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DocuSign Envelope ID: E865EBC7-DCBB-4CE6-A224-13D663E29E12 <br /> EXHIBIT A <br /> _. PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> This Cost per Individual must reflect the total program budget divided by the total number of <br /> program individuals in this application. <br /> Total Cost of Program $105,609 $125,779 $133,210 <br /> Total # of Individuals 821 725 775 <br /> Cost Per Individua ..........................� ���.� <br /> I $129 1 $173 $172 <br /> 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) <br /> Program Name: Communit Education and Civic Engagement <br /> Program Primary Contact and Title: Ardith Burkes, Associate Director <br /> Telephone Number: f 919)968-461Q E-Mail: ro rarn dir for g om+ , sct <br /> a) Indicate the type of Human Service Needs Priority, if program applicable: <br /> ❑ Priority Area #1: safety-net services for disadvantaged residents <br /> ® 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 X X X <br /> Family Resources X X X X <br /> Jobs/Jobs Training <br /> Food 1 .�.�. <br /> Transportation <br /> Other: Civic <br /> Engagement, <br /> Volunteerism, and <br /> Safety net for the <br /> Vulnerable <br /> X X X X � X <br /> PROGRAM INFORMATION 1/30/2017 4:02:21 PM 1) a (.1 a A3 5 o .i 4. tt <br />