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2016-655-E Finance - Voices Together - Outside Agency Performance Agreement
DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151 B77C 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 Voices Together, a not-for-profit corporation, located at 5007 Southpark Drive, Suite 230, Durham,NC 27713 ("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 Voices Together 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 15000. 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 $3,750. 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. (Voices Together) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151 B77C 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. (Voices Together) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151 B77C 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. (Voices Together) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151 B77C 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 Voices Together 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: (Voices Together) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151 B77C County: Finance&Administrative Services Provider:Voices Together Orange County 5007 Southpark Drive, Suite 230 Post Office Box 8181 Durham,NC 27713 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 on b dfaa ' l v1 PII11rovider blas un.�, W IL 11/14/2016 DA0401626r3747c... Date For an i' bf Orange County Government L6tht, tka"m rst 11/15/2016 0637994B755E477... Bonnie Hammersley, County Manager Date (Voices Together) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151 B77C 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 11� DXSKAivt, W IL 11/14/2016 Certified by: nA0401828F37476 Title: ceo Date: (Provider's Signature) (Voices Together) Orange County Outside Agency Performance Agreement Rev. 8/16 Docu Sign Envelope ID 16AB4DFA-7125-42E6-B3E7-C6B53151B77C Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency Voices Together Date/Time Complete Y/N Program(s) VT in Education Section For CDBG & HOME - Subsection HUD Regulations 1. Cover Page a. II Applicant Contact Information b. WI Project/Program Contact Information C. 5 Funding Requests Identified d. I Signed Application Cover Page 2. Agency a. Agency's Years in operation 24 CFR 570.506, Information - b. 12I Agency's Purpose/Mission 570.507, 570.610; 24 CFR Parts 84 or 85 C. 12I Agency's Types of Services Provided d. Ei Agency's Experience e. MI Other Pertinent Information 3. Program/ a. Li Type of Application and Program Identified 24 CFR 570.200(a), Project b. 12I Summary of Program 570.201-570. 208, Information - 507.503 C. 12 Description of Identified Need (for each d. 12 Description of Population to be Served program/ e. KJ Activity Manager and Location Description project for f. 12 Activity Implementation Timeline which funding g.is requested) a 121 Agency Collaboration - h. E Describe Impact of Reduced/No Allocation i. 5 Other Pertinent Information j. WI Complete Target Population/Beneficiary Chart k. WI Complete Schedule of Positions I. I Signed Conflict of Interest Disclosure m. 121 Complete Work Statement i a • o DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C L 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. IA Program Budget Worksheet 570.602, 570.607(b), is requested) b. n Program Budget Detail 570.611 24 CFR c. 5 Cost Per Unit 570.502-570.504, d. 5 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. El Part A: CDBG & HOME Sections (as B. El Part B: Construction/Rehab applicable) 6. Attachments a. 12 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. Ii IRS Federal Form 990 c. 121 NC Solicitation License d. 15 IRS Federal Tax-Exemption Letter e. 12 Certificate of Insurance f. I List of Board of Directors 24 CFR Parts 84 or 85 g. Articles of Incorporation/Bylaws 24 CFR 570.208, h. WI Authorization to Request Funds 570.500(c), 570.611 Authorized official designation j. Solid Waste Program Fee (SWPF) Verification Main Application 1/25/2016 12:01:57 PM Pao ° 2 of 21 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C t A - continued Provider's Outside Agency Application MAIN APPLICATION 1. COVER PAGE (Each program requires a separate application.) a) Applicant Contact Information Applicant Organization's Legal Name: Voices Together Applicant Organization's Physical Address: 5007 Southpark Dr. Ste 230 Durham, NC 27713 Applicant Organization's Mailing Address: 5007 Southpark Dr. Ste 230 Durham, NC 27713 Applicant Organization's Web Address: www.voicestogether.net Executive Director: Yasmine White Telephone Number: 919-942-2714 E-Mail: yasmine @voicestogether.net DUNS Number: (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) b) Project/Program Contact Information Project/Program Name: VT in Education Project/Program Primary Contact and Title: Carrie Kovalick, Communications Director Telephone Number: 919-942-2714 E-Mail: carrie @voicestogether.net c) Funding Request Identification Total Project/Program Cost: $15,000 Total Amount of Funds Requested: $15,000 Proposed Use of Funds Requested (2-3 Line Maximum): VT in Education program has been serving the students in Orange County School Exceptional Children classrooms since 2009. Children in these classrooms face academic and social challenges that can be devastating. Support from Orange County Outside Funding will help close the achievement gap, helping these children succeed academically and into adulthood. 