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DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Youth Community Project <br /> Applicant Organization's Physical Address: 179 E. Franklin St, Chapel Hill, NC 27514 <br /> Applicant Organization's Mailing Address: P.O. Box 915, Carrboro, NC 27510 <br /> Applicant Organization's Web Address: http://youthcommunityproject.org <br /> Executive Director: Christine Abernathy <br /> Telephone Number: (704) 277-0043 E-Mail: abernathy.christine @gmail.com <br /> Tax ID Number: 46-2369263 <br /> b) Funding Request <br /> List all FY17-18 Human Services (HS) Funding Being Requested — <br /> For All Programs) and the Proposed Use of Funds (2-3 lines or less) <br /> Program Carrboro Chapel Orange Total <br /> - HS Hill - HS County-HS <br /> Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 <br /> Afterschool Program Coordinator salary and <br /> materials for youth activities and projects <br /> 1. Youth Leadership Development: Youth Board <br /> $750 $2,250 $4,500 $7,500 <br /> and Freedom School <br /> 2. Youth Artists Exhibitions $200 $550 $1,250 $2,000 <br /> 3. Reintegration Support Network $800 $2,200 $10,000 $13,000 <br /> 4. LGBTQ Youth Community Building Initiatives: $750 $2,000 $4,250 $7,000 <br /> Fluid Revolutions, Queer Youth Drop In <br /> Totals $2,500 $7,000 $20,000 $29,500 <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 /> Signature: 01/31/2016 <br /> Executive Director Date <br /> Signature: 01/31/2016 <br /> Board Chairperson Date <br /> AGENCY INFORMATION 1/31/2017 12:37:26 PM Page 7 of 45 <br />