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2016-629-E Finance - Boys & Girls Club of Eastern Piedmont - Outside Agency Performance Agreement
DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA 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 Boys & Girls Club of Eastern Piedmont, a not-for- profit corporation, located at 288 East Street, Suite 1008,Pittsboro,NC 27312 ("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 Boys & Girls Club of Eastern Piedmont 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 5000. b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of $1,250. 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. (Boys &Girls Club of Eastern Piedmont) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA 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. (Boys &Girls Club of Eastern Piedmont) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA 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. (Boys &Girls Club of Eastern Piedmont) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA 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 Boys & Girls Club of Eastern Piedmont 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: (Boys &Girls Club of Eastern Piedmont) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA County: Finance&Administrative Services Provider: Boys & Girls Club of Eastern Orange County Piedmont Post Office Box 8181 288 East Street, Suite 1008 Hillsborough,NC 27278 Pittsboro,NC 27312 16. E ntire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 18. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For an �d �f,�}f the Provider ,�t-reont, (,tAMSE1 11/3/2016 8007@etYe48242f... Date For and E�ovOrange'Clounty Government 6lAkut, �A twtt-IrS"""I 11/4/2016 063Z924B75F477-- Bonnie Hammersley, County Manager Date (Boys &Girls Club of Eastern Piedmont) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA 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: iWbWlt, (,ttS� CEO 11/3/2016 Certified by: azus€a 442E Title: Date: (Provider's Signature) (Boys &Girls Club of Eastern Piedmont) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST Agency Boys & Girls Clubs of Eastern Piedmont Program(s) Chapel Hill Community for Impact program Section Subsection For CDBG & HOME - HUD Regulations 1. Cover Page a. N Applicant Contact Information b. N 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, 570.507, Information - b. ® Agency's Purpose/Mission 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 (for each program/ d. ® Description of Population to be Served project for e. ® Activity Manager and Location Description which funding f. ® Activity Implementation Timeline is requested) g. ® Agency Collaboration h. ® Describe Impact of Reduced/No Allocation Other Pertinent Information j. ® Complete Target Population/Beneficiary Chart k. N Complete Schedule of Positions I. ® Signed Conflict of Interest Disclosure m.171 Complete Work Statement DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA t A - continued Provider's Outside Agency 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, 570.507, project for 570.601, which funding a. ® Program Budget Worksheet 570.602, 570.607(b), is requested) b. ® Program Budget Detail 570.611 24 CFR 570.502-570.504, c. ® Cost Per Unit 570.506, d. ® Agency Operating Budget Worksheet 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circulars A-87 orA-122; Treasury Circular 1075 5. Supplement A.❑ Part A: CDBG & HOME al Sections (as B.❑ Part B: Construction/Rehab applicable) 6. Attachment a.® Audit: Organizations receiving $300,000 or OMB Circular A-133 s more 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 24 CFR Parts 84 or 85 f. ® List of Board of Directors 24 CFR 570.208, g.® Articles of Incorporation/Bylaws 570.500(c), 570.611 h.® Authorization to Request Funds i. ® Authorized official designation j. ❑ Solid Waste Program Fee (SWPF) Verification DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA - continued Provider's Outside AqpnLy_Application MAIN APPLILA I ION 1. COVER PAGE (Each program requires a separate application.) a) Applicant Contact Information Applicant Organization's Legal Name: Boys & Girls Clubs of Eastern Piedmont (BGCEP) Applicant Organization's Physical Address: 288 East Street, Suite 1008, Pittsboro, NC 27312 Applicant Organization's Mailing Address: PO Box 1788, Pittsboro, NC 27312 Applicant Organization's Web Address: bgcepnc.org Executive Director: Sarah Marion, MPA Telephone Number: 919-663-6159 E-Mail: smarion©bgcepnc.org DUNS Number: 079238323 a) Pro'ect/Pro.ram Contact Information Project/Program Name: BGCEP Community Impact Program in Chapel Hill Project/Program Primary Contact and Title: Marywinne Sherwood, Board Member Telephone Number_919-967-4264 E-Mail: marywinne@yahoo.com b) Funding Request Identification Total Project/Program Cost: $127,360 Total Amount of Funds Requested: $30,000 Proposed Use of Funds Requested (2-3 Line Maximum):Funds will be used to help support salaries and benefits for the full time Program Manager and for two part time assistants, without whom it would be impossible to deliver services to the youth in the