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. ❑ CDBG Non-Construction (CH) $ ❑ Grant [' Loan ❑ CDBG Construction (CH) $ ❑ Grant [' Loan ❑ HOME CHDO (OC) $ ❑ Grant [' Loan ❑ HOME Other (OC) $ ❑ Grant [' Loan x Human Services: ❑ Carrboro $ [' Chapel Hill $ X Orange County $15,000 d) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: 7 1/25/2016 Executive Director Date Main Application 1/25/2016 1:42:01 PM P a • e 3 o f 2 °1 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C t A - continued Provider's Outside Agency Application MAIN APPLICATION Signature: Phil Buchanan 1/24/2016 Board Chairperson Date Main Application 1/25/2016 1:42:01 PM Page • f 21 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C t A - continued Provider's Outside Agency Application MAIN APPLICATION 2. AGENCY INFORMATION Please provide the following information about your agency (Limit of 2 pages total): A. Years in Operation, Date of Incorporation (Month/Year) Voices Together was incorporated on January 12, 2006. For the past ten years, we have been serving of children, teens, and adults living in North Carolina. B. Agency's Purpose/Mission The mission of Voices Together is to empower individuals with developmental disabilities to transform their lives. Voices Together address critical life skills that enable students to make a healthy transition to an independent, healthy adulthood. Voices Together music therapy model, VOICSS, has been coined a best practice. Seamlessly integrating music and language development, our program promotes critical communication skills while helping develop student's social/emotional education. For a decade, we have brought our innovative curriculum into exceptional childrens' classrooms in Central North Carolina. Our program has achieved remarkable results in developing students' pivotal social, emotional, cognitive and self-management skills. C. Types of Services the Agency Provides Our current programs include VT in the Community, VT in Education, VT in Training, and Voices Youth Connection. Using a specialized music therapy approach, Board Certified Music Therapists use music as a tool to help improve social, cognitive, and emotional health to effect positive change in people's lives. Believing our approach is a best practice William R. Kenan, Jr., Charitable Trust has funded the initial phase of a national replication project that will change the classroom and the lives of thousands of students. D. Agency's Experience with Similar Programs as the Funding Request For a decade, Voices Together Board Certified Music Therapists have been providing weekly programming for students in Central North Carolina. Music Therapy is the clinical and evidence- based use of music interventions to accomplish non-musical goals. Public schools and agency administrators have labeled Voices Together a best practice. The North Carolina Department of Education, The Autism Society of North Carolina, and the ARC of North Carolina have all endorsed Voices Together programming. There is also qualitative and quantitative data that show students participating in weekly 45-minute sessions over a period of six to twelve months have shown significant improvement in their academic and social development. In 2014, lead by Dr. Geraldine Dawson of the Duke University Bass Connection, a research study was conducted to measure the efficacy of Voices Together in Education program in public school special education classrooms. This project is part of strong collaborative partnership with Duke University. Findings of study: "A study conducted in Durham Public Schools by Duke researchers in 2015 showed that provision of the Voices Together program resulted in significant increases in communication skills among children with developmental disabilities. The mean improvement reflected a change from one word to phrase speech. "- Dr. Geraldine Dawson Professor of Psychiatry and Behavioral Sciences' Pediatrics, Psychology and Neuroscience Main Application 1/25/2016 1:42:01 PM Page 5 • f 211 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C t A - continued