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2017-473-E DSS - The Exchange Club Center for the Prevention of Child Abuse in NC - Outside Agency Performance Agreement
DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2017, ("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 The Exchange Club Center for the Prevention of Child Abuse of North Carolina, Inc., a not-for-profit corporation, located at 200 N. Main Street, Graham, NC 27253 ("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 t, forth, the County and The Exchange Club's Center for the Prevention of Child Abuse of North Carolina Inc. agree as follows: I. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2017 to June 30,2018. 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 f in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit B, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of$9,638. b. All funds appropriated shall be used for purposes described in Exhibit B. 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 Quarterly Appropriation. 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. The Exchange Club Center for the Prevention of Child Abuse in North Carolina Orange County Outside Agency Petforn€ance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 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. 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 12,April 13, and July 9 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 Y p Y 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 The Exchange Club Center for the Prevention of Child Abuse in North Carolina Orange County Outside Agency Performance Agreement Page 2 of 7 Rev. 7/17 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 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. 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 k 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 u Hillsborough,NC 27278 The Exchange Club Center for the Prevention of Child Abuse in North Carolina Orange County Outside Agency Performance Agreement Page 3 of 7 Rev. 7/17 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 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 E; 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 p g � g 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 Non-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 $ 13.75 per hour. To the extent possible, Orange County recommends that The Exchange Club Center for the Prention of Child Abuse in North Carolina 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 The Exchange Club Center for the Prevention of Child Abuse in North Carolina Orange County Outside Agency Performance Agreement Page 4 of 7 Rev. 7/17 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 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: County: Finance&Administrative Services Provider: The Exchange Club Center for Orange County the Prevention of Child Abuse in Post Office Box 8181 North Carolina Hillsborough,NC 27278 200 N. Main Street Graham,NC 27253 16. E retire 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 N, 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. 18. 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. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy(each policy is incorporated herein by reference and may be viewed at htt //www.oran ecount nc. ov/de artments/ urchasin division/contracts. h Any g Y g p p g p p)• Y violation of this requirement is a breach of the Agreement and County may immediately terminate this Agreement without further obligation on part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. 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. 19. 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 1 1A 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. The Exchange Club Center for the Prevention of Child Abuse in North Carolina Orange County Outside Agency Performance Agreement Page 5 of 7 Rev, 7/17 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 4m tkehalf of the Provider (7andm k. I 9/1/2017 7E_B_13734ME0,4E7 Sarah Black,Director Date 74Fitififfidbthalf of Orange County Government j7j01A lt,tf, A-AJ' W(U'S 9/5/2017 0637994B755E477... Bonnie Hammersley,County Manager Date The Exchange Club Center for the Prevention of Child Abuse in North Carolina Orange County Outside Agency Performance Agreement Page 6 of 7 Rev. 7/17 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FOR OFFICE USE ONLY Agency The Exchange Club's Family Center in Alamance County Received By Pate/Tithe. �, Program(s) Parent Aide Program '' '..,_,... Section Subsection 1. Cover Page 9 a. ®Applicant Contact Information b. Funding Requests c. ®Signed Application Cover Page d. ®Signed Disclosure of Conflicts of Interest and Clause 2. Agency Information a. r Agency's Years In operation b. ®Agency's Purpose/Mission c. ®Agency's Types of Services Provided d. ®Agency's Experience with Programs e. ® Other Pertinent Agency Information f. ®Schedule of Positions g. ® Living Wage h. ®Agency Budget 3. Program Information a. ® Human Services Needs Priority b. ® Type of Program A separate Section 3 is C. ®Agency Collaboration required for each program. d. Summary of Program e. ® Description of Identified Need f. n Description of Population to be Served g. ® Program Staffing,Capacity, &Expertise h. ® Program Implementation Timeline L ®Value of Investment j. ® Impact of Reduced/No Allocation It. ® Other Pertinent Information I. [] Target Population/Beneficiary Chart - M. ®Work Statement n. Program Budget, Detail, &Cost per individual 4. Attachments a. ® Audit: Organizations receiving$300,000 or more in Federal financial assistance, and/or organizations with more than$500,000 of receipts and expenditures in a fiscal year,must secure an audit. b. ® IRS Federal Form 990 c. ® NC Solicitation License d_ ® IRS Federal Tax-Exemption Letter e. Certificate of Insurance f. ® List of Board of Directors g. ® Solid Waste Program Fee (SWPF)Verification Application Submittal Checklist 1/27/2017 1:48.20 PM Page I of 12 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION .- . ..,:. 1 CP1FER.PRGE; ; a) Applicant Contact Information Applicant Organization's Legal Name: The Exchange Club Center for the Prevention of Child d Abuse of North Carolina, Inc/The Exchange Club's Family Center in Alamance County Applicant Organization's Physical Address: 200 N. Main Street Graham, NC 27253 Applicant Organization's Mailing Address: 200 N. Main Street Graham, NC 27253 Applicant Organization's Web Address:www.exchangescan.orq I Executive Director: George Bryan. Interim/The Exchange Club Center for the Prevention of I Child Abuse of North Carolina, Inc./Sarah Black/The Exchange Club's Family Center in Alamance g County Telephone Number: 336-748-9028/336-227-5601 E-Mail: george.bryan(r�exchangescan.orq/ Ii, sarah.black( exchangescan.orq { Tax [D Number: b) Funding Request List all FY17-1 8 Human Services (HS) Funding Being Requested-- For All Programs) and the Proposed Use of Funds (2-3 lines or less) • l Program Carrboro Chapel -Orange: ' Total ! HS, N l,, HiU HS County HS ;3< - ,•yl- - -t .