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DocuSign Envelope ID: D90F57F1-8076-4358-9941-F62552053F84 <br /> Of the above, how many Hispanic/Latino 10 <br /> Of the above, how many non-Hispanic/Latino 15 <br /> Total n/a n/a n/a 25 <br /> Age <br /> 0-5 years 25 <br /> 6-18 years <br /> 19-50 years <br /> 51+years <br /> Total n/a n/a n/a 25 <br /> Geographic Location <br /> Town of Chapel Hill 25 <br /> Town of Carrboro <br /> Orange County(Outside of Chapel Hill/Carrboro) <br /> Outside of Orange County <br /> Total n/a n/a n/a 25 <br /> Income <br /> *Low-income(80%of the Area Median Income and Below) Please 15 <br /> see income table in the attachments <br /> Total n/a n/a n/a 25 <br /> *Low income determined by#of children who are Medicaid eligible <br /> 8. Cost Per Individual <br /> This cost per individual must reflect the total program budget divided by the total number of <br /> program individuals in this application. <br /> Actual 2018-19 Projected 2019-20 Projected 2020-21 <br /> Total Cost of Program n/a n/a $50,000 <br /> *Total #of Individuals 300 <br /> Cost Per Individual $167 <br /> *Includes estimated children,family members,providers and classmates served <br /> 9. Performance Indicators <br /> For Chapel Hill and Carrboro applicants: <br /> Please complete the following chart with information about the Strategic Objective, Intermediate Result, and <br /> the Agency Performance Indicator for each program for which you are applying for funding. Please see the <br /> Results Framework in the Attachments section as a reference. <br /> Program Name: KidSCope Outreach <br /> Strategic X Children improve their educational outcomes <br /> Objective ❑ Residents Increase their livelihood security <br /> (please choose one front <br /> the ResultsFratne)vork) 171 Residents improve their health outcomes <br />