OG-4929	Rev. 3/02	Michigan Department of Education

Grants Coordination and School Support	--PAGE 1-

AUTHORITY: Section 98(8) of the 2007

State School Aid Act	P.O. Box 30008, Lansing, Michigan 48909	Direct questions regarding this form to

(517) 373-1806.

COMPLETION: Voluntary. (Consideration for

funding will not be possible if form is not filed.)

MY DREAM EXPLORER GRANT

APPLICANT INFORMATION

TYPE OR PRINT:

APPLICANT	Legal Name of ISD

District Code

Address of District

City	Zip Code

Name of County

Name of Contact Person

Title

Telephone (Area Code)

( ) -
CONTACT PERSON	Address

City

Zip Code

E-Mail Address

Facsimile (A.C./No.)

( ) -

GRANT FUNDS REQUESTED:

ASSURANCES AND CERTIFICATION: By signing this assurances and certification statement, the applicant certifies that it will agree to perform all actions and support all intentions stated in the Assurances and Certifications on pages 2a and 2b, and will comply with all state and federal regulations and requirements pertaining to this program. The applicant certifies further that the information submitted on this application is true and correct.

SUPERINTENDENT OR

DATE	AUTHORIZED OFFICIAL ____________________________________________________________

SIGNATURE

TYPED NAME/TITLE

MAILING INSTRUCTIONS: Return this form to the Michigan Department of Education at the address shown above. The application with original signatures and three copies must be postmarked no later than September 22, 2006.

NOTE: Applications may no longer be hand delivered. Late applications will NOT be considered.

OG-4929 (Page 2)

ASSURANCES AND CERTIFICATIONS

STATE PROGRAMS

INSTRUCTIONS: Please review the assurances and certification statements that are listed below. Sign and return this page with the completed application.

ASSURANCE CONCERNING MATERIALS DEVELOPED WITH FUNDS AWARDED UNDER THIS GRANT
The grantee assures that the following statement will be included on any publication or project materials developed with funds awarded under this program, including reports, films, brochures, and flyers: “These materials were developed under a grant awarded by the Michigan Department of Education.”
CERTIFICATION REGARDING NONDISCRIMINATION UNDER FEDERALLY AND STATE ASSISTED PROGRAMS
The applicant hereby agrees that it will comply with all federal and Michigan laws and regulations prohibiting discrimination and, in accordance therewith, no person, on the basis of race, color, religion, national origin or ancestry, age, sex, marital status or handicap, shall be discriminated against, excluded from participation in, denied the benefits of, or otherwise be subjected to discrimination in any program or activity for which it is responsible or for which it receives financial assistance from the U.S. Department of Education or the Michigan Department of Education.
CERTIFICATION REGARDING TITLE II OF THE AMERICANS WITH DISABILITIES ACT (A.D.A.), P.L. 101-336, STATE AND LOCAL GOVERNMENT SERVICES (for Title II applicants only)
The Americans with Disabilities Act (ADA) provides comprehensive civil rights protections for individuals with disabilities. Title II of the ADA covers programs, activities, and services of public entities. Title II requires that, “No qualified individual with a disability shall, by reason of such disability be excluded from participation in or be denied the benefits of the services, programs, or activities of a public entity, or be subjected to discrimination by such entity.” In accordance with Title II ADA provisions, the applicant has conducted a review of its employment and program/service delivery processes and has developed solutions to correcting barriers identified in the review.
CERTIFICATION REGARDING TITLE III OF THE AMERICANS WITH DISABILITIES ACT (A.D.A.), P.L. 101-336, PUBLIC ACCOMMODATIONS AND COMMERCIAL FACILITIES (for Title III applicants only)
The Americans with Disabilities Act (ADA) provides comprehensive civil rights protections for individuals with disabilities. Title III of the ADA covers public accommodations (private entities that affect commerce, such as museums, libraries, private schools and day care centers) and only addresses existing facilities and readily achievable barrier removal. In accordance with Title III provisions, the applicant has taken the necessary action to ensure that individuals with a disability are provided full and equal access to the goods, services, facilities, privileges, advantages, or accommodations offered by the applicant. In addition, a Title III entity, upon receiving a grant from the Michigan Department of Education, is required to meet the higher standards (i.e., program accessibility standards) as set forth in Title III of the ADA for the program or service for which they receive a grant.
SPECIFIC PROGRAM ASSURANCES
The following provisions are understood by the recipients of the grants should it be awarded:

1. The selected grantee must work in partnership with Michigan Virtual University.

The selected grantee must develop a plan to provide the technical infrastructure and Help Desk support necessary to serve all participating schools.

The selected grantee must provide information and access to “My Dream Explorer” to all elementary, middle, and high schools in Michigan.

The selected grantee must secure a statewide license for FY2007 to make “My Dream Explorer” available to all Michigan pupils at no cost.

CERTIFICATION FOR PARTICIPATION AS GRANT MEMBER

---CERTIFICATION OF AGENCY DESIGNATED ADMINISTRATIVE AND FISCAL AGENT FOR THIS PROJECT---

Legal Name of Agency

District Code

Name and Title of Authorized Representative

Mailing Address (Street)

Signature
City

Zip Code

Telephone (Area Code/Local Number)

( ) -	Date Signed
Name and Title of Contact Person

Mailing Address (If different from agency address)

OG-4929 (Page 4)

MY DREAM EXPLORER GRANT BUDGET APPROVAL FORM

INSTRUCTIONS: The Budget Summary and the Budget Detail must be prepared by or with the cooperation of the Business Office using the School District Accounting Manual (Bulletin 1022).

1. BUDGET SUMMARY

LEGAL NAME OF APPLICANT:

District Code

MDE USE ONLY	Grant No.	Project No.	Project Type	Ending Date	FY of Approved Activity

2007

BUDGET OBJECTS:

FUNCTION CODE	FUNCTION TITLE	SALARIES	BENEFITS	PURCHASED SERVICES	SUPPLIES & MATERIALS	CAPITAL OUTLAY	OTHER EXPENDITURES	TOTAL EXPENDITURES
110	Instruction -- Basic Programs
120	Instruction -- Added Needs
130	Instruction -- Adult/Continuing Ed.
210	Pupil Support Services
220	Instructional Staff Services
230	General Administration
240	School Administration
253	Facility Acquisition & Construction Services
Operation and Maintenance
270	Pupil Transportation Services
280	Central Support Services
290	Other Support Services
SUBTOTAL
Indirect Costs _______ % Restricted Rate
TOTAL

SIGNATURE OF SUPERINTENDENT OR AUTHORIZED OFFICIAL	DATE

DATE	SUPERINTENDENT	SIGNATURE

DATE	BUSINESS OFFICE REPRESENTATIVE	SIGNATURE

2. BUDGET NARRATIVE

Explain each line item that appears on the Budget Summary, using the indicated function code and title, on a plain sheet. (Provide attachment(s) as needed..)

My Dream Explorer Grant

Application

My Dream Explorer Grant Application

HurleyJ

2006-09-21

State of Michigan\DIT