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DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) <br /> Program Name: Youth Afterschool Tutoring Program for Economically Disadvantaged <br /> Students Who Need Assistance in Reading and/or Mathematics <br /> Program Primary Contact and Title: Nancy Zeman <br /> Telephone Number: 919-967-8211 x28376 E-Mail: nzeman@chccs.kl2.nc.us <br /> a) Indicate the type of Human Service Needs Priority, if program applicable: <br /> ❑ Priority Area #1: safety-net services for disadvantaged residents <br /> X❑ Priority Area #2: education, mentorship, and afterschool programming for <br /> youth facing a variety of challenges <br /> ❑ Priority Area #3: programs aimed at improving health and nutrition of needy residents <br /> b) Indicate the type of program for which you are requesting funding <br /> (Check all that apply to this program) <br /> Program Category Youth Adult Elderly Disabled Public Housing <br /> Neighborhoods/Residents <br /> Affordable Housing <br /> Affordable Healthcare <br /> Education X <br /> Family Resources <br /> Jobs/Jobs Training <br /> Food <br /> Transportation <br /> Other: Afterschool <br /> X <br /> c) Provide a bulleted list of other agencies, if any, with which your agency <br /> coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) <br /> to be funded. For each, briefly describe the coordinated/collaborative efforts. <br /> • PSF coordinates with the Chapel Hill-Carrboro City School District (CHCCS) <br /> to provide the services. Students are identified by teachers/staff and receive <br /> instruction afterschool by certified staff at their home school facilities. <br /> • PSF is a partner with Family Success Alliance and collaborates to identify <br /> students in Zone 6 schools who need tutoring assistance in math and/or <br /> reading. <br /> Program Description (3 pages OR LESS) <br /> Please provide the following information about the proposed program: <br /> d) Summarize the program services proposed and how the program will address a <br /> PROGRAM INFORMATION 1/27/2017 11:05:26 AM Page 1 2 of 2 2 <br />