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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 /> m.) Work Statement <br /> This form is used to document program activities, program goals, performance measures, <br /> and actual results. (Add more rows as needed) If this is a new program, you will only <br /> document the projected information. <br /> • Program Activities should outline major activities the agency implements to accomplish its <br /> program goals. <br /> • Program Goal should explain what the program is trying to achieve/accomplish. Goals are <br /> statements about what the program should accomplish. SMART Goals <br /> • Performance Measures describe how you will evaluate the degree in which you achieved <br /> the stated goals. <br /> • Actual Program Results use program results to indicate the actual measureable <br /> achievement of goals. If goals were not met, please explain. <br /> Actual Estimated Projected <br /> 2014-2015 2015-2016 2016-2017 <br /> Coaches build relationships Coaches build relationships Coaches build relationships <br /> with athletes and their with athletes and their with athletes and their <br /> families to provide resources families to provide resources families to provide resources <br /> and mentoring to students and mentoring to students and mentoring to students <br /> who are at risk as part of the who are at risk as part of the who are at risk as part of the <br /> regular practices and regular regular practices and regular regular practices and regular <br /> Program contact they have with contact they have with contact they have with <br /> Activity 1 athletes athletes athletes <br /> 100%of athletes enrolled in 100%of athletes enrolled in 100%of athletes enrolled in <br /> our programs will remain in our programs will remain in our programs will remain in <br /> Program school and graduate High school and graduate High school and graduate High <br /> Goal School,when eligible School,when eligible School,when eligible <br /> Graduation statistics Graduation statistics Graduation statistics <br /> gathered through gathered through gathered through <br /> Performance information from coaches information from coaches information from coaches <br /> Measures and participants. and participants. and participants. <br /> 100%of students enrolled in 100%of students enrolled in 100%of students enrolled in <br /> Program our programs who are our programs who are eligible our programs who are eligible <br /> Results eligible to graduate did so. to graduate will do so. to graduate will do so. <br /> Practices will be organized Practices will be organized Practices will be organized <br /> and conducted by trained and conducted by trained and conducted by trained <br /> coaches. Equipment will be coaches. Equipment will be coaches. Equipment will be <br /> safe, clean, well maintained safe, clean, well maintained safe, clean, well maintained <br /> Program and provided for all and provided for all and provided for all <br /> Activity 2 participants. participants. participants. <br /> Main Application 5/24/2016 9:03:13 AM P 16 of 2 <br />