Exhibit 3

Application for Maryland 21st Century

Community Learning Centers Form

Application for Maryland 21st Century Community Learning Centers Cover Page
1. TITLE OF PROJECT:
2. GRANT APPLIED FOR: 21st Century Community Learning Centers
3. APPLICANT INFORMATION:
a. Lead Agency:	c. Employer/Taxpayer Identification Number (EIN/TIN):
b. Fiscal Agency (if different from Lead Agency)	d. Organizational DUNS:
e. Type of Organization (choose one)
f. Name and contact information of person to be contacted on matters involving this application Prefix: First Name: Last Name: Title: Telephone Number: Fax Number: Email:
g. Contact Address Street 1:
Street 2:
City: State: Zip / Postal Code:
h. Check one:
4. FEDERAL ABSOLUTE PRIORITIES
a. Eligible Schools All applications must propose to serve students (and families of students) who attend schools eligible for Title I school-wide programs or schools that serve a high percentage (at least 40%) of students from low-income families. List the schools eligible for this Absolute Priority that will be served by the proposed program.
Local School System	School Name	School ID Number	Address	City	Zip Code	% FARMS (2017-2018)
b. Partnerships All applications must include partnerships of eligible entities consisting of: (i) a local education agency and/or school(s); and (ii) community-based organization(s) or other public or private entity(ies). List the project partners that meet this Absolute Priority:
5. STATE ABSOLUTE PRIORITIES
a. Character Education All applications must integrate character education. Briefly (no more than 100 words) describe how the proposed project will integrate character education.
b. Service-Learning All applications must integrate service-learning. Briefly (no more than 100 words) describe how the proposed project will integrate service-learning according to Maryland’s seven best practices.
6. COMPETITIVE PRIORITIES
Additional points will be awarded to applications proposing to meet the following competitive priorities (see RFP for complete descriptions). Indicate which of the following you wish to be considered for (You may only select one competitive priority).
7. TARGET POPULATION AND OPERATIONS
a. Indicate which of the following grade(s) you propose to serve (check all that apply).
b. Number of students you propose to serve:
c. Times of operation Day(s) of the week (school year): School year weekday program start time: Program end time: (please indicate a.m. or p.m.) School year weekend program start time: Program end time: (please indicate a.m. or p.m.) Day(s) of the week (summer): Summer program weekday start time: Program end time: (please indicate a.m. or p.m.) Summer program weekend start time: Program end time: (please indicate a.m. or p.m.)
d. List the locations where the program will operate. For each site, indicate whether it is a school building or a community location:
Site/School Name	School or Community Site?	Address	City	Zip Code
e. Core subject focus area(s)
8. FUNDING
a. 21st CCLC funding requested per year Year 1: Year 2: Year 3:
b. Total number of days program will be in operation during Year 1:
c. Cost per student per day (based on Year 1): Formula: ( 8a / 8b ) / 7b Example: $400,000 / 80 days = $5,000 per day $5,000 / 100 students = $50 per student per day
9. PROJECT STATEMENT (100 word limit)
10. SIGNATURES
_________________________________________________________________________ Signature of Local Superintendent of Schools OR Head of Grantee Agency	____________________________ Date