how will you publicize the position, timeline for member selection, will you plan or participate in recruitment events, etc. V. SUSTAINABILITY Pending grant funding, program year 2017-2018 will be the second year of a three year funding cycle. While LC Service Corps welcomes new applications every year, federal AmeriCorps grant guidelines recommend AmeriCorps members be placed at the same host site for maximum of three years, with the intent that the site is to develop other resources to carry on the service started by the AmeriCorps member. During the three years, the site will be expected to increase match incrementally each program year. Please describe a possible plan for sustainability of the service being provided by the AmeriCorps member throughout the three year cycle (including increasing the match each year of the three years) and once the three year cycle is complete: POSITION DESCRIPTION IS REQUIRED PLEASE USE THE TEMPLATE ON THE FOLLOWING PAGE TO PREPARE YOUR POSITION DESCRIPTION Be sure to include specific skills and experience you require as well as day-to-day duties. For example, some tutoring experience, experience working with economically disadvantaged students and/or students with special or exceptional needs, etc. LC Service Corps 2017-2018 11

Your Site Name Here AmeriCorps Position Description Your Logo Here Your mission here. TEMPLATE/AmeriCorps Member Position Description The role of the Lewis-Clark Service Corps member at HOST SITE NAME is to provide need-based student support. Specific duties shall include, but not be limited to those listed below: (Example: Tutor kindergarten students in letters, numbers and shapes; assist students in all grades in homework help room before and after school ) Tutoring: Describe the specific day-to-day tutoring activities of the position. (Example: Tutor students individually and in small groups with lesson assignments to present and reinforce learning concepts, monitor students in a variety of settings ) Mentoring: If applicable, describe the specific mentoring component of this position. (Example: Assist students in academic success by helping them acquire time management skills, notebook organization skills, study techniques, test preparation ) Site-Specific Qualifications: List the specific education, experience and overall disposition desired in qualified applicants. (Example: Strong interpersonal skills, experience working with students in a classroom setting, bachelor s degree in education or related field ) Minimum AmeriCorps Qualifications: High School Diploma/GED Complete the (10 or 11 month) term of service. Complete the minimum hours requirement (920 hours part-time, 1720 hours full-time). Attend all required Lewis-Clark Service Corps training and events and complete required documentation. Community Service Component: Lewis-Clark Service Corps members are national service participants. In addition to host-site mandated expectations, members plan and implement three community based service projects over the course of the term. Each month members meet with an assigned regionally based team for required AmeriCorps training and service project planning. LC Service Corps 2017-2018 12

LC Service Corps Host Site Selection is contingent upon continued funding from the Corporation for National and Community Service. I have read the attached instructions, provisions and requirements of a LC Service Corps host site and agree to perform all actions and support all site responsibilities listed in the site provisions and requirements attachment. Name (Printed): Host Site Representative Title: Signature: Date: Supervisor Name (Printed) if different from above Supervisor's Signature: Date: ********************** Public Notice of Nondiscrimination It is against the law for organizations that receive federal financial assistance from the Corporation for National and Community Service to discriminate on the basis of race, color, national origin, disability, sex age, political affiliation, or, in most cases, religion. It is also unlawful to retaliate against any person who, or organization that, files a complaint about such discrimination. In addition to filing a complaint with local and state agencies that are responsible for resolving discrimination complaints, you may bring a complaint to the attention of the Corporation for National and Community Service. If you believe that you or others have been discriminated against, or if you want more information, contact: Lewis-Clark Service Corps Lewis-Clark State College 500 8 th Avenue Lewiston, ID 83501 208-792-2662 TTY: 800-377-3529 basyska@lcsc.edu (e-mail) or Office of Civil Rights and Inclusiveness Corporation for National and Community Service 1201 New York Avenue, NW Washington, D.C. 20525 (202) 606-7503 (voice); (202) 565-2799 (TTY) (202) 565-3465 (FAX); eo@cns.gov (e-mail) LC Service Corps 2017-2018 13

Attachment A Criminal History Check Certification I, (signatory), certify that (organization s name) will not clear for AmeriCorps service any individual who is registered, or required to be registered on a sex offender registry or who has been convicted of murder. Print Name Signature Date LC Service Corps 2017-2018 14

Attachment B LEWIS - CLARK SERVICE CORPS C o n n e c t i n g L e a r n i n g t o L i f e - T H R O U G H S E R V I C E Non-Criminal Justice Agency Criminal History Record Information (CHRI) CONFIDENTIALITY AGREEMENT Lewis-Clark Service Corps has very strict confidentiality regulations which are consistent with the National Crime Prevention and Privacy Compact, the Federal Bureau of Investigation (FBI)/Criminal Justice Information System (CJIS) Security Policy. Lewis-Clark Service Corps has granted you access to confidential criminal history information and files in the course of performing your professional duties and responsibilities as a host site supervisor with AmeriCorps selection responsibilities. As a host site supervisor you must be very careful not to release this information to the public. The word public may include co-workers who have not been authorized or to members of the general public. If you are ever in doubt as to a requestor s right to access, or the appropriate procedures to be followed, you must request direction from Lewis-Clark Service Corps. An infraction in this area is considered serious and may be grounds for loss of your AmeriCorps position(s). By signing this statement, you acknowledge that you will not share nor divulge the criminal history information to anyone who is not authorized to access this information or otherwise violate any of the rules, regulations policies or procedures Lewis-Clark Service Corps or the Idaho State Police have regarding this information. Supervisor name (please print) Supervisor signature Date LC Service Corps 2017-2018 15