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HomeMy WebLinkAbout2016-600-E Finance - Ligo Dojo of Budo Karate - Outside Agency Performance Agreement DocuSign Envelope ID:913F749B-B9E8-4103-AF9D-A4296D01069E 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 Ligo Dojo of Budo Karate, a not-for-profit corporation, located at 2518 B Millwood Court, Chapel Hill,NC 27514("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 Ligo Dojo of Budo Karate 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 2000. 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 $ 500. 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. (Ligo Dojo of Budo Karate) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID:913F749B-B9E8-4103-AF9D-A4296D01069E 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. (Ligo Dojo of Budo Karate) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:913F749B-B9E8-4103-AF9D-A4296D01069E 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. (Ligo Dojo of Budo Karate) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:913F749B-B9E8-4103-AF9D-A4296D01069E 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 Ligo Dojo of Budo Karate 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: (Ligo Dojo of Budo Karate) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:913F749B-B9E8-4103-AF9D-A4296D01069E County: Finance&Administrative Services Provider: Ligo Dojo of Budo Karate Orange County 2518 B Millwood Court Post Office Box 8181 Chapel Hill,NC 27514 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. For an ,��nl&*,+ It gf the Provider NLt&2 n, biy. 10/27/2016 15,4 IEFM194EAB9E7 Date For an rkdj, fb9f Orange County Government 61A uit, tkA mt-IrStt,t1 10/31/2016 O63-7994B755C477... Bonnie Hammersley, County Manager Date (Ligo Dojo of Budo Karate) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:913F749B-B9E8-4103-AF9D-A4296D01069E 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: Nat6A, executive director 10/27/2016 Certified by: 15n4 9B54FAME7_. Title: Date: (Provider's Signature) (Ligo Dojo of Budo Karate) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:913F749B-B9E8-4103-AF9D-A4296D01069E Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency Licio Doi() of Budo Karate Date/Time / Cornpiete Yj N Program(s) Young Warriors Program Section Subsection For CDBG & HOME- HUD Regulations 1. Cover Page a. Ej Applicant Contact Information b. Ej Project/Program Contact Information c. Li Funding Requests Identified d. Li Signed Application Cover Page 2. Agency a. E Agency's Years in operation 24 CFR 570.506, Information - b. n Agency's Purpose/Mission 57o.507, 570.610; 24 c. E Agency's Types of Services Provided CFR Parts 84 or 85 d. Li Agency's Experience e. E Other Pertinent Information 3. Program/ a. El Type of Application and Program Identified 24 CFR 570.200(a), Project I . El Summary of Program 570.201-570. 208, Information - c. 1 Description of Identified Need 507.503 (for each d. El Description of Population to be Served program/ e. El Activity Manager and Location Description project for f. 0 Activity Implementation Timeline which funding is requested) g. 0 Agency Collaboration h. Li Describe Impact of Reduced/No Allocation I. E] Other Pertinent Information j. Complete Target Population/Beneficiary Chart k. El Complete Schedule of Positions 1. 1 Signed Conflict of Interest Disclosure m. 1 Complete Work Statement ilPage DocuSign Envelope ID: 913F749B-B9E8-4103-AF9D-A4296D01069E t 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. El Program Budget Worksheet 570.602, 570.607(b), is requested) b. 0 Program Budget Detail 570.611 24 CFR c. LI Cost Per Unit 570.502-570.504, d. LI 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. E] Part A: CDBG & HOME Sections (as B. E Part B: Construction/Rehab applicable) 6. Attachments a. 0 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. E IRS Federal Form 990 c. LI NC Solicitation License d. 0 IRS Federal Tax-Exemption Letter e. Li Certificate of Insurance f. LI List of Board of Directors 24 CFR Parts 84 or 85 g. E Articles of Incorporation/Bylaws 24 CFR 570.208, h. E Authorization to Request Funds 570.500(c), 570.611 i. E Authorized official designation J. E Solid Waste Program Fee (SWPF) Verification Main Application 1/25/2016 10:16:09 AM Page 2 of 20 DocuSign Envelope ID: 913F749B-B9E8-4103-AF9D-A4296D01069E t 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: Society for the Betterment of the Human Condition through the Training, Instruction and Propagation of Budo Karate (d.b.a. Ligo Doio of Budo Karate) Applicant Organization's Physical Address: 630 Weaver Dairy Road Chapel Hill NC 27514 Applicant