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2016-645-E Finance - Boomerang Youth, Inc. - Outside Agency Performance Agreement
DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 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 Boomerang Youth, Inc., a not-for-profit corporation, located at 825A N. Estes Drive, 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 Boomerang Youth, Inc. 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$10000. 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 $2,500. 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. (Boomerang Youth,Inc.) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 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. (Boomerang Youth,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 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. (Boomerang Youth,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 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 Boomerang Youth, Inc. 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: (Boomerang Youth,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 County: Finance&Administrative Services Provider: Boomerang Youth, Inc. Orange County 980 Martin Luther King Jr. Blvd. 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 and i "-5,:4.,[ af>the Provider 1&u t P(/u(u' 11/9/2016 &B.-3-5,41431 Date 7 For a + i�*of Orange County Government 1561A,LAAt, AAAtwtGY'SUI 11/11/2016 0637994B755E477... Bonnie Hammersley, County Manager Date (Boomerang Youth,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 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. DVIVI ocuSigned by: rt,ift,r Executive Director 11/9/2016 Certified by: L35AF55l3l... Title: Date: (Provider's Signature) (Boomerang Youth,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency YMCA of the Triangle Area, Inc. Date/Time / 1 Complete Y/N Program(s) Boomerang Program Section Subsection For CDBG & HOME - HUD Regulations 1. Cover Page a. ❑ Applicant Contact Information b. ❑ Project/Program Contact Information c. ❑ Funding Requests Identified d. ❑ Signed Application Cover Page 2. Agency a. ❑ Agency's Years in operation 24 CFR 570.506, Information - b. ❑ Agency's Purpose/Mission 570.507, 570.610; 24 c. ❑ Agency's Types of Services Provided CFR Parts 84 or 85 d. ❑ Agency's Experience e. ❑ Other Pertinent Information 3. Program/ a. ❑ Type of Application and Program Identified 24 CFR 570.200(a), Project b. 570.201-570. 208, ❑ Summary of Program Information - c. ❑ Description of Identified Need 507.503 (for each d. ❑ Description of Population to be Served program/ project for e. ❑ Activity Manager and Location Description which funding f. ❑ Activity Implementation Timeline is requested) g. ❑ Agency Collaboration h. ❑ Describe Impact of Reduced/No Allocation i. ❑ Other Pertinent Information j. ❑ Complete Target Population/Beneficiary Chart k. ❑ Complete Schedule of Positions I. ❑ Signed Conflict of Interest Disclosure m. ❑ Complete Work Statement i o:° DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 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. ❑ Program Budget Worksheet 570.602, 570.607(b), is requested) b. ❑ Program Budget Detail 570.611 24 CFR c. ❑ Cost Per Unit 570.502-570.504, d. ❑ Agency Operating Budget Worksheet 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circulars A-87 or A- 122; Treasury Circular 1075 5. Supplemental A. ❑ Part A: CDBG & HOME Sections (as B. ❑ Part B: Construction/Rehab applicable) 6. Attachments a. [' Audit: Organizations receiving $300,000 or more OMB Circular A-133 in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ❑ IRS Federal Form 990 c. ❑ NC Solicitation License d. ❑ IRS Federal Tax-Exemption Letter e. ❑ Certificate of Insurance f. ❑ List of Board of Directors 24 CFR Parts 84 or 85 g. ❑ Articles of Incorporation/Bylaws 24 CFR 570.208, h. ❑ Authorization to Request Funds 570.500(c), 570.611 i. ❑ Authorized official designation j. ❑ Solid Waste Program Fee (SWPF) Verification Main Application 5/24/2016 9:22:20 AM 0:° J c 2 of 2 I DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 - continued flL „ CA000 rrAG0E (Each ph,grai req■,!, has a Sell arate app ctiCtion ) ay Applicant C arrhrr Acpiicact OrganitriulUchn,:5 tegall Nama: YMCA f q „A,Tte.la Aosititant Organ teutkyl's Addrossu CenteT D . Ste. 200. Raleigia, AtiP,p C?A 'Organirstion's Nola itinU Address: 980 r,qatin LJ th Of ruggr. 1,00911$00„0„(Chzipel H V V N IC; 27E14 Applicant Organ itratibit Wei,:)Address: imtutiv.ir triCA7rgistpal Executive Director: Doug, ihicitliiian Cruel Financial 0Difico Duran H citing Tele:phone Numb°it 7 -P22 Brhan.b1 uffnu a n "00,01 CAT itthaltitt o trg DUNS N 11 Elle r: 4,8860182,0091, IS) if rtslisopfri4i0?0r„trig Contact info rmatiga ProjectlFinggram Name: Dograslaing ProjectIP'rOgrarfl mart Contact and TVIln:, T,-,,:mttiP00!" P' iatl Director 'Telephone N bort 91 9,-98621 4 6 E-N1 Tarni.PiciforitginfiliCATrinitiolc.fera, e) Funding Request identifictithat, TEl Prrui,ectiPr ograM COSt„ S291.708 Totai Au Ott of Funds : $210000 Proposed Use of Funds P uois U Cr St cid ru rrRIrn)7 Ft!:rids 'MD support Pronram iiiinanitgoLausl ,Student Coordinator posit ipri aigiertou COT/tracts. and itirogram matoriais. PiciaSe (::110■Ck types, 500,1/roes, and a0i o0.00.107 tS o fliniding bitting roots eSled, You must submit on Auiplicali(WI package tor each 'funding scurat. 