Orange County NC Website
Browse       Search
DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> I. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: KidSCope/Chapel Hill Training Outreach Project, Inc. <br /> Applicant Organization's Physical Address:800 Eastowne Drive, Ste.105,Chapel Hill, NC 27514 <br /> Applicant Organization's Mailing Address: 800 Eastowne Drive, Ste. 105,Chapel Hill, NC 27514 <br /> Applicant Organization's Web Address: chtop.orq <br /> Executive Director: Mike Mathers <br /> Telephone Number: 919-490-5577 x 223 E-Mail: mmathers ( chtop.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- HS Count -HS <br /> Ex, Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 <br /> Afterschool Program Coordinator salary and materials <br /> for outh activities and projects 1 <br /> KidSCope Outreach: Early Childhood Mental Health $2,000.00 $4,500.00 1 $75,000.00 $81,000.00 <br /> therapist salary and_program expenses <br /> KidSCope Children's Learning Center: 1 $49.000 $49,000.00 <br /> Moving and program expenses to relocate Children's <br /> Learning Center to new Hillsborough site at Orange <br /> Enterprises <br /> 1 1 <br /> 1 1 <br /> 1 _ <br /> 1 1 I <br /> Totals $2,000.00 $4,500.00 $124,000 $130,000.00 <br /> c) To the best of my knowledge and belief all information and data in this application is <br /> true and current. The document has been duly authorized by the governing board of the <br /> applicant. <br /> Signature: <br /> , <br /> Executive Director Date <br /> (L- , „ 1 i , ', <br /> Signature: / ,, ti.k,N(1._ L.,/ L ,A I, itil 6'ir,R 01 1 <br /> Ballard Chairperson <br /> f <br /> Da e <br />