�, t l!1;j<j:'+�!I:�fil�;!�niS:'I!i ;�•I!sI'a!:ttlji!?ill!1, �;- .I•I:I t :!� ��: ! ',i! s t'' , !, _ @ i ESA Tooth Af rscl oo• rel opf p tE !•i; !!t 1{i :.t lilii!i�.Il:!I i ' -P i i$ 5 0 0=, $b V i 0 �0` k,:......:.....: :.E>!},:t :4:,t1,lr;,,,„!>.1.:; I;•I,Iie.:,•:!,i€:;i}:I:its,I!,:E+1<I kk�,!i!:! I!• Ii43,e➢.: >E,t•I�, I, ,!u,t,.!t!,.I,• r:.,,�.,It,4l1,.!1!::..s'I!,: ,.;+,��,•!ril i.:r..._,..�:?.� {� z.l.l t 1�,E.1l,.Itil.:.. l_I-]I:jl; JI lty.li E;.i t,,.1 kl.1!. ! ! •! i:};.,.i,...!..,!,tl:}L !t ! :I,=31.. :z•' , �fte: .gigO 13c i [X00,0�: i #; ;' c11 1!;IE!!�I1is!t•js 1 s..!!<'t.:ll�l'.11I;�!!i!I.€I{'(''u::I: ,tin 1 i t I Ij 1 !}��,'„ •s.:-��3 3,�,�s'�is�! Fl. .,,I:li :• .I!:�!; � ..r.:.�!I'I,n:{{.;j:. ;.11ljll!•t!- :I:- 1.-t i'.�:.€,i`i,lilu!:1:. >!'!-.x!u t sr i3s:cYr... '?' ; .1;1.ill!.,Ott, .,-,.ulu itn Ikys;hr.: ..'.�� :.:. .4v3 ..T• i e •:1, �_ � :I It•:i�� i Ott. .!.•�•L:•!:!i4::3;: .9'; !!� !S'!..,..L. ..1.,3,<.L,i-t_,; ...! ..,ILt_,t.i-L. !� .#.•c<.!, ts.t. .�.,d: :I.n •I .1�11•,�. 's �"jl%' #��IJ'141� ''P s•L .I II ilB l' .,.I!• !� }:IiS'j:; - .�;, :!i!:1 Ei. 14t1 t li t! i. -1 i'i•w!t:,li l l..i=,!.11 sill,Ili,l.lti,III z•. s,,n'ta==: ;i1t;a;,! a!; 5i ,! t '!: .p. .°.?!I!••,: ..II II : !,! Il 1 t !u,1,. .I. •!,. .is-..1.. ..- -• ..1t! Ii .'i:rl'.1'!`i.:,L.!..,..'!r�'.'i'r! 'tNaLi;^!d:,..........1,aieiS31!!'!1- 1 :.�4�:1�QUf�,.'e�li�l�{�1pSl'dl'1(�o,�1'Q���4�:4s.�:31IL!�:.i�:;�€Iji�€�,1;11�;t,El�,,l�l'•t!L•I:!.::,?a,fl!:6:!1,�11=;;k,?:s}1.�!�!!IEIS!:xlla:�rul,�;l:!tl!utett�h!I€ttli?+:::,;t=!-1 l- i-�';;:1-��E•�..:t. �!.. a:-i,. :.,,!..:1', Parent Aide Program:salary and benefits of program $ O0QJ tl ct3 100 $13,'!00: • $28,200 staff, mileage, supplies/client emergency funds, I I F 1,3'k !”I! rent/utilities/operations. ,W F il,l ! ,I , ! i il'i'1!x'-1:11!!. I I: It?II I t ! !�'' ! iriMiliEagti flla.l.t3tir L. _......c... .. ! iipi i Totals , c) ' To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: Y---- 2' 7'. J 7 Executive Director Date l 7,7-11,,? /, . . , , Signature: LA ) /JO-'196 fi 7 ,. .:oafd Ch ir` ersen Date AGENCY INFORMATION 1/27/2017 11:59:25 AM Page 2 of 1E, • •3 1 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO n ® a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ b) Members of or closely related to members of the governing bodies of the Town of Cerrboro, the Town of Chapel Hill, or Orange County? ❑ ® c) Current beneficiaries of the program for which funds are being 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. !' NONDISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to 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, gender identity/expression, 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. 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 program Ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. E' Signature: /4' 7 ;20 t7 Exec Director Date Signature: Viairperson-. / 3 / � _A Bo Date AGENCY INFORMATION__.-_......_._____..- 1/27/2017 11:59:25 AM Page 3 o f 1� DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 2. AGENCY INFORMATION (Be Very Brief and Concise) Please provide the following information about your agency(2 pages OR LESS): a) Years in Operation, Date of Incorporation (Month/Year): 01/2000 The Exchange Club's Family Center in Alamance County(Family Center in Alamance) has been in operation since 1997. In 1 999/2000 the agency began steps to operate as an independent center and incorporated in 01/00 with a filing date of 05/00. In 2001 the Family Center in Alamance came under the umbrella of Exchange Club Center for the Prevention of Child Abuse of North Carolina, Inc. Both agencies are a part of a national network of Child Abuse Prevention Centers sponsored by local Exchange Clubs. The agency has . A been offering services to Orange County since 2004. b) Agency's Purpose/Mission (no more than a few sentences): The agency's mission is the prevention and treatment of child abuse and neglect. The prevention and treatment of child abuse and neglect occurs through enhancing parent child relationships, by increasing community awareness, and increasing community involvement in prevention efforts. The center currently offers programming in 7 counties (Alamance, Orange, Chatham, Person, Caswell, Guilford, and Randolph) in the triangle/triad area. c) Types of Services the Agency Provides (bullet format): The Family Center has 7 prevention and treatment programs currently offered to families which include: • Intensive Family Preservation Services: evidence-based counseling services to prevent out of home placement of children in child welfare, mental health, and juvenile justice systems. • Parent Aide Services: evidence-based in-home visitation program. • Children's Parents parenting Classes • Adolescent Parenting Program: in-home/community visitation services for adolescent parents and their children. • Respite Services: temporary child care placements for families at-risk. • Parent/Teen Solutions: parenting classes for at-risk teens and their parents. • Adolescent Parent Support Program: in-home/community intensive visitation services for at-risk adolescent parents. • Triple P Positive Parenting Program and Safe Care Services, evidence-based curriculums, are offered in the context of some of our in-home programming. • 24-hour crisis line and Community Awareness. d) Agency's History with Providing These Services: The Family Center has 19 years of experience in administering grant funds and providing successful child abuse prevention services in the community. The agency has been offering Parent Aide services in Alamance County for 19 years, in Orange County for 10 years, and expanded into Caswell County in 2016. The Family Center was a part of the original randomized trial clinical study that helped to achieve the program's evidence-based status. The staff of the agency is versed in the complexity of child abuse prevention and has decades of experience in home visitation and parenting education. The agency also operates within a System of Care framework and collaborates on many levels with various community non-profits, for profits, social service agencies, and business. Agency staff sit on various committees, councils, and collaborative efforts_ e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year?Is there a new Executive Director?Are there new initiatives?) Over the years the Center has tripled in size and in budget since 2001 and therefore the Board of Directors of the Exchange Club's Family Center in Alamance County and the Agency Information 1/27/2017 1:48:20 PM- Page 4 of 12 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 • EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Exchange Club Center for the Prevention of Child Abuse of North Carolina, Inc. are working to transition the center once again to a stand-alone center status. The transition will be complete in the 2017-2018 contract year. Currently the center is still under the umbrella of 1. the Exchange Club Center for the Prevention of Child Abuse of North Carolina, Inc. f) Schedule of Positions (For Entire Agency) • Full Time Equivalent(FTE)staff will be noted as 1.00; half time as .50;quarter time as .25, etc. • Calculate a Full Time Lquivalent for all recorded volunteer hours using the following: Total Volunteer Hours =Volunteer FTE 2,080 # of FTE- Full-Time Paid Positions; 8 # of FTE- Paid Part-Time Positions: 2 # of Volunteers: 13 #of FTE -Volunteers:0 g) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes/No) Yes If yes, is this agency an Orange County Living Wage Certified Employer? No If no, please explain. The agency hasn't been through the certification process but is planning on in the next contract year if applicable. h) Agency Budget i. Is your agency currently receiving and/or requesting other(non-Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes/No) No If yes, please list below: Include all programs that have funding requests/awards/totals from Carrboro, Chapel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME Program FY16-17 FY'17-18 -.Source Award Request EX: Affor able Rental 0 $20,000.. .Carrboro-Affordable Housing Rehabilitation EX:Agericy Administratiori ': $15,000 $15,000 ..Carrboro-Other • Ex.Total ,. $15,000' $33;000 ,Carrboro Total Funding *Add rows or attach additional page, if needed. Submit your agency's budget. You may complete the provided template (separate xIs file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Does your agency budget show a Surplus or Deficit? Deficit Is there a significant change?Yes/No No Deficit is predicated on total expenditures of flex funds for treatment program for families served. Not all families use the funds so the deficit will likely not occur. iv. What is your agency's fiscal year? July 1, 2016 through June 30, 2017 Agency Information 1/27/2017 1:48:20 PM Page 5 of 12 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: The Exchange Club's Family Center in Alamance County Actual -..Estimated . . .Projected Percent AGENCY REVENUE 201' =16 ':. ...2016=17 , ' 2017-18 Change Private Donations $ 4,118_ $ 2,500 $ 2,500 0% Agency Generated Revenue(fees) $ 6,523 $ - $ - 0 Local Government Grants: Human Services-Town of Carrboro $ 1,000 $ 2,000 $ 2,000 0% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ 6,000 $ 10,350 $ 13,100 27% , Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 2,000 $ 6,175 $ 13,100 112% Other-Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ 385,648.00 $ 403,046.00 $403,046.00 $ - Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ 6,000.00 $ 79,872.00 �.$ 85,675.21 $ 0.07 Other Revenue $ 18,000 $ 15,000 $ 21,500 $ 0,43 Total Agency Revenue $ 429,289 $ 518,943 $ 540,921 4% AGENCY EXPENSES Compensation $ 314,613 $ 410,006 $ 421,984 3% Rent&Utilities $ 25,754 $ 27,692 $ 27,692 0% Supplies&Equipment $ 9,151 $ 6,719 $ 6,179 -8% Travel &Training $ 30,950 $ 31,305 $ 31,405 0% Other Expenses: $ 48,821 $ 45,647 $ 53,661 18% Total Agency;Expenses $ 429,289 $ 521369 , $ 540,921 4% - SURPLUSI(DEFICIT) FOR PERIOD: l$ - 1 $ (2,426)1 $ 0 f 100% it FY 2015-16 Comparative Agency Budget Revised 9/2912014 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM CNFORMIIIATION (Submit a separate Section 3 for each program) Program Name: Parent Aide Program Program Primary Contact and Title: Sarah Black, Director Telephone Number: 336-227-5601 E-Mail: sarah.black(cr�exchangescan.org a) Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area#1; safety-net services for disadvantaged residents Priority Area#2: education, mentorship, and afterschool programming for youth facing a variety of challenges ® Priority Area#3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding � (Check all that apply to this program) Program Category Ybe h , Adrift 1=lderly Res bled oncc Housing Neighbborhoods/Residents Affordable Housing Affordable Healthcare _ Education I� Family Resources X X X X X Jobs/Jobs Training X X X Food • Transportation X X X X Other: Please specify X (parenting support) x x x c) 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, briefly describe the coordinated/collaborative efforts. • Department of Social Services and Department of Health: referrals, governmental services. Agency has a Memorandum of Agreement with Orange County's Department of Social Services. • Department of Juvenile Justice and Orange County Court System: referrals. • Orange County I Chapel Hill School System/ UNC-Chapel Hill: referrals and interns. • Mental Health/Social Service Agencies/ Local Mental Health Entities: referrals and mental health services. • Exchange Clubs/Churches/Business: These entities assist the agency by providing monetary donations, concrete donations for items needed by families, and volunteers for serving families in Orange County. PROGRAM INFORMATION 1/27/2017 1:48:20 PM Page 6 of 12 • DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town/County priority/goal? The Parent Aide program will provide home visitation services to families at-risk for and/or involved in child abuse and neglect. Families average 13 months in the program but services can last up to 18. Service activities include parent education, coaching, role modeling/rnentorship, assistance with concrete supports,job/education training, case management, advocacy, and assistance with transportation needs Various evidenced- based curriculums are used to support service activities. The Parent Aide model is evidence-based and is currently listed on the California Evidence-Based Clearinghouse for Child Welfare's list as a Level 3 "Promising Research Evidence" status. The Parent Aide program provides services to many priority areas of concern for the community including: direct parent coaching and mentorship; child mentorship to address abuse and neglect dynamics; life skills/ money management skills and concrete supports which collectively increases access to safety-net services for families; transportation and