Organization's Mailing Address: 2418 A Millwood Court Chapel Hill NC 27514 Applicant Organization's Web Address: www.ligodojo.com Executive Director: Nathan Liqo Telephone Number: 919-923-6915 E-Mail: nligohotmail.com DUNS Number: n/a (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) b) Frolect/Proqram Contact Information Project/Program Name: Young Warriors Program Project/Program Primary Contact and Title: Nathan Ligo, Executive Director Telephone Number: 919-923-6915 E-Mail: nligohotmail.com c) Funding Request Identification Total Project/Program Cost: $35,600 Total Amount of Funds Requested: $2,000 each from Chapel Hill, Carrboro, and Orange County: $6000 total Proposed Use of Funds Requested (2-3 Line Maximum): The Young Warriors program instills discipline, increases self-esteem, and physical and mental health in referred, disadvantaged youth through martial arts training. Funding allows youths to attend ten or more weeks of karate training, two or more times per week at our location. Grant funds help ensure a diverse training environment for youth and their families. Please check all types, sources, and amounts of funding being requested. I- CDBG Non-Construction (CH) $ El Grant El Loan El CDBG Construction (CH) $ El Grant D Loan E HOME CHDO (OC) $ El Grant 1:1 Loan E HOME Other(OC) E] Grant El Loan Z Human Services: Z Carrboro $2,000 Chapel Hill $2,000 E Orange County $2,000 d) To the best of my knowledge an telief all information and data in this application is true and currffit-ifhe documen has been duly authorized by the governing board of the oi applicant. ii .„ „, Signature: `-'7 ...,,c A.3.14-- j ---- I Exe„,rti,vepirectrt _ + Date ) Signature: 'tli '. L(*--(1.,Z-, ,_ 1 I 2:::,- Boatd Chairperson Date l Main Application 1/25/2016 10:16:09 AM Page 3 of 20 DocuSign Envelope ID: 913F749B-B9E8-4103-AF9D-A4296D01069E t 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) b) Agency's Purpose/Mission c) Types of Services the Agency Provides d) Agency's Experience with Similar Programs as the Funding Request e) Other Pertinent Agency Information a) Years in Operation, Date of Incorporation (Month/Year) Chapel HiII/Carrboro native Nathan Ligo incorporated The Society for the Betterment of the Human Condition through the Training, Instruction and Propagation of Budo Karate as a 501.c.3 in 1999. After running a residential program for several years, Ligo Dojo of Budo Karate (our registered, shorter d.b.a. name) opened our first location in 2006. We are in our 9th year of operation, and our second location, Ligo Dojo of Budo Karate in Chapel Hill, has been in operation since 2011. b)Agency's Purpose/Mission Our mission is to 1. To strengthen the minds, bodies and hearts of young people through karate training, because hard physical training leads to increased spiritual strength and patience, which in turn leads to the ability to make better life decisions. 2. To deepen relationships between people of diverse backgrounds through hard training, an inherent 'equalizer' between people. 3. To strengthen American communities (starting in North Carolina, especially in Durham and Orange Counties) by thus strengthening individuals who might then serve as role models for other members of the community. 4. To create individuals who are 'community minded' and open minded people who VALUE works for the sake of community rather than merely for personal economic and social advancement. c) Types of Services the Agency Provides The program's goals coincides with our organization's overall mission: To strengthen the minds, bodies and hearts of young people through karate training, because hard physical training leads to increased spiritual strength and patience, which in turn leads to the ability to make better life decisions, and therefore strengthened communities. This project allows at-risk and financially challenged youths in Chapel Hill/Carrbaro/Orange County to participate in an athletic activity that is inherently life and character redefining, and inherently conducive to the formation of a leader-type mentality. Participating teens will see improvements in confidence, self-discipline and physical health. They will receive the support that they need to begin to make a better set of decisions in life and, in so doing, they will become either deliberate or unknowing role models for other similarly challenged members of the community. Referred youth attend 2-5 two-hour classes per week for 10 weeks. Court referred kids are often ordered to attend 20 classes, Classes are afternoons at 5 pm for younger kids, and 6:30 pm for teens and adults. Program staff maintains client files according to JCPC (Juvenile Crime