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Home My WebLink About2016-579-E Finance - Bridge II Sports - Outside Agency Performance Agreement DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT,made and entered into the first day of July 2016, ("Effective Date")by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ("County") and Bridge II Sports, a not-for-profit corporation, located at 4122 Bennett Memorial Rd, Suite 105, Durham,NC 27705 ("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Bridge II Sports agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2016 to June 30, 2017. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit"A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 5250. b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of $1,313. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Bridge II Sports) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 —December 31; January 1 —March 31 and April 1 - June 30. Reports are due on January 13,April 14, and July 14 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services,upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as "default"), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider, the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten(10)business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. (Bridge II Sports) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker's Compensation. For protection from claims under workers' or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance, including hired and non-owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury,bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE • Worker's Compensation Limits for Coverage A- Statutory State NC& Coverage B -Employers Liability $500,000 each accident, disease policy limit and disease each employee • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $500,000 Combined Single Limit • Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability)required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough,NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. (Bridge II Sports) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. 11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 12. Non-Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. 13. Non-Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. 14. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County's living wage is $ 13.15 per hour. To the extent possible, Orange County recommends that Bridge II Sports provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (Bridge II Sports) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 County: Finance&Administrative Services Provider: Bridge II Sports Orange County 4122 Bennett Memorial Rd, Suite Post Office Box 8181 105 Hillsborough,NC 27278 Durham,NC 27705 16. E ntire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 18. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below.Lhi-Mc Fora +d6Cof the Provider dtAi tb wtaS 10/25/2016 07A241CBD61441C... Date 7 For and 7pe11�i�lrOrange County Government 156lA,ltht, tka"mt-IrStui 10/26/2016 0637994B755E477... Bonnie Hammersley, County Manager Date (Bridge II Sports) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 ATTACHMENT "A" Orange County Certifications—FY 2016-17 Outside Agency Performance Agreement Chief Contact,Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name, title,residential address;phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing,with the name, physical address,mailing address and if possible,phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not,please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. DocuSigned by: 15(kiLui ttOmaS Executive Director 10/25/2016 Certified by: 07A241CB I61A41C Title: Date: (Provider's Signature) (Bridge II Sports) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency Bridge II Sports Date/Time / 1 Complete Y/N Program(s) Adapted Sports: Wheelchair Basketball, Boccia Ball, and Adapted Sports Day Section Subsection For CDBG & HOME - HUD Regulations 1. Cover Page a. ® Applicant Contact Information b. ® Project/Program Contact Information c. ® Funding Requests Identified d. ® Signed Application Cover Page 2. Agency a. ® Agency's Years in operation 24 CFR 570.506, Information - b. ® Agency's Purpose/Mission 570.507, 570.610; 24 c. ® Agency's Types of Services Provided CFR Parts 84 or 85 d. ® Agency's Experience e. ® Other Pertinent Information 3. Program/ a. ® Type of Application and Program Identified 24 CFR 570.200(a), Project b. ® Summary of Program 570.201-570. 208, Information - c. ® Description of Identified Need 507.503 (for each d. ® Description of Population to be Served program/ project for e. ® Activity Manager and Location Description which funding f. ® Activity Implementation Timeline is requested) g. ® Agency Collaboration h. ® Describe Impact of Reduced/No Allocation i. ® Other Pertinent Information j. ® Complete Target Population/Beneficiary Chart k. ® Complete Schedule of Positions I. ® Signed Conflict of Interest Disclosure m. ® Complete Work Statement i o:° DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION 24 CFR 570.200(a), 4. Financial (for Program Budget Worksheet and Detail should reflect 570.201-570. 208, each expenses for the entire program and ALL sources of 507.503 program/ funding. 