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DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> • Chatham-Orange Community Resource Connections for Aging and Disabilities <br /> Committee —AHH is a member of this group and participates in its initiatives. <br /> AHH regularly refers clients to, and receives referrals from: <br /> • The Orange County Department on Aging <br /> • Carolina Villages, Charles House <br /> • Orange County Health Department <br /> UNC Hospitals <br /> • Veteran's Administration <br /> • Meals on Wheels <br /> • Local physicians, social workers, and clinics <br /> h) Describe what would happen if requested funding is not awarded at all or if a reduced <br /> allocation is recommended. <br /> A Helping Hand is committed to its mission and will continue to provide services regardless <br /> of funding fluctuations. A reduced allocation will impact the number of seniors in the area that <br /> we are able to serve. We will also work to raise funds from other sources. <br /> i) Include any other pertinent information. <br /> ProgramlProiect Information <br /> j) Complete the Target Population and Program Beneficiary Demographics Chart <br /> k) Complete the Schedule- of Positions Chart for Program Staff <br /> 1) Disclosure of Potential Conflicts of Interested must be signed <br /> m) Complete the Work Statement Chart to describe the work to be performed, and be sure to <br /> attach copies of all data collection tools that will be used to verify achievement of program <br /> goals and objectives. Describe who will be responsible for monitoring progress. <br /> Information to Complete <br /> j.) Target Population <br /> Complete the following tables to the best of your ability. Show numbers of participants and <br /> percentages, as applicable, in each category. <br /> Please indicate whether this project/program will serve: ❑ Persons ❑ Households ❑ Units <br /> Program: Senior Companion Care <br /> Program Beneficiary Demo raphics <br /> Actual Estimated Projected <br /> 2014-15 2015-16 201E-17 <br /> Gender <br /> Male 51 60 65 <br /> Female 180 200 205 <br /> Total F 231 260 270 <br /> Main Application 1/25/2016 1:23:46 PM Page 1 0 o f 26 <br />