Provider's Outside Agency Application MAIN APPLICATION Director I Duke Center for Autism and Brain Development I Duke University School of Medicine Duke Institute for Brain Sciences E. Other Pertinent Agency Information Individuals with developmental disabilities often have greater difficulty in areas of basic communication and social skills. These skills are critical to learning in an academic setting and enabling students to become strong self-advocates, independent adults and experience full community participation. VT in Education has the following SMART goals for each classroom that we work with: • Provide weekly Voices Together music therapy sessions for students in selected Exceptional Children's classrooms resulting in an increase in students' verbal language and speech skills. We will administer pre-test and post-tests to teachers to measure the success of the objectives. • Voices Together will promote learning in classrooms receiving weekly music therapy sessions by working to increase a student's ability to remain seated and engaged in a group setting, and teach positive coping skills students can use that will decrease the number of emotional or physical outbursts. We will administer pre-test and post-tests to teachers to measure the success of the objectives. • Voices Together will support the development of student's communication and social skills by increasing their ability to initiate conversation, speak so others can understand them, and engage in actively listen. We will administer pre-test and post-tests to teachers to measure the success of the objectives. Main Application 1/25/2016 1:42:01 PM Page 6 • f 211 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C t A - continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: Voices Together 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: x Human Services (Main Application Only) ❑ CDBG Non-Construction — (Main Application AND Part A) ❑ CDBG Construction — (Main Application AND Part A AND Part B) ❑ HOME CHDO Set-aside — (Main Application AND Part A) ❑ HOME Other — (Main Application AND Part A AND Part B) Indicate the type of program for which you are requesting funding: Program Category Youth Adult Elderly Disabled Public Housing (not elderly) Neighborhoods/Residents Education X X 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? VT in Education is designed to advance education and student achievement by increasing the development of their social-emotional skills, and building a foundation to improve and expand communication and language capabilities. Social and emotional skills are defined as the ability to understand, manage, and express the social and emotional aspects of one's life in ways that enable the successful management of life tasks such as learning, forming relationships, solving everyday problems, and adapting to the Main Application 1/25/2016 1:42:01 PM °.' l. of 21 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C t A - continued Provider's Outside Agency Application MAIN APPLICATION complex demands of growth and development. Numerous research studies have shown that: • Students who are more self-aware and confident about their learning capacities try harder and persist in the face of challenges (Durlak et al., 2011). • Students who have self-discipline, motivate themselves, manage stress, and organize their approach to work learn more and get better grades. • Students who use problem-solving skills to overcome obstacles and make responsible decisions about studying and completing homework perform better academically (Durlak et al., 2011). The proposal, when funded, will enable Voices Together to continue to provide our program to students that desperately need intervention services such as ours. As we establish our program in classrooms, we also are building capacity in schools. As teachers watch our methods and participate, they gain skills that will carry through in their classroom instruction for maximum outcomes. 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. Over the last 12 years, the prevalence of developmental disabilities (DDs) in U.S. children has increased 17.1%—that's about 1.8 million more children with DDs compared to a decade earlier. The Orange County Schools identified approximately 1,036 students with DDs, or 13.7% of the student body. Developmental disabilities are a diverse group of severe chronic conditions that are due to mental and/or physical impairments. People with developmental disabilities have problems with major life activities such as language, mobility, learning, self-help, and independent living. This dramatic jump in the number of Exceptional Children's students increased the financial burden on our schools and families. While at the same time, there has not been