24 CFR 570.506, project for 570.507, 570.601, which funding a. ® Program Budget Worksheet 570.602, 570.607(b), is requested) b. ® Program Budget Detail 570.611 24 CFR c. ® Cost Per Unit 570.502-570.504, d. ® Agency Operating Budget Worksheet 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circulars A-87 or A- 122; Treasury Circular 1075 5. Supplemental A. ❑ Part A: CDBG & HOME Sections (as B. ❑ Part B: Construction/Rehab applicable) 6. Attachments a. [' Audit: Organizations receiving $300,000 or more OMB Circular A-133 in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ❑ IRS Federal Form 990 c. ® NC Solicitation License d. ® IRS Federal Tax-Exemption Letter e. ® Certificate of Insurance f. ® List of Board of Directors 24 CFR Parts 84 or 85 g. ® Articles of Incorporation/Bylaws 24 CFR 570.208, h. ® Authorization to Request Funds 570.500(c), 570.611 i. ® Authorized official designation j. ® Solid Waste Program Fee (SWPF) Verification Main Application 5/24/2016 9:03:13 AM 0 I:°' 2 of 2 DocuSign Envelope ID: 10C7B77C-A009-4AA3-964B-3B03B9585341 t xnibit A-continued Provider's Outside Agency Application MAIN APPLICATION 1. COVER PAGE (Each program requires a separate application.) a) Applicant Contact Information Applicant Organization's Legal Name: Bridge II Sports Applicant Organization's Physical Address: 4122 Bennett Memorial Rd Suite 105, Durham, NC 27705 Applicant Organization's Mailing Address: 4122 Bennett Memorial Rd Suite 105, Durham, NC 27705 Applicant Organization's Web Address: www.bridge2sports.org Executive Director: Ashley Thomas Telephone Number: 866-880-2742 E-Mail: ashleybridge2sports.org DUNS Number: 00-417-5108 (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) b) Project/Program Contact Information Project/Program Name: Adapted Sports: Wheelchair Basketball, Boccia Ball, and Adapted Sports Day Project/Program Primary Contact and Title: Ashley Thomas Telephone Number: 866-880-2742 E-Mail: ashleybridge2sports.org c) Funding Request Identification 4.4c ki 71,4-145!" 1 " Total Project/Program Cost: $39400Total Amount of Funds Requested: $24,000 Proposed Use of Funds Requested (2-3 Line Maximum): 1.Support for wheelchair basketball and boccia ball programs ($3000). 2. Funding to conduct adapted sports day in five Orange County Public Schools or Chapel Hill Carrboro City Schools ($5,000). Please check all types, sources, and amounts of funding being requested. You must submit an application package for each funding source. *The Participating Jurisdiction reserves the right to fund projects from any funding source, subject to eligibility and funding constraints. Li CDBG Non-Construction (CH) $ H Grant Loan fl CDBG Construction (CH) Grant - Loan — 7 HOME CHDO (OC) Grant Loan I- HOME Other (OC) P Grant - Loan E Human Services: 14 Carrboro $8,000 Fr Chapel Hill $8,000 14 Orange County $8,000 d) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. V , ti.tymt,p/ Signature: I'2-1 et u e irec r Date Signature: Board Chairperson Date Main Application 1/21/2016 10:52:15 AM Page 3 of 29 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION 2. AGENCY INFORMATION Please provide the following information about your agency (Limit of 2 pages total): a) Years in Operation, Date of Incorporation (Month/Year) - Years in Operation: In February 2016, Bridge II Sports will have been in operation for nine years. - Date of Incorporation: Bridge II Sports began on February 23, 2007 b) Agency's Purpose/Mission Bridge II Sports mission is to educate, develop, and implement opportunities for youth and adults with physical disabilities to play individual, team and recreational sports. Bridge II Sports provides equipment, develops sports, teams and coaching, thereby helping people with physical disabilities to discover tenacity, confidence, self-esteem, and the joy of finding the player within. Bridge II Sports vision is that by creating opportunities, Bridge II Sports develops a culture of empowerment that fosters respect for all abilities and has a life changing impact on all humanity. c) Types of Services the Agency Provides Bridge II Sports began with one event in 2007 and had 12 participants. In 2015, Bridge II Sports had 794 people participate in 14 programs. Current Bridge II Sports programs include wheelchair basketball teams, track and field, adaptive cycling (handcycling, recumbent, and tandem), goal ball, wheelchair and amputee tennis, boccia ball, fishing, kayaking, golf, Girls inspired Girls empowered (GiGe), and Paralympic experiences. Bridge II Sports also hosts the Valor Games Southeast, a three day competition for military and veterans with physical disabilities. Bridge II Sports also conducts adapted sports days in the public school system and teaches disability awareness and education. All of our programs are run through community partners to provide the coaching and play space. Bridge II Sports also does a lot of community outreach and in 2015 presented on adapted sports and disability awareness in the community 154 times. Bridge II Sports also hosts nationally sanctioned tournaments by the appropriate National Governing Body for the sport. In 2016, Bridge II Sports will host two National Wheelchair Basketball Association sanctioned youth tournaments. d) Agency's Experience with Similar Programs as the Funding Request Bridge II Sports has been running the programs for which we are requesting funding for the last nine years. Bridge II Sports is a Silver Medal US Paralympic Sports Club, a chapter of Disabled Sports USA, and a member of US Association of Blind Athletes. e) Other Pertinent Agency Information Bridge II Sports has s $3m child molestation insurance policy. Bridge II Sports staff and coaches are: • Those working with youth are background screened. • `Certified in Sport' [where applicable]. • Receive training and certification through the `Positive Coaching Alliance', `USOC Safe Sport', Darkness-to-Light' and `Heads Up Concussion Awareness', Red Cross Training in First Aid/CPR. Main Application 5/24/2016 9:03:13 AM P of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: Bridge II Sports Adapted Sports: Wheelchair Basketball, Boccia Ball, and Adapted Sports Day As you complete your application, complete only those sections that pertain to the type of application you are submitting. The application is divided into several sections and not all sections apply to every project. Every applicant MUST complete the main application. a) Check the type of funding request for this application package submittal and complete the required application and required supplemental sections (Parts) as specified below: ® Human Services (Main Application Only) ❑ CDBG Non-Construction — (Main Application AND Part A) ❑ CDBG Construction — (Main Application AND Part A AND Part B) ❑ HOME CHDO Set-aside — (Main Application AND Part A) ❑ HOME Other — (Main Application AND Part A AND Part