Atlanta Public Schools

2016-2017

SCHOOL
PROVIDER

RESPONSE FORM

A response form is required for all elementary and middle school after-school programs. All elementary and middle school after-school Independent Contractors must be authorized providers. Response forms that lack information and/or include information not requested will not be considered. Providers with more than one (1) school should have separate and completed forms for each school. The form should reflect what would occur at the individual school and not a universal response for the agency/organization. Do not include any forms that are not requested. All information must be typed. No attachments or addendums are required, unless requested.

For Expanded Day Use Only
Date Proposal Received

July 14, 2014

CHECK ONE: / CHECK ONE:
Before and After-School Program / School-Run Program
Before-School Program only / Independent Contractor-Run Program
After-School Program only / (Authorized After-School Provider)
  1. School Name
  2. Principal’s Name
  3. Independent Contractor Only: Agency, Organization, Group Name or Program Name

Address

Website Address

Telephone Number

President, Coordinator and/or Administrator

Title
E-mail Address / Fax Number

ContactPerson

Telephone Number
E-mail Address / Fax Number
  1. What is the mission of the program?
  1. What are the goals of the program and how will they be achieved?

GOALS / HOW WILL YOU ACHIEVE THEM?
  1. List the name and position of all staff members for this program.

POSITION / NAME
Site Leader/Director
  1. The exact date the program will start and end.

Start: / , / 2014 / End: / , / 2015
  1. What time will the program begin and end each day?

Begin: ______pmEnd: ______pm

What days of the week will you provide a program? Check all that apply.

Monday Tuesday Wednesday Thursday Friday Saturday

9. How long have you provided an after-school program at this school?

1

  1. Provide a schedule of offerings. Attached a copy of the schedule that the program will follow. All programs must provide choices of activities for all students. Include days of the week and time. (A schedule that reflects each day of the week). The schedule must show the connection to the school’s Achievement Plan. All schedules should be posted. The posted schedule should be the actual schedule followed.
  1. How are you incorporating the school’s Achievement/ImprovementPlan into your program? After-school programs should not be an extension of the regular day. However, the activities should have a positive effect on what is going on during the regular day. Staff should have knowledge of the areas for improvement and incorporate activities that assist with the plans. A response to this is possible only if you have discussed the school’s Achievement/ImprovementPlan with the Principal and ways in which the after-school program can assist. This component goes beyond homework. (See Assessment Rubric for Achievement Plan as a guide) Complete each area. Do not include an attachment.
  • Academic area(s) needing improvement:
  • Grade Level:
  • How will the staff work with the students?
  • Expected results:
  • What curriculum, if any, will you use for this component?
  • Type of activities to be involved with this component.
  • Resources and materials:
  • Type of staff to provide this component (certified teachers; non-certified staff; specialist, etc.)
  • Number of days per week to provide this connection:
  1. Independent Contractors only: What is the maximum number of students you can enroll in your program? This number should be based on your Bright from the Start license and budget.
  1. How many students do you propose to enroll in your program?
  1. Total number of students for whom an APS subsidy grant is being requested for each month. (Funding is solely dependant on an approved budget by Atlanta Board of Education) This request is for those programs on the elementary level that will request subsidy money for students on free and reduced lunch. Include the actual number of students for whom you propose to request subsidy. Subsidy grants can be adjusted based on program dates, fees and actual number of students.
  1. Parent Handbook and Student Registration Form: Do you provide a parent handbook to all parents of students enrolled in your after-school program? What are the procedures for providing a handbook to all parents and completion of student registration form? Attach a copy of your parent handbook/information that is provided to parents.
  1. Independent Contractors only: State the specific responsibilities of the school and the provider. Describe, in detail, the agreed responsibilities of the school and the provider.

RESPONSIBLE PARTY / RESPONSIBILITIES
Personnel (Salary/pay; Hiring; Evaluate)
Supplies/Materials:
Food:
Transportation:
Cleaning/Custodial:
Space:
  1. What procedures do you have for students who “drop-In”? Drop-in involves those students who do not attend on a regular basis and they pay a day-to-day fee and/or one day fee. Are those students pre-register? What are the procedures for communication with parent(s) of drop-in or day-to-day students? How are these parents aware of programs rules and regulations?
  1. Use of space. What type of space do you plan to use? This should include total program, indoor and outdoor spaces. Description of space should include number of classrooms, gym, auditorium, music room, cafeteria and etc. Independent Contractors must list the space that has been approved for the Bright from the Start license.

SPACE / Check if using space / How many? / √ Bright from the Start Approved Space
Classroom(s)
Gym
Auditorium
Music Room
Playground
  1. Safety and Security Plan. All after-school programs must submit a security plan to the school’s Safety Coordinator. The plan must include the following:

  • Memorandum of Understanding (MOU) between the after-school program, school and all safe locations (emergency areas). The MOU must include the following:

  • Dates
  • Authority
  • Purpose
/
  • Scope
  • Termination
/
  • Implementation
  • Signatures of all parties affected

  • Directions to all safe locations (emergency areas)

  • Map(s) of Evacuation Route based on location of after-school program

  • School emergency closing procedures

  • After-school program emergency drill schedule.

