Orange County NC Website
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I <br /> DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> I. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Ashley Thomas <br /> Applicant Organization's Physical Address: 3729 Murphey School Road, Durham, NC <br /> 27705 <br /> Applicant Organization's Mailing Address: 3729 Murphey School Road, Durham, NC <br /> 27705 <br /> Applicant Organization's Web Address: wwvv.bridge2sports.org <br /> Executive Director: Ashley Thomas <br /> Telephone Number:j866) 880-2742 E-Mail: ashley(@bridge2sports.orq <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FYI 7-18 Human Services (HS) Funding Being Requested - <br /> For All Programs) and the Proposed Use of Funds (2-3 lines or less) <br /> Program Carrboro Chapel Orange Total <br /> - HS Hill - HS county-HS <br /> Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 <br /> Afterschool Program Coordinator salary and materials <br /> for youth activities and projects <br /> Adapted sport programming in boccia and $5,000 $10,000 $6,500 $21,500 <br /> wheelchair basketball for individuals with <br /> disabilities. I <br /> Totals $5,000 $10,000 $6,500 $21,500 <br /> Funding is used to maintain boccia and wheelchair basketball programs for children and <br /> adults with disabilities. Both programs have served residents of Orange County, NC for 10 <br /> years. Qualified staff, travel costs, and equipment produce quality programming, creating <br /> positive outcomes for individuals with disabilities, as well as communities. <br /> c) To the best of my knowledge and belief all information and data in this application is <br /> true and current. The document has been duly authorized by the governing board of the <br /> applicant.1 <br /> . .0.1,4 4 i , A <br /> Signature. Arahm :1,4. , -- LOA OF 4 -1 <br /> ,„,,,, \ ll In <br /> Executive BA ector Date <br /> Signature: L harrnot b flq le44 .01/01711 i <br /> Board Chairperson Date <br /> AGENCY INFORMATION 1/26/2017 4:20:31 PM Page 6 of 25 <br />