Prevention Council) standards, attends JCPC meetings and court planning meetings, and interacts with referring counselors to achieve the best possible result for all program participants. Main Application 1/25/2016 10:16:09 AM Page 4 of 20 DocuSign Envelope ID: 913F749B-B9E8-4103-AF9D-A4296D01069E t A - continued Provider's Outside Agency Application MAIN APPLICATION Karate is an activity that teaches all students to be more "upstanding" in terms of personal behavior and personal presentation; it teaches them to stand up taller, walk lines in life more straight than before; youth interact with figures of authority in a more respectful manner improving pro-social skills and supporting factors—including physical health, confidence, self-esteem, self-discipline, anger management and conflict resolution—youths become less inclined to get themselves into trouble with crime, gangs, drugs, etc. d)Agency's Experience with Similar Programs as the Funding Request We have been operating our Young Warriors Program consistently for 8 years, funded by grant- making bodies including: the NC Governor's Crime Commission (GCC), Durham and Orange County's Juvenile Crime Prevention Councils (JCPC), Triangle Community Foundation (TCF), the City of Durham, the Cities of Chapel Hill and Carrboro, Orange County, Wells Fargo Foundation, the Mary Duke Biddle Foundation, Strowd Roses Foundation, and others. The Young Warriors Program accepts referrals of disadvantaged youth from over a dozen agencies in Durham and Orange County. Greater than that, however, would be a list of the successful programs we've run under the auspices of the NC Dept. of Juvenile Justice which we list here (each one represents a grant received) and the fact that we have measured success rates showing our accomplishments in the fives of the youths we have taught: Young Warriors (YW) JCPC Durham '09-10, YW JCPC Durham '10- 11, YW JCPC Durham '11-12, YW JCPC Orange '11-1012, YW CBT Level II Program '11- 12, YW JCPC Durham '12-'13, YW JCPC Orange '12-13, YW CBT Level II Program '12- 13, YW JCPC Durham '13-14 (current year), YW JCPC Orange '13- 14, YW CBT Level II Program '13-'14, ), YW JCPC Orange '14- 15, YW, YW JCPC Orange '15- 16 (current year) , e) Other Pertinent Agency Information Chapel Hill/Carrboro native Nathan Ligo founded The Society for the Betterment of the Human Condition through the Training, Instruction and Propagation of Budo Karate in 1999, and opened Ligo Dojo of Budo Karate in Durham (a d.b.a. name for the same 501.c.3 nonprofit) in 2006, and now our second location, Ligo Dojo of Budo Karate in Chapel Hill, in 2011. It has become a remarkably common occurrence for us that parents tell us "my child is SO much better behaved now at home," or "my child's teacher at school told us yesterday how she's doing so much better in class, and we know it's all because of karate!" or even "my child hasn't gotten in a single fight at school since he's been here at the dojo!" Beyond this type of recognition we have been recognized in numerous ways. ED Nathan Ligo was interviewed on ABC news (interview available on our website), the Raleigh N&O named him Tar Heel of the Week one week in 2012, and Governor Perdue wrote him a handwritten card congratulating him for his organization's successes. In 2010 Triangle Community Foundation awarded us its state-wide What Matters Innovation Award for Nonprofit Excellence. Main Application 1/25/2016 10:16:09 AM Page 5 of 20 DocuSign Envelope ID:913F749B-B9E8-4103-AF9D-A4296D01069E t A - continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT(PROGRAM INFORMATION Agency & Program Name: Licit) Dojo of Budo Karate Young Warriors Program 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: El Human Services Main Application Only) CDBG Non-Construction (Main Application AND Part A) LI CDBG Construction —(Main Application AND Part A AND Part B) E HOME CHDO Set-aside —(Main Application AND Part A) El HOME Other —(Main Application AND Part A AND Part B) Indicate the type of program for which you are requesting funding: " Program Category Category Youth Adult Elderly Disabled Public Housing (not elderly) Neighborhoods/Residents Education Health and Nutrition Job Training. Sports and Arts Activities Yes Pre-School Activities After-School Activities Yes Mentoring Transportation Housing Other: Yes Other Description: Karate is an activity that teaches all students to be more "upstanding" in terms of personal behavior and personal presentation; students will learn to stand up taller, walk lines in life more straight than before, interact with figures of authority in a more respectful manner improving pro- social skills and