'The Panicipaarip juris resv,rves the ri,ght „Qidd projects from any funding source, ,rs,1 elk:jiddayn and '',uniding constraints. Hilman Services: HZ cantor()sr1,000 [F] ch:a pell Hill $7„000 Orangc:, Couttry $1o,Dop d), To tiie best of my knowictige and belief all initsTric ition and date in this application ig• true and cuurent. The doccutent ha been ,000tit1y authorized by the governing hoard of the applica,0.t. D440,:aike 4wpm d .un,4 14u 11::w . • rya!, „I A f„, „,a ",,241(4,';A'k444p.14 LA ar011eCgr 41t,,,111/0 11; ''1„11"”, Si g bat 0 ire: „ft M11...14.144.11, inancial Officer/ffl D2'le Sign at u r e /hh° /)) :4?),.{))) )*)')”' 111 1taomgrang Board„PdreSidetA), Date r .00 %Arlin f1",ll l011 1.12 DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 t A - continued Provider's Outside Agency Application MAIN APPLICATION 2. AGENCY INFORMATION Boomerang is filing to become an independent non-profit organization, separating from YMCA of the Triangle Area, Inc.The YMCA's fiscal responsibility for Boomerang will end once the latter receives its 501(c)3 tax-exempt status (estimated August-September 2016). At that time, Boomerang will provide its own documentation—IRS Federal Tax-Exemption Letter, Certificate of Liability Insurance, and NC Solicitation License—to be in compliance with Outside Agency funding requirements. The YMCA of the Triangle Area, Inc., is deferring authorization and approval of this application to Boomerang's Board of Directors. Boomerang Board of Directors Board President: Isabel Geffner, Interim Education Director,Judea Reform Secretary: Dana Brinson, Oak Foundation Treasurer: Kellie Mannette, Mannette Law Directors: Gretchen Aylsworth, Community Member Jennifer Boger, Community Member Alonzo Jaynes, Assistant Police Chief,Town of Chapel Hill Sonny Kelly, Doctoral Student, UNC-Chapel Hill Quincy McDuffie, Student, Durham Tech Maggie Mraz, Parent/Community Member Kendra Suggs, Behavior Specialist, Chapel Hill-Carrboro City Schools 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 In 2005,the Chapel Hill-Carrboro Y brought together a broad-based, multi-agency'group to address the growing number of short-term suspended students who were out of school. In 2006, the Chapel Hill- Carrboro Y launched Boomerang as a resiliency-based alternative to short-term suspension that provided youth at risk for disconnection with their community a supportive alternative environment for out of school time. Boomerang's programs support Orange County youth in cultivating skills for personal success, academic growth, and community engagement in a supportive environment during out of school time. Positive Alternative to Suspension Boomerang's alternative to suspension program provides a structured and supervised environment for 6th to 12th grade students who have been short-term suspended from school. Students who are on 3, 5 or 10- day suspensions are referred by local public school systems. Parents/guardians may also refer their child. Students: • Engage in 1:1 sessions with licensed staff to discuss underlying issues that led to the suspension, identify their strengths and alternative behaviors. • Receive academic support and tutoring to stay on task with schoolwork. • Build social skills and identify core values during structured group discussions. 1 Chapel Hill-Carrboro YMCA,Chapel Hill-Carrboro City Schools,Community Backyard, Department of Juvenile Justice, Dispute Settlement Center, UNC and Volunteers for Youth. Main Application 5/24/2016 9:22:20 AM of 2 I DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 t A - continued Provider's Outside Agency Application MAIN APPLICATION • Participate in social-educational groups: conflict resolution, self-expression, healthy relationships, and substance use prevention &education. • Lead a wrap-up meeting with family and school representatives (and court counselor if applicable)to support their re-entry back to school. The Alternative to Suspension program operates Monday-Friday from gam to 2pm, and follows the traditional school calendar of both CHCCS and OCS. Opportunities for community service are provided on teacher workdays. Continuing Connections After School During the critical hours after school, Boomerang provides youth with additional learning opportunities and support, as well as recreational opportunities. Continuing Connections helps youth to: • Build skills that support academic achievement. • Gain confidence and cultivate leadership skills through service learning, community service and other civic engagement opportunities. • Learn independent living and leadership skills. • Develop conflict resolution