program. Please check all types, sources, and amounts of funding being requested. You must submit an application package for each funding source. *The Participating Jurisdiction reserves the right to fund projects from any funding source, subject to eligibility and funding constraints. El CDBG Non-Construction (CH) $ 0 Grant II Loan LI CDBG Construction (CH) El Grant Eli] Loan [I] HOME CHDO (00) Grant LI Loan 11 HOME Other(00) [1] Grant El Loan Human Services: EiCarriporo $10,000 Chapel Hill $10,000 ElOrange County $10,000 c) 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: (- 7< ; _ J_ Erectzr Date Signature: 6 ' Board Chair son Date Main Application 1/18/2016 13:13:17 al/p1 P a q a 3 a 22 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA 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: Boys & Girls Clubs of America has been in operation in the United States for 105 years. The Boys & Girls Clubs of Eastern Piedmont (BGCEP) — Program for Impact in Chapel Hill has been open for one year+ with 36 children enrolled. The Boys and Girls Clubs of Eastern Piedmont opened a Club in Siler City 6 years ago and has successfully operated since then with over 100 children registered and with a waiting list. Date of Incorporation (Month/Year): December 9, 2008 b. Agency's Purpose/Mission: The vision of the Boys & Girls Clubs of Eastern Piedmont (BGCEP) is to inspire and enable all young people, especially those who need us most, to achieve their full potential as productive, caring and responsible citizens. The Mission is to provide school age children and youth in the Chapel Hill-Carrboro area from challenging circumstances, with a professionally supervised, consistent environment where they are safe, equally accepted and able to participate in goal oriented programs that enhance their self-esteem and assist them to achieve their full potential. The purpose is to instill a sense of competence, a sense of belonging and a sense of having power and influence, especially over their own lives as well as in the community.We are chartered by the Boys & Girls Clubs of America to operate programs in Orange, Person and Chatham Counties of North Carolina. Our program in Chapel Hill employs the BGCA"Formula for Impact" which provides an outcome-driven club experience for youth who need us most, from Kindergarten through 12th grade with enumerated priority outcomes. c. Types of Services the Agency Provides: Our Agency provides youth from Kindergarten through 12th grade with an after-school youth development program focused on three main goals or outcomes: Academic success, Good Character and Citizenship, and Healthy Lifestyles. The PRIORITY OUTCOMES are: 1.Academic success in school with end-goal to graduate from high school ready for college, trade school, military or employment. 2. Good character and citizenship- to become an engaged citizen involved in the community, register to vote and model strong,positive character; 3. Healthy life style- to adopt a healthy diet,practice good lifestyle choices and make a lifelong commitment to fitness. This Outcome-driven experience is carried out at all levels by providing 1. A Safe, Positive Environment, 2. Supportive Relationships, 3. Fun with a Purpose, 4. Opportunities and Expectations 5. Recognition for achievements. 6. High yield activities 7. Targeted Programs 8. Regular attendance Programs are deliberately designed for members to achieve these priority outcomes.Average daily attendance, membership retention and academic and social success in school are tracked. While all Main Application 5/24/2016 8:59:25 a5/p5 0 4 i 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA t A - continued Provider's Outside Agency Application MAIN APPLICATION children are eligible to join, the Club focuses on the population who needs us most, those unable to access other Chapel Hill after-school programs, even on scholarship, which often have waiting lists. The program opened in January 2015 at the Northside School in Chapel Hill with 17 children enrolled. With this new school year, we have expanded to serve 32 elementary age children four days a week in the Community Impact Program at the Northside Elementary School in Chapel Hill with an average of 27 children in daily attendance. d. Agency's Experience with Similar Programs as the Funding Request: The BGCEP has opened a Boys & Girls Club in Siler City in Chatham County six years ago and it has grown to over 100 youth registered with a waiting list of 60 youth and from the high school graduating class this year, three of its members now are attending UNC and all went on to promising future plans, either more education or work and one into the armed services! e. Other Pertinent Agency Information: All Boys & Girls Clubs are unique in that it they are affordable and accessible. The charge for membership in the Chapel Hill Program for Impact is $20/year per child. Scholarship support is also available so that no child will be turned away because of lack of finances. The program is open four days a week during the school year, available to youth from kindergarten through 12th grade. This year we are exploring the possibility of a 6 week program for the summer of 2016 so that gains made during the year will not be lost over the summer.. 