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DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) <br /> Program Name: The Chapel Hill Community Impact Program under the auspices of <br /> Boys & Girls Clubs of Durham and Orange Counties (BGCDOC), <br /> Program Primary Contact and Title: Jerome Levisy, CEO <br /> Telephone Number: 919-687-4517, ext. 20 E-Mail: jlevisy©durhambgc.com <br /> a) Indicate the type of Human Service Needs Priority, if program applicable: <br /> O Priority Area#1: safety-net services for disadvantaged residents <br /> 14 Priority Area#2: education, mentorship, and afterschool programming for <br /> youth facing a variety of challenges <br /> O Priority Area#3: programs aimed at improving health and nutrition of needy residents <br /> b) Indicate the type of program for which you are requesting funding <br /> Check all that a..1 to this profram <br /> j 1 Public Housing <br /> Program Category Youth Adult Elderly Disabled 1 • <br /> Neighborhoods/Residents <br /> ........ . <br /> Affordable Housing <br /> Affordable Healthcare , <br /> I Focus on those who need <br /> Education X us most. <br /> „„.„.. <br /> 1 <br /> Emily_Resources <br /> Jobs/Jobs Training <br /> _ 1 <br /> Food / <br /> Tranagitation <br /> other: Please specify <br /> Focus on those who need <br /> Character us most. <br /> development, good <br /> citizenship and <br /> healthy life styles <br /> X <br /> 1 <br /> 1 1 <br /> c) 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 /> • We sought collaboration with the CHAPEL HILL-CARRBORO CITY SCHOOLS in late 2014 <br /> and secured space for one classroom to serve 17 youth beginning on January 5, 2015 in <br /> Northside Elementary School. The Northside School officials said they were "delighted" to <br /> have our program back in Fall 2015 in two large, sunny classrooms with 32 children <br /> enrolled (K-5) for the school year of 2015-16. With the continuing success of the BGC <br /> Community Impact Program, the Northside School has offered three rooms in 2016-17 for <br /> the program to expand to 50 children enrolled. Referrals to the program are primarily <br /> PROGRAM INFORMATION1/26/2017 14:54:11 al/p1 P a ge 12 o f 22 <br />