and mediation skills. Weekly:Tuesday through Thursday, 3:30-6pm -Service learning -Community service -Tutoring - Individual brief counseling Monthly: Reunions for youth to reconnect with Boomerang staff and their peers in a recreational setting. Quarterly: What's Next: independent living workshops designed for middle and high school students to inventory their personal and academic assets, explore career options, and prepare for post-secondary opportunities. Summer: Independent living& life skills workshops are planned for youth participating in summer employment programs and internships, such as Town of Chapel Hill's SYEP. To date, Boomerang has served over 2000 students in its Alternative to Suspension component and during after school programming. Brief Timeline 2006: Boomerang is launched as a pilot alternative to suspension program in January, serving one middle and one high school 2006: District Court Judge mandates CHCCS court-involved youth attend Boomerang 2007: Boomerang expands services to all CHCCS middle and high schools 2008: Boomerang expands services to court-involved youth in Orange County 2008: Boomerang becomes an approved adult community service site in 2008 2008: Boomerang and Volunteers for Youth enter an agreement allowing court-involved Orange County youth aged 16 and younger to complete court-ordered community service hours at Boomerang 2009: Boomerang offers after school hours on Wednesdays-Fridays for students to drop in to complete service hours and check in with staff 2010: Boomerang offers community service hours during the summer 2011: Boomerang expands services to Orange County Schools 2011: Boomerang expands to a 5-day program in September, adding to afterschool programming 2012: Boomerang expands services to select high schools in Chatham County 2014: Chapel Hill-Carrboro Y merges with YMCA of the Triangle Area, Inc. Main Application 5/24/2016 9:22:20 AM 0:' d J c 5 of 2 I DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 t A - continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: YMCA of the Triangle Area, Inc. / Boomerang Program 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) Indicate the type of program for which you are requesting funding: Program Category Youth Adult Elderly Disabled (not Public Housing elderly) Neighborhoods/Residents Education ✓ Health and Nutrition Job Training Sports and Arts Activities Pre-School Activities After-School Activities ✓ Mentoring Transportation Housing Other: Please specify 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? Boomerang is the only program that offers an alternative to short-term suspension for youth in Orange County. Students receive tutoring and 1:1 counseling by licensed staff (LCSW, LPC) and participate in psycho-educational groups. There is no cost to students/families. Our principal partners for student referrals are Chapel Hill-Carrboro City Schools, Orange County Schools and the Department of Juvenile Justice. In addition, Boomerang's after school programming provides wrap-around support to students at risk of disconnection. These services include tutoring, community service and service learning projects, and individual brief crisis counseling. Boomerang's programming aligns with the Chapel Hill Town Council's goal for 2014-16 to "Create A Strategy For Out Of School Time For Youth", and supports the goal to "Review and Refine Focus for Youth Services and Begin Planning for Youth-Centered Facilities". Boomerang's after school programs respond in part to the community's need for "low-cost/free activities that positively engage children and youth, especially those from at-risk and low-income households." (2012 report on Human Service Needs in Chapel Hill, under Education and Family Resources: Youth support and activities) As a member of Orange County Family Success Alliance, Boomerang is working collaboratively to respond to the need for "an integrated system of human services in which agencies not only assist individuals in Main Application 5/24/2016 9:22:20 AM 0:' a g c 6 of 2 I DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 t A - continued Provider's Outside Agency Application MAIN APPLICATION addressing a single human service need, but also help individuals to access other services they need. Participants supported the idea of "wrap-around," services, in which human service providers coordinate and communicate to serve an individual's multiple needs." 