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DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 <br /> txnibit A-continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> Program/Project Information <br /> j) Complete the Target Population and Program Beneficiary Demographics Chart <br /> k) Complete the Schedule of Positions Chart for Program Staff <br /> I) Disclosure of Potential Conflicts of Interested must be signed <br /> m) Complete the Work Statement Chart to describe the work to be performed, and be sure to <br /> attach copies of all data collection tools that will be used to verify achievement of program <br /> goals and objectives. Describe who will be responsible for monitoring progress. <br /> Information to Complete <br /> j.) Target Population <br /> Complete the following tables to the best of your ability. Show numbers of participants and <br /> percentages, as applicable, in each category. <br /> Please indicate whether this project/program will serve: ® Persons ❑ Households ❑ Units <br /> Program: Adapted Sports: Wheelchair Basketball <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> Gender <br /> Male 168 175 200 <br /> Female 54 60 100 <br /> Total 222 235 300 <br /> Of the females, how many are single- <br /> female Head of Households (Omit for <br /> Human Services) <br /> Ethnicity <br /> African-American 44% 43% 40% <br /> American Indian or Alaska Native 1% 1% 1% <br /> Asian 0% 1% 1% <br /> Caucasian 50% 50% 50% <br /> Native Hawaiian or other Pacific <br /> Islander 0% 0% 1% <br /> Other 5% 5% 5% <br /> Total 100% 100% 100% <br /> Of the above, how many <br /> Hispanic/Latino 0 0% 2% <br /> Of the above, how many non- <br /> Hispanic/Latino 100% 97% 95% <br /> Total 100% 100% 100% <br /> Age <br /> 0-5 years 0 0 0 <br /> 6-18 years 75% 75% 75% <br /> Main Application 5/24/2016 9:03:13 AM P of 2 <br />