3. PROJECT/PROGRAM INFORMATION Agency & Program Name :BGCEP; Community Impact Program (Program for Impact) in Chapel Hill, NC 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) n 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) Program Category Youth Adult Elderly Disabled Public Housing (not elderly) Neighborhoods/Residents Education X 0 0 0 0 Health and Nutrition X 0 0 0 0 Job Training Sports and Arts Activities Pre-School Activities Main Application 5/24/2016 8:59:25 a5/p5 0 t 5 f 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA t A - continued Provider's Outside Agency Application MAIN APPLICATION After-School 0 Activities X 0 0 0 Mentoring Transportation Housing Other: Please specify Indicate the type of program for which you are requesting funding: 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? The Program addresses the Goal to ensure a community network of basic human services and infrastructure that maintains, protects and promotes the well- being of all county residents and Priority 4 which aims to review services to identify and protect 'safety net' programs and services. Our Agency provides youth from Kindergarten through 12th grade with an after-school youth development program focused on three main goals or outcomes: Academic success, Good Character and Citizenship, and Healthy Lifestyles The PRIORITY OUTCOMES are: 1.Academic success in school with end-goal to graduate from high school ready for college, trade school, military or employment. 2. Good character and citizenship- to become an engaged citizen involved in the community, register to vote and model strong,positive character; 3. Healthy life style- to adopt a healthy diet,practice good lifestyle choices and make a lifelong commitment to fitness. While all children are eligible to join, the Club focuses on the population who "needs us most," those unable to access other Chapel Hil-Carrboro after-school programs, even on scholarship, which often have waiting lists and which present transportation problems. Providing after school academic enrichment and development to children who currently are poorly served or served not at all, centrally fills the stated Goal of maintaining,protecting and promoting the well-being of all of our county residents with this 'safety net' Program. 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. A needs survey found that, although there are many activities for children in the Chapel Hill- Carrboro area, most of them have waiting lists, have costs that prohibit low income children from taking part and are not open long enough or often enough to be helpful to and useful for our target population goals. According to the Chapel Hill City Schools web site, 35.38% of the student population at the Northside School currently is qualified for free or reduced lunch. In addition, 600 families in Chapel Hill/Carrboro live on $15,000/year or less and children in these families cannot afford any of the programs or after school, even on scholarship. After-School programs have consistent waiting lists and also pose transportation difficulties.. These kids are left to wander the streets during the most dangerous hours for kids- when they Main Application 5/24/2016 8:59:25 a5/p5 Pag 6 f 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA t A - continued Provider's Outside Agency Application MAIN APPLICATION either commit crimes or crimes are committed against them. Studies show that BGCs work to reduce drug, gang and early sexual involvement, and to increase the likelihood of graduating from High School. The Chapel Hill-Carrboro City Schools have been struggling for years to close the achievement gap between black and white students. A Boys & Girls Club, with its emphasis on school success, can be instrumental in helping to close that gap. In addition, because the club program continues through the summer months, children will not lose the gains they have made in the past year as they often do if they have no enrichment over the summer. A father of twins who attend the program starting from January 2015 said that he saw a difference in his boys immediately and that they are now"interested in math! of all things!" In addition, it has been widely reported that there is a racial divide in school disciplinary procedures. For example, African American students are 9 times more likely to be suspended from school as white students at Phillips Middle School. The trend was assumed for all the Chapel Hill- Carrboro Schools. Although African American students in the Chapel Hill-Carrboro City Schools comprise 11% of the population, they account for over 40% of the out of school suspensions. Boys & Girls Clubs act as a safety net (one of the Goals) since one of their three primary goals is to develop good character and leadership capabilities in the youth. We train students to listen, to follow directions and to improve their interactions with others. Boys & Girls Clubs are uniquely positioned to help with behavior problems and outcome studies show that school behavior improves