proportionate increases in federal special education appropriations or state education spending. Students with disabilities often face additional challenges with regards to school readiness and long-term academic success. For starters, it's difficult to overcome the adverse educational effects of some disabilities. Other potential causes include the association between disability and poverty, rigid testing policies and practices, misallocation of resources, lack of staff training or effectiveness, or failures in service delivery. Furthermore, families of students with a disability face complex financial challenges. Insufficient financial resources and/or inadequate access to intervention services often prohibit these families from receiving specialized therapy services. The partnership between Voices Together and the Orange County Schools will help close the achievement gap and help children from these families succeed academically and into adulthood. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. Working with the Exceptional Children's Department for Orange County Schools VT in Education Program and Training Director alongside the Director of the Exceptional Children's Main Application 1/25/2016 1:42:01 PM Page 8 • f 211 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C t A - continued Provider's Outside Agency Application MAIN APPLICATION department will select three classrooms or a total of no more than 30 students to participate in the program from September thru April. e) Who specifically will carry out the activities and in what location will they be carried out? Program delivery will be carried out by Voices Together Board Certified Music Therapist. All Voices Together Music Therapists have received additional training in the VOICSS method, and have between 2 —6 years of experience. Key personnel for this project includes: • Jenna Witcher— Lahiff, MT— Director of Program and Training • Kate Geouge, MT— Senior Music Therapist • Carrie Kovalick— Communications and Operations Director • Louis Martin — Director of Finance 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. Your funding will enable Voices Together to provide weekly 60-minute group music therapy sessions designed to address student's needs. Using a specialized music therapy approach, Board Certified Music Therapists use music as a tool to help improve social, cognitive, and emotional health of the students to effect positive change in their lives. The project will begin in late September and end in April with a year-end school performance that celebrates the tremendous efforts and achievement and individual worth of every child who participates. 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. • Duke University Bass Connection. Research partnership to measure the efficacy of Voices Together program model. • The William R Kenan, Jr. Charitable Trust. In cooperation with the William R Kenan, Jr. Charitable Trust, Voices Together is developing a plan for scaling nationally. • Our partnership with The Orange County School District, Director of Exceptional Children and classroom teachers are essential to the success we have experienced throughout our seven years in the district. h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Each child that does not have the opportunity to meet their maximum potential is a loss for not only that child, his/her family but also for the community. As these students age out of school, it is essential that they have the skills to become as independent as possible. Each student's ability to thrive is not only vital to the student and their families but to the community and it resources. Their ability to advocate and work with others can mean the difference between being able to work in a job setting or not. It can mean the difference between them being able to get a job. Without your funding, 30 students will be without this specialized skill building program that can help them navigate their day-to-day ability to function and potentially change their lives. Main Application 1/25/2016 1:42:01 PM Page * • f 2 °t DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C t A - continued Provider's Outside Agency Application MAIN APPLICATION Teachers in so many of our classrooms have shared how they gain new skills by watching and participating in our program. They have reported learning new skills in teaching emotional skills, self-management, socialization and leadership skills. i) Include any other pertinent information. Through this crucial grant, the county school fund and a few private grants, we were able to support all the classrooms for exceptional children this year for the district. The Orange County funding is essential and so very appreciated for our success in the Orange County Public