21st CCLC Program 21st Century Community Learning Centers (21st CCLC) Program Question Title * 1. Applicant Information Name, Last Name, First Mailing Address 1 Mailing Address 2 City State Zip Code Telephone (include area code) Cell phone Highest Degree Achieved Question Title * 2. The grant team will select reviewers based upon their professional and personal experiences as it relates to the goal, purpose, and needs of the 21st Century Community Learning Centers (21st CCLC) Grant Program. Please indicate your experience and background (check all that apply): Educator or Administrator Advanced graduate student (Pk-12; public/private/charter Community Leader/representative Faith-based representative Parent/parent liaison Education advocate University faculty/administrator Other (please specify) Question Title * 3. Please describe recent experiences: Question Title * 4. List all school districts, community based organizations, faith based organizations, or 21st CCLC that you are currently affiliated with. Question Title * 5. I have experience and/or an area of expertise in the following areas: (Please check all that apply). African-American Students Asian/Hawaiian Pacific Islander Students American Indian/Alaska Native Students Hispanic/Latino Students Title 1 Students Homeless Youth and Families Extended Day/After school/ Summer Programs Youth Development Reading Instruction Math Instruction Tutoring Homework Help Special Education Instruction LEP/NEP Instruction Family Literacy Programs Gifted & Talented Programs Academic Enrichment Programs Senior Citizen Volunteers Drug/Violence Prevention Programs Science Education Activities Cultural (art, music, etc.) Activities Technology Instruction/Activities Community Service/Service Learning Fiscal Reviews Grants Management Parental Involvement Activities Non-profit Management Faith-based Community Community Based Organizations Private School Issues Charter School Issues Elementary Students Middle School Students High School Students Professional Development Character Education Instruction Done