supporting factors—including physical health, confidence, self-esteem, self- discipline, anger management and conflict resolution—youths become less inclined to get themselves into trouble with crime, gangs, drugs, etc. Main Application 1/25/2016 10:16:09 AM Page 6 of 20 DocuSign Envelope ID: 913F749B-B9E8-4103-AF9D-A4296D01069E t 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? Ligo Dojo's outpost in Orange County at Chapel Hill's Cedar Falls Shopping Center in Chapel Hill has become a rare, and much needed facility in Orange County. Through it we bring positive youth development programming to a community that DOES have a demographic of at risk kids, and expected corresponding problems including juvenile crime, drug abuse and delinquent activity. As we have been in Durham for year, we work with DJJ referrals who are on diversion plans, with those under court supervision, and with those on post-release supervision, as well as "prevention kids" who are at-risk but are not yet involved in delinquent activity. We are actively working with law enforcement officers and school social workers who can identify youth who can benefit from pro- social activities and environments. Our Young Warriors Program has operated on an ongoing basis, first in Durham and later in Chapel Hill, since 2009. Program operates on a year-round basis. Referred youth attend 2-5 two- hour classes per week for 10 weeks. Court referred kids are often ordered to attend 20 classes. Classes are afternoons at 5 pm for younger kids, and 6:30 pm for teens and adults. 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. Orange County JCPC has determined that delinquent activity, presence of drugs, and occurrence of juvenile crime are priority needs to be addressed. Needs assessment by Juvenile Justice Court counselors indicate that 9% of juveniles assessed at intake have substantial gang involvement, and 62% of youth have serious school behavior problems. Agencies currently involved in delinquency intervention and suppression efforts lack features that can provide sufficient impact. One reason why young people become involved in delinquent activity is the lack of constructive after-school alternatives. This project will allow Chapel Hill/Carrboro and Orange County's at-risk youth to participate in a constructive after-school activity that exists as an enticing alternative to the gang/crime norm within underprivileged communities. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. JCPC has additionally determined that and 72% of adjudicated youth come from homes where parents/guardians have marginal to inadequate supervision skills. The Young Warriors program provides an opportunity for young people to train WITH their parents in an activity that has been shown to make people of all ages stronger and to bring parents and their kids closer together, and to a point of better shared understanding. That said, the program is not a miracle cure, and although we invite and encourage parents to participate, the frequency with which parents of court-referred youth do so is LESS than the frequency with which the parents of prevention youth do. The program is open to all youths, age 6 or greater, who are disadvantaged, or otherwise at-risk of becoming involved with delinquent behavior, or who already have become involved with delinquent behavior. Participating youths are referred by counselors of cooperating agencies. Main Application 1/25/2016 10:16:09 AM Page 7 of 20 DocuSign Envelope ID: 913F749B-B9E8-4103-AF9D-A4296D01069E t A - continued Provider's Outside Agency Application MAIN APPLICATION e) Who specifically will carry out the activities and in what location will they be carried out? Program Director, Nathan Ligo coordinates the referral process. Nathan attends monthly meetings with court counselors, and communicates recruitment opportunities with local agencies. He conducts informational sessions at El Centro and other agencies when requested. Youth classes are taught by head instructor, Nathan Ligo, or by unpaid volunteer adult instructors who have been trained within the program (our adult program) and who meet all requirements laid out by JCPC (NC Dept of Juvenile Justice). All class instruction is overseen by Nathan Ligo. Client file maintenance and reporting requirements are handled according to JCPC requirements. 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. Our Young Warriors Program has operated on an ongoing basis, first in Durham and later in Chapel Hill, since 2009. Program operates on a year-round basis. Referred youth attend 2-5 two- hour classes per week for 10 weeks. Court referred kids are often ordered to attend 20 classes. Classes are afternoons at 5 pm for younger kids, and 6:30 pm for teens and adults. 