Florida Afterschool Network APPLICATION FOR SITE SELECTION APPLICATION INSTRUCTIONS To apply, please complete the application on the following pages. Narrative responses should be no more than two typed pages. Applications may be submitted via hard copy (hand-delivery or mail) fax or e-mail. Applications submitted by email will receive a confirmation from FAN. For questions or additional information, please contact Samantha Thorstensen (Samantha.thorstensen@nasa.gov). Complete applications must be RECEIVED by 4:00 PM on Monday, APRIL 27, 2015. Selection notification will be April 30th. Submissions can be made via hard copy, fax, or e-mail. (email preferred) Hard Copy: Mail or hand-deliver completed applications to: Florida Afterschool Network ATTN: Samantha Thorstensen, Zero Robotics Mail Code: ERC Kennedy Space Center, Florida 32899 E-mail: E-mail completed application and attachments to samantha.thorstensen@nasa.gov with subject line “FAN 2015 Zero Robotics Application”. Fax 321-867-7242 Eligibility: Any community- or school-based organization that serves middle school youth is eligible to apply. Programs must serve a team of 10-20 youth for a minimum of 15 hours per week for 5 weeks (program times and days of operation may vary). Programs must have computers and internet access. Priority consideration will be given to programs that serve under-represented populations. PART I: Organizational Information Please provide organization information and community demographics. Organization: ____________________________________________________________________ Organization Name ____________________________________________________________________ Address City Zip ____________________________________________________________________ Phone Fax Website Check all that apply:  CBO (Community-Based Organization)  21st Century Community Learning Center  Other ___________________________ Contact Information:  AS/OST  School/School District ____________________________________________________________________ Executive Director and/or Principal Phone E-mail ____________________________________________________________________ Executive Director and/or Principal Phone E-mail 1 ____________________________________________________________________ Project Coordinator (if different) Phone E-mail ____________________________________________________________________ Project Coordinator (if different) Community Information: Phone E-mail Please indicate the percentage of students in your program in the following priority areas. If possible, please also indicate percentages for Zero Robotics Program Participants.  Gender: Program: Female:______% Male:______% | Participants: Female:______% Male:______%  Low-Income (receiving free or reduced lunch and/or contracts/vouchers/subsidies): Program: ______% | Participants: ______%  Children or youth with disabilities: Program: ______% | Participants: ______%  English Language Learners: Program: ______% | Participants: ______%  Students from Low-Performing Districts: Program: ______% | Participants: ______%  Racial/Ethnic Demographics (please indicate background, add lines as needed): __________________________ - Program: ______% | Participants: ______% __________________________ - Program: ______% | Participants: ______% __________________________ - Program: ______% | Participants: ______% __________________________ - Program: ______% | Participants: ______% PART II: Narrative Please respond to the following questions briefly and concisely (no more than 2 typed pages). 1. Provide a brief description of your program. 2. Does your organization currently offer a STEM course and/or curriculum (circle one)? Yes No  If yes, please describe your STEM offerings, any online or printed STEM curricula you have used (i.e. NASA K12 online curriculum, FIRST, EiE/EA), and explain how the Zero Robotics Project will complement your summer learning program.  If no, please explain how and why you would like to add a STEM component to your summer program through Zero Robotics. 3. Who will be your Project Director/Zero Robotics Curriculum Coordinator? Why was this person selected to lead the project? Please list their credentials. Indicate here if you intend to engage any other staff or volunteers to be part of this project. If so, how will they participate?  Check this box if any of these staff members or volunteers have experience with programming. 4. Strong partnerships are essential to a successful Zero Robotics program. Discuss which agencies, organizations, schools, or other service providers you plan to collaborate with on this project. Do you have a commitment from these partners? If so, have they agreed to provide volunteers, financial support, or another form of support? If you have not yet engaged partners, please explain why and/or your plan to do so. 2 PART III: Youth Letter of Interest Labeled as “Attachment A”, please include a letter from at least one youth who intends to participate in the Zero Robotics Summer SPHERES Program at your site. The goal of this program is to inspire interest and excitement around STEM subjects, activities and careers by introducing youth to space engineering and computer coding. Please attach a letter /essay from at least one youth who intends to participate in the summer program. The letter/essay should respond to the following prompt: Why do you want to participate in the Zero Robotics Summer Program, and work with robotic satellites during the summer? What do you want to learn this summer? PART IV: Required Commitment Please confirm that your site agrees to the program commitments by checking the boxes below and signing. __________________________________________________________________ agrees to the following: Organization/School name           My program will serve 10-20 youth for 5 weeks for a minimum of 15 hours per week (including field trips). My program agrees to target underserved and underrepresented youth for this project. My program has enough computers for youth to access, utilize, and learn on over the summer. At least one staff member will serve as the project’s Zero Robotics Curriculum Coordinator (ZRCC) and will commit to attend one educator training sessions, coordinate the Zero Robotics project, and serve as the main program site contact. My program will coordinate transportation to an all-competitor Field Day in the second week of the program. My program agrees to coordinate transportation and authorization/permission forms for youth and families to attend the final ISS Competition in the middle of August. One staff member (who can be the project’s ZRCC) will work with program evaluators to maintain, collect and submit required student, program and curriculum data. The ZRCC agrees to provide written feedback on curriculum design and ease of use to the Florida Afterschool Network. My program will communicate regularly with Zero Robotics organizers. Our staff agrees to have fun and learn alongside our students! Signed: __________________________________________________ Date: ________________________ Authorized Signature Florida Afterschool Network 3