platte county board of services application for funds - 2020

Platte County Board of Services Application for Funds - 2020

Agency Information

Program Title Transportation for Transition Employment

A. Legal Name of Agency Park Hill School District

Address 7703 NW Barry Road

City Kansas City State MO Zip 64153

Phone (816)359-4100 Fax (816) 359-4039

Website www.parkhill.kl2.mo.us

B. Board President/Chairperson Dr. Chris Daniels


City Kansas City state MO Zip 64153

Phone (816) 359-4100 Fax (816) 359-4039

C. Agency Director Sarah McDaniels PHS/Janell Deville PHHS

Address 4500 NW River Park Drive/7701 NW Barry Road

City Riverside/KC _state MO Zip 64150

Phone (816)359-4120 Fax (816)359-4129

E-mail address [email protected],us; [email protected]

D. Funding Period 01/01/2020 to 12/31/2020

Start Date End Date

Funding Packet - 2020 of35


Agency Information

History and background of agency (brief narrative description of agency's mission, past and present programs, persons served):

Vision

Building successful futures - each student - every day

Mission

Through the expertise of a motivated staff, the Park Hill School District provides a meaningful education in a safe, caring environment to prepare each student for success in life.

Values • Student Focus • Integrity • High Expectations • Continuous Improvement • Visionary Leadership

We, at Park Hill School District work with high school students with developmental delays such as mental retardation and autism. The majority of these students spend some or all of their day in the special services functional - life skills class. In the past, we have used PCBS funds for: 1) Students to job shadow within community businesses 2)Students to participate in community volunteer work experiences and 3) students to tour different job opportunities and living arrangements beyond high school. We believe that these experiences will provide an effective teaching model that is student-centered and applicable to real life situations. We are also hopeful that this experience will help enable students to find potential post-secondary employment. We would like to continue this program through PCBS funding.

F. List of Programs you are requesting funding for.

Note: There are a maximum of 5 programs you can apply for funding using this form. I f you need to apply for more than 5 programs contact PCBSDD. I f you apply for funding for less than five programs you will have empty pages within this form. Please omit the empty pages when sending in your application. A l l of the Program Names will automatically display in the Program Information sections once you enter them below.

1. Park Hill South/PHHS Essential Skills

2.

3.

4.

5.

Funding Packet - 2020 of


Program Information

G. Funding Request: Park Hill South/PHHS Essential Skills

Purchase of Service $ 78.00

Unit Cost X 40

# Units

$3,120.00

Total Requested

from PCBS

Unit of service = minutes

Grants

Total Project From other

Source(s)

$0.00

Total Requested

from PCBS

Total of all Funds Requested from PCBS $ 3,120.00

Purpose of Funds Requested:

n Expand an existing program

Establish a new program

E Maintain an existing program

n Enhance overall service delivery system

Funding Packet - 2020 of 3 5


Program Information

Park Hill South/PHHS Essential Skills Continued

Client Information:

Number of persons presently served in existing program:

40 Platte Countians w/Developmental Disabilities

Clay Countians w/Developmental Disabilities

Other

Non-Disabled

Number of additional persons to be served in new or expanded program:

7 Platte Countians w/Developmental Disabilities


Other

_ _ _ _ _ Non-Disabled

Indicate the total number of persons with developmental disabilities in Platte County to be

served by this program in the following categories:

Age

47

Under 3 years of age

3 years to 5 years

5 years to 21 years

21 years to 35 years



65 years and older

Primary Disability

16 Intellectual Disability

3 Cerebral Palsv

24 Autism

Learning Disability

Head Injury

4 Other

Funding Packet-2020 of 3 5


Program Information


J. Proposed Project Location:

Contact D r - Chris Daniels


City Kansas City State MO Zip 64153

Phone (816)359-4100 Fax (816)359-4039

Own __J Lease {__

2. I f the location is owned by other than the applicant, complete the following:

Name

Address

City State MO Zip

Phone Fax

Proprietary f*"l Public • Non Profit •

Funding Packet - 2020 of 35


Program Information


K. Narrative Description of Program

With the funding assistance (for transportation) through PCBS, we have been able to provide individuals with disabilities the opportunity to job shadow, tour employment opportunities and living arrangements available after high school. Students with developmental disabilities from Park Hill and Park Hill South High Schools will be provided hands-on, real-life experiences regarding vocational tasks.

State three or four program specific goals and objectives in measurable terms. The Agency will be required

to report on a quarterly basis, the progress toward the program goals and objectives. Include a description of

how applicant plans to evaluate the effectiveness and impact of the program, as related to the stated goals and objectives.

