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1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Piedmont Wildlife Center <br />Applicant Organization's Physical Address: 364 Leigh Farm Rd; Durham, NC 27707 <br />Applicant Organization's Mailing Address: same as physical address <br />Applicant Organization's Web Address: www.piedmontwiIdIifecenter.org <br />Executive Director: Gail Abrams <br />Telephone Number: 919 - 489 -0900 E -Mail: director @piedmontwildlifecenter.org <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 <br />Carrboro <br />Chapel <br />Orange <br />Total <br />- HS <br />Hill - HS <br />County_ <br />HS <br />Ex. Youth Afterschool Program <br />$10,000 <br />$15,000 <br />$5,000 <br />$30,000 <br />Afterschool Program Coordinator salary and <br />materials for youth activities and projects <br />Youth Afterschool Program at Carrboro <br />$2,500 <br />$2,500 <br />Elementary School - PWC program salaries, <br />materials, travel; teacher training; and <br />incentives <br />Summer Camp Program - staff salaries, <br />$2,000 <br />$10,000 <br />$127000 <br />materials,travel, and incentives allowing us to <br />offer up to 46 partial and full scholarships <br />Totals <br />$2,500 <br />$2,000 <br />$5,500 <br />$14,500 <br />c) To the best of my knowledge and belief all information and data in this application is true <br />and current. The document has been duly authorized by the governing board of the <br />applicant. <br />Signature: Gail Abrams <br />Executive Director <br />Signature: Martha Wewer <br />Board Chairperson <br />1/30/2017 <br />Date <br />1/30/2017 <br />Date <br />1/12/2017 2 :56 :42 PM 4 Of 29 <br />