Orange County NC Website
DocuSign Envelope ID: 1BB65AEA-3E6A-45BE-8A7F-19FFOF9A712A <br /> EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> Applicant Contact Information <br /> Applicant Organization's Legal Name: Chapel Hill/Carrboro Children's Museum <br /> Applicant Organization's Physical Address: 201 S. Estes Drive, St A-9, Chapel Hill, NC 27514 <br /> Applicant Organization's Mailing Address: as above <br /> Applicant Organization's Web Address: www.kidzuchildrensmuseum.org <br /> Executive Director: Lisa Van Deman <br /> Telephone Number: 919.933.1455 E-Mail: vandeman(a)kidzuchildrensmuseum.org <br /> Tax ID Number: 20-2058235 <br /> b) Funding Request <br /> List all FY18-19 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 HIII -HS Count -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 /> Out of school time educational support for $1,980 $14,015 $27,339 <br /> underserved communities throughout Orange County. <br /> -STEM Lead/Outreach Coordinator partial salary/ <br /> program staff)program materials/outreach marketing <br /> Totals <br /> c) To the best of my knowledge and belief all information and data in this application is true <br /> and current. The document has been duly authorized by the governing board of the <br /> applicant. <br /> Signature: V <br /> Exe utive Dlre or Date 1/22/18 <br />