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DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Chapel Hill/ Carrboro Children's Museum (aka Kidzu <br /> Children's Museum) <br /> Applicant Organization's Physical Address: 201 S. Estes Drive, Suite A-9, Chapel Hill, NC, <br /> 27514 <br /> Applicant Organization's Mailing Address: 201 S. Estes Drive, Suite A-9, Chapel Hill, NC, <br /> 27514 <br /> Applicant Organization's Web Address: www.kidzuchildrensmuseum.orq <br /> Executive Director: Lisa Van Deman <br /> Telephone Number: 919.933.1455 E-Mail: vandeman©kidzuchildrensmuseum.orq <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FY17-18 Human Services (HS) Funding Being Requested — <br /> For All Programs) and the Proposed Use of Funds (2-3 lines or less) <br /> Program Carrboro Chapel Orange Total <br /> - HS Hill - County- <br /> HS HS <br /> Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 <br /> Afterschool Program Coordinator salary and <br /> materials for youth activities and projects <br /> Outreach STEM Programs — community based $3,000 $9,275 $9,935 $22,210 <br /> (Outreach Coordinator (PT) salary, STEM <br /> educator, materials for academic enrichment <br /> activities during out-of-school time) <br /> Access STEM Programs — Kidzu based $1,922 $7,836 $10,984 $20,742 <br /> (STEM and museum educator compensation, <br /> academic enrichment program materials, <br /> family engagement materials, outreach <br /> marketing) <br /> Totals $4,922 $17,111 $20,919 $42,952 <br /> AGENCY INFORMATION 2/9/2017 1:27:17 PM Pago G of 30 <br />