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. We currently accept referrals from many agencies serving disadvantaged youth. They have included but are not limited to: • The Department of Juvenile Justice (court-involved youth) • Carolina Outreach (mental health) • Big Brothers and Big Sisters of the Carolina's (mentoring) • Exchange Club Family Center • Carolina Outreach • El Centro Hispano • Chapel Hill Refugee center • We continue to be popular among mental health agencies. • Law enforcement and school social workers can also make referrals. We have created an online referral and tracking system that has been very well appreciated by referring counselors in that they can track their kids' attendance and performance online. We accept nearly all referrals, and invite needy kids to participate indefinitely. Another unique quality of our program is that all students train together; creating a pro-social environment where no one is identified as being "a referral". In this way our regular student body provides a strong core as new students (referral and full dues paying alike) come together to train. h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. In the past three years we have undergone a dramatic transformation from an organization that virtually had surplus grant money (we did very well in Durham before changes in the State legislature meant that we were no longer eligible for certain funding streams) to one in which we are much more independent, thanks to the dues paid by non-referred members. In addition to serving at-risk youths who would never walk in our door without our grant funding (and the accompanying Main Application 1/25/2016 10:16:09 AM Page 8 of 20 DocuSign Envelope ID: 913F749B-B9E8-4103-AF9D-A4296D01069E t A - continued Provider's Outside Agency Application MAIN APPLICATION network of agencies that make referrals), the fact that we receive grant money also allows us to keep our rates low, which allows us to keep our paying population diverse. It is out intention to remain in Orange Country (Chapel Hill) indefinitely serving JCPC referred and funded kids. At $20,000 JCPC remains our largest fuding source. This year Chapel Hill decided NOT to fund us for the first time, Carrboro continued to fund us, and Orange County decided TO fund us for the first time. In regards to Chapel Hill, we certainly understand the high demand for these funds, but these smaller pots of money lend credence to or work and efforts that help ensure that JCPC continues to fund us. This year, we would appeal to Carrboro and Orange County NOT to follow Chapel Hill's last year's decision, and we would like to appeal to Chapel Hill to resume their support of us as before. Doing so, keeping our funding streams diverse, plays a critical role in ensuring that the entire funding package (including JCPC) remains intact. We intend to remain in Chapel Hill indefinitely, but one possible outcome for us, should we at some point in the future lose the JCPC funding, would be that we would have to raise our rates, thus potentially pushing out the kids that need us most. Please understand that we DO seek financial independence, but to lower our support this early in our development, in Chapel Hill after all, would be to threaten out longevity as an entity that remains diverse and open to kids who can't afford to pay. I) Include any other pertinent information. Two years ago we were notified that the NC Department of Public Safety would end funding for our Young Warriors Cognitive Behavior Therapy Program. starting July 1st, 2014.(Although this program shares the name "Young Warriors" in common, it was a different program offering therapy to court- referred youth.) We had received this funding $45,000/year for 3 years and the loss (which is no fault of ours; NC is changing the way this fund base is allocated) was a devastating blow to our overall agency budget, hence endangering this Young Warriors Program as well. As a result, we have been working hard to identify alternative funds, and are clearly having to turn to a larger number of grant makers, each which typically award much smaller amounts of money. Our projected program budget and agency budget look strong on paper but we expect that several of our requests will be funded to amounts less than requested, rendering each one of these requests (Orange County, Carrboro and Chapel Hill) all the more vital. 