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DocuSign Envelope ID: D13694BA-66F1-4441-9114-5334F2B6AC3D XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Program: Sexual Health Education and Outreach <br /> Cost Elements Cost (_,$) Quantity/Unit of measure Subtotal($) <br /> Refreshments Teen Voices(TV),Smart Girls, $7 'TV- 15 participants x 12 sessions $3,132 <br /> Alumni Smart Girls - 10 participants x 10 sessions <br /> Alumni--8 participants x 12 sessions, <br /> 1 Graduations-TC$200,SG,$150,PM$150 <br /> Refreshments- Parents,chats $7 5-15 participants per workshop x 2 parent ' $280 <br /> workshops and 2 chats <br /> Incentives . Gift Cards $300+$2 fee TV- 15 participants $4,530 <br /> $100+$2 fee Smart Girls- 10 participants $1,020 <br /> $50 1 drawing per workshop x 2 nt $200 <br /> workshops and 2/chats <br /> Parent Matters incentives$15x5 sessions $750 <br /> x10,parents <br /> Incentives-T-shirts $7.50 TV-- 15 participants $247.50 <br /> Smart Girls—10 participants <br /> Alumni-8 participants <br /> Rental Variable , TV and Smart Girls-$300 each $1,150 <br /> . nts and chats-$200 each <br /> Alumni-$150 <br /> Mileage- Community Educator $0.54 175 miles per month x 12 $1,134 <br /> 1, Training-New Educator on curriculum $995 1 participant $995 <br /> I <br /> Copies <br /> : ', $0,50 800 copies for worksheets,promotional fliers $400 <br /> Office Supplies $40 Per month x 12 $480 <br /> Brochures $40 Per 100 x 10 topics $400 <br /> , <br /> Promotional materials-swag $2 3 promotional items(keychains,pens, $ I <br /> carbineers,etc) x 150 of each <br /> Guest Trainers- TV $100 2 speakers $200 <br /> Peer Assistant - TV $100 1 assistant $100 <br /> Supplies for Child Care $40 I Per workshop,2 nt workshops and 2 $160 <br /> chats <br /> Field Trip--Bus rental for Youth Advocacy Day $420 1 day $420 <br /> A PPCNC Conference $250 2 registrants $500 <br /> Education Materials- TV $20 Worksheets x 15 participants $300 <br /> Postage $0.49 50 stamps per month x 12 $294 <br /> Salary -Community Health Educator 2 educators x 50%of time each <br /> Salary Sr. Director of Education 1 director x 5%of time <br /> Benefits--25% 2 staff salary x 25% <br /> Total $39,074 <br /> 3. This program budget represents what percent of the agency budget? 002% <br /> ,C COST PER INDIVIDUAL <br /> PROGRAM INFORMATION 1/27/2017 3:10:56 PM <br />