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DocuSign Envelope ID: oo-98o*3oe55r3Ao8E5 <br /> EXHIBIT A <br /> PROVIDERS OUTSIDE AGENCY APPLICATION <br /> Durham County 0 0 0 <br /> Wake County 0 0 0 <br /> Orange County Breakdown <br /> Chapel Hill Public Housing 3 5 5 <br /> Town of Chapel Hill (Non-Public Housing) 64 58 55 <br /> Town of Carrboro 23 25 25 <br /> Town of Hillsborough 0 <br /> City of Mebane (Orange County) 0 <br /> Orange County (Outside K8unicipm|ities) 10 12 _ 15 <br /> Total 100 100 100 <br /> Work Statement <br /> I) Complete the Work Statement Chart to describe the work to be performed. <br /> This chart is used to document program activities, program goals, performance measures, <br /> and actual results. (Add more rows as needed) If this is a new program, you will only <br /> document the projected information. Every program is required to have AT LEAST 1 <br /> Program Activity, which should be SMART(Specific, Measurab/e, Achievable, Relevant, and <br /> Time-bound. Click on SMART Goals to learn more. <br /> • Program Activities should outline major activities the agency implements to accomplish its <br /> program goals. (i.e. Deliver meals to elderly/disabled residents.) <br /> • Program Goal should explain what the program is trying to achieve/accomplish. Goals are <br /> statements about what the program should accomplish. (i.e. Deliver 100 meals per day <br /> Monday-Friday.) <br /> • Performance Measures describe how you will evaluate the degree in which you achieved <br /> the stated goals. (i.e. Will track the number of meals delivered each day.) <br /> • Actual Program Results use program results to indicate the actual measureable <br /> achievement of goals. If goals were not rnet, please explain. (i.e. Delivered an average of <br /> 105 meals per day.) <br /> Work Statement Chart for Program Blue Ribbon Mentor-Advocate Youth Leadership Institute <br /> 1. Program Activity Name Youth Leadership Summer Camp <br /> Program Goal Students will receive leadership training that will give them the skills <br /> and confidence to participate in a myriad of school and civic youth <br /> clubs/organizations. <br /> Performance Measures 100 students will actively participate in YLI and either a school club <br /> or community organization Students will understand and adhere to <br /> the mission and goals of such organizations. <br /> Previous Year Program Results Students shared information about the benefits of participating in <br /> various clubs and organizations <br /> Current Year Estimated Results More students of color will participate in school and civic clubs. For <br /> example, take a leadership role in student and class councils and <br /> town advisory boards. <br /> Next Year Projected Results More students of color will have a presence in school o|uba, <br /> councils and to n adviso boards <br /> 2. Program Activity Name YLI Alternative Spring Break <br /> Program Goal Students will be exposed to providing service outside of North <br /> PROGRAM INFORMATION 1/30/2017 9:08:16 AM H G g B 1 7 of 2 2 <br />