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 Main Application 1/25/2016 10:16:09 AM Page 9 of 20 DocuSign Envelope ID:913F749B-B9E8-4103-AF9D-A4296D01069E t A - continued Provider's Outside Agency Application MAIN APPLICATION 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: Eg Persons 0 Households 0 Units Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 15 18 17 Female 13 12 16 Total 28 30 33 Of the females, how many are single- female Head of Households(Omit for Human Services) Ethnicity African-American 5 9 10 American Indian or Alaska Native Asian 8 3 4 Caucasian 11 10 11 Native Hawaiian or other Pacific Islander Other 4 8 8 Total 28 30 ' 33 Of the above, how many Hispanic/Latino 4 _ 8 8 Of the above, how many non- Hispanic/Latino 24 22 25 Total 28 30 33 Age 0-5 years 6-18 years 28 30 33 Total 30 30 33 Geographic Location Durham City Durham County Carrboro 8 10 11 Chapel Hill 6 6 7 Chapel Hill Public Housing Residents 6 6 6 Orange County 8 8 9 Raleigh Wake County Total 28 30 33 Main Application 1/25/2016 10:16:09 AM Page 10 of 20 DocuSign Envelope ID 913F749B-B9E8-4103-AF9D-A4296D01069E 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 A Total Retirement * 2014-15 2015-16 2016-17 Budget Vacant •. Staff+ Plan (H)Health Plan Program Director 1.00 $26,000 $30,000 $35,000 33% Instructor .125 0 $2,000 $2,000 2% Volunteer Administrator 1 .25 20/week 20/week 10/week N/A Volunteer .05 2/week 2/week 2/week N/A Instructor 1 Notes: • Similar positions can be combined: i.e.8 Occupational Therapists can be inserted as one line item. O ** 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 1/25/2016 10:16:09 AM Page 11 of 20 DocuSign Envelope ID: 913F749B-B9E8-4103-AF9D-A4296D01069E t 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 El IS] a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? El b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? LI 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: cl..11A 2-6) E 4utivp pirtr,i Date , Signature: ) / 2-C; Board Cha4-persbn Date Main Application 1/25/2016 10:16:09 AM Page 1 2 of 20 DocuSign Envelope ID: 913F749B-B9E8-4103-AF9D-A4296D01069E t 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. • Main Application 1/25/2016 10:16:09 AM Page 13 of 20 DocuSign Envelope ID:913F749B-B9E8-4103-AF9D-A4296D01069E t A - continued Provider's Outside Agency Application MAIN APPLICATION Actual Estimated Projected 2014-2015 2015-2016 2016-2017 2-5 classes per week 2-5 classes per week 2-5 classes per week for ten weeks, for ten weeks, for ten weeks. Program Activity 1 80%Participants will have 80%Participants will have 90%Participants will have no new complaints during no new complaints during no new complaints during program participation. program participation_ program participation. Program Goal Performance Measures See Following Page See Following Page See Following Page Program Results 100% 80%YTID 2-5 classes per week 2-5 classes per week 2-5 classes per week for ten weeks, for ten weeks, for ten weeks- Program Activity 2 80%Participants completing 80%Participants completing 90%Participants completing the program will demonstrate the program will demonstrate the program will demons trate a reduction in problem a reduction in problem a reduction in problem behaviors for which they behaviors for which they behaviors for which they were referred by termination, were referred by termination, were referred by termination. Program Goal Performance Measures See Following Page See Following Page See Following Page Program Results 92% 75%YTD 2-5 classes per week 2-5 classes per week 2-5 classes per week for ten weeks, for ten weeks. for ten weeks, Program Activity 3 80%of children admitted will 80%of children admitted will 90% of children admitted will participate in a promotion participate in a promotion participate in a promotion test at the end oftheir test at the end of their test at the end oftheir term(s)and will receive the term(s)and will receive the tezw(s)and will receive the validation of new belt 'validation of new belt validation o f ew belt color/promotion, color/promotion. color/promotion. Program Goal Performance Measures See Following Page See Following Page See Following Page 86% 83%YTD Program Results 2-5 classes per week 2-5 classes per week 2-5 classes per week for ten weeks, for ten weeks, for ten weeks. Program Activity 4 80%Participants completing 80%Participants completing 90%Participants completing the program will demonstrate the program will demonstrate the pro gram will demonstrate improvement in targeted improvement in targeted improvement in targeted skills as specified in the skills as specified in the skills as specified in the individual service plan by individual service plan by individual service plan by termination. termination, termination. Program Goal Performance Measures