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DocuSign Envelope ID: E546BA93-2CAA-4121-B91A-3F2107563B4D <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) A. •licant Contact Information <br /> Applicant Organization's Legal Name: Movement of Youth, Incorporated <br /> Applicant Organization's Physical Address: 406 Nac well Street, Suite B030, Durham, NC <br /> 27701 <br /> Applicant Organization's Mailing Address: Same as above <br /> Applicant Organization's Web Address: www.movementof outh.or•. <br /> Executive Director: Atrayus Goode <br /> Telephone Number: (800) 956-3820 E-Mail: a,000de move entofvouth.orq <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FY17-18 Human Services (HS) Funding Being Requested — <br /> For All Pro•ram ) and the Proposed Use of Funds (2-3 lines or less) <br /> M Brother's Keeper(MBK) gunge County, Carrboro Cha al Orange Total <br /> -HS Hill-HS County-HS <br /> Admit.Me. Online support system where students get 250.00 250.00 <br /> expert support on how to represent their academic <br /> background, activities, goals, and interests for schools <br /> College Tour. Travel and Lodging for 50 students 26,250.00 26,250.00 <br /> from MBK-related agencies <br /> Institute for Civic Engagement for WEmerging ...... ...... . _. <br /> 25,000.00 25,000.00 <br /> Leaders. Cost for supplies, food, presenters, and <br /> instruction during two-week intensive summer <br /> enrichment academy for 50 students from MBK- <br /> related agencies <br /> Racial Equity Institute. Cost for 50 students nITIT ts....._ _..... ..... _ __..__...0 <br /> from 11,250.00 11,250.00 <br /> MBK-related agencies to attend REI training <br /> MBK Director of Programs. Cost for technical 40,000.00 40,000.00 <br /> assistance and staff support to direct MBK Orange <br /> County. <br /> AmeriCorps VISTA. Cost share for 3 full time 12,000.00 12,000.00 <br /> AmeriCorps members to support and manage project. <br /> MBK Opportunity Summits. Cost for supplies, food, 10,000.00 10,000.00 <br /> presenters, and materials for two (2) MBK Opportunity <br /> Summits for high school students, college students, K- <br /> 12 educators, and community and business leaders. <br /> Summits will focus on student achievement, <br /> career/personal/professional development, social <br /> .ustice and en.a.ement, and mentorship. <br /> AGENCY INFORMATION 1/31/2017 3:24:15 PM P a 0 0 il 0 t 2 9 <br />