  • Fire Drills (3 or more)
/
  • Tornado Drills (3 or more)

  • Location of First Aid Kits

  • Designated Meeting Location

  • Telephone(s) location (Telephone other than main office. Telephone should be available in program area)

  • Emergency Procedure Instructions (Include role responsibilities)

  • Abuse
/
  • Missing Child

  • Bioterrorism
/
  • Power Outages

  • Bomb Threat
/
  • Serious Injury/Death

  • Earthquake
/
  • Sick Child

  • Fire
/
  • Suspicious Person

  • Floods
/
  • Terrorism

  • First Aid
/
  • Tornado/Hurricanes

  • Gas Outage/Leak
/
  • Unauthorized Person

  • Hazardous Materials
/
  • Violence

  • Loss of Water
/
  • Winter Storm

  • Minor Injury

  • List emergency codes

Safe location is a place where everyone will meet outside of the building. Every school has a safe location. This information can be found in the school’s safety plan. The after-school program staff must have knowledge of the school’s safe location.

The complete safety and security plan, with after-school provider signature, must be turned in by due date of the Response Form packet. The complete safety and security plan, with all signatures, must be turned in one week prior to the first day of school.

You must provide a copy of all incident reports to the principal and Expanded Day/Special Projects office.

  1. Field trips. State the plan and location for field trips. Explain how the field trips will benefit the students.

Check if the program is not planning any field trips.
Explain field trip plans:
  1. Transportation plan. State what plan you will have for children to return home and/or to go on field trips.
  1. Program Fees:

Registration Fee
Weekly Fee
Activity Fee (s)
Day-to-Day Fee
Drop-In Fee
Late Fee
Sliding Fee Scale*

*A sliding fee scale should not show a range of fees, but a scale that is by income and/or number in families and any other deductions. If you do not plan to have a sliding fee scale, please indicate that you will not have one.

  1. Budget and Budget Narrative: Provide a detailed and complete budget for the entire school year for the proposed school only. The budget must show costs for operating your program for a school year. Include number of staff, salary, benefits, expected cost of supplies, snacks, transportation, and any other cost to the program. Provide a detailed description of each cost with a total for the entire budget for that school year. The budget must reflect the hourly/yearly/monthly/daily rate and/or salary of each staff. Do not include an attachment. Type the budget in the space below.

CATEGORY / DESCRIPTION/NARRATIVE / BUDGET
TOTAL
  1. Identified Revenue Source. The revenue source must reflect, in detail, what monies you will have in order to financially support this program. Include fees, grants, and/or other monies coming into your program. Revenues should cover the cost of your program for an entire school year. Subsidy grant from Atlanta Public Schools should not be considered a revenue. Do not include an attachment. Type the budget in the space below.

FUNDING SOURCE / DESCRIPTION / REVENUE AMOUNT
TOTAL

Your packet will not be approved if the revenue source is lower than the program budget.

  1. Staff-Student Ratio. All programs must have a ratio of one staff for every fifteen students or less.

What is the staff/child ratio?
Explain how you will ensure that staff-child ratios will be met at all times.
  1. Employee and Volunteer Background Check. All employees and volunteers must have a positive criminal background check, cleared by APS Human Resource Department, before any contact with children. Please note: An employee or volunteer who is a registered sex offender and/or former employee of the Atlanta Board of Education who is ineligible for rehire, cannot work in the after-school program.

What is the process the program has established for fingerprinting and background checks for all employees and volunteers?
  1. How many staff members are certified in CPR and First Aid? This is in reference to staff who will be working in the after-school program at the proposed site. List the name(s) of the staff member(s) who are certified in CPR and First Aid.
  1. Evidence of Insurance. Write, in detail,the plan to make sure every participant has insurance coverage for accidents. All students should have accidental insurance coverage.

Detailed Insurance plan:
Will the student’s parent’s or program’s insurance policy cover accidents? Check all that apply.
Parents / Program insurance policy
If parents are expected to have an accidental insurance policy for their child (ren), how will information be collected and filed? Also, explain the plans for coverage if a parent does not have accidental insurance coverage.
  1. What training opportunities are offered to the staff? What staff development (training) will be provided to staff during the school year? All training must be relevant to the after-school program implementation.

NAME/TYPE OF TRAINING/PROFESSIONAL DEVELOPMENT
  1. How willthe program and staff be evaluated? If there was a program at this location during the previous school year, what was the result of the evaluation from parents, students and teachers? If this is the first year at this location or an evaluation was not completed in the previous year, how will the program and staff be evaluated? All programs must evaluate program and staff.