Schools. Program/Project Information j) Complete the Target Population and Program Beneficiary Demographics Chart k) Complete the Schedule of Positions Chart for Program Staff I) Disclosure of Potential Conflicts of Interested must be signed m) Complete the Work Statement Chart to describe the work to be performed, and be sure to attach copies of all data collection tools that will be used to verify achievement of program goals and objectives. Describe who will be responsible for monitoring progress. Information to Complete j.) Target Population Complete the following tables to the best of your ability. Show numbers of participants and percentages, as applicable, in each category. Please indicate whether this project/program will serve: x Persons ❑ Households ❑ Units Program: VT in Education Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 10 10 15 Female 8 8 10 Total 18 18 25 Of the females, how many are single- female Head of Households (Omit for Human Services) Ethnicity African-American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Main Application 1/25/2016 1:42:01 PM P a 1, e °1 H of 21 DocuSign Envelope ID: 10Ao4orA-7125-42E0-a3E7-C6o53151o77C [ /\ - continued Provider's Outside Agency Application MAIN APPLICATION Other Total 0 0 0 Of the above, how many Hispanic/Latino Of the above, how many non- Hispanic/Latino Total 0 0 0 Age 0-5 years 6-18 years 18 18 25 19-50 years 51-61 years 62+ years Total 18 18 25 Geographic Location Durham City Durham County Carrboro Chapel Hill Chapel Hill Public Housing Residents Orange County 18 18 25 Raleigh Wake County | | Total | 18 18 25 | Income Level—See following chart (Omit for HS) < 3096 Area Median Income 31-50%Area Median Income 51-80%Area Median Income > 80%Area Median Income Total 0 0 0 Special Needs (Omit for HS) Elderly (Over 62) Disabled (not elderly) 18 18 25 Homeless People with HIV/Aids Total 18 18 25 Main Application 1/25/2016 1:42:01 PM Page 1111 of 211 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C t A - continued Provider's Outside Agency Application MAIN APPLICATION CDBG & HOME ONLY - Area Benefit Activities (Infrastructure and Public Facilities) Street Census Tract Block Group Total Persons #LMI Persons 2015 Area Median Family income Limits U.S. Department of Housing & Urban Development (HUD) 2015 Area Median Family Income Limits Effective March 15, 2015 Income 1 2 3 4 5 6 7 8 Level person people people people people people people people 30% AMI $14,150 $16,200 $20,090 $24,250 $28,410 $32,570 $36,730 $40,890 50% AMI $23,600 $27,000 $30,350 $33,700 $36,400 $39,100 $41,800 $44,500 80% AMI $37,750 $43,150 $48,550 $53,900 $58,250 $62,550 $66,850 $71,150 100% AMI $47,188 $53,938 $60,688 $67,375 $72,813 $78,188 $83,563 $88,937 115% AMI $54,266 $62,028 $69,791 $77,481 $83,734 $89,916 $96,097 $102,278 http://www.huduser.org/portal/datasets/iI/i115/FY2015_ILnc.pdf Main Application 1/25/2016 1:42:01 PM Pago 12 of 21 DocuSign Envelope ID: 10Ao4orA-7125-42E0-a3E7-C6o53151o77C [ /\ - 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) * FTE° Actual Estimated Projected ��To�| = Fom1t1on ° Program Retirement 2014-15 2015-16 2016-17 Budget Vacant Staff* Plan (H) Health Plan President/CEO 1 25% 87844 98828 99500 15.6% H Music Therapists 4 100% 202185 222403 229500 35.996 H Office Staff 2 10% 122105 134315 146000 22.8% H 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 1/25/2016 1:42:01 PM Page 113 of 211 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C t A - continued Provider's Outside Agency Application MAIN APPLICATION I.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST Are any of the Board Members or employees of the agency which will be carrying out this project, or members of their immediate families, or their business associates: YES NO ❑ ® a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? ❑ ® b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? ❑ ® c) Current beneficiaries of the project/program for which funds are requested? ❑ ® d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the project ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. G�a of. ( Signature: �/ 1/24/2016 Executive Director Date Signature: Phil Buchanan 1/24/16 Board Chairperson Date Main Application 1/25/2016 1:42:01 PM P a , o °1 4 o f 2 °1 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C 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 2014-2015 2015-2016 2016-2017 Program Activity 1 Program Goal:Provide weekly Voices Together music therapy sessions for students in selected Orange County School Exceptional Children's classrooms resulting in an increase in students'verbal language and speech skills. Performance Measures: Precentage of students who are able to tell someone how they feel using verbal or visual cues. N/A 25% 