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DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 2.AGENCY INFORMATION (Be Very Brief and Concise) <br /> Please provide the following information about your agency(2 pages OR LESS): <br /> Years in Operation, Date of Incorporation (Month/Year): 77 years in operation; <br /> incorporated in 1942 <br /> Agency's Purpose/Mission (no more than a few sentences): <br /> Mission:To inspire and enable all young people, especially those who need us most, to <br /> reach their full potential as productive, caring and responsible citizens. <br /> Purpose:To instill a sense of competence, a sense of belonging and a sense of having <br /> power and influence, especially over their own lives as well as in the community. <br /> Types of Services the Agency Provides (bullet format): <br /> • Help with homework (Power Hour) with goal of academic success and graduation from high <br /> school <br /> • Character development through volunteer programs, healthy interaction with peers and <br /> adults, and opportunities to get involved throughout the community <br /> • Health education (both mental and physical) that incorporates age-appropriate lessons to <br /> ensure that Club members are able to make positive choices. Programs include: Smart <br /> Moves, Healthy Habits, Smart Girls, and Passport to Manhood. <br /> • Summer camp that helps children continue to engage in educational activities between <br /> spring and fall school semesters <br /> Agency's History with Providing These Services: <br /> The Durham Club has been successfully operating for 77 years and the Chapel Hill Program for <br /> Impact has been successfully operating for three years. <br /> Other Pertinent Agency Information (Ex. Has the agency experienced any major changes <br /> in the past year?Is there a new Executive Director?Are there new initiatives?) <br /> The BGC Program for Impact in Chapel Hill (formerly part of the BGCEP)merged with the <br /> BGC of Greater Durham in August of 2016 with the composite new name of Boys & Girls <br /> Clubs of Durham and Orange Counties; legal name change is in process. <br /> The CEO of the Durham Club, Jerome Levisy, is now the CEO of the combined Boys & Girls <br /> Clubs of Durham and Orange Counties. The BGCEP Club in Slier City merged, at the same <br /> time, with the BGC Club in Sanford, Lee County. <br /> Everyone believes these mergers are in the best interest of all parties involved. <br /> Agency Information 1/26/2017 14:54:11 a1/p1 Page Bof 22 <br />