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2016-584-E Finance - Piedmont Wildlife Center - Outside Agency Performance Agreement
DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA 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 Piedmont Wildlife Center, a not-for-profit corporation, located at 364 Leigh Farm Rd., Durham,NC 27707 ("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 Piedmont Wildlife Center 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 3500. 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 $ 875. 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. (Piedmont Wildlife Center) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA 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. (Piedmont Wildlife Center) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA 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. (Piedmont Wildlife Center) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA 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 Piedmont Wildlife Center 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: (Piedmont Wildlife Center) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA County: Finance&Administrative Services Provider: Piedmont Wildlife Center Orange County 364 Leigh Farm Rd. Post Office Box 8181 Durham,NC 27707 Hillsborough,NC 27278 16. Entire 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. L ;a)L For and htt 'svf1he Provider QigV'A.1MS 10/25/2016 01l42F7FC9fiF54DA Date For and on , , ,.r?,:41Assange County Government 156lAkuit, tkawtmt-IrStt 10/26/2016 0637-994&73SE4A... Bonnie Hammersley, County Manager Date (Piedmont Wildlife Center) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA 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: Pat.(' igKAA AS Executive Di rector 10/25/2016 Certified by: n42F2FC9fiF54nA Title: Date: (Provider's Signature) (Piedmont Wildlife Center) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency _Piedmont Wildlife Center Date/Time Complete Y/N Program(s)_Nature Day Camp Subsection For CDBG & HOME - Section 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 507.503 c. Description of Identified Need d. Description of Population to be Served (for each e. Activity Manager and Location Description program/ project for f. Activity Implementation Timeline which g. Agency Collaboration funding is h. Describe Impact of Reduced/No Allocation requested) i. Other Pertinent Information j. Complete Target Population/Beneficiary Chart k. Complete Schedule of Positions I. Signed Conflict of Interest Disclosure a. Complete Work Statement 1 o:���` DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION 24 CFR 570.200(a), 4. Financial Program Budget Worksheet and Detail should reflect 570.201-570. 208, (for 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 a. Program Budget Worksheet 570.602, 570.607(b), funding is b. Program Budget Detail 570.611 requested) 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. Supplement A. Part A: CDBG & HOME al Sections B. Part B: Construction/Rehab (as 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 g. Articles of Incorporation/Bylaws 24 CFR Parts 84 or 85 h. Authorization to Request Funds 24 CFR 570.208, i. Authorized official designation 570.500(c), 570.611 j. Solid Waste Program Fee (SWPF) Verification 0:°'age 2 of 23 000 aignsnvowpo/o:snnorns1-82Fo-4xoo-BocF-6ocums4cxox - 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: Piedmont Wildlife Center Applicant Organization's Physical Address: 364 Leigh Farm Rd, Durham, NC 27707 Applicant Organization's Mailing Address: 364 Leigh Farm Rd, Durham, NC 27707 Applicant Organization's Web Address: yvvvvv.piedmpntvvi|d|ifecenter.orK Executive Director: Gail Abrams Telephone Number: 918-489'0900 E-Mail: dinantorapiwdrnontwi|d(if*cantor.nrg DUNS Number: 008434741 (Dun& Bradstreet, Inc. provides this number at no charge,and it is required for Federal funding recipients.) b) ProjectlProqram Contact Information Project/Program Name: Nature Day Camp Project/Program Primary Contact and Title: Gail Abrams, Executive Director Telephone Number: 919'489-0900 E-Mail: dinoctorpiedmontwi|d|ifeoentor.orq c) Funding Request Identification Total P ject/Program Cost: $ 331,433 Total Amount of Funds Requested: $ 10.000 Proposed Use of Funds Requested (2-3 Line Maximum): We currently have children from Orange county that attend our Durham camps, and now we are partnering with Orange County Parks and Rec to offer camps at Blackwood Farm Park in Chapel Hill. We would