See Following Page See Following Page See Following Page 94% 80%YTD Program Results Program Activity S Program Goal Performance Measures Program Results Main Application 1/25/2016 10:16:09 AM Page 14 of 20 DocuSign Envelope ID: 913F749B-B9E8-4103-AF9D-A4296D01069E t A - continued Provider's Outside Agency Application MAIN APPLICATION Our performance measures would not fit in the format provided above. They are as follows: • We track student attendance online • A designee of referred youth fills out a person ISP document (Individual Service Plan) that identifies what skills are identified as needing to be addressed (for example: self discipline, ability to focus, pro-social interaction). These plans are reviewed and signed by designee at the end of referred youth's participation. • Information from JCPC tracking database • Central to our ability to evaluate our program's success is collaboration with counselors from referring agencies including Orange County Juvenile Court counselors. • We already have a system in place for tracking measurable goals and objectives for the juvenile delinquency prevention grant-making bodies to which we already have to answer. Main A .._ ............. ......................................................................... ..._ .___.,_........._.........................____,____.. pp lication 1/25/2016 10:16:09 AM Page 15 of 20 DocuSign Envelope ID:913F749B-B9E8-4103-AF9D-A4296D01069E t 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 1/25/2016 10:16:09 AM Page 16 of 2 0 DocuSign Envelope ID: 913F749B-B9E8-4103-AF9D-A4296D01069E t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Progran Ligo Dojo of Budo Karate:Young Warriors Program Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations 1,000 $ 1,089 5 3,000 175% Agency Generated Revenue (fees) Local Government Grants; Orange County 2,000 $ 2,000 $ 2,000 0% Town of Chapel I-1111 - $ - $ 2,000 0 Town of Carrboro 2,000 $ 2,000 $ 2,000 0% Other Local: OC JCPC $ 19,000 $ 19,000 $ 19,000 0% Other Local: OC match for JCPC 3,600 $ 3,600 $ 3,600 0% Other Local: 0 t more than 3 sources,please provide a separate list Non-Local Government Grants Triangle United Way 0 State Government 0 Federal Gm.ernment Other Grants: 0 Other Grants: 0 Miscellaneous/Other Revenue 2,000 5 3,000 $ 4,000 33% Reese list 3 largest Miscellanous sources; Wells Fargo $ 1,000.00 Strowd Roses $ 1,000.00 Wells Fargo(projected) $ 4,000.00 Total Agency Revenue $ 29,600 $ 30,689 $ 35,600 ME AGENCY EXPENSES Compensation 8,900 $ 14,089 $ 18,000 28% Rent&Utilities $ 20,700 $ 14,600 5 15,100 3% Supplies&Equipment 2,000 $ 2,500 25% Travel &Training 0 Other Expenses: 0 Reese list 3 largest"Other Expenses": $ - $ - $ - Total Agency Expenses $ 29,600 $ 30,689 $ 35,600 16% SURPLUS/(DEFICIT)FOR PERIOD: I $ J $ - J $ Main Application 1/25/2016 10:16:09 AM Page 17 of 20 DocuSign Envelope ID:913F749B-B9E8-4103-AF9D-A4296D01069E t 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(5) Quantity/Unit of Measure Subtotal ($) Credit Counseling Teacher–in class $25 96 hours(8 hrshnth x 12 months) $2,400 Credit Counseling Teacher—class prep $25 46 hours(4hrsimth x 12 mths) $1,200 Credit Counselor--one-on-one $20 120 hours(10 hrslmth x12 mths $2,400 Materials $25 120 course packets/credit reports $3,000 Total $9,000 Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: _Young Warriors Program Cost Elements Cost($) Quantity/Unit of measure Subtotal (5) instruction $300/child Per child X 33 kids $9,900 Case Management $245/child Per child X 33 kids $8,100 Utilities& Rent $458/child % Cost X 33 kids $15,100 Su plies &Equipment $75/child $75/child uniform X 33 kids $2,500 Total $35,600 C.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 201 6-17 Total Cost of Program 29,600 30,689 35,600 Total # of Units 28 30 33 Cost Per Unit 1,057 1,022 1,078 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 1/25/2016 10:16:09 AM Page 18 of 20 DocuSign Envelope ID: 913F749B-B9E8-4103-AF9D-A4296D01069E 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. 