B) Indicate the type of program for which you are requesting funding: Program Category Youth Adult Elderly Disabled Public Housing (not elderly) Neighborhoods/Residents Education x x x Health and Nutrition x x x Job Training Sports and Arts Activities x x x Pre-School Activities After-School Activities x x Mentoring x x x Transportation Housing Other: Please specify Main Application 5/24/2016 9:03:13 AM P , 5 of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION Program/Project Description (Label your responses as outlined below; not to exceed 3 pages.) Please provide the following information about the proposed program/project: b) Summarize the program services proposed and how the program will address the chosen Town/County priority? Adapted sports meet the need for people with physical disabilities by providing a healthy and safe way to exercise. The programs Bridge II Sports offers provide after school activities for youth with physical disabilities. There are not any other organizations in the Triangle providing after school sport programs for youth with physical disabilities. Bridge II Sports also provides mentors for participants with physical disabilities in our programs by hiring individuals who have disabilities to coach our programs. Wheelchair basketball provides individuals with spinal cord injuries, amputees or able bodied individuals who want to play wheelchair basketball on a team to play weekly. The program provides a healthy and safe environment for athletes to socialize and collaborate together as they work toward healthier lifestyles. Bridge II Sports maintains and provides specialized wheelchairs for anyone interested in participating for a low program fee or offers scholarships to participants unable to afford program fees. Bridge II Sports currently has a wheelchair basketball team for youth until they graduate from high school. The team practices once a week and travels to tournaments throughout the season. Boccia ball provides individuals with cerebral palsy or who have all four of their limbs affect to play a competitive or recreational sport. This is a population that is often over looked and boccia is an strategic game designed for this population of people. Bridge II Sports provides specialized boccia balls and ramps for anyone interested in participating for a low program fee or offers scholarships to participants unable to afford program fees. Bridge II Sports currently has a boccia ball team for youth and adults with significant physical disabilities. The team practices once a week and travels to tournaments throughout the season. The adapted sports day in public schools will provide education and support to encourage and equip schools to include kids with physical disabilities into PE classes, extracurricular activities and sports teams within the schools. These presentations will provide education about adaptive sports and people with disabilities and promote tolerance and inclusion within our schools and communities. c) Describe the local need or problem to be addressed in relation to the Consolidated Plan or other community priorities (i.e. Council/Board Goals). Cite local data to support the need for this program and the population being served. The Bridge II Sports adapted sports programs align with the Council/Board Goals Priority Area #2 to fund education, mentorship, and afterschool programming for youth facing a variety of challenges. Youth served through our programs have challenges such as disability, low income, low self-confidence and self-esteem, obesity and secondary health concerns, and lack of access to programs designed for their specific challenges. The Centers for Disease Control and Prevention reports that children with physical disabilities are at a 38% higher risk of obesity and its associated health consequences than children without disabilities. Adapted community sports and physical activity programs are likely avenues for addressing the health and fitness needs of this population. However, sports are difficult for people with physical disabilities to access because of the specialized equipment required to play. Bridge II Sports provides mentors to athletes with physical disabilities, educates athletes with disabilities and their peers about the value of inclusion, tolerance, and acceptance, and provides after school programming for youth with physical disabilities. Main Application 5/24/2016 9:03:13 AM P 6 of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. The population served through our program is people with physical disabilities. The area to benefit includes Chapel Hill, Carrboro, and Orange County, as well as other surrounding Triangle communities. Beneficiaries are identified through the school system, rehabilitation and specialty medical clinics, and word of mouth. e) Who specifically will carry out the activities and in what location will they be carried out? Bridge II Sports certified coaches and staff will carry out the wheelchair basketball, boccia ball, and adapted sports day programs. Wheelchair basketball is offered in Durham and Raleigh. Boccia ball is offered in Cary, with the possibility of expansion to Chapel Hill in the 2016-2017 seasons. Adapted sports days are offered to any public school in the state of North Carolina, however funding requested in this funding application will go towards adapted sports days to be offered in Orange County Public Schools or Chapel Hill Carrboro Public Schools. f) Describe specifically the period over which the activities will be carried out, the frequency with which the activities will be carried out, and the frequency with which services will be delivered. Include an implementation timeline. Wheelchair basketball: Bi-weekly August 2016-April 2017 Boccia ball: Weekly August-November 2016, January-April 2017 Adapted Sports Day: Offered during the school year g) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, give specific examples of the coordinated/collaborative efforts. • The following agencies provide donated play space for the wheelchair basketball and boccia ball programs: o Boccia Ball: Chapel Hill