for Club participants. A teacher at the Northside School stated, "I am very impressed that one of my students has not been in trouble yet this [fall 2015] school year, when in the past, he was in the principal's office about once a week!" Chapel Hill had to close its Apple Chill street festival, now, many years ago because of dangerous gang activity. Chapel Hill has a nascent gang presence (our older children talk about the Crips, openly) and BGCA studies show that, because kids want to belong, where there is a club, gang activity goes down, reducing the likelihood that Chapel Hill-Carrboro will develop a full blown gang presence. BGCs foster a sense of belonging. As District Court Judge Joe Buckner says, regarding the Boys & Girls Club in Chapel Hill, "There is no greater need." He should know because he sees from the bench, the problems that kids are involved with and which impact our community, every day. It is clear that the Impact of the BGC Program will greatly enhance the quality of life in Chapel Hill! d. Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. The population we will serve encompasses all children from K-12 in Orange County who wish to belong. The program at this time can only accommodate 32 children at any one time at the Northside Elementary School, from Kindergarten- 5th grade. We do not discriminate while at the same time our target population is youth "who need us most." At the present time, all of our Club members are from the Northside School and are referred into the program by the school Social Worker and teachers. Our future plans are to expand to other schools, especially Middle Schools, so that the children who graduate will not be deprived of continuing Club membership. e.Who specifically will carry out the activities and in what location will they be carried out? Main Application 5/24/2016 8:59:25 a5/p5 Pag 7 f 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA t A - continued Provider's Outside Agency Application MAIN APPLICATION At present, the location for the Club is at the Northside Elementary School in Chapel Hill. The full time Program Director, Brittney Goldston, and two part time teachers, plus volunteers do and will carry out the program. Our Program Director, Brittney Goldston, has five years' experience with leading Boys & Girls Clubs programs. Brittney spends a minimum of 40 hours per week, all on the Chapel Hill Community Impact Program. She is building relationships in the community, working closely with the staff of Northside and teachers, and she is responsible for developing and implementing the program which is based on the long-standing Boys & Girls Clubs of America basic programs which have been enhanced over the years in order to maximize the outcomes of Academic Success, Good Character and-Citizenship,andHealthyLifestyles. We have two part-time employees, who are both teachers during the day at the Northside Elementary School. They become employees for the Chapel Hill Program as soon as the school day ends and work for our program from 2:30 - 5:30 on Monday - Thursday, the days the program is currently open. One of these part-time employees also has experience working with Boys & Girls Clubs programs through the Clubs in Raleigh. Prior experience is a bonus for the organization as well as for the members. Many of the youth we work with are high-maintenance and all the employees we have for all programs know and accept this, and in effect, thrive from the work they do because of the very nature of the clientele we serve. Brittney has been able to secure several volunteers for the program during August - December. During this time, Brittney had a high school student, an APPLES intern, a Board member and a two UNC students volunteer to work with the youth. Beginning in this past January, the volunteers assisting each week have increased as relationships have grown to include two additional groups as noted in the affiliates section of the grant. We do not lease the space at Northside. We do not have total access to the space, and are contracted to use the two classrooms we are currently in through the school and the Chapel Hill- Carrboro Schools Administration. In a recent meeting with Todd LoFrese, Assistant Superintendent of Schools, we were given permission to approach other schools, including middle schools, in the future, to expand our programs. The school administration as well as the Principal and Social Worker at Northside are excited about our program and the impact we are already having with the youth. They already would like to see us continue to expand as we have more youth wishing to be in the program than we can handle with the space being provided at Northside. We see no possibility that the need and the opportunities will decrease in the future, but instead, they will continue to grow. The $20 per school year membership fee for each child mainly covers their registration. Some families cannot afford this and the fee is paid by either the Northside PTA or by scholarship. We do not turn away youth due to the inability to pay. This fee helps us to ensure that those youth who want to come to the program actually do come. We cannot have the impact we desire if a child only attends occasionally. They need to attend at least three days a week. If after several weeks, they do not attend the minimum amount of days and it is determined there is no reasonable explanation for the lack of attending, parents are given notice that the child will lose their place in the program unless they attend as expected. If a child then continues not to attend as expected, the spot is opened up for another child on the waiting list who will attend the required days that Main Application 5/24/2016 8:59:25 a5/p5 Pag 8 f 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA t A - continued Provider's Outside Agency Application MAIN APPLICATION will have the most favorable impact for that child.. 