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. Suspension is a strong indicator of disconnection, especially for students with greater risk and fewer protective factors who are unsupervised during out-of-school time. Suspended students are 3 times more likely to drop out of school, providing the rationale for a constructive alternative to suspension. As the only program offering an alternative to short term suspension for youth in Orange County, Boomerang effectively keeps these students engaged during out-of-school time by keeping them on-task in schoolwork, providing them with life skills-building opportunities and with afterschool programs. Out-of-School Suspensions by School District School District 2012-13 2013-14 2014-15 Chapel Hill-Carrboro City Schools 380 237 207 Orange County Schools 573 580 n/a Source: NCDPI,Annual Report of Suspensions&Expulsions,2012-13,2013-14;2014-15 CHCCS&OCS unofficial data Boomerang Alternative to Suspension 2012-13 2013-14 2014-15* Chapel Hill-Carrboro City Schools 101 109 88 Orange County Schools 59 83 58 Total 160 192 146 * 2014-15: Both districts reported that Boomerang's temporary location in Meadowmont was an impediment to student participation. Boomerang After School Program #of participation instances 2012-13 2013-14 2014-15 Chapel Hill-Carrboro City Schools 537 417 254 Orange County Schools 38 60 32 Graduates 131 76 0 Enrolled in College 32 19 0 GED students 4 0 0 Other Youth 55 34 0 Total 797 606 286 Boomerang is collaborating with school districts on (i)ways to effectively meet the needs of students with learning and behavioral challenges at greater risk for disciplinary action, (ii) addressing school policy and climate to reduce racial disparities in disciplining students, and (iii)targeting social-emotional skill building for vulnerable students.The program has contributed to declining out-of-school suspension rates in CHCCS. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. As in years past, the majority of the population Boomerang serves from both school districts—male, low- income, English language learners, Black and Latino students, and students with special educational needs— is particularly vulnerable as many of them are challenged by academic underperformance and face greater Main Application 5/24/2016 9:22:20 AM 0:' a g c / of 2 I DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 t A - continued Provider's Outside Agency Application MAIN APPLICATION suspension rates than their peers. For the alternative to suspension component, school administrators are the primary referral source, followed by court counselors. Families may also 'self-refer' their student.The table below provides data for the last 3 school years. Client characteristics Alternative to Suspension 2012-13 2013-14 2014-15 Male 133 145 101 Gender Female 27 47 45 Other 0 0 0 African-American 67 77 76 Race/Ethnicity Caucasian 44 62 38 Hispanic 37 41 22 Asian 4 1 2 Multi-Racial 8 11 7 Native American 0 0 1 e) Who specifically will carry out the activities and in what location will they be carried out? Boomerang has 3 full-time staff that work with students, including a licensed clinical social worker (program director) and a licensed professional counselor(program manager). In addition, an MSW intern from UNC and a Bonner intern support the program. All activities are carried out at Boomerang's offices located at 825-A North Estes Drive in Chapel Hill. 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. Alternative to Suspension and after school programming (Tuesday-Thursday) is provided during the school year. In addition, students have community service and service learning opportunities during the summer, as well as independent living/life skills workshops are planned for youth participating in summer employment programs and internships (weekly over 6 weeks). 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. • School districts-Chapel Hill-Carrboro City Schools and Orange County schools—are core partners in coordinating services provided to suspended students and transitioning them back to school. • Department of Juvenile Justice is a core partner in coordinating services and follow-up with court- involved students. • UNC Outpatient Substance Abuse Clinic provides bimonthly workshops on substance use to supplement Boomerang's assessments and psycho-educational skill-building activities; an important service as substance use has been the most common reason for suspension over the last 2 years. • Dispute Settlement Center provides weekly skills-building sessions in conflict resolution to supplement Boomerang's conflict and communication skill-building activities; an important service as fighting is the second most common reason for suspension. • Orange County Rape Crisis Center/Compass Center provides weekly workshops on healthy relations and sexual health to supplement Boomerang's self-care and communication skill-building activities. • Boomerang has a formal partnership with Volunteers for Youth and the Adult Community Service office to provide approved community service programming for juvenile and adult court involved youth during after school hours. Main Application 5/24/2016 9:22:20 AM 0:' a g c 8 of 2 I DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 t A - continued Provider's Outside Agency Application MAIN APPLICATION • New partnerships for community service with The ARC of Orange County and NC Botanical Gardens expanded opportunities for youth to provide meaningful service in the community. • Boomerang has a formal partnership with UNC's