like to be able to offer the equivalent of 40 scholarships to be allocated for children from Orange County to attend either the Chapel Hill or Durham camps offered throughout the year. Please check all types, sources, and amounts of funding being requested. You must submit an application package for each funding source. tThe Participating Jurisdiction reserves the right to fund projects from any funding source, subject to e and funding constraints. CDBG Non-Construction (CH) $ Grant Loan CDBG Construction (CH) Grant Loan HOME CHDO (OC) Grant Loan ����e3 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA [ 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: Piedmont Wildlife Center Applicant Organization's Physical Address: 364 Leigh Farm Rid, Ourhom, NC 27707 Applicant Organization's Mailing Address: 364 Leigh Farm Rd, Durham, NC 27707 Applicant Organization's Web Address: www.piedmontwildlifecenter.org Executive Director: Gail Abrams Telephone Number: 919-489-0900 E-Mail: Uirec0orAp{admnontvvi|d|ifeoent*r.orq DUNS Number: 008434741 (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: Nature Day Camp Project/Program Primary Contact and Title: Gail Abrarns, Executive Director Telephone Number: 919-489-0900 E-Mail: dinscborApiedmn8ntwi|d|ifaoenter.nnl c) Funding Request Identification Total Project/Program Cost: $ 331,433 Total Amount of Funds Requested: $ 10.000 Proposed Use of Funds Requested (2-3 Line Maximum): We currently have children from Orange county that attend our Durham camps, and now we are partnering with Orange County Parks and Rec to offer camps at Blackwood Farm Park in Chapel Hill. We would like to be able to offer the equivalent of 40 scholarships to be allocated for children from Orange County to attend either the Chapel Hill or Durham camps offered throughout the year. 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 p i*ctofronnany/undingaouxce. aubec/bza6gibilitvmndfundingronoba/ntn. CDBG Non-Construction (CH) $ Grant Loan CDBG Construction (CH) Grant Loan HOME CHD{] (C)C) Grant Loan �»��Cl 3 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA [ A - continued Provider's Outside Agency Application MAIN APPLICATION Human Services: Carrboro $ . 2500 Chapel Hill $ 2500 Orange County $ 5000 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. Signature: 1/25/2016 E>66utive Director Date Signature: 1/25/2010 a|rperann Date 2. AGENCY INFORMATION Please provide the following infor ation about your agency (Limit of 2 pages total): a) Years in Operation, Date of Incorporation (Month/Year) Years in Operation: 13, Date of Incorporation: December 31, 2002 b) Agency's Purpose/Mission Inspiring people to develop a positive lifelong connection with the natural world & encouraging active engagement in conservation. c) Types of Services the Agency Provides Education programs are geared to school-aged ohi|dren, their families, adults and the general public as we work to instill in the community an awareness and deeper appreciation for nature and the wildlife that share our environment. We give children direct mentoring and support to explore the wonders of nature like never before. We offer them the skills to become passionate learners and environmental leaders. We offer children and teenagers experiences in nature to foster confidence, natural curiosity, a deepening awareness of the intricacies of the world around them, and a chance to develop into leaders and mentors in their community. We offer adults a,community, a place to reawaken their connections to each other and nature as well as outdoor and leadership skills providing a better quality, more sustainable way of life. Our conservation programs work to restore and enhance wildlife habitat in the local area and in the backyards and schoolyards of the community. We work to connect citizens to the needs of wildlife and to our conservation projects through various citizen scientist opportunities. Our wildlife assistance program encourages more local veterinarians to treat wi|d|if*, and the Center operates a dawn to dusk volunteer staffed wildlife hotline to refer citizens with wildlife issues to the closest and most appropriate source of care and/or humane removal. d) Agency's Experience with Similar Programs as the Funding Request ����� 4 23 • DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION 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 a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? NO b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? NO c) Current beneficiaries of the project/program for which funds are requested? NO d) Paid providers of goods or services to the program or having other financial interest in the program? NO 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: ---/{ 6-Z)Z.