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. The Program is currently being carried out after school (2:30- 5:30) M-Th during the school year. The program is already in action and has been open since January of 2015. A summer program is being explored and the school-time program is planned to continue permanently each school year. g. Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, give specific examples of the coordinated/collaborative efforts. * We sought collaboration with the CHAPEL HILL-CARRBORO CITY SCHOOLS in late 2014 and secured space for one classroom to serve 17 youth beginning on January 5, 2015. The Northside School officials said they were "delighted" to have our program back in the Northside School in Fall 2015 in two large, sunny classrooms with 32 children enrolled (K-5) this year. Referrals by the school social worker and teachers. * In January 2016, Ron Reeves of BRIDGE BUILDERS at UNC, which focuses on work with at risk children in grades 3-6, will start work with our program. This is a group of 20-30 African- American men who are employees of UNC in departments associated with athletics and in professions including graphic design, training, business, fund raising, ticket sales and coaching. They desire to serve as role models and build bridges to adulthood,provide field trips to the UNC campus to encourage kids to see themselves as future students on campus. They will tutor and help kids with their homework, as well. • We are collaborating with the KIDZU MUSEUM to arrange field trips to their museum for low or no cost * UNC APPLES PROGRAM. There are many other opportunities through the Apples program at UNC which provide volunteers and support to our Program. * The UNC AUTOGRAPH BASKETBALL PROGRAM has granted our Program $5000 this year as well as in past years. They wish to support the youth from whom, they expect, some star athletes may arise and attend UNC. * TWIG gift store in Chapel Hill supports us each year at Christmas time with 20% of purchases donated when the buyer requests the donation to go to the BGC. * THE CHAPEL HILL-CARRBORO CHAMBER OF COMMERCE will feature our Program as the non-profit of the month May spotlight at their After-Hours Program. We are members and make use of the monthly non-profit roundtable program. Other collaborations in the pipeline: * THE WALKING CLASSROOM. We are in the process of exploring using the program, especially in the summer session, negotiating with Executive Director, Laura Fenn * YMCA possible collaboration to build a teen program together. * KAPPA ALPHAP SI,.African American fraternity on campus talking about volunteering with homework/recreation as well as taking the Northside Program on as a service project. * Y.O.GA. FOR YOUTH_ to collaborate to provide yoga training. KIDZNOTES orchestral training and music appreciation for underserved pre-K-high school youth. h. Describe what would happen if requested funding is not awarded at all or if a reduced Main Application 5/24/2016 8:59:25 a5/p5 Pag 9 f 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA t A - continued Provider's Outside Agency Application MAIN APPLICATION allocation is recommended. If Funding is not awarded, we would have to find additional sources for support because one thing that will not happen if we are not funded by this grant is that we would let this program close- because the youth are too important for that to happen. It is hard to understand, though, why the funds sought would not be provided for this program that is so central to goals and priorities and so important to the quality of life in the Chapel Hill- Carrboro area. And these funds are for children who, truly, need us most, who have not heretofore had access to afternoon programs in Chapel Hill-Carrboro. The program is currently supported by ongoing individual donors, corporate donations, and grants. We expect to be chartered by BGCA during 2016 which will open up additional opportunities for funding assistance through Boys & Girls Clubs of America and state and national funding. All of this will assist us in being able to support the program. Did you know that over 70% of adults who have attended BGCs in their youth said it SAVED THEIR LIVES? We are in the business of saving lives. Why would organizations not want to fund us fully? Program/Project Information d) Complete the Target Population and Program Beneficiary