other basic need issues (like food and housing); and increased positive health outcomes for families. Trauma histories have been proven over the last 30 years to lead to lower brain functioning, mental health issues, and physical health issues so addressing trauma means improving overall health (www.cdc.gov/ace/index.htm). e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro goals, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment)to support the need for this program. Child abuse and neglect is a significant present problem in Orange County. From July 2015 to June 2016, there were 1,130 children reported for child abuse and/or neglect in Orange (Duncan et al., 2017). Of the 1,130 children reported for abuse/neglect, 37.96% of them were between the ages of 0-5. As of December 2016 there were 93 children in foster care in the county(Duncan et. al, 2017). Children that end up in the foster care system often stay in the system longer than a year increasing the cost for taxpayers, From July 2015 to June 2016, 8511% of the children that were in the Orange County foster care system remained in the system for over a year(Duncan et. al, 2017). This child maltreatment data speaks to the need for population targeted intervention services in the County to address the issue of child abuse and neglect/trauma in the county. The program will directly address these statistics by providing interventions to help families avoid new or repeat involvement with the child welfare system. The Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill 2020 Council Goals, and Carrboro goals all have a common theme in their agendas, that of providing a safe and healthy community for their citizens. These council and county goals recognize that as much as basic needs (employment, housing, food, etc.) are important to the families of the county social detriments of health are also necessary to address in order to achieve healthy communities. Child Abuse and Neglect in the community and the resulting trauma that it creates lead to unhealthy families that impact directly the achievement of the goals of the county. Goals such as "Nurturing Our Community", "Community Prosperity and Engagement" and foundational programs PROGRAM INFORMATION 1/27/2017 1:48:20 PM Page 7 of 12 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION such as "Protect and Provide for a Safe Community" are impossible to achieve without addressing the trauma risk factors of the community. Numerous individual, family, and community factors can contribute to abuse and neglect (Centers for Disease Control and Prevention, 2016). Individual factors such as age, disability, and mental health factors put a child at risk. Community and Family factors such as poverty, low education, substance use, mental health disorders, domestic violence, prison, history of child abuse, lack of knowledge of parenting/child development, social isolation, and community disadvantage (e.g., community violence, high poverty and residential instability, high unemployment rates, and high density of alcohol outlets) also can lead to concentrate rates of child abuse and neglect/trauma. These risk factors are connected to town needs assessments and Orange County social values. Overall Orange County appears to have the following community concerns: insufficient basic needs; transportation, need for financial stability; mental illness/substance abuse rates and need for services; and community and family violence rates (Orange County Community Health Assessment, 2015). Orange County has 14.3% of its people living in poverty according to the 20015 U,S. Census Bureau. The Small Area Income and Poverty Estimate [SAIPE] by the U.S. Census Bureau shows that Orange County has 13.1% of the youth living in poverty (2016). In Orange County, 9.8% of the population are Medicaid eligible (NC DHHS, Division of Medical Assistance [DMA], 2015).Though Parent Aide services cannot wholly improve financial status, we will assist families with supports that will help to buffer the risk of abuse and neglect from factors relating to poverty. Domestic Violence brings a risk of trauma exposure to children in homes of the families !h experiencing this problem, which leads to long term consequences of abuse/neglect. In 2013-2014 in Orange County there were 1,542 domestic violence calls, 360 clients were provided with domestic violence services, and 1,252 calls and 457 clients served due to sexual assault(North Carolina Council for Women, 2013-14). Studies have found abused li and neglected children to be at least 25 percent more likely to experience problems such as delinquency, teen pregnancy, low academic achievement, substance abuse, and mental illness (Kelley, Thornberry, & Smith, in U.S. DHHS Child Welfare Gateway, 2012). As abused and neglected children develop, studies show that they are 11 times more likely to be arrested for criminal behavior as a juvenile, 2.7 times more likely to be arrested for violent and criminal behavior as an adult, and 3.1 times more likely to be arrested for one of many forms of violent crime as juveniles or adults (English, Widom, & Brandford, 2004). Delinquent rates in 2014 in Orange County of youth 6-15 is 11.74% (DPS County Databook, 2014). Parent Aide services address these risk factors directly in the home by providing concrete parenting education, case management, and advocacy to assist families in finding needed services to address mental health and substance abuse, and transportation assistance. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? The target population of Parent Aide Program services is 20 families (11 with these funds) in Orange County(5), Chapel Hill (5), and Carrboro (1) at risk of and/or involved in abuse and neglect, These families include various socioeconomic backgrounds and will match the diversity of the County (76.6% white, 12.3% Black, 8.5% Hispanic/Latino, and 7.9% Asian per the 2015 US Census). Marketing to county referring sources (Dept. of Social Services, Dept. of Public Health, Schools, Non-profits, For-profits, businesses, mental health companies, churches, local mental health entity, etc.) will allow the agency to solicit referrals for families needin g made Self-referrals e b _. . . . . .. ... .. .. Y parents in the community will be PROGRAM INFORMATION 1/27/2017 1:48:20 PM Page 8 of 12 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION solicited by general agency marketing efforts (social media, website, etc.). Beneficiaries are identified when the referral is received and the family agrees to services. Qualification for services (identified beneficiaries)will be determined by families that meet at least 3 risk factors on the risk scale. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) The staff that will implement the program includes bachelor level professionals with experience in social work, counseling, or human services. Current staff have extensive W' training in child abuse and neglect, trauma, protective factors, substance abuse, mental health, system of care, and are certified in evidence-based curriculums. All staff are provided both internal and external training opportunities to increase their capacity to effectively serve the client populations. Volunteers, or paraprofessionals can be used under the supervision of the Parent Aide Supervisor. Volunteer Parent Aides receive the same internal 12 hour training on Child Abuse and Neglect/ Parent Aide services that professional staff are given. Volunteers are also interviewed and reference/background checked to ensure safety of working with children. The current Program Supervisor, acts as the agency's Director and has a Master's degree with '111 years of executive level management and administration experience, 12 years of programmatic administration and implementation, and over 16 years of clinical and service delivery experience. 141 h) Describe the specific period over which the activities will be carried out and include an implementation timeline. Implementation of programming will begin immediately as Parent Aide services already , exist on a smaller scale in the county due to current funding levels. Home visits for programming occur weekly and last anywhere from 1-4 hours depending upon the risk level in the home. i) Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) Child abuse costs the nation $220 million every day(Prevent Child Abuse, Cost Data, 2012). Costs are hidden in the social service systems, healthcare costs, and poverty initiatives. Flexible programming that focuses on parenting while addressing the risk factors will help to reduce both direct costs of trauma and indirect costs hidden in other systems. This Parent Aide flexible approach allows families from different starting points to get their specific needs addressed affordably preventing duplication of funds being spent on one family in multiple systems. Children that grow up safe, nurtured, and with sufficient basic needs met will turn into successful productive citizens that contribute to society and the economy. The Parent Aide program is a very cost effective ($2700) competitive service for preventing child abuse and neglect. Most other interventions are short in duration (4-8 weeks) and cost anywhere from $6,000-12,000 per family. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. If the full funding request was not allocated to the agency, the agency would reduce the number of clients served, apply for matching funds, and reduce the number of hours of the position. k) Include any other pertinent information. PROGRAM INFORMATION 1/27/2017 1:48:20 PM Page 9 of 12 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information I) Target Population 9 p ' Complete the following tables, with numbers (not percentages)of individuals served and to be served, to the best of your ability, *(numbers reflecting estimates for this funding request not total from other funding supports. broken down by#of families in geographic section) Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender . .. ' .'. "_..,� 8 Families [[ 10 11 I Male 14 22 18 j Female 11 18 22 Total 25 40 40 African-American 4 12 10 American Indian or Alaska Native 0 0 0 Asian 0 0 0 Caucasian 12 24 26 Native Hawaiian or other Pacific Islander 0 0 0 Other: specify . Multiple Ethnicities 9 4 4 Total 25 40 40 Of the above, how many Hispanic/Latino 9 4 12 Of the above, how many non-Hispanic/Latino 16 36 28 Total 25 40 40 . Age 0-5 years 7 11 12 6-18 years 8 11 11 19-50 years 10 16 16 51+years 0 2 1 Total 25 40 40 Geographic Location Alamance County _ 0 0 0 Chatham County 0 0 0 1 Durham County 0 0 0 Wake County . 0 0 0 1 Orange County Breakdown Families Chapel Hill Public Housing 1 1 2 Town of Chapel Hill(Non-Public Housing) 3 3 3 Town of Carrboro 0 o �' a rbaro 0 1 1 Town of Hillsborough 3 4 5 City of Mebane(Orange County) 0 0 0 Orange County(Outside Municipalities) 1 1 0 . Total 25 , 36 40 1. PROGRAM INFORMATION 1/27/2017 1:48:20 PM Page 10 of 12 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement m) Complete the Work Statement Chart to describe the work to be performed. This chart 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. Every program is required to have AT LEAST 1 Program Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and Time--bound. Click on SMART Goals to [earn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday-Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (/.e. Will track the number of meals delivered each day) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e_ Delivered an average of 105 meals per day.) Work Statement Chart for Program,Parent Aide Program .1, Program Aetivity..Name . Parent Aide Program: Home Visiting Program Goal Parents will increase parenting skills and parent/child interaction and increase problem-solving skills and family functioning. Performance Measures Protective Factors Survey(Retrospective Post), North Carolina F Family Assessment Scale(Pre, Mid, Post), Adult Adolescent Parenting Inventory(Pre/Post), Safe Care Assessments. Previous Year Program Results 93% Current Year Estimated Results 96% Next Year Projected Results 95% 2 Program Activity.Name _ Parent Aide Program: Home Visiting i Program Goal Parents enhance home safety, increase linkages to social/community supports, and improve their capacity to maintain their child's health. F Performance Measures Protective Factors Survey(Retrospective Post), North Carolina Family Assessment Scale(Pre, Mid, Post), Adult Adolescent F Parenting Inventory(Pre/Post), Safe Care Assessments. Previous Year Program Results 93% Current Year Estimated Results 96% Next Year Projected Results 95% • 3:'-:'Program:Actiuity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 4.. Program Activity.Name Program Goal PROGRAM INFORMATION 1/27/2017 1:48.20 PM Page 1 1 of 1 2 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Performance Measures • Previous Year Program Results Current Year Estimated Results Next Year Projected Results n) Program Budget 1. Submit your program budget.You may complete the provided template (separate xls file)or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template). Program Budgets are required to define budget amounts for the previous program • year, current program year, and next program year for the following categories: 2. Program Budget Detail --Provide description of"other" budget items, not defined. 3. This program budget represents what percent of the agency budget? 18% Other Expenses: Emergency Funds for Parent Aide clients $50 a family and operational costs for program implementation. 4. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. 3�b �.. �l"� 4 `3� .vii �`?i�,�� a F�s-Kr`� . �'.ir, a���i��m ,�� �`1�i-1},,�+ r �r� amm o, ,u �€ ► tiv Q rtrtl. versa cxed� C� 7 _ Total Cost of Program $9,000 $18,175 $29,700 Total #of Individuals 25 40 46 II Cost Per Individual $360 $454 $645 • • • • ' 1 PROGRAM INFORMATION 1/27/2017 1:48:20 PM Page 12 of 12 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME The Exchange Club's Family Center in Alamance County .Actual . Estimated Projected •Percent PROGRAM REVENUE • 2098-16' ` ' ;'.2016-17.. 2017-18 Change Private Donations $ - $ - $ 1,500 0 Program Generated Revenue $ - $ - $ - 0 Local Government Grants: Human Services-Town of Carrboro $ 1,000 $ 2,000 _$ 2,000 0% Other-Town of Carrboro _$ - . $ - $ - 0 Human Services-Town of Chapel Hill $ 6,000 $ 10,350 $ 13,100 27% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 2,000 $ 6,175 $ 13,100 112% Other-Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - -$ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBGIHOMEIetc.) $ - $ - $ - 0 Private Foundation Grants $ - $ - $ - 0 Other Revenue $ - $ - $ .. 0 Total Program Revenue $ 9,000 $ 18,525 $ 29,700 60% PROGRAM EXPENSES Compensation $ 6,634 $ 12,377. $ 22,886 85% Rent&Utilities $ 696 $ 453 $ 746 65% Supplies&Equipment $ 85 $ 746 $ 400 -46% Travel&Training $ 1,739 $ 4,949 $ 4,458 - -10% Other Expenses: $ - $ - $ 1,210 0 Total Program-Expenses. $ 9,155. $ 18,525 $ 29,700 60% SURP LUSI DEFICI T} FOR PERIOD: � $. {155) $ 1 � $ - � -100/ 1 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 EXHIBIT"B" Scope of Services--FY 2017-18 Outside Agency Performance Agreement Agency Name: The Exchange Club's Family Center in Alamance Program Name: Parent Aide,Services Funding Award: $9,638 Outline how the agency will spend Orange County's funding award. Expense Description Amount Personnel Salary&Benefits $6,427 Mileage $2,106 Rent&Utilities $872 Supplies $233 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Provide in-home visitation to 7 families (6 with funding and 1 family with volunteer assistance) through the Parent Aide program through professional level staff and Masters level interns. • Provide weekly home visits in the home to at-risk families to increase safety,parenting,problem- solving, social support,and health of the family. 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. Anticipated Performance Measures Results rl Number of(unduplicated)families enrolled in Parent Aide in-home visitation services and 7-w/MA receiving weekly visits to reduce the risk of child maltreatment. Interns Average number of hours for weekly visits for families enrolled in Parent Aide program. 2 Average number of month's families are enrolled in Parent Aide program. 10 Percent of families who will increase parenting skills and parent/child interaction. 95% Percent of families who will enhance home safety and parental supervision. 95% Percent of families who will increase problem-solving skills and family functioning. 95% Percent of families who will increase linkages to social/community support. 95% Percent of familie banijleidigprove their capacity to maintain their child's health. 95% SAle tk, I/ 1 2FB' /373400E0 2.. / county Di rector 9/1/2017 c by: f [ j Title: r✓ Date: r/ /17 (Provider's Signature) DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 ATTACHMENT "A" Orange County Certifications—FY 2017-18 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: O 151.a County Director 9/1/2017 Certified by: 2FB1373400E04F2.. Title: Date: (Provider's Signature) • The Exchange Club Center for the Prevention of Child Abuse in North Carolina Orange County Outside Agency Performance Agreement Page 10 of 7 Rev. 7/17 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 NC DRPARTM T OF PUBLIC SAFETY Idol FOR PROFIT ° '` 'iDPS CONFLICT OF..INTEREST POLICY STATEMENT This document is only required from not for profit organizations ONLY:In accordance with . the N.C,G.S. 143C-6-23 (b) every Grantee shall file with the State agency/Grantor a copy of the Grantee's agency policy addressing conflicts.of interest that may arise involving the Grantee's management employees and the members of its board of directors or other governing body. The policy shall address situations in which any of these individuals may directly or indirectly benefit, except as the Grantee's employees or members of its board or other governing body,from the Grantee's disbursing of State funds and shall include actions to be taken by the Grantee or the II. individual, or both to avoid conflicts of interest and the appearance of impropriety. Agency conflict of interest policy shall be submitted to the Department of Public Safety(DPS)to avoid any delay with the disbursement ofDPSJCPCfunds. The Grantee shall submit this form(Not for Profit DPS Conflict of Interest Policy Statement Form DPS 13 001)along with the agency's conflict of interest policy when applying for finding. Accordingly, no member or board member of the private, nonprofit entity may receive directly.or indirectly, any funds received from the State of North Carolina, except for duly, authorized staff compensation and benefits, and reimbursement for expenses actually incurred in connection with the private, nonprofit entity's business and in accordance with final approved grant agreements. • WI-MR.EAS, Exchange Club Center for the_Prevention of Child Abuse of North Carolina,Inc. desires to require its Board of Directors and'managing employees to avoid conflicts of interest or the appearance of impropriety in the disbursement of State funds; THEREFORE, no member of the Board of Directors-or staff members of said private, • nonprofit entity shall participate' in the 'solicitation, negotiation, formation, award, arbitration,modification, or settlement of any contract or grant funded in whole or in part by State funds or of any dispute arising-Finder such contract or grant when the director or staff members stands to benefit, either directly or indirectly,from such grant or contract; PROVIDED, no member of the Board of Directors or staff members shall be deemed to benefit directly or indirectly from any contract or grant funded in whole or in part by State funds if he/she receives only the salary or stipend due to him/her in the normal course of employment with, or service to, said private,nonprofit entity. FURTHERMORE, said private,nonprofit entity has written conflict of interest policies and reporting procedures applicable to board members,staff members and volunteers who have any interest or any authority regarding the resources of the private,nonprofit entity. These policies have been communicated to board members, staffin.enbers and volunteers and full disclosure has been provided for any possible appearance of conflict of interest that may exist. Form DIPS 13.001 Not for Profit DPS Conflict of Interest Policy Statement Form structure last revised fuly 2014 NC Department of Public Safety Page 1 of 3 i1 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 is s�d�° • a _ .d ■ �a NC DEPART IsTT of PUBLIC.SAFETY�� NOT FOR PRQlTI'• 7 -� BPS CONFLICT OF INTEREST POLICY STATEMENT The following serves to identify and document any personal interest staff members, officers, and members of the Board ofDzrectoi.s"may have• This document is also to be used to disclose any transactiorfs that.May result in personal,financial professional • and/or�Political.gain at the expense.of,DPS.. The statement requires that all personal relationships that may inci. rap riatel - influence ias . actions be disclosed Relatoriships,be.it persorial;.f_rnancial,' irofessionaland/or_political are required to be disclosed to Nis. CorifZici means a conf liet or the.appearance of a Conflict between the private interests and officud responsihilzt es of a person in a position of trust .Persons in it position of trust include staff Members Or.the.Board of Directors. • Private, nonprofit entities shall make fun disclosure by notice in writing to the full Governing Board/Council all Coittlicti of interest, if"yes"is answered to any of the • following: (Check.all that apply). . . - • .• 1: A Board member is related to_a staff member:: . 1 1 IZI 2.. ••A staff member in a supervisory capacity is related to another staff 1 . A•• ieinber whoni he/she supervises.'• '•. - • . 3. A staff member is related to ai..other staff Member. . .. . f l V 4.-'••A board memberor•staff member.has or.mayhave personal,• • - I I . L .:fO aanciai,professional,and/or political gain at the expense or• benefit of the private,nonprofit entity•••° : •: • • - - . .: 5.. •There as a business entity which a.•staff,_ ioard,,or family member C. El • . • •participates that may be viewed�as.having direct oradirect •, . .': . influence over the private,'nohprof f entity's business. .'6. A staff board'or family member.ma beviewed.as having direct • ' C . .. •or indirect f nan.cial g from.personal orbirsiness .:` . .•investments/interest in real ro held• by that sta board,or . p P y .family biember:'• :::' :.:': : •• ::'f,'.-• :'`°••. . . :. • .•• . - •• . • • • 7: :A staff or board member received honorarium-or other• ` . •C - : compensataon.'outside of the scope of ernployment/operations.with • ' . •. the private,nonprofit eiitity"that creates'or appears td create bias: . S: A_staff or board member secured employment with a competitor or [ El .`'. other similar private,noiiprd t entity•': . :.,. .9.... . Ongoing,paid consulting work outside of the staff member's current employment orboard member's with your'private, :, . -nonprofit entity exists. • • Form:DPS 13 0.01 Not for Profit DPS Conflict of Merest Po7 cy Statement • ' •• Form structure last_revised.July 204- ,. . .1\Ta:.pelithimept ofPuiblic Safety • . Page 2 of 3 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 NC DEPARTmlENr. OF PUBLIC SAFETY •. NOT FOR PROFIT DPS CONFLICT OF INTEREST POLICY STATEMENT 1. If "yes" is checked to any of the aforementioned items, the JCPC Program Manager and Board Chair must ensure details for any transaction that exists are described and attached to this form, 2. If this statement fails to list a transaction that may exist that is non-financial in nature,please attach details. 3. Details must include at least the name, and, address, or persons involved, and a description of the relationship and the transaction. Note: Failure to disclose any-conflict of interest transaction that exists or is - potential within your private,nonprofit entity may result in the cessation of any further DPS JCPC State funds. County: Alamance . Agency's Name: (Legal.Applicant) Exchange Club Center for the Prevention of Child Abuse of North Carolina, Inc. Federal Tax ID#: • Private,Nonprofit Entity Name: The Exchange Club's Family Center in Alamance Executive Director's Print George Bry (Date of Signature) Name: Sign I12412-Di 7 Board Chair's Print Jennifer L. Mardi. _ (Date of Signature) • Name: Sign f ! I /_�" ce-- /7 70- Sworn to and subscribed before me on the Jaime E Ledbetter Day of the date of said irtifitition NOTARY PUBLIC Forsyth County, NC 8°I/L4-(1`fotarYPu‘bl ic1 ; E /re° /OJ/Er/2 is Form DPS 13 001 Not for Profit DPS Conflict of Interest Policy Statement Form structure last revised July 2014 NC Department of Public Safety Page 3 of 3 DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 - EXCHANGE CLUB CENTER FOR THE PREVENTION OF CHILD ABUSE OF NORTH CAROLINA, INC. (EXCHANGE / SCAN) FORSYTH COUNTY POLICY ON CONFLICT OF INTEREST WHEREAS,the varied interests and backgrounds of the Directors, Officers, and Executives of Exchange I SCAN could result in situations where the giving of service involves a dual interest which might be interpreted as a conflict of interest; and WHEREAS,the service of such Directors, Officers, and Executives should not be rendered impossible solely by reason of duality of interest or possible conflict of interest; and WHEREAS, duality of interest of possible conflict of interest on the part of such Directors, Officers and Executives can most properly be controlled by full disclosure of any such interest and by the abstention from voting on any matter where any possible conflict of interest is or might be thought to be involved,now therefore be it RESOLVED: That the following policy concerning possible duality of interest or conflict of interest on the part of Directors, Officers, and Executives is hereby adopted: 1. All Directors, Officers, and Executives of Exchange/SCAN, shall scrupulously avoid any conflict between their own respective individual interests and the interests of Exchange/SCAN in any and all actions taken by them on behalf of Exchange/SCAN in their respective capacities; and 2. In the event any director, Officer,or Executive of Exchange/SCAN, shall have any direct or indirect interest in or relationship with any individual or organization which proposes to enter into any transaction with Exchange/SCAN for the sale,purchase,lease or rental of property or to render or employ services,personal or otherwise, such Director, Officer,or Executive shall forthwith give the Board of Directors of Exchange/SCAN notice of such interest or relationship and shall thereafter refrain from voting or otherwise attempting to affect its decision to participate or not to participate in such transaction. Minutes of appropriate meetings should reflect that such disclosure was made, and that such Director abstained from voting and was not counted for the purpose of determining a quorum; and 3. The foregoing requirements,however, should not be construed to prevent a particular Director from briefly stating his position in the matter, nor from answering pertinent questions of other Directors by reason of the fact that personal knowledge on the matter may be of assistance to the other Directors in reaching their decision; and 4. A copy of this statement shall be furnished each Director, Officer, and Executive who is presently serving Exchange/ SCAN,or who may hereafter become associated with Exchange/SCAN. is DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 Exchange C14 CJ'C "l'Cll.l brdmlion of Child Abuse of North Carolina,Inc. Date a -:`. 1/24/2017 To: State Agency Head l il*• f Wilgerrthwest Boulevard Winston-Saleiry N.C.27105 Certification: (336)748.9028 FAX(336)748.903D wFVw-exchangeseanmo g r'r_ , :.>:�-!3.1�!. v.�i4'�`,�•-5Y".aii��r� s'1���_F'1Hi�.'�]�f:�.".o�.�P'%;."='�y�: °iF?'^.T.�I::�c — �.?F. We certify that the 'et tinge;e cr at>veafel, a��;; h ? e err r limo C tX�ct abuse n C nc Or Name] C .� [Organization's does not have any overdue tax debts, as defined by N.C.G.S. 105-243.1, at the federal, State, or local level. We further understand that any person who makes a false statement in violation of N.C.G.S. 143C-6-23(c) is guilty of a criminal offense punishable as provided by N.C.G.S. 143C-10-1. Sworn Statement: Jeri€er, gar ? name of Board Chair and vGea1' g �`: n ,:n�:^s.a.-•- ` � � ] .-w".•�� ��ra[name Of SeCd d AU thorizing Official] being duly sworn, say that we are the Board Chair and ec,ut uj treEta}[Title of the Second Authorizing Official], respectively ?4x'"!�:s? '"y` ?t�1-�;r;,•,�'T's!�:Pi�Fi �eiti"i:d�y,rr'�:,-u?�:y, "- ," a rLsll--y ��ay'„tlhs'-- of f E it a �l C n er a e� , eye t a ;a iNta tl t f. Enc(Organization's Name]of 19 �-ti*-•RF ki3Yr c i is b . alem[City]in the State of [state], and that the foregoing certification is true, accurate and complete to the best of our knowledge and was made and subscribed by us. We also acknowledge and understand that any misuse of State funds will be reported to the appropriate authorities for further action. °P--a"--- Jaime E Ledbetter Siena Date NOTARY PUBLIC Forsyth County, NC •lam . �� ! ` "• 17 Seco . Authorizing Official, in.ture Date ON Y� [�j/� .siA =4.� u>3w!.'.n 3s:n,�-n:i4 ON `AlunQ3 inASJOO EKe u5] cOprreq�to 01181141 ` Title of Second Authorizing Official � wie da�agpa'� � ea�l>~r Sworn to and subscribed before me on the day of the date of said certification. i ! . . '` My Commission Expires: l 0f/iSf L� (Not-ry Signature and Sear 1 If there are any questions, please contact the Department of Public Safety that funded the program agreement. If needed, you may contact the North Carolina Office of State Budget and Management, NCGrants®osbm.nc.gov- (919) 807-4795 G.S. 105-243.1 defines: "Overdue tax debt.-Any part of a tax debt that remains unpaid 90 days or more after the notice of final assessment was mailed to the taxpayer.The term does not include a tax debt, however, if the taxpayer=entered into an installment agreement for the tax debt under G.S. 105-237 within 90 days after 1#NCD Fow;i:. A NV' Lily 1,2005 Revised July 18 2006 7/07 9/08;7110 i is form• r' '�. ectronic format(Microsoft Word document)at http://ncarts.org/grants/grant-forms/ y3' Nationa/Exchange Club Foundation For The Partially funded by Prevention of Child Abuse United Way DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 1 - ACOREP CERTIFICATE OF LIABILITY INSURANCE [SATE(rAM106lYYYY)6/23/201.7 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(tes) must be endorsed. If SUBROGATION 1S WAIVED,subject to Me terms and conditions of the-policy,certain policies may require an endorsement. A statement on this certificate dons not confer rights to the certificate holder In lieu of such endorsement(s). , PRODUCER C rrACT Traoie Hawkins NAME; The Phoenix Company, LLC F1210,Fxn: (336)765-9332 IMa,NO(336)765-7191 P.O. Box 26396 aonFIlE„,tracieh @thephoers.ixaompany.com INSURER(S)AFFORDING COVERAGE NAIL A Winston-Salem NC 27114.6396 €NSURERABerkshire Hathaway Specialty 22276 INSURED INSURER BWe9C0 Insurance Company 25011 Exchange Club Center for the Prevention of INSURER C: Child Abuse of North Carolina INSURER D: 500 West Northwest Boulevard INSURERE: Winston--Salem NC 27105 INSURER E: _ COVERAGES CERTIFICATE NUMBER:CL17 51 64 642 REVISION NUMBER: '-s 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 INSR Vain POLICY NUMBER (MM!DDIYYYY1 (MM)DD!YYYYI GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence)rental S 1,000,00 0 .,, A CLAIMS-MADE Fd OCCUR 47SPK14916102 4/12/2017 4/12/2018 MED EXP(Any ane person) $ 20,000 PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 11 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 3,000,000 ( I POLICY Tim PRO [ LOC b AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) S 1,000.000 A X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED ■SCHEDULED 471=14916202 4/12/2017 4/12/2018 BODILY INJURY(Pea accident) $ ' HIRED AUTOS © NON-OWNED OS (PerraEdRdnnt)dMAGE $ $ UMBRELLA L1AB _OCCUR EACH OCCURRENCE 3 EXCESS LIAB CLAIMS-MADE AGGREGATE $ . DED I I RETENTIONS $ WORKERS COMPENSATION x I WC STATU• I 10T11- AND EMPLOYERS'LIABILITY Y!N TORY LIMITS I ER WWC3259691 1/27/2017 1/27/2018 E.L.EACH ACCIDENT $ 100 000, ANY PROMEMBERtEXCLUDRlF>(ECUTIVE I N N 1 A L OFFICERIMEMBER ER ExDLUD6D7 - B (Mandatory In NH) 'E.L.DISEASE-EA EMPLOYEE 5 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below -EL DISEASE-POLICY LIMIT,$ 500,000 A Professional Liability 47SPK14916102 4/12/2017 4/12/2919 $1.0o0,000 Each incldeni $3,000,000 Ag A Abuse/Molestation Liab. • 47sPK14916102 4/12/2017 4/12/2018 $100,000 Each Event $300,000 Aggr DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If mere space is required) [ Ii 1 I CERTIFICATE HOLDER CANCELLATION j (336)7149367 adavis@cphs.org SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE § THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. I CenterPoint Human Services • ' Attn; Anne Davis ) 4045 University Parkway NORIZEDREPRESENTATIVE I AUT Winston--Salem, NC 27106 1 T Hawkins, CISR/HATTlC2 u , ACORD 25(2010105) @1988-2010 ACORD CORPORATION. All rights reserved, ,/ INS025I7nsnnnenl The.Arnizn Hama and innn a,A,Arne+Arcri marks nr Ar_r1R17 I 1 9 a 7