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DocuSign Envelope ID: DlA09OF6-2A4E-4FOB-9FB7-92FFFC9El3D2 XHIBIT A: <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Boomerang Youth Inc. <br /> Applicant Organization's Physical Address: 825A N. Estes Drive Chapel Hill NC 27514 <br /> Applicant Organization's Mailing Address: 825A N. Estes Drive, Chapel Hill, NC 27514 <br /> Applicant Organization's Web Address: hops:llbvomerangyouth.org <br /> Executive Director: Tami Pfeifer <br /> Telephone Number:-(919) 968-2146 E-Mail: tami.pfeifer&boomeran gyouth.or <br /> Tax ID Number: 47-4660452 <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 Carrboro Ch_ apel Orange Total <br /> - HS Hill -HS Count -HS <br /> Alternative to Suspension Program <br /> Program Manager salary and contracts for psycho- <br /> educational skill building groups (conflict resolution, 5,000 11,000 15,000 31,000 <br /> healthy relations, substance use, communication and <br /> self-expression, personal rowth <br /> Continuing Connections After School Program 0 1,000 1,000 2,000 <br /> Contracts& materials for after school activities <br /> Totals 5,000 12,000 16,000 330000 <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 /> applicant. �-•, <br /> Signatu �.. <br /> a Pfeifer,'Ex u ive actor D to <br /> Signature: <br /> Isa el Geffner, and it erson Date <br /> AGENCY INFORMATION Page 8 of 20 <br />