-.------ j---/ 1/25/2016 EXEl tive Director Date ,,,,---- -- ----) Signature: /) , 1/25/2016 B6ard cfiaifperson Date /---- 14 o 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION Piedmont Wildlife Center has been offering camps to children, ages 4 to 18, from Orange, Durham, Chatham, and Wake counties for 12 years. Each year the number of children that attend our camps has grown. We now offer summer camps and intersession camps throughout the year in Durham and Raleigh, serving over 1100 children per year. This summer we will be offering camps at a third location, Blackwood Farm Park, between Chapel Hill and Hillsborough. Each year requests for scholarships have increased. In 2015 we awarded 70 full or partial scholarships, and turned down numerous children due to lackof funding. e) Other Pertinent Agency Information For the past four years we have run after school programs at some schools in Durham Public Schools and Chapel Hill Carrboro Community School System, and a 28 week homeschool program at Leigh Farm Park in Durham. Many of the students that participated in our after school programs ended up coming to our camps to strengthen their outdoor skills and be part of a community. We have received grant funding for the after school programs for the last four years; however, we feel we can make a much bigger impact during a camp week where we work with the students for 30 hours a week as opposed to 7 hours over a 7 week session in after school. Additionally, it takes an incredible amount of administrative support on top of teaching time for the after school program, making it extremely cost prohibitive. 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: Piedmont Wildlife Center Nature Day Camp 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) Page. 5 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Category Yout Adult Elderly Disabled (not Public Housing h elderly) Neighborhoods/Residents Education x Health and Nutrition Job Training Sports and Arts Activities Pre-School Activities After-School Activities Mentoring x Transportation Housing Out of school activities x Nature Connection x Indicate the type of program for which you are requesting funding: Human Services 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 Piedmont Wildlife Center proposes to offer 40 full scholarships to our year-round summer camps at Leigh Farm Park in Durham county, or Blackwood Farm Park in Orange county. We currently provide intersession and one-day day camps throughout the school year at Leigh Farm Park but hope to offer camps during fall and spring breaks at the Orange county location this year. We also offer exclusive camps for teens all summer long at our Durham location. These camps include an Outdoor Leadership program, a few destination backpacking camps, as well as several others that provide challenges, teach outdoor skills, and connects them with nature and their peers. These camps in particular address a town of Chapel Hill goal of addressing services for youth; gives Orange county a way to support a local business/non-profit that is expanding; and gives youth a connection to our parks, motivating a desire to take care of park land and share them with others. Page. 6 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION 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. According to the Consolidated Plan for Orange County along with the Towns of Chapel Hill, Hillsborough and Carrboro, one of the purposes of the CDBG and HOME Programs is to enhance the quality of life for the low to moderate income residents by increasing the capacity of public facilities and services for non- profit organizations in an efficient, responsive, and non-discriminating manner through organizational partnerships, available resources, and innovative approaches. By offering full camp scholarships to those in low to moderate income families, Piedmont Wildlife Center camps would be directly impacting the quality of life for those children by getting them outside, utilizing the new Orange county park, and instiling a love and interest in their community's public natural spaces. Because we are a local non-profit teaching outdoor education, we would be addressing Chapel Hill's proposal to address the community's needs for public services by