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 1/25/2016 10:16:09 AM Page 19 of 20 DocuSign Envelope ID: 913F749B-B9E8-4103-AF9D-A4296D01069E t A - continued Provider's Outside Agency Application MAIN APPLICATION Section VI.Financial Data Operating Budget for Entire Agency AGENCY NAME: Ligo Dojo of Budo Karate Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 - 2016-17 Change Private Donations Agency Generated Revenue(fees) 5 66,600 $ 73,920 5 75,000 1% Local Government Grants: Orange County $ 3,600 $ 5,600 $ 5,600 0% Town of Chapel Hill $ 2,000 $ - $ 2,000 Town of Carrboro $ 2,000 5 2,000 5 2,000 0% Other Local: OC JCP $ 19,000 $ 19,000 $ 19,000 0% Other Local: 0 Other Local: 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: Other Grants: Miscella neousfOther Revenue $ 2,000 $ 2,000 $ 7,000 250% Reese Est 3 gest Iiiiscellanous sources: Well Fargo $ 4,000.00 Individual gift 5 3,000,00 strowd roses/wells fargo $ 2,000.00 Total Agency Revenue $ 95,200 $ 102,520 $ 110,600 8% AGENCY EXPENSES Compensation 5 26,000 $ 32,000 $ 37,000 16% Rent S.Utilities $ 36,200 $ 37,020 $ 40,500 9% Supplies&Equipment $ 2,000 $ 2,500 $ 3,000 20% Travel&Training $ 5,000 $ 5,000 $ 4,100 Other Expenses: $ 26,000 $ 26,000 $ 26,000 0% Reese fist 3 largest"Rther apenses": Insurance $ 2,000.00 Loan repayment $ 24,000.00 Total Agency Expenses $ 95,200 $ 102,520 $ 110,600 8% SURPLUS/(DEFICIT)FOR PERIOD: I$ - I $ - I $ - I 0 Main Application 1/25/2015 10:16:09 AM Page 20 of 20 DocuSign Envelope ID:913F749B-B9E8-4103-AF9D-A4296D01069E EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Ligo Dojo of Budo Karate Program Name: Funding Award: $2,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Facility Rent and Program Support Expenses 2,000 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. • Instills discipline, creases self-esteem, and physical and mental health in referred, disadvantaged youth through martial arts training. • Youth attend 10 or more weeks of karate training—two or more times per week. • Diverse training environment for youth and families 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 Track student attendance online 100% Participation successful with no new complaints in the 12 month following completion 90% Participants demonstrating a reduction in problem behaviors for which they were referred 90% Participants will demonstrate improvement in targeted skills as specified in the indvididual 90% service plan. DocuSigned by: Certified by: �� Title: executive di rector Date: 10/27/2016 15A tF654-RAdk4 C 7... (Provider's Signature) DocuSign Envelope ID:913F749B-B9E8-4103-AF9D-A4296D01069E ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) L------- 09/20/2016 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 have ADDITIONAL INSURED provisions or 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 NAME: Mass Merchandising Underwriting K&K Insurance Group, Inc. PHONE FAX 1-260-459-5940/Co,Ext): / , 1712 Magnavox Way E-MAIL Fort Wayne IN 46804 ADDRESS: info @martialartsinsurance-kk.com PRODUCER CUSTOMER ID: INSURER(S)AFFORDING COVERAGE NAIC# '.. INSURED INSURER A: Nationwide Mutual Insurance Company 23787 Society for the Betterment of the Human Condi INSURER B: DBA:Ligo Dojo of Budo Karate INSURER C: 2518 A Millwood Court Chapel Hill,NC 27514 INSURER D: A Member of the Sports,Leisure&Entertainment RPG INSURER E: . INSURER F: COVERAGES CERTIFICATE NUMBER: W00918360 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 SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS W LTR INSD VD (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY 6BMAS0000005853700 09/20/2016 09/20/2017 EACH OCCURRENCE $1,000,000 CLAIMS- OCCUR 9:08 AM EDT 12:01 AM DAMAGE TO RENTED $500��� MADE X PREMISES(Ea Occurrence) MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS—COMP/OPAGG $1,000,000 POLICY I I PRO- JECT LOC PROFESSIONAL LIABILITY $1,000,000 OTHER: LEGAL LIAB TO PARTICIPANTS $1,000,000 A AUTOMOBILE LIABILITY 6BMAS0000005853700 09/20/2016 09/20/2017 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO 9:08 AM EDT 12:01 AM BODILY INJURY(Per person) OWNED AUTOS SCHEDULED BODILY INJURY(Per accident) ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY (Per accident) _ X NOT PROVIDED WHILE IN HAWAII UMBRELLA LIAB OCCUR EACH OCCURRENCE — EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND N/A STATUTE OTHER EMPLOYERS'LIABILITY — ANY PROPRIETOR/PARTNER/ Y/N E.L.EACH ACCIDENT EXECUTIVE OFFICER/MEMBER E.L.DISEASE—EA EMPLOYEE EXCLUDED?(Mandatory in NH) If yes,describe under DESCRIPTION E.L.DISEASE—POLICY LIMIT OF OPERATIONS below A MEDICAL PAYMENTS FOR PARTICIPANTS 6BMAS0000005853700 09/20/2016 09/20/2017 PRIMARY MEDICAL 9:08 AM EDT 12:01 AM EXCESS MEDICAL $150,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Location#1:630 Weaver Dairly Rd,Suite 107,Chapel Hill,North Carolina 27514;Location#2:2518 A Millwood Court,Chapel Hill,North Carolina 27514 Martial Arts style(s):Karate Sexual Abuse or Sexual Molestation Liability-$1,000,000 each occurrence(included above)/$1,000,000 aggregate(included above) CERTIFICATE HOLDER CANCELLATION Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Coverage is only extended to U.S.events and activities. **NOTICE TO TEXAS INSUREDS:The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD