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DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) <br /> Program Name: Wheelchair Basketball <br /> Program Primary Contact and Title: Ashley Thomas, Founder& Executive Director <br /> Telephone Number: (866) 880-2742 E-Mail: Ashley @bridge2sports.org <br /> o) 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 /> p) 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 <br /> Family Resources X X X X <br /> Jobs/Jobs Training X X X <br /> Food <br /> Transportation <br /> Other: Please specify <br /> Health and Fitness X X X X <br /> q) 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 /> • Local Church —We collaborate to use the Church for practices and competitions. <br /> • UNC Chapel Hill — We accomplish programming, volunteer opportunities and <br /> experiential learning skills for UNC students and faculty members. <br /> • Disabled Sports USA —As a member of DSUSA, we have low-cost insurance that is <br /> required to safely execute program objectives for athletes, volunteers and supporters. <br /> • Chapel Hill/Carrboro local businesses and organizations — Donate raffle and auction <br /> items <br /> • Chapel Hill Chamber of Commerce —Work together to network and promote BIIS <br /> services for sponsorship engagement <br /> PROGRAM INFORMATION 1/27/2017 3:48:29 PM P g I "'/ of 2 6 <br />