Demographics Chart e) Complete the Schedule of Positions Chart for Program Staff f) Disclosure of Potential Conflicts of Interested must be signed g) 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: BGCEP Program for Impact Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Not open Male Not open 22 40 Female Not open 10 26 Total 32 66 Not open Main Application 5/24/2016 8:59:25 a5/p5 P 10 o of 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA t A - continued Provider's Outside Agency Application MAIN APPLICATION Of the females, how many are single- female Head of Households (Omit for Human Services)N/A N/A N/A Ethnicity African-American Not open 25 44 American Indian or Alaska Native " 0 0 Asian " 2 6 Caucasian " 3 11 Native Hawaiian or other Pacific Islander 0 Other" 2 5 Total I 0 32 66 Of the above, how many Hispanic/Latino " 3 10 Of the above, how many non- Hispanic/Latino " 33 56 Total 0 32 66 Age 0-5 years Not open 6 9 6-18 years " 26 57 19-50 years " 0 51-61 years " 0 62+ years " 0 Total I 0 32 66 I Geographic Location Durham City Not open 0 Durham County " 0 Carrboro " 16 15 Chapel Hill" 41 Chapel Hill Public Housing Residents" unk 10 Orange County " 0 Main Application 5/24/2016 8:59:25 a5/p5 III. 11 o of 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA t A - continued Provider's Outside Agency Application MAIN APPLICATION Raleigh" 0 Wake County" 0 Total 0 32 66 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 I 0 0 0 Special Needs (Omit for HS) Elderly(Over 62) Disabled (not elderly) Homeless People with HIV/Aids Total I 0 0 0 I CDBG & HOME ONLY- Area Benefit Activities (Infrastructure and Public Facilities) Street Census Tract Block Group Total Persons #LMI Persons Main Application 5/24/2016 8:59:25 a5/p5 P 12 o of 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA 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 Income 1 2 3 4 5 6 7 8 Level person people people people people people people people $14,15 $20,09 $24,25 $28,41 $36,73 30%AMI 0 $16,200 0 0 0 $32,570 0 $40,890 $23,60 $30,35 $33,70 $36,40 $41,80 50%AMI 0 $27,000 0 0 0 $39,100 0 $44,500 $37,75 $48,55 $53,90 $58,25 $66,85 80%AMI 0 $43,150 0 0 0 $62,550 0 $71,150 $47,18 $60,68 $67,37 $72,81 $83,56 100%AMI 8 $53,938 8 5 3 $78,188 3 $88,937 115%AMI $54,26 $62,028 $69,79 $77,48 $83,73 $89,916 $96,09 $102,278 6 1 1 4 7 http://www.huduser.orq/portal/datasets/i1/i115/FY2015 IL nc.pdf Main Application 5/24/2016 8:59:25 a5/p5 0:' 13 o t 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA t A - continued Provider's Outside Agency Application MAIN APPLICATION k.) Schedule of Positions Please include program staff positions followed by volunteer positions; these financial figures should match the personnel figures in your Agency Comparative Budget Excel Form. Similar positions can be combined. (i.e., 8 Occupational Therapists can be inserted as one line item). If provided, indicate: Position Titles % (R) *= Position FTE* Program Actual Estimated Projected %Total Retirement Vacant Staff+ 2014-15 2015-16 2016-17 Budget Plan (H) Health Plan Chief Professional $26,000.0 officer 1 50.00% $24,500.00 $25,000.00 0 20.00% $33,000.0 Program Director 1 92.00% $0.00 $29,000.00 0 26.00% H 2-3 Program $26,441.0 Assistants ..25 100.00% $3,757.00 $12,000.00 0 21.00% Total Volunteer hours 1920 Notes: • Similar positions can be combined: i.e. 8 Occupational Therapists can be inserted as one line item. • ** Full Time Equivalent staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • + Denotes the percentage of staff time involved with this program. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 1,960 Main Application 5/24/2016 8:59:25 a5/p5 P 14 o of 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA - continued ProviderMs0A98wil4 A plication 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 El a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? Li El b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? El:. c) Current beneficiaries of the project/program for which funds are requested? Ell Cl 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. The two part time staff are teachers employed by the Chapel Hill-Carrboro School district during the school day but are employees of the Boys & Girls Club during the Club after school hours. We are applying for funds to help pay the salaries/benefits of the two part time employees as well as for the Program Director (who is not employed by the schools- is 100% employed by BGCEP). 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 ma result in the termination of an •rant awarded. Signature: / (/ he a xecutive irector Date j Signature: \, ,It 6 /if 7„e)4 ard Chair rson Date Main Application 1/13/2016 12:06:34 al/p1 , e 16 of 22 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA 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. ACTUAL ESTIMATED PROJECTED 2014-15 2015-16 2016-17 Program Activity 1 Program Goal To provide academic & tutoring assistance for at-risk youth to improve grades. Performance Measures Report Cards Program Results To increase grades in Reading and/or Math by 1 point (on the scale of 1-4) for 20% of the youth members. Program Activity 2 Program Goal To monitor personal & social skills of program members to increase development of positive behaviors Program Measures Report Cards —4 categories: 1) Follows classroom rules 2) Takes responsibility for behavior & actions 3) Respects & cooperates with others 4) Follows directions Program Results 75% of members will meet the standards set by schools in 4 of 14 categories. Main Application 5/24/2016 8:59:25 a5/p5 P 16 o of 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA 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. 