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DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF <br /> EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 3. Program Activity Name Cooking and Nutrition Classes (Level I & II); Arc HOOPS; <br /> Friday Fun Day <br /> Program Goal Using a combination of paid Direct Support Professionals and <br /> Volunteers, sixty individuals with I/DD will learn about and <br /> participate in leading healthy lifestyles through good nutrition, <br /> exercise and social activities. This includes participation in Cooking <br /> and Nutrition Classes (Level I and 11), Friday Fun Day, and Arc <br /> HOOPs basketball. <br /> Performance Measures Attendance records, participant annual surveys <br /> Previous Year Program Results Approximately 50 individuals were served in our community <br /> programs in the Orange County area. 185 individuals are served <br /> through Individual services in Orange County. 35 people increased <br /> participated in Cooking and Nutrition Classes, Friday Fun Day, and <br /> Arc HOOPS basketball. <br /> Current Year Estimated Results 40 people increased their health by participating in Cooking <br /> Classes, Friday Fun Day, and Arc HOOPs basketball. <br /> Next Year Projected Results 75 people will learn more about the importance of exercise and <br /> movement, healthy lifestyles and good social choices by <br /> participating in Cooking and Nutrition Classes (Level I & II), Friday <br /> Fun Day. and Arc HOOPs. <br /> f) Program Budget <br /> 1. Submit your program budget. You may complete the provided template (separate As file) or <br /> you may submit your own budget file (as long as it contains the same information, in the same <br /> format, as requested in the provided template). <br /> Program Budgets are required to define budget amounts for the previous program year, <br /> current program year, and next program year for the following categories: <br /> • Revenues <br /> o Private Donations <br /> o Program Generated Revenue <br /> o Local Government Grants <br /> ■ Carrboro Human Services <br /> ■ Carrboro Other <br /> ■ Chapel Hill Human Services <br /> ■ Chapel Hill Other (DO NOT include CDBG funding here) <br /> ■ Orange County Human Services <br /> ■ Orange County Other (DO NOT Include HOME funding here) <br /> o Other Government Grants <br /> ■ Triangle United Way <br /> ■ State Government <br /> ■ Federal Government (CDBG/HOME/etc.) <br /> ■ Private Foundation Grants <br /> o Other Revenue <br /> • Expenditures <br /> o Compensation <br /> o Rent & Utilities <br /> o Supplies & Equipment <br /> o Travel & Training <br /> o Other Expenses <br /> PROGRAM INFORMATION 1/20/2018 3:58:40 PM Page 20 of 24 <br />