developing a strong partnership with Piedmont Wildlife Center. (p. 11 of the FY 2010-2015 Consolidated plan of Orange County HOME Consortium). The town council of Chapel Hill has a goal to refine focus for youth services. The "Chapel Hill 4 YOUth" initiative is a project they are working on to better meet the needs of community youth ages 12 -18. Through this project their goals are to o Engage dffectlly and etfect.i'oveoy wirk.ln youth o Rase youth awareness of the town's current programs and spaces o Collaborate and i'iinnovate to devellop and deplloy new programs and services o Cointliinuuualllly assess and evalluuuate initiatives (from Town of Chapel Hill Vision 2020/Council Goals: Review and refine focus for youth services and begin planning or Youth-centered facilities). Piedmont Wildlife Center offers opportunities for teens aged 12 to 18 to engage in teen specific camps and/or become leaders through our Counselor in Training program at the Blackwood Farm Park in Chapel Hill. By growing our pilot partnership with Orange County Parks and Rec we could develop new exclusive teen camps at Blackwood Farm and possibly other facilities in the Chapel Hill, Hillsborough and Carrboro areas. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. Camps serve children ages 5 to 18 years old. The age group for the camps offered at Blackwood Farm Park will be for youth, 7 to 12. Scholarships are offered through an application process so we can determine who is from Orange county as well as what their financial needs are. e) Who specifically will carry out the activities and in what location will they be carried out? Jarl Rasmussen, our camp coordinator, a support counselor, a college intern, and possible Counselors in Training (Teen leadership training) for the Blackwood Farm location, 4215 NC-86, Chapel Hill, NC 27514. The Camp Director, Sarah Haggerty along with several veteran lead counselors and support counselors, college interns, and Counselors in Training, at the Leigh Farm Park, 364 Leigh Farm Rd, Durham, NC 27707. Page. 7 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION 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. Camps at Blackwood Farm Park will be week-long day camps. The camp day runs from 9:00 a.m. to 3:00 p.m. An option for Early Care from 8:00 a.m. to 9:00 a.m. and/or After Care from 3:00 p.m. to 5:30 p.m. may be added on. Camps will be offered for 6 consecutive weeks starting June 13 and running through July 22, 2016. Camps at Leigh Farm Park in Durham, NC, will also be week-long day camps with the same operating hours as Blackwood Farm. Early and/or aftercare are an option, from 8:00 - 9:00 a.m. and/or 3:00 - 5:30 p.m. Camps in Durham are offered each week from June 13 through August 26, 2016. There is also a day camp offered June 10, 2016. All of these camps have been posted on our website and registration is currently open. 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. - Orange County Parks and Rec - We have established a pilot partnership to run 6 camps at Blackwood Farm Park this summer. - Send a Kid to Camp through the Triangle Community Foundation - awards us funding to offer scholarships to families in need - Chapel Hill Carrboro Youth Forward - Lisiting our organization on their website and moblie app they are developing so families can find us. - Chapel Hill Carrboro Community Schools - We currently run a nature connection program with three of their elementary after school programs involving all students enrolled at each school, providing a teacher training for afterschool staff who, in turn, helps facilitate the activities. This is carried out utlizing grant money from Orange County, the Town of Chapel Hill, the Town of Carrboro, and funding raised through other avenues. - Global Giving Foundation - we have a "Send 70 Kids to Nature Camp" project through this foundation helping Piedmont Wildlife Center raise needed funds to provide scholarships. h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Each year the requests for financial aid for our camps increases. We have to turn people away and the chance to connect that child with nature and their community forming a deep and lasting bond with their surroundings is diminished. By expanding our camp locations, we can better serve our surrounding communities, reaching those who want to pariticipate but not able to get to our Durham location. Without additional funding, and Piedmont Wildlife Center's desire and ability to offer the same ratio of scholarships for all of our