Fill out the following information and click the “Submit” button. Items marked with an asterisk (*) are required.

                  Nature of Proposed Program (check one)*:

         Remediation   /   Tutorial   /   Test  Preparation   /   Parent Education

Description of Proposed Program:* (Describe the type of program you are planning). 
Example:  We are planning an after school algebra 1 tutoring program to be led by a certified math teacher from our faculty.
The teacher will be assisted by members of our honor society and math club who will give individual attention to each student
after a concept has been presented by the teacher.

What is the target population,* how many students, and how are they identified? 
Example:  40 at-risk students who tested at level 1 and 2 on the FCAT practice test.

What statistical outcome(s)* do you expect?  Example:  At least 50% of the students will test at level 3 by the end of the program.

Start/End Dates, Days, Times of Program:*

Number of Hours* (60 hrs max):       Type numbers only in this field: Example: 40

What pre-program evaluation* (pre-test) will you use to establish a baseline to measure student knowledge?

• Except for parent education programs, select from SRI (reading), SSS (math), Algebra 1 Pre-Test, Diagnostics.

• Example: We will use the Diagnostics.

• Choose one assessment only.

• Do not use the FCAT Practice Test as a pre-test evaluation tool. Program results have to be submitted prior to the May FCAT results.

What post-program evaluation* (post-test) will you use to measure student achievement?

• Except for parent education programs, select from SRI (reading), SSS (math), Algebra 1 Pre-Test, Diagnostics.

• Choose one assessment only.

• Do not use the FCAT as a post-test evaluation tool. Program results have to be submitted prior to the May FCAT results.

Schools will be sent an email indicating whether or not the application has been approved.

Sponsored by the Community Schools of the Palm Beach County School District.

PBSD 2374 (New 5/7/2010)