State Agency Children Funds Application Request Form

The Kentucky Educational Collaborative for State Agency Children is very pleased that your school district is requesting to enter into a program agreement or new district agreement with KECSAC.

The deadline for new programs to apply for next year funding is April 1st.

In order to process this request, the following information must be submitted and returned to our office at your earliest convenience. If you have any questions, please contact our office at (859) 622-6552.

(Please Print or Type)

Educating School District                                                                                                                                   

Address                                                                                                                                                          

City                                                                                      Zip                                                                      

Phone                                                                                  FAX                                                                          

School Administrator                                                                    E-mail                                                       

Superintendent                                                                              E-mail                                                       

Signature                                                                                                 Date                                               

Please provide the following information regarding the State Agency Children Program(s) in your district for which you are requesting funding.

Name of Program                                                                                                                                           

Program Administrator                                                                 E-mail                                                       

Address                                                                                                                                                          

City                                                                                      Zip                                                                      

Phone                                                                                  FAX                                                                    

Number of State Agency Children                                    Licensed Program Capacity                                  

This program is          

  residential               day treatment.

State Agency Children in this program are currently being provided educational services (please check one):

      A. DJJ operated/Contracted Program

      B. Non-DJJ Operated/Contracted Program

      C. Department of Mental Health Day Treatment Program

      D. Other, please specify                                                                                                            

Please return this application to:

KECSAC

Eastern Kentucky University

521 Lancaster Avenue

104 Case Annex

Richmond , KY 40475

Phone: (859) 622-6552

Fax: (859) 622-8051

Web: www.kecsac.eku.edu