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DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> 2. AGENCY INFORMATION <br /> Please provide the following information about your agency (Limit of 2 pages total): <br /> a. Years in Operation: Boys & Girls Clubs of America has been in operation in the United <br /> States for 105 years. The Boys & Girls Clubs of Eastern Piedmont (BGCEP) — Program for <br /> Impact in Chapel Hill has been open for one year+ with 36 children enrolled. The Boys and <br /> Girls Clubs of Eastern Piedmont opened a Club in Siler City 6 years ago and has <br /> successfully operated since then with over 100 children registered and with a waiting list. <br /> Date of Incorporation (Month/Year): December 9, 2008 <br /> b. Agency's Purpose/Mission: The vision of the Boys & Girls Clubs of Eastern Piedmont (BGCEP) <br /> is to inspire and enable all young people, especially those who need us most, to achieve their full <br /> potential as productive, caring and responsible citizens. The Mission is to provide school age children <br /> and youth in the Chapel Hill-Carrboro area from challenging circumstances, with a professionally <br /> supervised, consistent environment where they are safe, equally accepted and able to participate in goal <br /> oriented programs that enhance their self-esteem and assist them to achieve their full potential. The <br /> purpose is to instill a sense of competence, a sense of belonging and a sense of having power and <br /> influence, especially over their own lives as well as in the community.We are chartered by the Boys & <br /> Girls Clubs of America to operate programs in Orange, Person and Chatham Counties of North <br /> Carolina. Our program in Chapel Hill employs the BGCA"Formula for Impact" which provides an <br /> outcome-driven club experience for youth who need us most, from Kindergarten through 12th grade <br /> with enumerated priority outcomes. <br /> c. Types of Services the Agency Provides: Our Agency provides youth from Kindergarten <br /> through 12th grade with an after-school youth development program focused on three main <br /> goals or outcomes: Academic success, Good Character and Citizenship, and Healthy <br /> Lifestyles. <br /> The PRIORITY OUTCOMES are: <br /> 1.Academic success in school with end-goal to graduate from high school ready for college, <br /> trade school, military or employment. <br /> 2. Good character and citizenship- to become an engaged citizen involved in the community, <br /> register to vote and model strong,positive character; <br /> 3. Healthy life style- to adopt a healthy diet,practice good lifestyle choices and make a <br /> lifelong commitment to fitness. <br /> This Outcome-driven experience is carried out at all levels by providing <br /> 1. A Safe, Positive Environment, <br /> 2. Supportive Relationships, <br /> 3. Fun with a Purpose, <br /> 4. Opportunities and Expectations <br /> 5. Recognition for achievements. <br /> 6. High yield activities <br /> 7. Targeted Programs <br /> 8. Regular attendance <br /> Programs are deliberately designed for members to achieve these priority outcomes.Average daily <br /> attendance, membership retention and academic and social success in school are tracked. While all <br /> Main Application 5/24/2016 8:59:25 a5/p5 0 4 i 23 <br />