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DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Tides Center <br /> Applicant Organization's Physical Address: 1012 Torney Ave., San Francisco, CA 94129-1755 <br /> Applicant Organization's Mailing Address: PO Box 29907, San Francisco, CA 94129-0907 <br /> Applicant Organization's Web Address: www.tides.org <br /> Executive Director: Tabitha Blackwell (Protect Executive Director for Youth Forward) <br /> Telephone Number: (919) 960-1673 E-Mail: tblackwell(a-)_chcyouth.org <br /> Tax ID Number: 94-3213100 <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 materials <br /> for youth activities and projects <br /> ConnectMe! App 5,000 10,000 5,000 20,000 <br /> Funds for developer and staff salary to finalize and <br /> launch an app to assist youth and parents find <br /> services <br /> Totals <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 / 30 /2017 <br /> xecutive Director Date <br /> Signature: 0,1V4 01 / 30 /2017 <br /> Board Chairperson Date <br /> AGENCY INFORMATION 1/30/2017 8:39:52 PM Page 6 of 17 <br /> Doc ID:2eb6ac1433140dd445c9fc9978251c59361ba75e <br />