School of Social Work to provide our program with a qualified MSW intern each year. The intern functions as staff and provides additional support during alternative to suspension and afterschool programming. • Boomerang partners with UNC's APPLES Service Learning program;volunteers provide academic support to students, including 1:1 tutoring, as well as after school support. • Boomerang works with partner agencies to refer students and families for follow-up services: Carolina Outreach provides mental health services to students, and Family Advocacy Network provides critical assistance to parents raising school-age children with emotional/behavioral issues, mental illness, learning differences, substance abuse problems and other challenges. • Boomerang is a community impact partner of Orange County Family Success Alliance, contributing to the development of activities and services for youth on the cradle to college/career continuum. • Boomerang is a member of the Third Sector Alliance, a community organization that seeks to address community needs and support collaborations to improve the quality of life of all who live and work in Orange County. h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. As Boomerang transitions away from the YMCA for the 2016-17 school year, securing adequate levels of funding is critical as the program will not have the YMCA as a safety net. If funds are not awarded or a reduced allocation is received, this may affect staffing levels, contracts with service providers and the number of students served. Program/Project Information i) 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: Program Beneficiary Demographics—Alternative to Suspension Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 101 105 110 Female 45 45 40 Total 146 150 150 Of the females, how many are single- female Head of Households (Omit for Human Services) Ethnicity African-American 76 65 60 American Indian or Alaska Native 1 0 0 Asian 2 2 2 Caucasian 60 73 78 Main Application 5/24/2016 9:22:20 AM P a g e 9 of 2 I DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 t A - continued Provider's Outside Agency Application MAIN APPLICATION Native Hawaiian or other Pacific Islander 0 0 0 Other 7 10 10 Total 146 150 150 Of the above, how many Hispanic/Latino 22 26 30 Of the above, how many non- Hispanic/Latino 124 124 120 Total 146 150 150 Age 0-5 years 0 0 0 6-18 years 144 148 148 19-50 years 2 2 2 51-61 years 0 0 0 62+ years 0 0 0 Total 146 150 150 Geographic Location Durham City 0 0 0 Durham County 0 0 0 Carrboro 23 30 30 Chapel Hill 61 60 60 Chapel Hill Public Housing Residents na na na Orange County 62 60 60 Raleigh 0 0 0 Wake County 0 0 0 Total 146 150 150 Main Application 5/24/2016 9:22:20 AM 0:' a g o 1 I of 2o DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 t A - continued Provider's Outside Agency Application MAIN APPLICATION j) 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 % Actual Projected (R) *= Position FTE** Program 2014-15 Estimated 2016-17 %Total Retirement Vacant Staff+ Wages 2015-16 Wages Budget Plan (H) Health Plan Boomerang Program Director 1.00 53,305 55,973 57,200 R, H Operations Director (Dec 2015) 1.00 0 0 36,000 52,000 Program Manager 1.00 35,287 36,961 41,600 R, H Student Coordinator (Jan 2016) 1.00 0 0 15,600 31,200 R, H Office Manager 0.50 13,087 18,100 18,100 Program Specialist 0.50 12,094 948 0 Inclusion Facilitator 0.15 2,140 0 0 Payroll Taxes& Benefits - 27,158 33,218 33,930 VOLUNTEER HOURS (MSW intern, Bonner intern,APPLES volunteers)' 0.5 Note: Position converted to FT Student Coordinator in January 2016. Main Application 5/24/2016 9:22:20 AM P a g e 11 of 2o DocuSign Envelope ID:B701CF6A-1C9A-46CB-9234-56F771D80955 continued Providet% rciabn4, ittit*Appli cation 10 1. „•S1..?RE * 1 *TENWLC. FLIC S OF I EST Are arhoi info RJ ihidlernhers or employees of th e: agarley urruenn,:un be carrying out this project or MOM 1;':Ulueurus of Pleb immediate families, or their besino rs nisseciaiese YES Fi tJ ErriolOyees of ;or closely related to employees of the Town of Chapel Hill, Orange County, Carrhoro, o HilabOnnagn? d) Members of or clOSely reistob to members of the preventing bodies of Cheorel Hili, Carthrere, iiiiilsbora gh, or Orange COL nty? d) Current den efibanes of the proleribUoirop ram for which fonds are ran nested? Ej la) Paid providers of goods or services to the program or raving other firiancial rraanausi in the po& ani? you have answered YES to any question, please provide a full explanatiev below. To the best of my knowteioge ap,,d belief all of th ei. vc information is true current. I acknowii,*ge and un, Herstand that the existe, cc rir potential corneflict of i.I.,)terrest does het nocessariiy ,linake the project ineiigible for f nih , but the oeogsteir rree Of an 11,11diSuclOSued POP u filet nee„. result in the termination of n trent imarleti., 5igned lba Bryan A,%Auffman cAl=faryian A.Hulfirina /A=Wil C A uf the yk!, ry , A..A try ou—C,had mare.hn affair A. „ " - ern d krBrydn.Hurfa II u ru ?MCA Tri m gle.0 g Dee:2011,6.01.21 000602-0.5'012 Sign t lure; Chief liinitincial OffiCaur Data ,uu , ) u„) r.74 I 4,"'■ Signetarer Boornelkanii, BoarCiPireisidetyt) (115 raise Appanation 12 2 1 12 C ','.urur34,,,b4 uU DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 t A - continued Provider's Outside Agency Application MAIN APPLICATION I.) 