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DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Bridge II Sports <br />Applicant Organization's Physical Address: 3729 Murphey School Road, Durham, NC <br />27705 - <br />Applicant Organization's Mailing Address: 3729 Murphey School Road, Durham, NC <br />27705 <br />Applicant Organization's Web Address: www.bridge2sports.org <br />Executive Director: Ashley Thomas <br />Telephone Number: (866) 880 -2742 E -Mail: ashleyCcDbridge2sports.org <br />Tax ID Number: 20- 8577055 <br />b) Funding Request <br />List all FY18 -19 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-HS <br />Ex. Youtli:Afterschovl Program : <br />$10,000 <br />$15,000 ". <br />$5;000 <br />130,000. <br />Afterschool Program Coordinator salary and materials <br />for.youth activities and projects : " <br />Host 3 Adapted sport competitions to be held <br />$5,000 <br />$10,000 <br />$6,000 <br />$21,000 <br />in Orange County to include Valor Games SE, <br />utilizing UNC, students and the community at <br />large. <br />Adapted Sports Programs serving youth and <br />$5,000 <br />$10,000 <br />$5,000 <br />$20,000 <br />adults with disabilities to include Boccia, <br />Archery, Air Rifle, Wheelchair Basketball. <br />Program Coordinator salary, equipment, and <br />materials for activities. <br />Totals <br />$10,000 <br />1 $20,000 <br />1 $11,000 <br />1 $41,000 <br />c) To the best of my knowledge and belief all information and data in this application is <br />true and current. The document has been duly authorized by the governing board of the <br />applica <br />Signature: <br />Signature <br />nt. , <br />Executive Director <br />Board Chairperson <br />Date <br />Date <br />AGENCY INFORMATION 1/22/2018 10:12:15 AM Page 7 of 30 <br />