Parks and Recreation o Boccia Ball: Cary Parks and Recreation o Wheelchair Basketball: Raleigh Parks, Recreation, and Cultural Resources o Wheelchair Basketball: Braggtown Baptist Church • Duke and UNC Students: Serve as volunteers to assist with wheelchair basketball and boccia ball programs • City of Durham: Funding to help support wheelchair basketball, adaptive cycling, adaptive archery and adaptive air rifle programs and events. • Disabled Sports USA — As a member, the cost of insurance is affordable for the level that we are required to carry due to our venues, athletes and funders. h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Bridge II Sports would not be able to run our programs without the requested funding. Bridge II Sports is the only organization offering adapted sports for people with physical disabilities in the Triangle. Without this funding, there would be no opportunities people with physical disabilities to participate in adapted sports programs. i) Include any other pertinent information. Main Application 5/24/2016 9:03:13 AM P of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION Program/Project Information j) Complete the Target Population and Program Beneficiary Demographics Chart k) Complete the Schedule of Positions Chart for Program Staff I) Disclosure of Potential Conflicts of Interested must be signed m) Complete the Work Statement Chart to describe the work to be performed, and be sure to attach copies of all data collection tools that will be used to verify achievement of program goals and objectives. Describe who will be responsible for monitoring progress. Information to Complete j.) Target Population Complete the following tables to the best of your ability. Show numbers of participants and percentages, as applicable, in each category. Please indicate whether this project/program will serve: ® Persons ❑ Households ❑ Units Program: Adapted Sports: Wheelchair Basketball Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 168 175 200 Female 54 60 100 Total 222 235 300 Of the females, how many are single- female Head of Households (Omit for Human Services) Ethnicity African-American 44% 43% 40% American Indian or Alaska Native 1% 1% 1% Asian 0% 1% 1% Caucasian 50% 50% 50% Native Hawaiian or other Pacific Islander 0% 0% 1% Other 5% 5% 5% Total 100% 100% 100% Of the above, how many Hispanic/Latino 0 0% 2% Of the above, how many non- Hispanic/Latino 100% 97% 95% Total 100% 100% 100% Age 0-5 years 0 0 0 6-18 years 75% 75% 75% Main Application 5/24/2016 9:03:13 AM P of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION 19-50 years 20% 20% 20% 51-61 years 5 5 5 62+ years 0 0 0 Total 100% 100% 100% Geographic Location Durham City 20% 20% 20% Durham County 5% 5% 5% Carrboro 0% 5% 5% Chapel Hill 10% 10% 5% Chapel Hill Public Housing Residents Orange County 15% 15% 15% Raleigh 25% 25% 25% Wake County 15% 15% 15% Total 90% 95% 95% Income Level —See following chart (Omit for HS) < 30%Area Median Income 31-50% Area Median Income 51-80% Area Median Income > 80%Area Median Income Total 0 0 0 Special Needs (Omit for HS) Elderly(Over 62) 0 0 0 Disabled (not elderly) 100% 100% 100% Homeless 0 0 0 People with HIV/Aids 0 0 0 Total 100% 100% 100% Program: Adapted Sports: Boccia Ball Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 19 30 60 Female 47 75 100 Total 66 105 160 Of the females, how many are single- female Head of Households (Omit for Human Services) Ethnicity African-American 36% 38% 37% American Indian or Alaska Native 0% 0% 0% Asian 0% 2% 3% Caucasian 50% 50% 50% Main Application 5/24/2016 9:03:13 AM .. • of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION Native Hawaiian or other Pacific Islander 0% 0% 1% Other 10% 10% 10% Total 100% 100% 100% Of the above, how many Hispanic/Latino 0 3% 5% Of the above, how many non- Hispanic/Latino 100% 97% 95% Total 100% 100% 100% Age 0-5 years 0 0 0 6-18 years 25% 30% 35% 19-50 years 65% 60% 55% 51-61 years 10% 10% 10% 62+ years 0 0 0 Total 100% 100% 100% Geographic Location Durham City 15% 15% 15% Durham County 5% 5% 5% Carrboro 0% 5% 5% Chapel Hill 20% 20% 20% Chapel Hill Public Housing Residents Orange County 15% 15% 15% Raleigh 20% 20% 20% Wake County 15% 15% 15% Total 90% 95% 95% Income Level —See following chart (Omit for HS) < 30%Area Median Income 31-50% Area Median Income 51-80% Area Median Income > 80%Area Median Income Total 0 0 0 Special Needs (Omit for HS) Elderly(Over 62) 0 0 Disabled (not elderly) 100% 100% 100% Homeless 0 0 People with HIV/Aids 0 0 Total 100% 100% 100% Main Application 5/24/2016 9:03:13 AM .. I 0 o of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION Program: Adapted Sports: Adapted Sports Day Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 500 1,000 7,500 Female 500 1,000 7,500 Total 1,000 2,000 15,000 Of the females, how many are single- female Head of Households (Omit for Human Services) Ethnicity African-American 22% 22% 35% American Indian or Alaska Native 1% 1% 1% Asian 3% 3% 3% Caucasian 63% 63% 63% Native Hawaiian or other Pacific Islander 0% 0% 1% Other 11% 11% 11% Total 100% 100% 100% Of the above, how many Hispanic/Latino 9% 9% 9% Of the above, how many non- Hispanic/Latino 91% 91% 91% Total 100% 100% 100% Age 0-5 years 5% 5% 5% 6-18 years 95% 95% 95% 19-50 years 0 0 25% 51-61 years 0 0 0 62+ years 0 0 0 Total 100% 100% 100% Geographic Location Durham City 25% Durham County Carrboro 0% 0% 33.33% Chapel Hill 20% 25% 33.33% Chapel Hill Public Housing Residents Orange County 25% 33.33% Raleigh 30% Wake County 25% 25% Total 100% 75% 100% I Income Level —See following chart (Omit for HS) Main Application 5/24/2016 9:03:13 AM P I of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION < 30%Area Median Income 31-50% Area Median Income 51-80% Area Median Income > 80%Area Median Income Total 0 0 0 Special Needs (Omit for HS) Elderly(Over 62) 0 0 Disabled (not elderly) 10% 10% 10% Homeless 0 0 People with HIV/Aids 0 0 Total 10% 10% 25% Main Application 5/24/2016 9:03:13 AM Pa I 2 of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION 2015 Area Median Family income Limits U.S. Department of