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DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 0-5 years <br /> 6-18 years 6 6 7 <br /> 19-50 years 6 7 7 <br /> 51+years 1 2 3 <br /> Total 13 15 17 <br /> Geographic Location <br /> Alamance County 1 1 1 <br /> Chatham County <br /> Durham County 2 2 2 <br /> Wake County 5 5 6 <br /> Orange County Breakdown <br /> Chapel Hill Public Housing <br /> Town of Chapel Hill (Non-Public Housing) 4 6 7 <br /> Town of Carrboro <br /> Town of Hillsborough <br /> City of Mebane (Orange County) <br /> Orange County(Outside Municipalities) <br /> Other 1 1 1 <br /> Total 13 15 17 <br /> Work Statement <br /> m) 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 document <br /> the projected information. Every program is required to have AT LEAST 1 Program Activity, <br /> which should be SMART(Specific, Measurable, Achievable, Relevant, and Time-bound. Click <br /> 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 met, please explain. (i.e. Delivered an average of <br /> 105 meals per day.) <br /> Work Statement Chart for Program: Bridqe II Sports Chapel Hill Boccia <br /> 1. Program Activity Name Boccia Physical Development: Skills Test <br /> Program Goal Practices are structured to develop the physical health and sport <br /> specific skills of athletes. <br /> Performance Measures During each season, execute a skills development test at the start, <br /> middle, and end of each season. Skills will test endurance, <br /> distance, and accuracy. <br /> Previous Year Program Results 100 %of athletes completed a skills test for each sport season. <br /> PROGRAM INFORMATION 1/27/2017 3:48:29 PM P g o of 2G <br />