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 5/24/2016 9:22:20 AM 0:' a g o 13 of 2o DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 t A - continued Provider's Outside Agency Application MAIN APPLICATION Actual Estimated Projected 2014-2015 2015-2016 2016-2017 - 1 Program Activity 1 75%of all eligible students will 75%of all eligible students will 80%of all eligible students will attend Boomerang and complete attend Boomerang and complete attend Boomerang when referred the program when referred during the program when referred during Program Goal during their suspension their suspension. their suspension. School referral forms;daily School referral forms;daily School referral forms;daily attendance records,qualitative attendance records,qualitative attendance records,qualitative notes on student's participation notes on student's participation notes on student's participation and behavior;student progress and behavior,student progress and behavior;service notes. notes to schools/court;internal notes to schools/court;internal Performance Measures service notes. service notes. Of the 179 referrals,146 attended 112 of 150 referrals will 112 of 150 referrals will successfully/satisfactorily successfully/satisfactorily Program Results Boomerang X82%). complete the program. complete the program. Program Activity 2 Youth will participate in at least Youth will participate in at least 50%of Boomerangs community 50%of Boomerang's community service days,engaging in projects service days,engaging in projects that enhance connections between that enhance connections between 75%of students participating in individuals and the community; individuals and the community; community service at Boomerang enhance life skills;and facilitate enhance life skills;and facilitate will complete at least 5 hours of connections with positive adults connections with positive adults Program Goal service and youth peers in the community. and youth peers in the community. Incoming community service Incoming community service Incoming community service referral forrru,daily tirnesheets, referral forms,daily tirnesheets, referral forrru,daily tirnesheets, reports to Volun teers for Youth reports to Volunteers for Youth reports to Volunteers for Youth and Adult Community Service, and Adult Community Service, Performance Measures and Adult Community Service. youth surveys. youth surveys. At least 30 youth will participate in At least 30 youth will participate in cornmunity service projects and at community service projects arrd at least 15 youth will self-report least 15 youth will self-report learruing/improving skills,and learning/improving skills,and 68%completed at least 5 hours of improved connectedness to improved connectedness to Program Results communityservice at Boomerang. community. community. - 1 Program Activity 3 75%of youth attending What's 75%of youth attending What's 50%of youth attending Next?life skills workshops wil Next?life skills workshops wil Boomerang's"What's Next?" workshops will attend at least 2 report having improved knowledge report having significantly of subject area or learned improved knowledge of subject group sessions. Program Goal something new. area. Success is measured bycalculating the number of youth who attend at least two"What's Next"group sessions during the 2014-15 school year and comparing th s with the number who attend just Performance Measures one. Post session surveys Post-session surveys 32%:38 attended 30 out of 40 youth will improve 30 out of 40 youth will improve Program Results 12 attended more than one knowledge/learn something new knowledge/learn something new. Program Activity 4 50%of youth identified for 50%of youth identified for 50%of youth identified for intensive follow up services show intensive follow up services show intensive follow up services show an increase in social an increase in social an increase in social connectedness by the end of the connectedness by the end of the connectedness by the end of the Program Goal school year. school year. school year. Post surveys/evidence of Readiness to Change scale;post Readiness to Change scale;post engagement in activities,teacher surveys/evidence of engagement surveys/evidence of engagement and parent feedback,grades, in activities,teacher and parent in activities,teacher and parent compliance with school rules, feedback,grades,compliance with feedback,grades,compliance with Performance Measures decreased recidivism. school rules,decreased recidivsm, school rules,decreased recidivsm. 