State the results and plans for improvement/change from the previous year’s staff and parents evaluation.
State plans for evaluating program and staff for the 2015-2016 school year. Include the process for improvement and/or changes based on evaluation results.
  1. Improving your program. How will the Georgia Afterschool Quality Standards be used to improve the program? Include the plans for self-monitoring and program staff involvement.
  1. Describe your parent involvement component? All programs must have a parent involvement component.
  1. Describe how the community will be involved in the program.
  1. All children and staff records must be kept in the program area. Children’s records must include identifying information about the child and parents; names and addresses of the person(s) to whom the child may be released; emergency contact person(s); health and allergies; parent signatures and special procedures and information. The staff files must include emergency contact; criminal background check; qualifications; and evidence of all training. Indicate the location of the files in the program area.

Location of children’s records
Location of staff’s records
  1. Posted Notices. All programs must have posted notices in the program area. The notices must include the following:

Rules and Regulations / Parents’ Rights to Review Report
Parental Access / Communicable Disease Chart
Responsible Person / Emergency Plans
Visitors Statement / Current Date Snack Menu
Current Bright from the Start License / Program Schedule and Activities
Program Room Locations / Response Form
The following notices must be posted by each program telephone:
Physician/Hospital / Ambulance
Local Fire Department / Police
County Health Department / Poison Control
APS Security Number
Location of Posted Notices: (include room and/or area)
Posted Notices
Notices by telephone
  1. State the location of program materials and supplies:
  1. State plans to provide USDA approved snacks. Will snacks be purchased or received from the APS Nutrition Department? State the location of the snacks.

Plans:
Location:
  1. Will the program administer medication?

Yes / No
If yes, provide a detailed plan that includes authorization and storage of medication.
  1. Each program must have a first aid kit in the program area. It would be beneficial to your program to have more than one first aid kit for each room/area. One staff person, who is CPR/FA certified, must be present at all times. For Independent Contractor programs, 50% of your staff must be CPR/FA certified. The kit must include the following non-expired items:

Scissors / Tweezers / Gauge pads
Adhesive / Thermometer / Ipecac Syrup
Assorted sizes of band-aids / Anti-bacterial ointment / Inset sting prep.
Antiseptic cleaning solution / Rubber gloves / Triangular band aids
Cold pack / First Aid Manual
Number and location of First Aid Kit(s):
  1. Attach the following to this form:
  • Independent Contractor Agreement: (Independent Contractors only). All independent contractors must complete an agreement. Executive Director and Principals must sign the Agreement as “Recommended By Principal”. Information must be typed and signed in blue ink.
  • Certificate of Insurance: (Independent Contractors only). Each independent contractor must have Commercial General Liability for bodily injury and property damage combined single limit that includes Contractual Liability Insurance in the amount of $1,000,000.00. The insurance must cover the entire Service Agreement. Every insurance certificate must list Atlanta Independent School System as an “Additional Insured.” The address on the certificate must be 130 Trinity Ave., SW, Atlanta, Georgia 30303. The Certificate of Insurance is needed before any Independent Contractor can begin the implementation of a program.
  • Copy of State of Georgia Business License: (Independent Contractors only)
  • Bright from the Start License: (Independent Contractors only) All independent contractors must have a Bright from the Start License or exemption before they can begin the implementation of a program. Attach a copy of the license and the last inspection report for the program. If the program is exempt, attach a copy of the exemption letter.
  • Program Contact Information Form
  • Written expression of support from local PTA or other community organization. This letter must include the school name, date, provider, and a signature of the representative from the PTA or community organization. A letter from the principal is not acceptable. The original letter must be attached; no copy or fax will be accepted.
  • Form 1 Approval Process: This form must be completed by all principals and submitted with this packet.
  • Program Staff Information. Information about program staff position and employment.
  • Program Schedule
  • Parent Handbook/Parent Information
  • Response Form Checklist

RESPONSE FORM CHECKLIST

Check the items that are included in the response form, sign and date at the bottom of this page. One checked copy should be submitted with the form. Respond to the following:

Authorized Provider / 25 / Staff and Student Ratio
Type of Program / 26 / Criminal Background Check
1 / School Name / 27 / CPR/FA
2 / Principal’s Name / 28 / Accidental Insurance
3 / Agency Information / 29 / Training
4 / Mission / 30 / Evaluation
5 / Goals / 31 / Improving Your Program
6 / Staff Members / 32 / Parent Involvement
7 / Program Dates / 33 / Community Involvement
8 / Program day and time / 34 / Children and Staff Records
9 / Number of Years at School / 35 / Posted Notices
10 / Schedule of Offerings / 36 / Materials and Supplies Location
11 / School Achievement Connection / 37 / USDA Snacks
12 / Number of Students – License / 38 / Medication
13 / Number of Students / 39 / First Aid Kit
14 / Number of Students for Subsidy / Independent Contractor Agreement
15 / Parent Handbook/Registration Form / Certificate of Insurance
16 / Responsibilities of Program / Georgia Business License
17 / Drop-In Procedures / Bright from the Start License/Exemption
18 / Use of Space / Contact Information Form
19 / Safety and Security Plan / Expression of Support
20 / Field Trips / Form 1 – Approval Process
21 / Transportation Plan / Program Staff Information
22 / Program Fees / Before School Program
23 / Budget and Budget Narrative / Program Schedule
24 / Revenue Source(s) / Parent Handbook/Information
Checklist

______