Primary Applicant

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E-mail Address

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Phone Number

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Grade Levels to be Impacted

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Teaching Assignment

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Additional Email Address

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Additional Applicants

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# of Students to be Impacted

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Proposal or Program Name

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Content Area:

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Specific needs of the students and staff and the process used to identify the needs:

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Goals and measurable objective with explanation of the relations of the goals and objectives to identified needs:

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Explanation of proposal, including relation of activities to the goals and objectives and general timeline:

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Explanation of evaluation of results of proposal or program:

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Explanation of plan for continuing program after initial funding:

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Expenditures: List the item(s) to purchase with specific ordering information, source and cost. Add 18% for sales tax and shipping:

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Comments:

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