25% Program Results Program Activity 2 Program Goal: Voices Together will promote learning in classrooms receiving weekly music therapy sessions by working to increase a student's ability to remain seated and engaged in a group setting,and teach positive coping skills students can use that will decreasing the number of emotional or physical outbursts. Performance Measures: Precentage of students who are able to use self- regulation/coping strategies 19% 25% 25% Program Results Program Activity 3 Program Goal:Voices Together will support the development of student's communication skills by increasing their ability to speak so others can understand them and in their ability to actively listen. Performance Measures: Precentage of students who are able to acknowledge others by using appropriate N/A 20% 20% Program Results Program Activity 4 Program Goal:Provide weekly Voices Together music therapy sessions for students in selected Orange County School Exceptional Children's classrooms resulting in an increase in students'verbal language and speech skills. Performance Measures: Precentage of students who will initiate verbal or non- verbal social conversation with peers. 50% 50% 50% Program Results Program Activity 5 Program Goal: Voices Together will promote learning in classrooms receiving weekly music therapy sessions by working to increase a student's ability to remain seated and engaged in a group setting,and teach positive coping skills students can use that will decreasing the number of emotional or physical outbursts. Performance Measures: Precentage of Students who can ask for help. 40% 45% 45% Program Results Main Application 1/25/2016 1:42:01 PM Page 1 5 • f 21 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C t A - continued Provider's Outside Agency Application MAIN APPLICATION 4. FINANCIAL INFORMATION FOR SERVICE PROGRAMS a.) Program Budget Please complete a Program Budget Excel Form for each requested program. The Program Budget should reflect only figures and amounts associated with the Program(s) for which you are seeking funding and not the total agency budget. If the program's finances experienced significant changes that you would like to explain, please use the space below. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 1/25/2016 1:42:01 PM Pago la of 21 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Program: Voices Together Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ - IMII $ - 0 Agency Generated Revenue(fees) 1/11111111'/1111111111/11111111 0 Local Government Grants: Orange County $ 7,000 $ 15,000 $ 15,000 0% Town of Chapel Hill $ - $ - $ - 0 Town of Carrboro $ - $ - $ - 0 Other Local: Orange County Schools $ - $ 5,000 $ 5,000 0% Other Local: $ - $ 15,000 $ 15,000 0% Other Local: $ - $ - $ - 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government $ - $ - $ - 0 Other Grants: Foundations $ - $ - $ - 0 Other Grants: Corporations $ - $ - $ - 0 Miscellaneous/Other Revenue $ - MI $ - 0 Please list 3 largest Miscellanous sources: $ - $ $ - Total Agency Revenue $ 7 000 $ 35 000 $ 35 000 0% AGENCY EXPENSES Compensation $ 5,000 $ 27,350 $ 27,350 0% Rent&Utilities $ 750 $ 2,365 $ 2,365 0% Supplies&Equipment $ 500 $ 850 $ 850 0% Travel&Training $ 100 $ 500 $ 500 0% Other Expenses: $ 650 $ 3,935 $ 3,935 0% Please list 3 largest"Other Expenses": $ - $ - $ Total Agency Expenses $ 7 000 $ 35 000 $ 35 000 0% SURPLUS/(DEFICIT)FOR PERIOD: $ - I $ - I $ - I 0 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C t A - continued Provider's Outside Agency Application MAIN APPLICATION Main Application 1/25/2016 1:42:01 PM Page 1 * 1 21 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C 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 $9,000 Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: VT in Education Cost Elements Cost($) Quantity/Unit of measure Subtotal ($) Board Certified Music Therapist Program $500 70 program units $35,000 Delivery Total $35,000 c.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program Total # of Units Cost Per Unit This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries (households or persons) in this application and must be consistent with report submittals from previous years (if applicable). Main Application 1/25/2016 1:42:01 PM Page t f 211 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C t A - continued Provider's Outside Agency Application MAIN APPLICATION d.) Agency Operating Budget Please show all sources and amounts of funding for your entire current fiscal year. What is your agency's fiscal year? Example: July 1, 2016 through June 30, 2017. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 1/25/2016 1:42:01 PM I' ago 2 1 t 2 1 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C t A - continued Provider's Outside Agency Application MAIN APPLICATION AGENCY NAME: Voices Together Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 37,602 $ 35,000 $ 35,000 0% Agency Generated Revenue(fees) $ 36,325 $ 45,000 $ 45,000 0% Local Government Grants: Orange County $ 7,000 $ 15,000 $ 15,000 0% Town of Chapel Hill $ - $ - 0 Town of Carrboro $ - $ - $ - 0 Other Local: $ 115,000 $ 126,250 $ 130,000 3% Other Local: $ - $ - $ - 0 Other Local: $ - $ - $ - 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government $ - $ - $ - 0 Other Grants: Foundations $ 199,288 $ 305,000 $ 316,000 4% Other Grants: Corporations $ 72,393 $ 95,000 $ 100,000 5% Miscellaneous/Other Revenue [1111111.1111111111111111 0 Please list 3 largest Miscellanous sources: $ $ $ - Total Agency Revenue $ 467 608 $ 621 250 $ 641 000 3% AGENCY EXPENSES Compensation $ 381,588 $ 456,720 $ 475,000 4% Rent&Utilities $ 41,549 $ 43,685 $ 45,000 3% Supplies&Equipment $ 27,394 $ 22,358 $ 25,000 12% Travel&Training $ 4,891 $ 5,500 $ 6,000 9% Other Expenses: $ 23,017 $ 87,505 $ 88,000 1% Please list 3 largest"Other Expenses": $ - $ - $ - Total Agency Expenses $ 478 439 $ 615 768 $ 639 000 4% SURPLUS/(DEFICIT)FOR PERIOD: $ (10,831) $ 5,482 1 $ 2,000 J -64% Main Application 1/25/2016 1:42:01 PM Page 21 • f 21 DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151 B77C EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Voices Together Funding Award: $15,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Programmatic Expenses- Supplies 15,000 Personnel Expenses—Salaries 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 weekly Voices Together music therapy sessions for students in selected Orange County School Exceptional Children's classrooms resulting in an increase in student's verbal languega and speech skills. • Support the development of student's communication skills by increasing their ability to speak so other's can understand them an din their ability to actively listen. • Promote learning in the classrooms — receiving weekly music therapy sessions by working to remain seated and engaged in a group setting, and teach positive coping skills students can use that will decrease the number of emotional or physical outbursts. 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 Percentage of students who are able to tell someone how they feel using verbal or visual cues. 25 % Percentage of students who are able to use self-regulation/coping strategies 25 % Percentage of students who are able to acknowledge others by using appropriate communication 20% skills Percentage of students who will intiate verbal or non-verbal social conversation with peers 50% Percentage of students who can ask for help 45 % —DocuSigned b//y:1 11� �aSittAivt, W IL ceo 11/14/2016 Certified by: Title: Date: (Provider s Signature) DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151 B77C AC J CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)9/13/2016 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 Dawn Weyandt NAME: y Nonprofit Insurance Services (A/CNNo,Ext): (717)630-1030 FAX No): (717)630-1188 195 Stock Street, Suite 118 %%16s:dawnw@insureanonprofit.com P.O. Box 933 INSURER(S)AFFORDING COVERAGE NAIC# Hanover PA 17331 INSURERAANI-RRG 10023 INSURED INSURER B: Voices Together INSURER C: 5007 Southpark Dr. , Suite 230 INSURERD: Suite 230 INSURERE: Durham NC 27713 INSURER F: COVERAGES CERTIFICATE NUMBER:2016-2017 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) $ 500,000 2016-35634 10/10/2016 10/10/2017 MED EXP(Any one person) $ 20,000 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: Increased Aggregate $ 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 $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Orange County is named as Additional Insured CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 South Cameron Street ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE Brian Barrick/DW CM cz ,C. ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 nmam t DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151 B77C ADDITIONAL COVERAGES Ref# Description Coverage Code Form No. Edition Date Improper Sexual Conduct ISC Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 1,000,000 3,000,000 $1,148.00 Ref# Description Coverage Code Form No. Edition Date Add'I for policy minimum premium APMP Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium $581.00 Ref# Description Coverage Code Form No. Edition Date Social Service Prof Liab SSP Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 1,000,000 3,000,000 $840.00 Ref# Description Coverage Code Form No. Edition Date Liquor Liability LIQUR Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 1,000,000 1,000,000 Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium OFADTLCV Copyright 2001,AMS Services,Inc.