camp locations will not be possible. We would have to reduce the amount of scholarships per venue impacting families in several counties. a) Include any other pertinent information. The young people of today are in danger of losing the skills and ability to connect with the natural world because they are no longer going outside. Research has shown that children are spending half as much Page. 8 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION time outside as they did 20 years ago. On average, children spend 4.5 hours a day on the internet, playing video games and/or watching TV. Offering sufficient outdoor time improves the overall health of our children while lengthening attention spans, diminishing aggressiveness, improving test scores and ultimately advancing learning. A plethora of research has indicated that hands-on environmental education has a measurably positive impact not only on student achievement in science, but also in reading, social studies, and mathematics. Outdoor activity has also been proven to improve eyesight, provide Vitamin D for strong bones and healthy hearts, lower body weight, and has been shown to reduce attention deficit symptoms. Most school curricula do not include time spent outdoors, much less time spent studying nature. Numerous studies have tested the impact of nature on children with ADHD. A 2009 study by researchers Andrea Faber Taylor and Frances E. Kuo found that twenty minutes in a park setting was sufficient to elevate attention performance relative to the same amount of time in other settings. These findings indicate that environments can enhance attention not only in the general population but also in ADHD populations. Researchers concluded that "doses of nature" might serve as a safe, inexpensive, widely accessible new tool in the tool kit for managing ADHD symptoms. Faber Taylor, A. & Kuo, F.E. (2009). "Children with attention deficits concentrate better after walk in the park."Journal of Attention Disorders, 12, 402-409. Studies also show that children with more participatory learning experiences have a greater aptitude for leadership, vision and inspired action. Childhood obesity has become one of the major issues facing our country. Getting kids active and outdoors is a consistent strategy in helping to address this critical issue. Piedmont Wildlife Center is working to meet the needs of our children through our camp programs. Program/Project Information b) Complete the Target Population and Program Beneficiary Demographics Chart c) Complete the Schedule of Positions Chart for Program Staff d) Disclosure of Potential Conflicts of Interested must be signed e) 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: Piedmont Wildlife Center Nature Day Camp Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Page. 9 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION Male 722 731 795 Female 469 466 507 Total 1191 1197 1302 Of the females, how many are single- female Head of Households (Omit for Human Services) Ethnicity African-American 17 18 30 American Indian or Alaska Native Asian 37 26 40 Caucasian 1137 1153 1232 Native Hawaiian or other Pacific Islander Other Total 1191 1197 1302 Of the above, how many Hispanic/Latino 36 29 42 Of the above, how many non- Hispanic/Latino 1155 1168 1260 Total 1191 1197 1302 Age 0-5 years 51 110 115 6-18 years 1138 1085 1185 19-50 years 2 2 2 51-61 years 62+ years Total 1191 1197 1302 Geographic Location Durham City 608 595 600 Durham County 12 20 20 Carrboro 30 45 60 Page. 10 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION Chapel Hill 319 305 357 Chapel Hill Public Housing Residents Orange County 36 45 60 Raleigh 76 116 130 Wake County 75 47 50 Other 35 24 25 Total 1191 1197 1302 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) Disabled (not elderly) Homeless People with HIV/Aids Total 0 0 0 CDBG & HOME ONLY- Area Benefit Activities (Infrastructure and Public Facilities) Street Census Tract Block Group Total Persons #LMI Persons Page. 11 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t 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 1 2 3 4 5 6 7 8 Income 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 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). Page. 12 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION If provided, indicate: Position Titles FTE** Program Actual Estimated Projected %Total Retirement *= Position Vacant Staff+ 2014-15 2015-16 2016-17 Budget Plan (H) Health Plan Executive Director 1 29% 74320 76144 77772 