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DocuSign Envelope ID:78 e-B256-33o571Ae4687 [ /\- continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> ° N.C. Botanical Gardens collaboration in horticulture therapy <br /> w Chapel Hill Library—collaboration on community service pr jects for children's library <br /> • Ackland Art Museum—collaboration on museum visits for dementia. <br /> * Chapel Hill Service League collaboration on community service projects for the League's Christmas <br /> 1-louse. <br /> � <br /> IFC's ffomcStart Homeless Shelter collaboration on community service projects, including flower <br /> arrangements for the Home Start shelter. <br /> � <br /> Carol Woods Retirement Community—collaboration on community outreach and service to residents. <br /> � <br /> Carolina Meadows -w|)aborudoudouugbCu/nliooMeadovvmcononnuoityuAcnoy [uoJioAprogrmnuod <br /> service to residents. <br /> * Various home health agencies; area assisted living and nursing care facilities collaboration on service <br /> coordination, client refelTals, etc. <br /> • Various area schools—student groups, including music groups, volunteer at Charles House. <br /> p <br /> Area civic groups, churches—community outreach, church and group members often volunteer at Charles <br /> House. <br /> g) Describe what would happen if requested funding is not awarded at all or if a reduced <br /> allocation is recommended. <br /> If this funding request were not aw rdcd or if it were reduced, Charles I-louse would be limited in its <br /> financial ability to accept the reduced contractual rates from the Departments of Social Services and on <br /> Aging. There would be a reduction in the access to Charles House services by families of need. <br /> h) Include any other pertinent information. <br /> Program/Project Information <br /> R Complete the Target Population and Program Beneficiary Demographics Chart <br /> j) Complete the Schedule of Positions Chart for Program Staff <br /> k) Disclosure of Potential Conflicts of Interested must be signed <br /> I) 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: A Persons Households Units <br /> Program: Charles House Daytime Eldercare Program <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2014-15 2015-10 201847 <br /> Gender <br /> Male 30 35 40 <br /> Female 49 55 60 <br /> ' <br /> Total 79 90 100 <br /> Main Application 1/25/2016 11:54:37 AM Page 8 of 2 1 <br />