2020Unified Champions School School Application Form

School Name:

School Address:

Program Coordinator:Email: Phone:Signature: Date:

Coach:Email: Phone:Signature Date:

Principal:Email: Phone:Signature: Date:

Eric Archambault at Eric.Archambault@specialolympicsma.org Special Olympics Massachusetts (SOMA) 512 Forest Street, Marlborough, MA 01752

Phone: 508-485-0986 Fax: 508-481-0786

Signatures on this application are a formal expression of your school’s commitment to a 3-year program of inclusion, acceptance and respect of all students through the implementation of the 3 components of the Unified Champion Schools Program. Please see below the requirements of your school.

Special Olympics Ma Unified Champion Schools© will strive to help promote climates of dignity, respect, and inclusion in schools for students with and without intellectual disabilities.

Schools that are accepted as a new school in the 2019- 2020 school year will commit to a 3 year program. Each year will have the following general activities:

1. A fall and/or spring culminating event that highlights the sport skills all participants have learned.2. A minimum of two whole school engagement events that promotes inclusion, acceptance and support of

the students with intellectual disabilities.3. Continuous youth leadership throughout the year of friendships being made and youth being the agents of

change.

Grant Funding: With a 3 year commitment to being a Unified Champion School, your school will be provided a $500 stipend for the first two years, totaling $1000 over two years. Attached is an item sheet that you have a choice on deciding how to spend the $500. The program is at no cost for your school! Requirements: Schools must commit to the minimum criteria listed in the Criteria checklist below, complete the spring evaluation process and send quarterly updates on the program. Schools must provide paperwork to Special Olympics consisting of student names, date of birth, gender and if they are an athlete or partner before/after their events.

Unified Champion Schools Check at least one option in each category.

UNIFIED SPORTS□ Unified P.E./ Recess □ Unified Developmental Sports□ Unified School Day Games □ Unified Fitness□ Unified Young Athletes

YOUTH LEADERSHIP □ Unified Young Readers Club□ Recess Buddies □ Friends Program (please name):________________________________________________□ Peer Mentors□ Jr. Coaches/ Coaches in training □ Other: ___________________________________

WHOLE SCHOOL ENGAGEMENT□ Fans in the Stands at Unified Events□ Participate in Kindness Week□ Respect Campaigns□ Morning Inclusion Announcements□ Special Olympics Fundraisers□ Other: ___________________________________

Grant Funding Provided by Special Olympics MA

Special Olympics will provide schools with a menu of options worth $500 for their first and second year totaling $1,000 over the two years and the school being self-sustaining on their third year. Please see attached page for options on how to spend the $500 provided to you to make your program successful.

$500 Grant AwardWith a 3 year commitment to being a Unified Champion School, you will receive a grant of $500 for the 1st two years that you can use towards any of the following items to help grow your Unified Champion School so that it can be self-sustaining by year 3. School Name:_________________________________________________School Liaison Name & Signature:_________________________________

Amount Total

Reimbursement for After-School Programming stipend _____Max $500 _____

Amount can be up to $500. Middle Schools who participate in after-school programming are eligible

Curriculum Books Quantity Total

Young Athlete Playbook _____ x $20 ea _____Elementary Playbook _____ _____Middle School Playbook _____ _____High School Playbook _____ _____Unified Physical Education Playbook _____ _____Unified Fitness Playbook (plus Fit 5 Curriculum) _____ _____

Total: _____Sports Equipment

Quantity TotalYoung Athlete Sport Kits _____ x $200 ea _____General Sports Equipment Kits _____ _____

Includes enough sports equipment to run a program with 15-20 students

Game Day T-shirts Amount Total

School will receive up to $500 towards the cost of approved and branded t-shirts for culminating events.

Must submit an invoice and SOMA will pay up to $500 _____

Max $500 _____

Game Day Medals Quantity Total

Medals for culminating eventsComplimentary Participant Ribbons or Young Athlete Ribbons are available

free of charge _____ x $4 ea _____Spread the word Inclusion Poster & Stickers

Quantity TotalSpread the word Inclusion Poster and sticker pack Includes 1 poster and 100 stickers _____ x $20 ea _____

Must not exceed $500 Grand Total: _____