Housing & Urban Development (HUD) 2015 Area Median Family Income Limits Effective March 15, 2015 Income 1 2 3 4 5 6 7 8 Level person people people people people people people people 30% AMI $14,150 $16,200 $20,090 $24,250 $28,410 $32,570 $36,730 $40,890 50% AMI $23,600 $27,000 $30,350 $33,700 $36,400 $39,100 $41,800 $44,500 80% AMI $37,750 $43,150 $48,550 $53,900 $58,250 $62,550 $66,850 $71,150 100% AMI $47,188 $53,938 $60,688 $67,375 $72,813 $78,188 $83,563 $88,937 115% AMI $54,266 $62,028 $69,791 $77,481 $83,734 $89,916 $96,097 $102,278 http://www.huduser.ord/portal/datasets/il/ill 5/FY2015 IL nc.pdf Main Application 5/24/2016 9:03:13 AM 13 of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION k.) Schedule of Positions Please include program staff positions followed by volunteer positions; these financial figures should match the personnel figures in your Agency Comparative Budget Excel Form. Similar positions can be combined. (i.e., 8 Occupational Therapists can be inserted as one line item). If provided, indicate: Position Titles % (R) *= Position FTE* Program Actual Estimated Projected %Total Retirement Vacant Staff+ 2014-15 2015-16 2016-17 Budget Plan (H) Health Plan Executive Director 1 $50k $65k $70k 6% No Program Insurance Coordinator 2 $35k $67k $70k 6% Stipend Insurance Event Manager 1 $31k $40k $45k 4.5% Stipend Administrative Insurance Assistant 1 P.T$18k F.T$30k $32k 3.2% Stipend Insurance Accountant .2 $15k $20k $22k 2.2% Stipend Insurance Grant Writer .3 $12k $18k $20k 2% Stipend Insurance Assistant Director 1 $40k $42k 4.2% Stipend Volunteers 4.3 8065 8100 8500 Notes: • Similar positions can be combined: i.e. 8 Occupational Therapists can be inserted as one line item. • ** Full Time Equivalent staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • + Denotes the percentage of staff time involved with this program. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 1,960 Main Application 5/24/2016 9:03:13 AM P 1 4 of 2 DocuSign Envelope ID: 10C7B77C-A009-4AA3-964B-3B03B9585341 t xnibit A-continued Provider's Outside Agency Application MAIN APPLICATION I.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST Are any of the Board Members or employees of the agency which will be carrying out this project, or members of their immediate families, or their business associates: YES NO IZ a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? 1- El b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? - El c) Current beneficiaries of the project/program for which funds are requested? d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the project ineligible for funding, but the existence of an, undisclosed conflict may result in the termination of any grant awarded. Signature: 7-1 I (a E ecutive Dirr Date N't Signature: .01 Board Chairperson Date Main Application 1/21/2016 10:53:34 AM Page 15 of 28 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION m.) Work Statement This form is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. • Program Activities should outline major activities the agency implements to accomplish its program goals. • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. SMART Goals • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. Actual Estimated Projected 2014-2015 2015-2016 2016-2017 Coaches build relationships Coaches build relationships Coaches build relationships with athletes and their with athletes and their with athletes and their families to provide resources families to provide resources families to provide resources and mentoring to students and mentoring to students and mentoring to students who are at risk as part of the who are at risk as part of the who are at risk as part of the regular practices and regular regular practices and regular regular practices and regular Program contact they have with contact they have with contact they have with Activity 1 athletes athletes athletes 100%of athletes enrolled in 100%of athletes enrolled in 100%of athletes enrolled in our programs will remain in our programs will remain in our programs will remain in Program school and graduate High school and graduate High school and graduate High Goal School,when eligible School,when eligible School,when eligible Graduation statistics Graduation statistics Graduation statistics gathered through gathered through gathered through Performance information from coaches information from coaches information from coaches Measures and participants. and participants. and participants. 100%of students enrolled in 100%of students enrolled in 100%of students enrolled in Program our programs who are our programs who are eligible our programs who are eligible Results eligible to graduate did so. to graduate will do so. to graduate will do so. Practices will be organized Practices will be organized Practices will be organized and conducted by trained and conducted by trained and conducted by trained coaches. Equipment will be coaches. Equipment will be coaches. Equipment will be safe, clean, well maintained safe, clean, well maintained safe, clean, well maintained Program and provided for all and provided for all and provided for all Activity 2 participants. participants. participants. Main Application 5/24/2016 9:03:13 AM P 16 of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION Organize and conduct regular practices for wheelchair basketball and boccia ball. Bridge II Sports staff and coaches are trained through Positive Coaching Alliance to coach wheelchair basketball by striving to win,while also Organize and conduct regular Organize and conduct regular pursuing the even more practices for Jr. Dragons practices for Jr. Dragons important goal of teaching Program (youth), Carolina Dragons (youth), Carolina Dragons life lessons to people with Goal (adults) and adapted cycling. (adults) and adapted cycling. disabilities through sports. Practices for Wheelchair Basketball—105 practices Practices for Jr. Dragons—35 Practices for Jr. Dragons—35 were conducted (193 practices practices program hours with athletes) Practices for Dragons—35 Practices for Dragons—35 Practices for Boccia Ball—24 