1) Become informed of the world of work through on-site job experiences and job shadows. 2) Begin establishing goals and interests in regards to post-secondary job opportunities. 3) Become knowledgeable of supportive services available to the students after high school - regarding living arrangements, job training and job opportunities.

These goals will be evaluated through informal/formal senior interviews and through our districts transition outcome surveys.

L. Program Goals/Objectives



Program Information


M. Program Standards:

1. List those mandatory licensing/certification/regulatory requirements which apply

to the applicant's proposed project (attach copy of certificate):

By Whom Period Covered



to

to

to

2. List those voluntary regulatory/accredited requirements to which applicant intends for program to ascribe (attach copy of certificate):



to

to

By Whom Period Covered to



Proposed Program Income Plan Park Hill South/PHHS Essential Skills Continued

List Each Income Previous Year Current Operating Proposed Program

Source for Program Income Program Income Budgeted Income

Program Amounts Amounts Amounts

(2017) (2018) (2019)

PCBS $3 120

Totals $0 $0 $3,120



Program Information

G. Funding Request:

Purchase of Service

Unit Cost # Units

$0.00

Total Requested

from PCBS


Grants


Source(s)

$0.00

Total Requested

from PCBS

Total of all Funds Requested from PCBS $ 0-00


f l Expand an existing program

n Establish a new program

Maintain an existing program

Enhance overall service delivery system



Program Information

Continued

I . Client Information:

1. Number of persons presently served in existing program:

Platte Countians w/Developmental Disabilities


Other

Non-Disabled

2. Number of additional persons to be served in new or expanded program:


_ _ _ _ _ Clay Countians w/Developmental Disabilities

_ _ _ _ _ Other

Non-Disabled

3. Indicate the total number of persons with developmental disabilities in Platte County to be served by this program in the following categories:

Age Primary Disability

Under 3 years of age _ _ _ _ _ Intellectual Disability

3 years to 5 years Cerebral Palsy

5 years to 21 years Autism

21 years to 35 years _ _ _ _ _ Learning Disability

35 years to 55 years Head Injury

55 years to 65 years Other

65 years and older



Program Information

Continued


Contact

Address

City State MO Zip

Phone Fax

Own [__ Lease [~1

I f the location is owned by other than the applicant, complete the following:

Name

Address

City State MO Zip

Phone Fax

Proprietary _ Public _ _ ] Non Profit Q

Funding Packet-2020 of 35


Program Information

Continued





how applicant plans to evaluate the effectiveness and impact of the program, as related to the stated goals and objectives.



Program Information

Continued




ByWhom_ Period Covered to



2. List those voluntary regulatory/accredited requirements to which applicant intends for program to ascribe (attach copy of certificate):






Proposed Program Income Plan Continued

List Each Income

Source for

Program

Previous Year

Program Income

Amounts

(2017)

Current Operating

Program Income

Amounts

(2018)

Proposed Program

Budgeted Income

Amounts

(2019)

Totals $0 $0 $0



Program Information

G. Funding Request:

Purchase of Service

Unit Cost # Units

$0.00

Total Requested

from PCBS

Unit of service :

minutes

Grants


Source(s)

$0.00

Total Requested

from PCBS

Total of all Funds Requested from PCBS $ ° - 0 Q

H. Purpose of Funds Requested:

1"1 Expand an existing program

O Establish a new program

O Maintain an existing program




Program Information

Continued

Client Information:

1. Number of persons presentlv served in existing program:



Other

Non-Disabled




Other

Non-Disabled

3. Indicate the total number of persons with developmental disabilities in Platte County to be



Under 3 years of age Intellectual Disability

3 years to 5 years _ _ _ _ _ Cerebral Palsy


21 years to 35 years Learning Disability



65 years and older



Program Information

Continued


Contact

I . Address 7703 NW Barry Road

City State MO Zip .

Phone Fax

Own _ Lease __J


Name

Address

City State MO Zip

Phone Fax

Proprietary _ Public • Non Profit _



Program Information

Continued





how applicant plans to evaluate the effectiveness and impact of the program, as related to the stated goals and

objectives.



Program Information

Continued







2. List those voluntary regulatory/accredited requirements to which applicant intends for

program to ascribe (attach copy of certificate):







List Each Income

Source for

Program

Previous Year

Program Income

Amounts

(2017)

Current Operating

Program Income

Amounts

(2018)

Proposed Program

Budgeted Income

Amounts

(2019)

$0 $0 $0



Program Information

G. Funding Request:

Purchase of Service

Unit Cost # Units

$0.00

Total Requested

from PCBS


Grants


Source(s)

$0.00

Total Requested

from PCBS

Total of all Funds Requested from PCBS $


PI Expand an existing program

n Establish a new program

n Maintain an existing program




Program Information

Continued

Client Information:




Other

Non-Disabled


_______ Platte Countians w/Developmental Disabilities


Other

Non-Disabled










65 years and older



Program Information Continued


Contact

1. Address

City State MO Zip _

Phone Fax

Own _ _ Lease [Tj


Name

Address

City State MO Zip

Phone Fax

Proprietary ___ Public [__ Non Profit f**1




Narrative Description of Program





objectives.



