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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: Blue Ribbon Youth Leadership Institute <br /> Program Primary Contact and Title: Lode L. Clark, Blue Ribbon High School Specialist <br /> Telephone Number: 919-918-2170# 2 E-Mail: Iclark(a�chccs.k12.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: Youth <br /> Leadership/ Mentoring <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 /> • Chapel Hill-Carrboro City Schools —all students are enrolled in CHCCS <br /> • Habitat For Humanity—students volunteer for various projects with <br /> Habitat, especially A Brush with Kindness which focuses on local repair. <br /> • Rogers-Eubanks Neighborhood Association (RENA) — Students have <br /> participated in various service events at RENA. Ongoing projects include <br /> the Fall Festival, Spring and Community Festival. <br /> • Dignity in Schools —focuses on school-to-prison pipeline issues and <br /> advocacy training for students <br /> PROGRAM INFORMATION 1/27/2017 2:16:38 PM Page 1 1 o f 2 2 <br />