practices practices practices were conducted Performance Practices for Cycling- 14 Practices for Cycling- 14 (36 program hours with Measures practices practices athletes) Metrics were gathered during Metrics were gathered during Metrics were gathered during the year to track practices the year to track practices the year to track practices Program and number of athletes and number of athletes and number of athletes Results attending. attending. attending. Increase number of athletes Increase number of athletes participation in adaptive participation in adaptive Program basketball and cycling by 10% basketball and cycling by 10% Activity 3 in 2015-2016 in 2016-2017 Participation in adaptive Participation in wheelchair Program basketball and cycling will basketball and boccia will Goal increase by 10%. increase by 10%. Conduct adaptive sports Conduct adaptive sports awareness programs within awareness programs within 20 schools in Durham (5 20 schools in Durham (5 schools) and Orange County schools) and Orange County (15 schools). Program 2 of (15 schools). Program 2 of this proposal is funding for this proposal is funding for Performance the 15 schools in Orange the 15 schools in Orange Measures County, CH/CCS. County, CH/CCS. Metrics will be gathered Metrics will be gathered during the year to track during the year to track Program practices and number of practices and number of Results athletes attending. athletes attending. Main Application 5/24/2016 9:03:13 AM P of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION Conduct five adaptive sports Conduct 2 adaptive sports days in identified Orange days in identified Orange County Public Schools, County Public Schools or Conduct 10 adaptive sports Program Chapel Hill/City of Carrboro days in identified Chapel Activity 4 Schools Hill/City of Carrboro Schools Visit the identified school and Visit the identified school and present adaptive sports to present adaptive sports to students/faculty and staff students/faculty and staff within the school to promote within the school to promote awareness, inclusion and awareness, inclusion and tolerance. We will also tolerance. We will also encourage any students with encourage any students with disabilities to join our disabilities to join our adaptive sports teams to adaptive sports teams to Program promote health and increase promote health and increase Goal positive outcomes. positive outcomes. Fifteen schools in Orange 2 schools in Orange County County Public Schools/Chapel Public Schools/Chapel Hill Hill Carrboro City Schools will Carrboro City Schools will be be visited producing visited producing increased increased awareness, awareness, inclusion and inclusion and tolerance Performance tolerance toward people with toward people with Measures disabilities. disabilities. Metrics will be gathered for Metrics will be gathered for each visit to calculate number each visit to calculate number of schools visited as well as of schools visited as well as number of attendees to number of attendees to Program Bridge II Sports' Bridge II Sports' Results presentations presentations Raise awareness in the Raise awareness in the Raise awareness in the community of adaptive sports community of adaptive sports community of adaptive sports and the importance of and the importance of and the importance of Program inclusion and acceptance of inclusion and acceptance of inclusion and acceptance of Activity 5 people with disabilities. people with disabilities. people with disabilities. Main Application 5/24/2016 9:03:13 AM P 1 of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION Use adapted sports to educate our schools and communities on what people with disabilities can to,thus impact employment for those with disabilities and increase the social capital. Conduct Conduct practices in places Conduct practices in places practices in places where able where able bodied athletes where able bodied athletes bodied athletes compete and compete and be deliberate compete and be deliberate be deliberate about about integrating able bodied about integrating able bodied integrating able bodied athletes, their supporters and athletes, their supporters and athletes, their supporters and our athletes with disabilities our athletes with disabilities our athletes with disabilities Program to promote inclusion and to promote inclusion and to promote inclusion and Goal acceptance acceptance acceptance 15 schools in Chapel Hill Carrboro City Schools and Orange County Public Schools will experience an adapted sports day. Over 1300 people will be exposed to adaptive Over 1300 people will be Over 1300 people will be sports from wheelchair Performance exposed to adaptive sports exposed to adaptive sports basketball and boccia ball Measures from these programs. from these programs. practices. Metrics will be gathered for each visit to calculate number of schools visited as well as number of attendees to Bridge II Sports' presentations Metrics will be Metrics will be gathered Metrics will be gathered gathered during the year to during the year to track during the year to track track practices and number of Program practices and number of practices and number of spectators and volunteers Results athletes attending. athletes attending. attending. Main Application 5/24/2016 9:03:13 AM Pa 1 of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION 4. FINANCIAL INFORMATION FOR SERVICE PROGRAMS a.) Program Budget Please complete a Program Budget Excel Form for each requested program. The Program Budget should reflect only figures and amounts associated with the Program(s) for which you are seeking funding and not the total agency budget. If the program's finances experienced significant changes that you would like to explain, please use the space below. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 5/24/2016 9:03:13 AM 20 of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Program Bridge II Sports: Wheelchair Basketball Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 14,592 $ 36,241 $ 30,265 -16% Agency Generated Revenue(fees) $ - $ 2,100 $ 4,500 114% Local Government Grants: Orange County $ 1,250 $ 1,250 $ 1,500 20% To of Chapel Hill $ 750 $ 750 $ 1,500 100% Town of Carrboro $ 2,500 $ 1,750 $ 1,500 -14% Other Local: Durham County $ 3,000 $ 3,000 $ 3,000 0% Other Local: 0 Other Local: 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way 0 State Government 0 Federal Government 0 Other Grants: 0 Other Grants: 0 Miscellaneous/Other Revenue $ 2,000 $ 1,500 $ 4,500 200% Please list 3 largest Miscellanous sources: Team Fundraising $ 4,500.00 $ - Total Agency Revenue $ 24 092 $ 46 591 $ 46 765 0% AGENCY EXPENSES Compensation $ 5,250 $ 8,800 $ 8,800 0% Rent&Utilities $ 3,342 $ 8,994 $ 8,994 0% Supplies&Equipment $ 15,000 $ 28,197 $ 28,197 0% Travel&Training $ 500 $ 600 $ 774 29% Other Expenses: 0 Please list 3 largest"Other Expenses": Total Agency Expenses $ 24,092 $ 46,591 $ 46,765 0% SURPLUS/(DEFICIT) FOR PERIOD: I $ - I $ - I $ - I 0+ Main Application 5/24/2016 9:03:13 AM Pa 21 of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Program Bridge II Sports: Boccia Ball Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 2,250 $ 3,778 $ 2,878 -24% Agency Generated Revenue(fees) $ - $ 150 $ 300 100% Local Government Grants: Orange County $ 1,250 $ 1,250 $ 1,500 20% Town of Chapel Hill $ 750 $ 750 $ 1,500 100% Town of Carrboro $ 2,500 $ 1,750 $ 1,500 -14% Other Local: Town of Cary $ 2,000 $ 3,000 $ 3,000 0% Other Local: 0 Other Local: 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way 0 State Government 0 Federal Government 0 Other Grants: 0 Other Grants: 0 Miscellaneous/Other Revenue $ 2,000 $ 2,000 0% Please list 3 largest Miscellanous sources: Team Fundraising Total Agency Revenue $ 8 750 $ 12 678 $ 12 678 0% AGENCY EXPENSES Compensation $ 2,000 $ 2,400 $ 2,400 0% Rent&Utilities $ 150 $ 150 $ 150 0%I Supplies&Equipment $ 6,000 $ 9,399 $ 9,399 0% Travel&Training $ 600 $ 729 $ 729 0% Other Expenses: 0 Please list 3 largest"Other Expenses": Total Agency Expenses $ 8,750 $ 12,678 $ 12,678 0% SURPLUS/(DEFICIT) FOR PERIOD: I $ - I $ - I $ - I 01 Main Application 5/24/2016 9:03:13 AM .. 22 of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Program Bridge II Sports Adapted Sports Day Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations 0 Agency Generated Revenue(fees) $ - 0 Local Government Grants: Orange County $ 5,000 0 To of Chapel Hill $ 5,000 0 To of Carrboro $ 5,000 0 Other Local: Durham County 0 Other Local: 0 Other Local: 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way 0 State Government 0 Federal Government 0 Other Grants: 0 Other Grants: 0 Miscellaneous/Other Revenue 0 Please list 3 largest Miscellanous sources: Total Agency Revenue $ - $ - $ 15 000 0 AGENCY EXPENSES Compensation $ 8,100 0 Rent&Utilities 0 Supplies&Equipment $ 6,600 0 Travel&Training $ 300 0 Other Expenses: 0 Please list 3 largest"Other Expenses": Total Agency Expenses $ - $ - $ 15,000 0 SURPLUS/(DEFICIT) FOR PERIOD: I $ - I $ - I $ - I 0+ Main Application 5/24/2016 9:03:13 AM .. ag 23 of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION b.) Program Budget Detail What is the cost to deliver your project/program? List each project/program element in the table below, including the cost of each element, the quantity and unit of measure, and the subtotal for each element. Where necessary, allocate costs to the use of shared space, vehicles or equipment. Example Program: Credit Counseling Class Cost Elements Cost($) Quantity/Unit of Measure Subtotal($) Credit Counseling Teacher–in class $25 96 hours (8 hrs/mth x 12 months) $2,400 Credit Counseling Teacher—class prep $25 48 hours (4hrs/mth x 12 mths) $1,200 Credit Counselor—one-on-one $20 120 hours (10 hrs/mth x12 mths $2,400 Materials $25 120 course packets/credit reports $3,000 Total $9,000 Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: Adapted Sports: Wheelchair Basketball Cost Elements Cost($) Quantity/Unit of measure Subtotal ($) Program Coordinator(2) $25 352hr x $25 $8,800 Equipment Storage Rent Cost $2,998 Equipment x 3 programs $8,994 Printing, equip. maintenance, admin, etc $28,197 $9,399 x 3 programs $28,197 Travel $.575 1,344 miles x .575/mile $774 Total $46,765 C.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program $24,092 $46,591 $46,765 Total # of Units 222 235 300 Cost Per Unit $102.52 $198.26 $155.88 This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries (households or persons) in this application and must be consistent with report submittals from previous years (if applicable). Main Application 5/24/2016 9:03:13 AM P 21 of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION Program: Ada•ted S•orts: Boccia Ball Cost Elements Cost($) Quantity/Unit of measure Subtotal ($) Program Coordinator $25 Cost/Hour/$25 (96hrx$25) $2,400 Equipment Storage Rent Cost $150 Equipment x 1 programs $150 Travel $.575/mile 1,268 x .575/mile $729 Printing, equip. maintenance, admin, etc $9,399 $9,399 x 1 program $9,399 Total $12,678 d.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program $8,750 $12,678 $12,678 Total # of Units 66 105 160 Cost Per Unit $132.58 $120.74 $79.24 This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries (households or persons) in this application and must be consistent with report submittals from previous years (if applicable). Main Application 5/24/2016 9:03:13 AM 25 of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION Program: Ada•ted S•orts Da Public Schools Cost Elements Cost($) Quantity/Unit of measure Subtotal ($) Program Staff $30 2 Staff x 9 hours x 15 schools $8,100 Equipment $10 11 equip. x$15 x 8hr x 15sch $6,600 Travel $20 $20 mileage x 15 schools $300 Total $15,000 e.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program $15,000 Total # of Units 15,000 Cost Per Unit $1 This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries (households or persons) in this application and must be consistent with report submittals from previous years (if applicable). Main Application 5/24/2016 9:03:13 AM 26 of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION f.) Agency Operating Budget Please show all sources and amounts of funding for your entire current fiscal year. What is your agency's fiscal year? Example: July 1, 2016 through June 30, 2017. Bridge II Sports fiscal year is January 1-December 31. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 5/24/2016 9:03:13 AM P 27 of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 txnibit A-continued Provider's Outside Agency Application MAIN APPLICATION Section VI.Financial Data Operating Budget for Entire Agency AGENCY NAME: Bridge II Sports Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 38,100 $ 26,685 $ 30,000 12% Agency Generated Revenue(fees) $ 7,400 $ 24,793 $ 30,000 21% Local Government Grants: Orange County $ 2,500 $ 2,500 $ 8,000 220% Town of Chapel Hill $ 1,500 $ 1,500 $ 8,000 433% Town of Carrboro $ 5,000 $ 3,500 $ 8,000 129% Other Local: Durham County $ 6,000 $ 6,000 $ 6,000 0% Other Local: Town of Cary $ 3,000 $ 3,000 $ 3,000 0% Other Local: 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way 0 State Government 0 Federal Government 0 Other Grants: $ 224,500 $ 228,907 $ 377,000 65% Other Grants: 0 Miscellaneous/Other Revenue $ 140,800 $ 67,896 $ 75,000 10% Please list 3 largest Miscellanous sources: Bussiness Donations $ 62,440.00 Event/Program Fundraising $ 5,456.00 $ - Total Agency Revenue $ 428 800 $ 364 781 $ 545 000 49% AGENCY EXPENSES Compensation $ 142,500 $ 105,257 $ 150,000 43% Rent&Utilities $ 51,815 $ 29,120 $ 75,000 158% Supplies&Equipment $ 15,400 $ 17,511 $ 30,000 71% Travel&Training $ 51,310 $ 32,576 $ 20,000 -39% Other Expenses: $ 167,775 $ 174,512 $ 270,000 55% Please list 3 largest"Other Expenses": Consultants $ 51,949.07 Bookkeeping $ 17,433.36 Uniforms $ 14,171.56 Total Agency Expenses $ 428,800 $ 358,976 $ 545,000 52% SURPLUS/(DEFICIT)FOR PERIOD: $ - I $ 5,804 I $ - 1 -100%1 Main Application 5/24/2016 9:03:13 AM .. 2 o o of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 xnibit A-continued Provider's Outside Agency Application MAIN APPLICATION Main Application 5/24/2016 9:03:13 AM Pa 2 of 2 DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Bridge II Sports Funding Award: $5,250 Outline how the agency will spend Orange County's funding award. Expense Description Amount Support for Wheelchair basketball and boccia ball programs 5,250 Conduct adapted sports day in five Orange County Public Schools or Chapel Hill Carrboro City Schools Program Services For assistance with this or the following section, please reference the Exhibit A instructions and example, located within the contract and reporting memorandum. Outline the major activities the agency will employ to attain the Anticipated Outcomes below,by June 30,2016. • Bridge II sports will provide Orange County Residents adapted sports opportunties in the areas of wheelchair basketball and Boccia Ball pgrams. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results Athletes enrolled in our programs will remain in schools and graduate High School 100% Practices for Wheelchair Basketball 105 practies Practices for Boccia Ball 24 practices Conduct adaptive sports awareness programs within Orange County 3 schools Exposure to adaptive sports from wheelchair basketball and boccia ball practices in Orange 1300 people County and Chapel Hill Carrboro City Schools DocuSigned by: aS Vt,bwtAS 10/25/2016 Certified by: 07A241cBD61441c... Title: Executive Director Date: (Provider's Signature) _DocuSign Envelope ID: 1007B77C-A009-4AA3-964B-3B03B9585341 CERTIFICATE OF INSURANCE 12/28/2015 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY American Specialty Insurance&Risk Services, Inc. OR NEGATIVELY AMEND,EXTEND,OR ALTER THE COVERAGE AFFORDED BY THE POLICIES 7609 W.Jefferson Boulevard, Suite 100 BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND Fort Wayne, Indiana 46804 THE CERTIFICATE HOLDER. INSURED INSURERS AFFORDING COVERAGE Disabled Sports USA, Inc. INS.A: Greenwich Insurance Company 451 Hungerford Drive,Suite 100 INS.B: Rockville,MD 20850 INS. C: BRIDGE II SPORTS CERT NUMBER: 1001273598 COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT WITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS POLICY POLICY POLICY LTR TYPE POLICY NUMBER EFFECTIVE EXPIRATION LIMITS General Aggregate-Per Club 5,000,000 GL ASG089703601 12/01/2015 12/01/2016 Products-Completed Operations Aggregate 5,000,000 A Personal and Advertising Injury 1,000,000 12:01 a.m. 12:01 a.m. Each Occurrence 1,000,000 Damage to Premises Rented to You(Any One Premises) 1,000,000 Medical Expense Limit(Any One Person) Excluded Abuse-Molestation-Each Occurrence 1,000,000 Abuse-Molestation-Aggregate 1,000,000 Each Occurrence 5,000,000 XS ASX089704001 12/01/2015 12/01/2016 Products-Completed Operations Aggregate 5,000,000 A General Aggregate-Per Club 5,000,000 12:01 a.m. 12:01 a.m. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS - Evidence of coverage as respects to the BRIDGE II SPORTS. - Coverage available under policy#SRPO-50219-203 is on file with the policyholder.Excess Accident Medical for Class 1&2-$25,000 with a$250 deductible per injury per covered accident.Accidental Death&Dismemberment is$10,000 per person per accident.Class 3&4-$100,000 with a$250 deductible per injury per covered accident.Accidental Death& Dismemberment is$10,000 per person per accident. - With regards to the Excess Accident Medical Coverage,Class 1&3 is all registered/approved participants and volunteers of the Participating Organization and its Chapters with respect to sonsored and approved activities including direct travel to and from the activity and home,not including overnight trips. - With regards to the Excess Accident Medical Coverage,Class 2&4 is all registered/approved participants and volunteers of the Participating Organization and its Chapters with respect to sponsored and approved overnight trips including direct travel to and from the activity and home. CERTIFICATE HOLDER CANCELLATION DISABLED SPORTS USA, I NC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BRIDGE I I SPORTS BE CANCELLED BEFORE THE EXPIRATION DATE 4122 BENNETT MEMORIAL RD THEREOF,NOTICE WILL BE DELIVERED IN SUITE 105 AND 109 ACCORDANCE WITH THE POLICY PROVISIONS. DURHAM,NC 27705 AUTHORIZED REPRESENTATIVE