6 out of 12 students in the 6 out of 12 students in the 80%-15 students were tracked intensive follow up component will intensive follow up component will 1.2 students showed increase in show an increase in show an increase in Program Results connectedness. connededness. connectedness. Main Application 5/24/2016 9:22:20 AM Pdgo, 1 . of 2o DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 t A - continued Provider's Outside Agency Application MAIN APPLICATION FINANCIAL INFORMATION FOR SERVICE PROGRAMS a.) Program Budget Please complete a Program Budget Excel Form for each requested program. The Program Budget should reflect only figures and amounts associated with the Program(s) for which you are seeking funding and not the total agency budget. If the program's finances experienced significant changes that you would like to explain, please use the space below. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 5/24/2016 9:22:20 AM 0:° J c lb of 2l DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Program: Boomerang Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ - $ 3,000 $ 30,000 900% Agency Generated Revenue(fees) $ - $ - $ 0 Local Government Grants: Orange County $ 5,000 $ 5,000 $ 10,000 100% Town of Chapel Hill $ 2,000 $ 2,500 $ 7,000 180% Town of Carrboro $ 1,500 $ 1,600 $ 4,000 150% Other Local: JCPC $ 32,760 $ 32,850 $ 32,850 0% Other Local: CFICCS,OCS $ 35,000 $ 55,000 $ 55,000 0% Other Local: ESA $ - $ 10,000 $ 10,000 0%' It more than 3 sources,please provide a separate Est Non-Local Government Grants Triangle United Way $ 8,646 $ 4,000 $ 5,000 25% State Government $ - $ - $ 0' Federal Government $ - $ - $ - o' Other Grants: Oak Foundation $ 80,000 $ 100,000 $ 100,000 0% Other Grants: Other Foundations $ 5,000 $ 15,000 $ 50,000 233%' MiscellaneousfOther Revenue $ 14,998 $ 30,000 -100% Please list 3 largest Miscellanous sowces: YMCA $ 14,998.00 $ $ Total Agency Revenue $ 184 904 $ 258 950 $ 303 850 17% AGENCY EXPENSES Compensation $ 143,071 $ 196,800 $ 234,030 19% Rent&Utilities $ - $ 20,682 $ 22,980 11% Supplies&Emipment $ 6,154 $ 14,085 $ 17,477 24% Travel&Training $ 234 $ 300 $ 600 100% Other Expenses: $ 35,445 $ 12,000 $ 10,000 -17% Please list 3 largest"Other Expenses: Contract Services $ 35,445.00 $ _ $ Total Agency Expenses $ 184,904 $ 243,867 $ 285,087 17% SURPLUSI(DEFICIT)FOR PERIOD: $ - I $ 15,083 I $ 18,763 I 24% Main Application 5/24/2016 9:22:20 AM Pdgr, 16 of 2 ' DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 t A - continued Provider's Outside Agency Application MAIN APPLICATION b.) Program Budget Detail Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: Boomerang Cost Elements Cost($) Quantity/Unit of measure Subtotal ($) Contract: Dispute Settlement Center 50 30 hours (1hr/wk x 30wks) 1,500 Contract: OCRCC/Compass Center 50 30 hours (1 hr/wk x 30wks) 1,500 Contract: UNC Substance Abuse Clinic 175 16 hours (1 hr/wk x 16 wks) 2,800 Contract: NOAH IT Services 85 12 months 1,020 Food for Students 15 180 days 2,700 Total 9,520 b.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program 184,904 243,867 285,087 Total # of Units* 618 951 1026 Cost Per Unit 299 256 278 *Unit of Service is defined as follows: 1 student referral with 2-4 day suspension(ATS;including 2-day court-involved)=1 unit of service 1 student referral with 5-7 day suspension(ATS)=2 units of service 1 student referral with 8-10+day suspension(ATS)=3 units of service 1 student instance(students completing at least 5 community service hours)(CS)=1 unit of service 1 student referral receiving intensive follow-up services=3 units of service 1 student instance attending at least 1 What's Next group=1 unit of service As of 2015-16:1 student instance receiving tutoring/schoolwork help after school=2 units of service 1 student attending Open Doors=0.5 unit of service 2014-15 Program Component Units Served ATS 2-4 days 83 ATS 5-7 days 86 ATS 8+days 51 Community Service(instances) 192 What's Next?(instances) 56 Intensive Follow Up 45 After School Open Doors 105 TOTAL 618 Attendance/participation in Boomerang programs was lower in 2014-15 while it was temporarily located in the Meadowmont neighborhood of Chapel Hill; school districts, students and families stated that transportation to and from Meadowmont was a problem. Main Application 5/24/2016 9:22:20 AM O:' a g e 1 "'' of 2 I DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 t A - continued Provider's Outside Agency Application MAIN APPLICATION c.) 