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DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Total 1555 1609 1641 <br /> Work Statement <br /> m) Complete the Work Statement Chart to describe the work to be performed. <br /> This chart is used to document program activities, program goals, performance measures, and <br /> actual results. (Add more rows as needed) If this is a new program, you will only document the <br /> projected information. Every program is required to have AT LEAST 1 Program Activity, which <br /> should be SMART (Specific, Measurable, Achievable, Relevant, and Time-bound. Click on <br /> SMART Goals to learn more. <br /> • Program Activities should outline major activities the agency implements to accomplish its <br /> program goals. (i.e. Deliver meals to elderly/disabled residents.) <br /> • Program Goal should explain what the program is trying to achieve/accomplish. Goals are <br /> statements about what the program should accomplish. (i.e. Deliver 100 meals per day, <br /> Monday-Friday.) <br /> • Performance Measures describe how you will evaluate the degree in which you achieved <br /> the stated goals. (i.e. Will track the number of meals delivered each day.) <br /> • Actual Program Results use program results to indicate the actual measureable <br /> achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of <br /> 105 meals per day.) <br /> Work Statement Chart for Program Youth & Teen Nature Day Camp <br /> 8. Program Activity Name Scholarship recipients from Orange County will <br /> participate in at least one day camp <br /> Program Goal Award 14 full camp scholarships to Orange County <br /> residents <br /> Performance Measures Keep a daily attendance sheet at camp to show that <br /> recipients attended camp <br /> Previous Year Program Results Not applicable (N/A) <br /> Current Year Estimated Results 16 full scholarships were used to attend camp <br /> Next Year Projected Results 30 full scholarships <br /> 9. Program Activity Name Give transportation financial assistance to those in <br /> need (up to 10 families over the summer) <br /> Program Goal provide gas cards or cab fare for one family living <br /> further than 5 miles from the camp location to cover <br /> transportation costs to get child(ren) to camp for a <br /> week <br /> Performance Measures Track who received transportation financial aid and <br /> 1/12/2017 2:56:42 PM Page 25 •f 29 <br />