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AGENCY INFORMATION 1/23/2018 3:25:53 PM Page 2 of 22 1. COVER PAGE a) Applicant Contact Information Applicant Organization’s Legal Name: Orange County Rape Crisis Center Applicant Organization’s Physical Address: 506 E. Franklin Street, Suite 302 Chapel Hill, NC 27514 Applicant Organization’s Mailing Address: PO Box 4722, Chapel Hill, NC 27515 Applicant Organization’s Web Address: https://ocrcc.org Executive Director: Alyson Culin Telephone Number: 919-968-4647 E-Mail: alyson@ocrcc.org Tax ID Number: 58-1356356 b) Funding Request List all FY18-19 Human Services (HS) Funding Being Requested – For All Programs) and the Proposed Use of Funds (2-3 lines or less) Program Carrboro - HS Chapel Hill - HS Orange County-HS Total Ex. Youth Afterschool Program Afterschool Program Coordinator salary and materials for youth activities and projects $10,000 $15,000 $5,000 $30,000 Client Services: Intervention and response services (including a 24- Hour Help Line, advocacy and accompaniment, support groups and workshops, therapy, and referrals) for survivors of sexual violence, their loved ones, and professionals who support them $11,400 $22,200 $36,000 $69,600 Community Education: Education programs, training, and advocacy on sexual violence prevention and response, including programs in Chapel Hill-Carrboro City Schools, Orange County Schools, and independent schools $7,600 $14,800 $24,000 $46,400 Totals $19,000 $37,000 $60,000 $116,000 c) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: 1/23/2018 Executive Director Date Signature: 1/23/2018 Board Chairperson Date