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DocuSign Envelope ID: 17COF518- 9238 - 480E- 96E6- 77F FCC C2626B <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />'3. P. ROGRAM.INFORMATION (Submit a se.pa.rate Section 3'for each program) <br />Program Name: Florence Gray Soltys Adult Day Health Program <br />Program Primary Contact and Title: Swayzene Riggsbee <br />Telephone Number: 919 -245 -2417 E -Mail: sri sbee oran ecount nc. ov <br />a) Indicate the type of Human Service Needs Priority, if program applicable: <br />x❑ Priority Area #1: safety -net services for disadvantaged residents <br />❑ Priority Area #2: education, mentorship, and afterschool programming for <br />youth facing a variety of challenges <br />x❑ 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 />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 />• Orange County Department on Aging- Referrals to our program from OC <br />Cares, Caregiver Respite Support, $25,000 in -kind donation for nutritious <br />meals. <br />• Orange County Department of Social Services- Referrals from adult division <br />of DSS <br />• Veterans Administration Services; provide federal contract for Adult Day <br />Health qualified veterans. <br />• Triangle J Council of Governments- (HCCBG) Home Community Care Block <br />Grant Funding annually for adult day h ealth and social participants. <br />Program Description (3 pages OR LESS) <br />Please provide the following information about the proposed program: <br />PROGRAM INFORMATION 1/23/2018 4.21:18 PM P a g e 15 of 2 5 <br />