2014-15 was a transitional year for us. After strategic planning sessions, the decision was made to concentrate on opening and beginning a program in Chapel Hill. With funds already in the bank from past fund raising efforts which gave us a cushion, there was not another scaled effort to approach donors again that year. We focused on getting our programs up and running at the Northside Elementary School in Chapel Hill. We believed that we would have successful measurable outcomes to report along with many stories about the positive impact of the Boys & Girls Club program on Club members and that we would then be in a more favorable position to raise funds in the future to make the now- existing Program sustainable. We began the Community Impact Program at the Northside School in January, 2015 with 17 youth enrolled and operated it until school ended in June, 2015. We had only one classroom to use and we still managed to have an impact on an array of students from grades K-5. Beginning with the fiscal year 2015-16, we have begun fundraising efforts on a full scale as we have the program established with continued support from not only the Chapel Hill- Carrboro Schools Administration but also the staff and faculty at the Northside Elementary School. Discussions have already been held with the Principal of the Northside School as well as with Todd LoFrese, Assistant Superintendent, regarding expansion for the next fiscal year and for a summer program in 2016. The partnership with the schools is strong. Main Application 5/24/2016 8:59:25 a5/p5 0:' a g 17 o t 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA t A - continued Provider's Outside Agency Application MAIN APPLICATION PROGRAM BUDGET Actual 2014-15 Estimated 15-16 Projected %change Revenues Private donations 9901 41526 50,328 "donations Agency generated fees 218 249 928 more members local gov't. grants Orange Co. 2610 10,000 Town of Carrboro 10,000 Town of CH 10,000 Other local 830 Non gov't grants Triangle UW 322 830 840 State govt 4150 3000 Dhhs/nc alliance Other grants 24,900 21,000 Misc/other revenue Special events 127 16,500 21,000 Other 4,765 264 TOTAL REVENUE 13,178 93,790 127,360 AGENCY EXPENSES Compensation 3757 40,965 59,640 add 1 class/1 school Rent/utilities 2649 1287 4620 potential Dir. office Supplies/equip 1710 3632 11,500 summer program travel/training 1550 2100 additional staff other expenses-3 largest listed Office supplies/mail 707 1694 2100 professional dues 425 415 880 corporate support 41,000 44,247 46,520 TOTAL AGENCY EXPENSES 50,248 93,790 127,360 SURPLUS/DEFICIT FOR PERIOD 161,983 0 0 Main Application 5/24/2016 8:59:25 a5/p5 0:' a g 18 o t 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA t A - continued Provider's Outside Agency Application MAIN APPLICATION 3-R FEE VERIFICATION NOT REQUIRED SINCE THIS PROGRAM IS OPERATED IN A SCHOOL AND NOT IN OUR OWN PREMISES. Main Application 5/24/2016 8:59:25 a5/p5 19 o t 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA 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($) 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 $9,000 Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: Cost Elements Cost($) Quantity/Unit of measure S Community Impact Program Director $15.87 After-school pgm direct service 516 hrs (12 hrs/wk 5 Community Impact Program Director $15.87 Summer session direct service-225 hrs (45hrs/wk 3 Community Impact Program Director $15.87 Planning,prep,pgm.mtgs/780hrs(15hrs/wkX52 wks 2 Community Impact Program Director $15.87 Volunteer training Comm. School outreach, etc. 2 Part time Program employee (3) $12.00 After School Program 516 hrs.(12 hrs/wk X 43 3 Part time Program Employee (2) $12.00 Summer session Program-200 hrs.(40hrs/wkX5wk 3 Employee Benefits $666.00 FICA, unemplymt,health insur., (1 staff @80% 2 Rent & utilities $385.00 Office space for employees Supplies & equipment $958.00 snacks, summer meals, supplies,ipads, equipment Travel& training $2100.00 Workshops/Program training Office supplies/mailings $2100.00 office supplies, mailings to family/commumity Professional dues $880 for Program Directors/workshops/training Corporate support $46,520 Insurance,Marketing,%CEO time, keeping Program reports/outreach/leading/students Main Application 5/24/2016 8:59:25 a5/p5 P 20 of 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA t A - continued Provider's Outside Agency Application MAIN APPLICATION c.