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Nominators Name
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Nominators Title
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School
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County
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Contact Information
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Prefered Email
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Child's name (please use a pseudonym):
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Child's Grade
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Child's age
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Gender (if an individual)
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Program Hours Per Week
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Days Per Week
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Programs Run
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Child's level of participation
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Program elements (check all that apply)
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Basic Human Needs (i.e., access
to meals, healthcare, a safe place) |
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Fine Arts (i.e., drama, dance,
music, art) |
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Physical Activity (i.e.,
physical education/gym class, organized sports teams) |
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Academic Enhancement (i.e., homework
help/time, tutoring, academic enrichment classes or
clubs) |
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Social-emotional (i.e., friendship
groups, anger management classes, behavioral interventions,
counseling, life skills, mentoring, drug/alcohol use
prevention/intervention) |
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Other (please specify)
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| Describe or list which specific elements
most impacted or engaged this child.
This success story is an example of how a community
school (check all that apply).
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Improved a child's school attendance |
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Improved a child's behavior at school |
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Improved a child's behavior during
out-of-school time and at home
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Improved a child's grades |
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Exposed children to new ideas/activities |
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Complemented the school-day focus |
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Provided a safe and enriching after-school
environment |
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Other (please specify)
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| Can you provide supporting documentation?
Please check all that apply. |
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School attendance records demonstrating
increased attendance |
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Grade reports/report cards for the
student demonstrating improved grades |
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Incident reports or behavioral issues
tracking system reports demonstrating an improvement
in behavior |
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Testimonials from the family and/or
student |
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Letters attesting to improvement from
faculty/ staff and/or community members |
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Event attendance records |
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Survey results (i.e., user surveys,
satisfaction surveys) |
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Photos, videos, etc. of events related
to the highlighted program |
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Other (please specify)
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What else do you want to tell us about your success
story?
Don't see a category that fits your story? Tell us
about it anyway! Email the Federation at melissa@ilcommunityschools.org
and tell us about your story, and make comments about
additions that we might make to the forms.
Thanks for your participation! When the case study
is complete, you will receive a PDF file of the finished
success story.
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