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DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 3. PROG A M INFORMATION (Submit a separate Section 3 for each program) <br /> Program Name: Samaritan Relief Ministry <br /> Program Primary Contact and Title: Kay Stagner, Manager of Client Services <br /> Telephone Number: 919-732-6194 ex.12 E-Mail: ocimsrmembargmail_com <br /> a) Indicate the type of Human Service Needs Priority, if program applicable: <br /> X Priority Area #1: safety-net services for disadvantaged residents <br /> Lii Priority Area#2: education, mentorship, and afterschool programming for <br /> youth facing a variety of challenges <br /> X 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 apply to this program) <br /> Public Housing <br /> Program Category Youth Adult Elderly Disabled <br /> Neighborhoods/Residents <br /> Affordable Housin. <br /> Affordable Healthcare <br /> Education <br /> Famil Resources <br /> Jobs/Jobs Training <br /> Food X X X X <br /> Transportation <br /> Other: Financial <br /> assistance for <br /> rent, utility, prescription <br /> medication X X X X <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 /> • Orange County Department of Social Services: The Samaritan Relief <br /> Ministry receives referrals for individuals and families needing food and <br /> emergency financial assistance. <br /> • Orange County Health Department: 'WIC" and other maternity/young <br /> children related programs make referrals for food, baby formula, and diapers. <br /> • Lutheran Family Services and other ental health case management <br /> programs: social workers and case managers refer clients to the Samaritan <br /> Relief Ministry for food. <br /> PRnrs.RAM 11\1Mr)MATICW 1/.q1/9n17 R.411-7,4 AM Pr 1 r ff,31 <br />