Agenda - 09-02-2010 - 4f - Laserfiche WebLink

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3 ORGANIZATION NAME Orange County Parks and Recreation Department Please check the appropriate box for the Focus Area/grant type (select only one): ^ Health of Vulnerable Populations (HVP) Improving health outcomes for North Carolinians served by health care safety-net organizations ^ Healthy Active Communities (HAC) ®Equipment-only requests Increasing physical activity and access to healthy (Healthy Active Communities only) food for North Carolinians ORGANIZATIONAL PROFILE Legal Name of Requesting Organization: PO Box and/or Street Address: Department of Environment, Agriculture, Parks and PO Box 8181 Recreation De artment DEAPR Hillsborou h NC 27278 City, State, Zip: County: Hillsborou h NC 27278 Oran e Phone Number (Area code): Fax Number (Area code): 919 245-2660 919 644-3042 Executive Director Name: Executive Director Email Lori Taft Address: Itaft@co.oran e.nc.us Grant Request Contact Name: Grant Request Contact Email Mark Hassig Address: mhassi @co.oran e.nc.us Organization Web Site Address: Date of Incorporation http://www.co.orange.nc.us/recparks/recreation.asp ~ (mm/dd/yyyy): 02/05/1979 Tax ID Number: Tax Status (check one): ^ 501 (c)(3) Tax-exempt public charity ® Government entity If invited to submit a grant application you will be required to submit proof of your tax status. Is your organization classified as a supporting organization? Are any Blue Cross and Blue (This should be noted on your IRS tax determination letter): Shield of North Carolina ^ Yes employees associated with ® No your organization as board members, volunteers, etc.? If yes, what type of supporting organization are you? ^ Yes ^ Type I supporting organizations are operated, supervised, or ®NO contra//ed bythe supported organization. If yes, please list names and ^ Type II supporting organizations are supen~ised or contra//ed in their association with your