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Name of Program <br /> <br /> DIVISION OF YOUTH SERVICES <br /> <br /> PROGRAM AGREEMENT <br />Home Based Services <br /> <br />--County's Federal I.D. Number <br /> <br /> Sponsoring Agency <br /> <br /> of Social Services <br /> <br /> 56600028 IE <br />Cabarms County Department <br /> <br />County <br /> <br />CABARRUS <br /> <br />--Contact Person (name and address) <br />Deedee Wright, SWS Ill <br /> <br />P.O. Box 668 <br /> <br />-Concord, NC Zip 28026-0668 <br /> <br /> Phone# (704) 7924)401 Fax~ (704) 788-8420 <br /> <br /> Referral Sources District Court Judge, Juvenile <br /> <br />Court Counselors, Parent/Caretakers, School <br />_._Personnel, DSS <br /> <br />*Client Capacity 80 <br /> <br />Estimated number of youth to be served during funding period <br /> <br />Program Type <br /> <br />Home Based Services <br /> <br />Funding Period <br />7/1/98 <br /> <br />CBA Assigned I.D.# <br />213005 <br /> <br /> New Program <br /> Continuation X <br /> <br />. Anticipated average length of stay <br /> <br /> 82 <br /> <br />6/30/99 <br /> <br />120 . · <br /> <br />(days).- <br /> <br />*Actual number of youth admitted last fiscal year: <br /> <br />60 <br /> <br />N/A <br /> <br />60 <br /> <br />Reported using Client Tracking forms <br /> <br />Reported using Annual Program Review <br /> <br /># Juvenile Court or law enforcement referred <br /> <br />100 % <br /> <br />Date received in Regional Office <br /> <br /> Please submit 4 copies with original signatures. <br /> <br />*If thc funds being requested will be used for more than one program component please provide this/nformation for component on a <br />cparate sheet. <br /> <br />-DYS (REV. 10-95) <br /> <br /> <br />