Program Information

Continued















List Each Income

Source for

Program

Previous Year

Program Income

Amounts

(2017)

Current Operating

Program Income

Amounts

(2018)

Proposed Program

Budgeted Income

Amounts

(2019)

$0 $0 $0



Program Information

G. Funding Request:

Purchase of Service

Unit Cost # Units

$0.00

Total Requested

from PCBS


Grants


Source(s)

$0.00

Total Requested

from PCBS

Total of all Funds Requested from PCBS $0.00

H. Purpose of Funds Requested:

n Expand an existing program

f"~l Establish a new program

O Maintain an existing program




Program Information

Continued

I . Client Information:


_ _ _ _ _ _ Platte Countians w/Developmental Disabilities


Other

Non-Disabled




. Other

_ _ _ _ _ Non-Disabled









55 years to 65 years _ _ _ _ _ _ Other

65 years and older





Contact

1. Address

City State MO Zip.

Phone Fax

Own _ _ ] Lease __j


Name

Address

City State MO Zip

Phone Fax

Proprietary _ Public _ Non Profit [""1

Funding Packet-2020 of 3 5


Program Information

Continued






objectives.

Funding Packet -2020 of 3 5


Program Information

Continued















List Each Income

Source for

Program

Previous Year

Program Income

Amounts

(2017)

Current Operating

Program Income

Amounts

(2018)

Proposed Program

Budgeted Income

Amounts

(2019)

$0 $0 $0



Application Support Documents

Please submit one copy of each document. Number and code support documents per the following:

1. Financial

A. Copy of most recent agency audit, including management letter.

B. Complete copy of the agency's most recent IRS Form 990, including all supporting schedules.

C. Copy of current fiscal year agency budget including projected income.

D. Copy of current monthly balance sheet, including income and expense statement.

2. Corporate

A. Copy of Certificate of Incorporation.

B. Copy of agency 501(c)(3) Tax Exemption Letter.

C. Copy of board member roster including name, position held, term

expiration, and phone numbers.

D. Proof of Insurance coverage.

3. Licensure/Accreditation

A. Copy of approval letter(s) of most recent licensure, certification or accreditation report.

4. Compliance

A. Satisfaction Survey Results.

B. Copy of most recent CARF survey, or ACQR (Annual Confomiance to Quality Report) and Response from

CARF (if CARF accredited).

C. Copy of most recent Outcomes Report.

5. Agency

A. Agency/program brochure(s).

6. Additional Information ( if specified).



Corporate Resolution

The Park Hil l School District Board of Directors having

Applicant

met on 09/24/2019 voted to apply for funds from the Platte County Board of Services for the

Date

Developmentally Disabled in the amount of $ 3,120.00 for the purpose of:

Assisting with transportation costs for students with developmental delays to participate in work experiences/job shadowing/touring agencies. These experiences will help students work toward goals and experiences related to work after high school.

The authorized individual(s) to enter in to contractual arrangements with the Platte County Board of Services is (are):

Park Hill School District

Dr. Chris Daniels, Sarah McDaniels, Janell Deville

Respectfully Submitted,

By- Dr. Chris Daniels

j j t le Director of Special Education

Date



Affidavit

I certify that to the best of my knowledge and belief the infonnation included in this Application for Funds is true, complete, and

correct.

Christopher Daniels

Name of person completing this application (typed or printed)

Director o f Special Services

Title

Signature of preparer

09/10/2019

Date

State of Missouri

County of P l a t t e

On this 10 day of S e P | e m b e r j n the year 2019 before me, the undersigned notary public, personally

appeared C.V\ C ̂ c!-.~V^r'iKa.c Cj a. w, \ x1 known to me to be the person whose name is \

subscribed to the within instrument and acknowledged that he/she executed the same for the purposes

therein contained.

In witness whereof, 1 hereunto set my hand and official seal.

"1 'IJ—_ j~ s\ in / 4 ^ 3 t A A ^ (7\ jrv^JCy

Notary Public

CYNTHIA L. SMALL Notary Public - Notary Seal

State of Missouri - Platte County Commission # 15477403

My Commission Expires 10/21/2019
