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DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 4. LGBTQ Youth <br /> Work Statement <br /> m) Complete the Work Statement Chart to describe the work to be performed. <br /> This chart is used to document program activities, program goals, performance measures, and <br /> actual results. (Add more rows as needed) If this is a new program, you will only document the <br /> projected information. Every program is required to have AT LEAST 1 Program Activity, which <br /> should be SMART (,2pecific, Measurable, Achievable, Relevant, and _Time-bound. Click on <br /> SMART Goals to learn more. <br /> • Program Activities should outline major activities the agency implements to accomplish its <br /> program goals. (i.e. Deliver meals to elderly/disabled residents.) <br /> • Program Goal should explain what the program is trying to achieve/accomplish. Goals are <br /> statements about what the program should accomplish. (i.e. Deliver 100 meals per day, <br /> Monday-Friday.) <br /> • Performance Measures describe how you will evaluate the degree in which you achieved the <br /> stated goals. (i.e. Will track the number of meals delivered each day.) <br /> • Actual Program Results use program results to indicate the actual measureable achievement <br /> of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per <br /> day.) <br /> Work Statement Chart for Program LGBTQ Youth Community Building Initiatives: Queer Youth Drop <br /> In and Fluid Revolutions <br /> 9. Program Activity Name QYDI Weekly Meetings <br /> Program Goal To hold 45 90-minute meetings weekly throughout the year plus four <br /> additional quarterly special events and/or field trips and a social. <br /> Performance Measures QYDI tracks both repeated and one-time attendance. <br /> Previous Year Program Results QYDI held 37 90-minute meetings throughout the year plus 2 field <br /> trips to Raleigh and Durham and collaborated on a social with <br /> iNSIDEoUT. <br /> Current Year Estimated Results QYDI will have held 40 90-minute meetings throughout the year plus <br /> 1 open game night, 1 dance, and 2 field trips to Durham. <br /> Next Year Projected Results QYDI will hold 45 90-minute meetings throughout the year plus 3 <br /> field trips to Durham, Raleigh, and Hillsborough and host a winter <br /> dance. <br /> 10. Program Activity Name FR Queer Youth Circus Camp <br /> Program Goal To plan, fundraise for and implement a week-long aerial camp for <br /> queer and transgender youth to kick off a weekly circus program. <br /> Performance Measures Enrollment of 5 youth in the camp and a half hour long performance <br /> for friends and family at the end of the week. <br /> Previous Year Program Results Enrollment of 6 youth in the camp and a half hour long performance <br /> for friends and family at the end of the week. <br /> Current Year Estimated Results Enrollment of 9 youth in the camp and an hour long performance for <br /> friends and family at the end of the week. <br /> Next Year Projected Results Enrollment of 15 youth in the camp and an hour and a half long <br /> performance for friends and family at the end of the week. <br /> 11. Program Activity Name FR Weekly Queer Youth Circus lessons <br /> Program Goal To help youth learn to be bold in aerial moves, conditioning, and <br /> choreographing in both partner and solo pieces; creating supportive <br /> peer environments to build self-confidence and recognition of their <br /> capacities to grow beyond their own expectations; connect to and <br /> DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 40 of 45 <br />