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DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1) What efforts do you make to seek feedback about your program from your target population <br />(e.g. survey, evaluations, etc. ?) In 2018, a survey will be implemented capturing growth <br />pre- and post - season. In addition to the survey, each individual program captures four <br />(4) unique goals from participants to evaluate personal development. Those goals <br />are. Sport specific skill goal, Team goal, Education specific goal (to compete, athlete <br />must be passing with a C or above), and Independent living goal. <br />m) Include any other pertinent information. <br />B11S has a $1 million child molestation insurance policy <br />BIIS staff and Tier 1 Coaches: <br />• Working with children are background screened <br />• Are trained and certified in the SafeSport program created by the USA <br />Olympic /Paralympic Committee <br />• Are trained and certified in concussion training by the Centers for Disease <br />Control (CDC) <br />• Are trained and certified in Positive Coaches Alliance <br />• Are trained and certified in Red Cross First Aid, CPR, and AED <br />• Certified in adapted sport if available <br />Additional Pro ram Information <br />n) Target Population <br />Complete the following tables, with numbers (not percentages) of individuals served and to be <br />served, to the best of your ability. <br />Program Target Population Demographics <br />Actual Estimated Projected <br />2016 -17 2017 -18 2018 -19 <br />Gender <br />Male <br />Female <br />Total <br />Ethnicity <br />African- American <br />American Indian or Alaska Native <br />Asian <br />Caucasian <br />Native Hawaiian or other Pacific Islander <br />Other: specify Chose not to say <br />Total <br />80 <br />95 <br />105 <br />46 <br />55 <br />70 <br />126 <br />150 <br />175 <br />41 <br />60 <br />75 <br />2 <br />4 <br />8 <br />55 <br />60 <br />72 <br />5 <br />10 <br />10 <br />2 <br />16 <br />10 <br />F1 26 <br />150 <br />175 <br />Agency Information 1/22/2018 10:12:15 AM P a g e 15 of 3 0 <br />