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program $50,248 $93790 $127,360 Total # of Units $24 36 66 Cost Per Unit $1689 $2605 $1930 This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries (households or persons) in this application and must be consistent with report submittals from previous years (if applicable). Main Application 5/24/2016 8:59:25 a5/p5 0:' a g 21 o f 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA 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 through June 30, 2017 See agency budget on next page. Main Application 5/24/2016 8:59:25 a5/p5 P 22 o of 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA t A - continued Provider's Outside Agency Application MAIN APPLICATION Section VI.Financial Data Operating Budget for Entire Agency AGENCY NAME: Boys&Girls Clubs of Eastern Piedmont-Chapel Hill Community Impact Program Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Balance Carried Forward Private Donations $ 11,380 $ 57,000 $ 60,000 5% Agency Generated Revenue(fees) $ 250 $ 300 $ 1,100 267% Local Government Grants: Orange County $ 3,000•$ 10,000 Town of Chapel Hill ••$ 10,000 Town of Carrboro ••$ 10,000 Other Local: $ 1,000- OtherLocal: --- 1 Other Local: --- 1 It more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way-Designations $ 1,000 $ 1,000®i'. State Government $ 5,000 $ 9,200 Federal Government •••stu Other Grants: $ 30,000 $ 25,000 Other Grants: --- 1 Miscellaneous/Other Revenue --- 0 Please Ilst 3largest Miscellanous sources: Special Events Other $ - $ - Total Agency Revenue MN MN WEI 12% AGENCY EXPENSES Compensation $ 3,757 $ 48,087 $ 71,000 48% Rent&Utilities $ 3,044 $ 1,431 $ 5,500 284% Supplies&Equipment-Program $ 1,710 $ 3,632 $ 11,500 217% Travel&Training $ 1.550 $ 2.500 61% Office Supplies/Mailing $ 812 $ 1,800 $ 2,500 39% Professional Dues $ 489 $ 500 $ 1,000 100% Corporate Support $ 51,000 $ 50,900 $ 53,000 4% Fundraising Expense $ 20.100 $ 4.600 -77% Other Expenses: 0 Please Ilst 3largest"Other Expenses, Total Agency Expenses 60 812 . 128 000 . 151 600 18% SURPLUS/(DEFICIT)FOR PERIOD: I$ 161,983 I$ 128,283 I$ 136,683 I 7%1 Main Application 5/24/2016 8:59:25 a5/p5 P a g . 23 o . 23 DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Boys & Girls Club of Eastern Piedmont Funding Award: $5,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Salaries and Benfits of full-time Program Manager and two part-time assistants 5,000 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. • Provide academic and tutoring assistance for at-risk youth to improve grades • Monitor personal and social skills of program members to increase development of positive behaviors. 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 Increase grades in reading and/or Math by 1 point(on the scale of 1-4)of youth members 20% Members willmeet the standards set by the schools in 4 of 14 categories 75 % DocuSigned by: Dvow. tSbi 11/3/2016 Certified by: Bao,R�F��aR,a,E Title: cEO Date: (Provider's Signature) DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA 20BOYSGIR2 ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)11/03/2016 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 Terrie G. Roberts NAME: BB&T Insurance Services, Inc. PHONE 919 281-4500 FAX ): 8887468761 (A/C,No,Ext): (A/C,No Post Office Box 13941 E-MAIL 1.:. ro t g berts^bbandt.com ADDRESS: Durham, NC 27709 INSURER(S)AFFORDING COVERAGE NAIC# 919 281-4500 INSURER A:Riverport Insurance Company 36684 INSURED INSURER B:FirstComp Insurance Company 27626 Boys &Girls Club of Greater Durham INSURER C:Travelers Indemnity Company 25658 PO Box 446 INSURER D: Durham, NC 27702-0446 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. LTR L POLICY EFF POLICY EXP TYPE OF INSURANCE SR WVD POLICY NUMBER N LIMITS (MM/DDIYYYY) (MM/DDIYYYY) A X COMMERCIAL GENERAL LIABILITY 13242855 09/09/2016 09/09/2017 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $3,000,000 OTHER: $ A AUTOMOBILE LIABILITY 13242855 09/09/2016 09/09/2017 (Eo acccdentSINGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) A x UMBRELLA LIAB OCCUR BINDER13242856 09/09/2016 09/09/2017 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DED RETENTION$ $ B WORKERS COMPENSATION MWC005544003 09/09/2016 09/09/2017 STATUTE EORH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? y N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 C D&O/Empl Prac 105991654 09/09/2014 09/09/2017 1,000,000 A Professional Liab 13242855 09/09/2016 09/09/2017 1,000,000/3,000,000 A Sexual Abuse 13242855 09/09/2016 09/09/2017 1,000,000/3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) **Workers Comp Information** Other States Coverage Proprietors/Partners/Executive Officers/Members Excluded: Jerome Levisy, CEO (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION Orange County Risk Manager SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g y g er THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 8181 ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 2 The ACORD name and logo are registered marks of ACORD #817079500/M 16784881 TGR DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA DESCRIPTIONS (Continued from Page 1) Orange County is named as Additional Insured with respects to General Liability as required in a written agreement. 1 SAGITTA 25.3(2014/01) 2 of 2 #S17079500/M16784881