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DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Work Statement Chart for Program Chapel Hill Program for Impact <br /> 1. Program Activity Name Provide homework&tutoring assistance for at-risk youth <br /> Program Goal To increase grades in reading and/or math by I point(scale 1-4) for 20%of <br /> youth members. <br /> Performance Measures Report card indicators <br /> Previous Year Program Results Met goal <br /> Current Year Estimated Results Already exceeded by 24%over goal <br /> Next Year Projected Results Expect to reach or exceed goal. <br /> 2. Program Activity Name Monitor personal&social skills of youth members <br /> Program Goal 75%of youth members will meet standards set by school in four categories. <br /> Performance Measures Report card indicators: 1. Follows classroom rules. 2. Takes responsibility <br /> for behaviors & actions. 3. Respects & cooperates with others. 4. Follows <br /> directions. <br /> Previous Year Program Results Met goal. <br /> Current Year Estimated Results 92%success in reaching goal so far and expect goal will be fully met. <br /> Next Year Projected Results Expect to reach or exceed goal, <br /> 3. Program Activity Name <br /> Program Goal <br /> Performance Measures <br /> Previous Year Program Results <br /> Current Year Estimated Results <br /> Next Year Projected Results <br /> 4. Program Activity Name <br /> Program Goal <br /> Performance Measures <br /> Previous Year Program Results <br /> Current Year Estimated Results <br /> Next Year Projected Results <br /> DO NOT SUBMIT THIS PAGE 1/26/2017 15:32:56 a1/p1 Page 19 o !r 22 <br />