14.06% H, R Admin assistant 1 56% 33895 29859 31454 5.69% H Camp Director 1 50% 49249 49203 50192 9.07% H Camp Coordinator 1 32% 41679 40915 42905 7.76% H Conservation Coordinator 1 3% 42034 41365 43203 7.81% H 3 Lead Camp Counselor 1.25 100% 15,852 18000 18975 3.43% 9 Head/specialty counselor 3.75 100% 17,350 41000 41975 7.59% 3.7 9 Support Counselor 5 100% 16,675 25000 25200 4.56% 1.2 6 Interns 5 100% 6559 9850 20599 3.86% 0.3 5 Aftercare staff 5 100% 3338 8100 9250 1.73% 0.7 3 Office Assistants 5 59% 17568 26497 26659 5.00% 2 Counselors in Training Level 3 0.5 100% 400 600 800 0.15% 3 afterschool educators 1 0% 12897 22586 4509 0.85% 4 intersession counselors 1 100% 17511 19000 20692 3.88% 5 contractual 0.1 educators 5 0% 11081 7800 8103 1.52% Page. 13 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION 11 Counselors in Training 2 100% 0 0 0 0.00% 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 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 a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? NO b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? NO c) Current beneficiaries of the project/program for which funds are requested? NO d) Paid providers of goods or services to the program or having other financial interest in the program? NO 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: 1/25/2016 Executive Director Date Signature: 1/25/2016 Board Chairperson Date 0:°P . 14 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION 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 2014-15 Estimated 2015-2016 Projected 2016-2017 Program Activity 1 Receive applications for financial aid to attend camp Program Goal Award 40 full camp scholarships to Orange County residents Performance Measures Evaluate how many scholarships were requested from Orange county families from our registrations Program Results 40 full scholarships granted Program Activity 2 Offer camps that connect students to nature Program Goal Deepen inborn sense of wonder Performance Measures Counselors and/or parents will listen to questions campers have about nature and give feedback to staff at end of camp. Program Results Campers will be curious about something they are drawn to in nature and ask questions about it Program Activity 3 Teach campers about flora and fauna of our area,and/or outdoor skills (using field guides,survival skills) Program Goal Campers will feel more confident in knowledge of local flora and fauna and/or outdoor skills Page. 15 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION Performance Measures Counselors or parents will observe campers sharing what they have learned and share it in a summary at the end of camp. Program Results Campers will be able to demonstrate the skills learned or share their knowledge with others 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. �:° 16 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Program: Piedmont Wildlife Center Day Camps Actudi Estimated Pr*lected P meat AGENCY REVENUE 11415 2015-16 2016-17 Ch lag a Private Donations $ 8,551 $ 7,000 14,000 100% Agency Generated Revenue (fees) $249,409 5267,100 $294,843 10% Local Government Gra nts Orange County 5 5 5,000 0 Town of Chapel RI 5 - 5 2,500 0 Town of Carthoro 5 2,500 0 Other Local: DurhamCounty 5 6,390 0 Other Local: 0 Other Local: 0 paas parcvida a separata Non-Local Glove mime nt G rants Triangle United Way 0 State Government 0 Federal Government 0 Other Grants: Triangle Community Four $ 2,500 5 5,000 5 5,000 0% Other Grants: UNC Chapel Hill 5 1,200 $ 1,200 5 1,200 Mi well aneou slOthe r Revenue 0 Rasa e 1St 3 larg4E,t cps Is nous s ourplE, - Total Agency Revenue $261,660 $280 300 $331,433 1 AGENCY EXPENSES Compensat on 5160,190 5191,567 $237,878 24% Rent& Utilities 5 13,366 $ 14,567 5 15,205 Supplies& Equipment 5 15,957 5 15,374 5 17,500 Travel &Training 0 Other E xpen ses 5 72,187 5 75,850 5 60,850 -20% Fleas a t 3 larg, t"Other awns insurance/admin s 30,8500 camp scholarships given $30,00 13.00 Total Agency Expenses $261 700 $2973 : $331 433 111f, SURPL U StiDEF ICIT)FOR PERIOD: $ i40 $ 07,0581 $ - I 1,11",. DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION 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 $9,000 Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: Nature Day Camp I I Cost Elements Cost($) Quantity/Unit of measure Subtotal ($) Executive Director Salary 77,772 29% of salary x 77,772 $22,554 Office Coordinator Salary 31,454 56% of salary x 31,454 $17,614 Director of Education Salary 50,192 50% of salary x 50,192 $25,096 Education Coordinator Salary 42,905 32% of salary x 42,905 $13,730 Conservation Coordinator Salary 43,203 3% of salary x 43,203 $1,296 Page. 18 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION Lead Counselor Salary $627 11 sessions x 3 counselors $20,691 Speciality Counselor Salary $681 19 groups x 1 counselors $12,939 Head Counselor Salary $708 38 groups x 1 counselor $26,904 Support Counselor Salary $436 63 groups x 1 counselor $27,468 Teen Trip Counselors $981 2 counselors x 3 trips $5,886 Interns $327 63 groups x 1 intern $20,601 Aftercare Staff $10 (12.5hr/w x 11 w x 5 staff) + $9,250 (12.5hr/w x 11w x 1 staff)+(12.5hr/w x 8 w x 1 staff) Office Assistants $10.90 1171 hrs between 3 office $12,764 assistants Counselors in Training Level 3 $100 8 CIT III x$109 $800 afterschool educators $10.90 413.67hr between 3 educators $4,509 intersession counselors 477 17 groups with 1 counselor $8,103 contractual educators 153 50 classes taught by various $7,673 educators background checks 35.71 21 staff checked $750 telephone use 50 2 camp cell phones $100 materials & supplies various 10 binoculars, food for trips, $5,750 paper supply, arts & crafts, cooking gear, backpacks, printing fliers advertising various advertising in Herald Sun, News $6,050 & Observer, INDY, print & online for all of them transportation $1.85 gas needed to drive 1,081 miles $2,050 to trip locations, pick up 0:'' 19 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION supplies for all camps accident insurance $300 camp accident insurance $300 portable toilets $40.90 portable toilet rental for 11 $900 weeks, 2 toilets rental & camping fees for teen trip camps 1150 fees to camp in parks, van $1,150 rentals cleaning fees $25 10 hours of cleaning our camp $250 office tech support $35.71 42 hours of tech support for $1,500 office computers liability insurance $10,000 general liability insurance $10,000 credit card fees 3.5% 3.5% credit card processing fees $12,000 for program registartion annual audit $6,300 cost for annual audit $6,300 dues $500 dues for camp association $500 payroll fees $450 payroll processing fees $450 office supplies $50 paper& postage $50 camp scholarships $250 120 full scholarships $30,000 truck maintenance & insurance $1,425 vehicle maintenance & insurance $1,425 on PWC truck utilities $7,000 gas &electric for 3 facilities $7,000 building & grounds maintenance $3,250 building & grounds maintenance $3,250 at Leigh Farm Park telephone & computer service $3,500 telephone& computer service $3,500 0:°'age 20 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION rent $30 reduced rate by Durham City $30 Total $331,433 c) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program $261,700 $297,358 $331,433 Total # of Units 1191 1197 1302 Cost Per Unit 219.73 248.42 254.55 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). 0:°f 21 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued Provider's Outside Agency Application MAIN APPLICATION d) 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. Submit operating budget in your own format. Do not include funds that have been applied for but not yet awarded: If the total revenue is not the same amount as the budget for any fiscal year, please attach a statement explaining the deficit or surplus. 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. Fiscal Year: July 1, 2016 - June 30, 2017 Surplus of funds in 2014-15 was due to increased donations received and higher enrollment in nature camps than budgeted. Deficit in 2015-16 is projected due to major decrease in individual donations and less revenue received in our November 2015 Auction. Page. 22 of 23 DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA A - continued Provider's Outside Agency Application MAIN APPLICATION Section MI. Financial Data Comparative Budget for Entire Agency AGENCY NAME: Piedmont Wildlife Center Actual IE stimated Projected Percent AGENCY REVENUE 2014-15 201546 2016-17 Change Private Donations 5 61,121 S 61,365 S 64,43,9 5% ...ency Generated Revenue(fees) S 412,409 S 431,859 5 455,032 5% Local Government Grants: Orange County 5 2,000 S 5,000 150% Tom of Chapel Hill 5 1,000 5 1099 S 2,500 150% TOM of Carrboro S 2000, 5 2200, 5 2,500 14% Other Local: Durham County 5 8,190 S 8,190 5 6,390 -22% Other Local: Durham Public Schools S 2,000 S - S Other Local: 0 If more than 3 sour cies„please pr ovide,as,ecar ate list Non-Local Government Grants Triangle United Way State GoRrnment 0 Federal Government 0 Other Grants Triangle Community Foundatior 5 2,500 S 5,099 5 5,000 0% Other Grants Chapel Hill Carrboro Youth For S 5,000 S 5,000 S 5,000 0% Other Grants 0 Other Grants Global Gi,Ang Foundation S 5,059 5 5,009 S 1,350 -73% Co !torations S 4,470 S 6,009 5 6,000 0% wellaneous?Other Revenue 5 31,000 s 31,099 5 31,000 0% Rena It3 harges t Ft celb nous sour ces: Durham City in-kind facilities 5 31,000.00 S - Total ,Aency Revenue $ 534,749 558,644 $ 584211 5% AGENCY EXPENSES Compoensalion S 36,0,408 5 415,919 5 422,28,8, 2% Rent& Utilites S 45,374 S 44,366 S 46,205 4% Supplies& Equipment 5 60,256 5 58,305 5 62,156 7% Travel &Training S 600 5 750 S 1,000 33% Other Expenses S 46,353 5 49 . 7 S 52,562 6% ReEEE I t 3 harges t'Other Expenses": member programs S 7,339.100 insurancelaccounting S 29,243)010 conseration S 9,„771 0,0 Total Agency Expenses $ 512,991 S 569,147 $ 584,211 3% SURPLUS/(DEFICIT) FOR PERIOD: $ 21168 $ (10503) 100% DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Piedmont Wildlife Center Funding Award: $3,500 Outline how the agency will spend Orange County's funding award. Expense Description Amount Programmatic Cost—Scholarships 3,500 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. • Receive applications for Financial Aid to attend camp • Offer camps that connect students to nature • Teach campers about flora and wildlife area, and/or outdoor skills 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 Scholarships Awarded to Orange County Residents 14 raDocuSigned by: Ctit gigre 1MS Executive Di rector 10/25/2016 Certified by: Title: Date: 0°4 81-34DA... (Provider's Signature) DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA 1 OP ID: DS coRO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `••--°''� 10/25/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Jeff Rubish High&Rubish Insurance Agency PHONE FAX P.O.Box 3040 (A/C,No,EXt):919-913-1144 (A/C,No): 919 913-1155 6015 Farrington Rd.Ste 101 ADDRESS:Jeff @highandrubish.com Chapel Hill,NC 27517 PRODUCER PIEDM-3 High&Rubish CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED Piedmont Wildlife Center, Inc. INSURER A:Auto-Owners Insurance 18988 364 Leigh Farm Rd. INSURER B:Allen J Flood Companies, Inc. Durham, NC 27707 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING 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. IN SR TYPE OF INSURANCE I POLICY EFF POLICY EXP INSR WVD POLICY NUMBER /Y LIMITS (MM/DD YYY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ X POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (PER ACCIDENT) NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X WC STATU- 0TH- AND EMPLOYERS'LIABILITY TORY LIMITS ER Y/N A ANY PROPRIETOR/PARTNER/EXECUTIVE 35041122 03/04/2016 03/04/2017 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 B Accident policy AHH001419 06/13/2016 06/13/2017 Acc Med 25,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION ORANGEC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County Government THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 8181 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA ACC?R°J CERTIFICATE OF LIABILITY INSURANCE 09/13/2016 L.,.r THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Chris Rubish HIGH & RUBISH INSURANCE AGENCY PHONE FAX 6015 FARRINGTON ROAD (A/C,No,Ext): 919-913-1144 (A/C No): 919-913-1155 PO BOX 3040 Mass: chrisr©highandrubish.com CHAPEL HILL NC 27515 INSURER(S)AFFORDINGCOVERAGE NAIC# INSURERA: NAUTILUS INSURANCE COMPANY 17370 INSURED INSURER B: PIEDMONT WILDLIFE CENTER, INC. INSURER C: 364 LEIGH FARM ROAD INSURERD: INSURER E: DURHAM NC 27707 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING 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. INSR TYPE OF INSURANCE ADDL INSR SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DD/YYYY) (MM/DD/YYYY) GENERAL LIABILITY X NN706894 09/01/2016 09/01/2017 EACH OCCURRENCE $1 , 000 , 000 A X COMMERCIAL GENERAL LIABILITY PR S RENTED PREMISES((Ea occurrence) $100 , 000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $5, 000 PERSONAL&ADV INJURY $1 , 000 , 000 GENERAL AGGREGATE $2, 000 , 000 GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $INCLUDED X POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) WILDLIFE PER FORM L805 TS L805 (5/09) . HIREDAAUTOION, 000 , 000/$1 , 000 , 000; NON OWNED AUTO $1 , 000 , 000/$1 , 000 , 000 . CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ORANGE COUNTY GOVERNMENT AUTHORIZED REPRESENTATIVE PO BOX 8181 HILLSBOROUGH, NC 27278 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD