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DocuSign Envelope ID: 42882613- 58E8 -4BA1- 9376- A348D7FC56CA <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) <br />Program Name: The Chapel ffdl Impact Program under the auspices 2f t& am A fawE Clvbs g:{ <br />Durham and Orange Counties (BGCDOC) <br />Program Primary Contact and Title: Jerome Levisy, CEO <br />Telephone Number: 919 - 687 -4517. ext 20 E -Mail: ie y0bacdoc.org <br />a) Indicate the type of Human Service Needs Priority, if program applicable: <br />❑ Priority Area #7: safety -net services for disadvantaged residents <br />r Priority Area #2: education, mentorship, and afterschool programming for youth <br />facing a variety of challenges <br />❑ Priority Area #3: programs aimed at improving health and nutrition of needy residents <br />b) Indicate the type of program for which you are requesting funding <br />(Check all that apply to this program) <br />Program Category <br />Yout <br />Adult <br />Elderly <br />Disabled <br />Public Housing <br />h <br />NeighborhoodslResidents <br />Affordable Housing <br />Affordable Healthcare <br />focus on those who need <br />Education <br />!t <br />us most <br />Family Resources <br />Jobs /Jobs Training <br />Food <br />Transportation <br />Other. Please specify <br />focus on those who need <br />character <br />us most <br />development, good <br />citizenship and <br />healthy lifestyles <br />1 19 <br />c) Provide a bulleted list of other agencies, if any, with which your agency <br />coordinates /collaborates to accomplish or enhance the Projected Results in the Program(s) <br />to be funded. For each, briefly describe the coordinated /collaborative efforts. <br />• East Cares- A program at East Chapel Hill High School that provides mentors for young <br />people. We work with them to pair high school students with younger children. <br />• Carolina Outreach- This program provides mental health and family crisis services for our <br />Club members and their families. <br />We sought collaboration with the Chapel Hill- Car-boro City Schools in late 2094 and secured <br />space for one classroom to serve 17 youth beginning on January 5, 2015 in Northside <br />Elementary School. The Northside School officials said they were "delighted" to have our <br />