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DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> b.) Program Budget Detail <br /> What is the cost to deliver your project/program? List each project/program element in the table below, <br /> including the cost of each element, the quantity and unit of measure, and the subtotal for each element. <br /> Where necessary, allocate costs to the use of shared space, vehicles or equipment. <br /> Example Program: Credit Counseling Class <br /> Cost Elements Cost($) Quantity/Unit of Measure Subtotal (S.) <br /> Credit Counseling Teacher–in class $25 96 hours(8 hrs/mth x 12 months) $2,400 <br /> Credit Counseling Teacher—class prep $25 48 hours(4hrs/mth x 12 mths) $1,200 <br /> Credit Counselor—one-on-one $20 120 hours(10 hrs/mth x12 mths $2,400 <br /> Materials $25 120 course packets/credit reports $3,000 <br /> Total $9,000 <br /> Complete the table below for the project/program for which you are requesting funds. <br /> Attach additional rows/pages, as needed. <br /> Program: Sexual Health Education and Outreach <br /> Cost Elements Cost($) Quantity/Unit of measure Subtotal ($) <br /> Refreshments—Teen Voices(TV), Smart Girls, $7 TV— 15 participants x 12 sessions $2,632 <br /> Alumni Smart Girls— 10 participants x 10 <br /> sessions <br /> Refreshments—Parents,charlas/chats $7 5-15 participants per workshop x 2 parent $280 <br /> workshops and 2 charlas/chats <br /> Incentives—Gift Cards $300+$2 fee TV- 15 participants $4,530 <br /> $100+$2 fee Smart Girls— 10 participants $1,020 <br /> $50 1 drawing per workshop x 2 parent $200 <br /> workshops and 2 charlas/chats <br /> Incentives—T-shirts $7.50 TV— 15 participants $247.50 <br /> Smart Girls— 10 participants <br /> Alumni—8 participants <br /> Rental Variable TV and Smart Girls-$300 each $1,150 <br /> Parents and chats-$200 each <br /> Alumni-$150 <br /> Mileage—Community Educator $0.54 175 miles per month x 12 $1,134 <br /> Training—New Educator on curriculum $995 1 participant $995 <br /> Copies $0.50 800 copies for worksheets,promotional $400 <br /> Office Supplies $40 Per month x 12 $480 <br /> Brochures $40 Per 100 x 10 topics $400 <br /> Promotional materials-swag $2 3 promotional items(keychains,pens, $900 <br /> carbineers,etc) x 150 of each <br /> Guest Trainers- TV $100 2 speakers $200 <br /> Peer Assistant - TV $100 1 assistant $100 <br /> Main Application 1/21/2016 18:35:26 a1/p1 Page 21 of 2 " <br />