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DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> Teachers in so many of our classrooms have shared how they gain new skills by watching and <br /> participating in our program. They have reported learning new skills in teaching emotional skills, <br /> self-management, socialization and leadership skills. <br /> i) Include any other pertinent information. <br /> Through this crucial grant, the county school fund and a few private grants, we were able to <br /> support all the classrooms for exceptional children this year for the district. The Orange County <br /> funding is essential and so very appreciated for our success in the Orange County Public <br /> Schools. <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: x Persons ❑ Households ❑ Units <br /> Program: VT in Education <br /> Program Beneficiary Demographics <br /> Actual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> Gender <br /> Male 10 10 15 <br /> Female 8 8 10 <br /> Total 18 18 25 <br /> Of the females, how many are single- <br /> female Head of Households (Omit for <br /> Human Services) <br /> Ethnicity <br /> African-American <br /> American Indian or Alaska Native <br /> Asian <br /> Caucasian <br /> Native Hawaiian or other Pacific <br /> Islander <br /> Main Application 1/25/2016 1:42:01 PM P a 1, e °1 H of 21 <br />