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. PLEASE NOTE: WE WERE UNABLE TO EMBED THE WORKSHEET. iT iS CORED ON THE NEXT PAGE, AND EMAiLED AS AN ATTACHMENT. Main Application 5/24/2016 9:22:20 AM P d g r, 1 8 0 f 2 DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 t A - continued Provider's Outside Agency Application MAIN APPLICATION Section VI. Financial Data Operating Budget for Entire Agency Agency/Program: Boomerang Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $- $3,000 $30,000 900% Agency Generated Revenue(fees) $- $- $- 0% Local Government Grants: Orange County $5,000 $5,000 $10,000 100% Town of Chapel Hill $2,000 $2,500 $7,000 180% Town of Carrboro $1,500 $1,600 $4,000 150% Other Local: JCPC $32,760 $32,850 $32,850 0% Other Local: CHCCS,OCS $35,000 $55,000 $55,000 0% Other Local: FSA $- $10,000 $10,000 0% If more than 3 sources, please provide a separate list. Non-Local Government Grants Triangle United Way $8,646 $4,000 $5,000 25% State Government $- $- $- 0% Federal Government $- $- $- 0% Other Grants: Oak Foundation $80,000 $100,000 $100,000 0% Other Grants: Other Foundations $5,000 $15,000 $50,000 233% Miscellaneous/Other Revenue $14,998 $30,000 -100% Please list 3 largest Miscellanous sources: YMCA $14,998.00 $- $- Total Agency Revenue $ 184,904 $ 258,950 $ 303,850 17% AGENCY EXPENSES Compensation $143,071 $196,800 $234,030 19% Rent&Utilities $- $20,682 $22,980 11% Supplies&Equipment $6,154 $14,085 $17,477 24% Travel&Training $234 $300 $600 100% Other Expenses: $35,445 $12,000 $10,000 -17% Please list 3 largest"Other Expenses": Contract Services $35,445.00 $- $- Total Agency Expenses $ 184,904 $ 243,867 $ 285,087 17% SURPLUS/(DEFICIT)FOR PERIOD: $- I $15,083 I $18,763 I 24% Main Application 5/24/2016 9:22:20 AM 0:' a g o 19 of 2o DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Boomerang Youth, Inc. Funding Award: $10,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Salaries—Program Managers 10,000 Cost of Program Materials 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. • 75 %of all eligible students will attend boomerang and complete the program • Youth will participate in 50%of Boomerang's community service days • 75 %of youth attending"What's Next"life skills workshops • 50 %of youth identifed for intensive follow up services show an increase in social connectedness by the end of the school year 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 School referred students will successfully/satisfactorily complete the program. 112 Referrals Youth will participant in community service projects 30 youth Post-Session surveys—Youth will improve knowledge/learn something new 30 youth Readiness to Change Scale;post surveys/evidence of engagement in activies,teacher and parent 6 students feedback,grades,compliance with school rules, decreased recidivism. DocuSigned by: L6B35AF5c2c51431 Executive D irector 11/9/2016 Certified by: . Title: Date: (Provider's Signature) DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 AC J CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)9/12/2016 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 Crystal Ireland NAME: y Business Insurers of Carolinas (A/CNNo,Ext): (919)968-4611 FAX No): (919)968-8991 800 Eastowne Drive, Suite 208 aDRle55.cireland @business-insurers.com PO Box 2536 INSURER(S)AFFORDING COVERAGE NAIC# Chapel Hill NC 27515-2536 INSURERA:Western World Insurance Company 0043 INSURED INSURER B:United States Liability Insurance 25895 Boomerang Youth Inc INSURER C: 825-A North Estes Dr INSURERD: INSURER E: Chapel Hill NC 27514 INSURERF: COVERAGES CERTIFICATE NUMBER:CL167615718 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 SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 NPP8393501 7/1/2016 7/1/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: NonOwn Auto Liab Ul UIM $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Directors & Officers ND01570583 7/1/2016 7/1/2017 LIMIT $1,000,000 Liability DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Carrboro THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 301 West Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Carrboro, NC 27510 AUTHORIZED REPRESENTATIVE � ., C Ireland/IREL01 ti/L x ^�tek.,/ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 nmam i DocuSign Envelope ID: B701CF6A-1C9A-46CB-9234-56F771D80955 AC J CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)9/12/2016 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 Crystal Ireland NAME: y Business Insurers of Carolinas (A/CNNo,Ext): (919)968-4611 FAX No): (919)968-8991 800 Eastowne Drive, Suite 208 aDRle55.cireland @business-insurers.com PO Box 2536 INSURER(S)AFFORDING COVERAGE NAIC# Chapel Hill NC 27515-2536 INSURERA:Western World Insurance Company 0043 INSURED INSURER B:United States Liability Insurance 25895 Boomerang Youth Inc INSURER C: 825-A North Estes Dr INSURERD: INSURER E: Chapel Hill NC 27514 INSURERF: COVERAGES CERTIFICATE NUMBER:CL167615718 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 SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 NPP8393501 7/1/2016 7/1/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: NonOwn Auto Liab Ul UIM $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Directors & Officers ND01570583 7/1/2016 7/1/2017 LIMIT $1,000,000 Liability DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Chapel Hill THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 405 Martin Luther King Jr Blvd ACCORDANCE WITH THE POLICY PROVISIONS. Chapel Hill, NC 27514 AUTHORIZED REPRESENTATIVE � ., C Ireland/IREL01 ti/L x ^�tek.,/ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 nmam i