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HomeMy WebLinkAbout2017-478-E Finance - Chapel Hill-Carrboro Public School Foundation - Outside Agency Performance Agreement DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 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 Chapel Hill-Carrboro Public School Foundation, a not-for-profit corporation, located at 750 South Merritt Mill Road, Chapel Hill,NC 27516 ("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 Chapel Hill-Carrboro Public School Foundation agree as follows: 1. Term of the Agreement. The tenn 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 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 563 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 140.75. 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. (Chapel Hill-Carrhoro Public School Foundation) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 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 13 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. (Chapel Hill-Carrhoro Public School Foundation) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 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. (Chapel Hill-Carrhoro Public School Foundation) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 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 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 Chapel Hill-Carrboro Public School Foundation 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: (Chapel Hill-Carrhoro Public School Foundation) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 County: Finance &Administrative Services Provider: Chapel Hill-Carrboro Public Orange County School Foundation Post Office Box 8181 750 South Merritt Mill Road Hillsborough,NC 27278 Chapel Hill,NC 27516 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. 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 http://www.orangecountync.gov/departments/purchasing_division/contracts.php). Any 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 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 shrh fof the Provider 8/31/2017 0C298F75CF6B475... , Date (Chapel Hill-Carrhoro Public School Foundation) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 rFora ..,> of Orange County Government bl AAA,it, ikam tMt..rstu1 9/5/2017 �1"]OOA R7-5. "]7... Bonnie Hammersley, County Manager Date (Chapel Hill-Carrhoro Public School Foundation) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FY 2017-2018 Outside Agency Funding Application HUMAN SERVICES • ORANGE COUNTY • TOWN OF CARRBORO • TOWN OF CHAPEL HILL Orange County (OC) Town of Carrboro (CA) Town of Chapel Hill (CH) 200 S. Cameron Street 301 W. Main Street 405 Martin Luther King, Jr. Blvd. Hillsborough, NC 27278 Carrboro, NC 27510 Chapel Hill, NC 27514 041, too rotilN O b - ark 7 • I ' . • A� My �'`*•;;,CA q.. '9P .r DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1"- FOR OFFICE USE ONLY Agency: Chapel Hill-Carrboro Public School Four( I Received By Program(s): After School Tutoring; Blue Ribbon N Date/Time / , Advocate Section Subsection 1. Cover Page a. x Applicant Contact Information b. x Funding Requests c. x Signed Application Cover Page d. x Signed Disclosure of Conflicts of Interest and Clause 2. Agency Information a. x Agency's Years in operation b. x Agency's Purpose/Mission c. x Agency's Types of Services Provided d. x Agency's Experience with Programs e. x Other Pertinent Agency Information f. x Schedule of Positions g. x Living Wage h. x Agency Budget 3. Program Information a. x Human Services Needs Priority b. x Type of Program A separate Section 3 is C. x Agency Collaboration required for each program. d. x Summary of Program e. x Description of Identified Need f. x Description of Population to be Served g. x Program Staffing, Capacity, & Expertise h. x Program Implementation Timeline I x Value of Investment j. x Impact of Reduced/No Allocation k. x Other Pertinent Information I. x Target Population/Beneficiary Chart m. x Work Statement n. x Program Budget, Detail, &Cost per Individual 4. Attachments a. x 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. x IRS Federal Form 990 c. x NC Solicitation License d. x IRS Federal Tax-Exemption Letter e. x Certificate of Insurance f. x List of Board of Directors g. x Solid Waste Program Fee (SWPF)Verification Application Submittal Checklist 1/27/2017 10:08:56 AM P a e 5 of 22 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Chapel Hill-Carrboro Public School Foundation Applicant Organization's Physical Address: 750 S. Merritt Mill Road, Chapel Hill, NC 27516 Applicant Organization's Mailing Address: P. 0. Box 877, Carrboro, NC 27510 Applicant Organization's Web Address: www.publicschoolfoundation.orq Executive Director: Lynn Lehmann Telephone Number: 919-968-8819 E-Mail: Ilehmannchccs.k12.nc.us Tax ID Number: b) Funding Request List all FY17-18 Human Services (HS) Funding Being Requested - For All Programs) and the Proposed Use of Funds (2-3 lines or less) Program Carrboro Chapel Orange, Total, - HS Hill -HS County-HS Youth Afterschool Tutoring Program for Economically $840 $11,160 $0 $12,000 Disadvantaged Students Who Need Assistance in Reading and/or Mathematics Blue Ribbon Youth Leadership Institute $1,875 $4,500 $1,125 $7,500 Totals $2715 $15,660 $1,125 $19,500 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. ,_ / - 3°- / 7 Signature: Executive Director Date SignaturLi/ IL - A ' (0-, or I - 30 -IT B•ard C airperson Date AGENCY INFORMATION 1/27/2017 10:33:14 AM Page * of 2 2 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 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 0 X a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? 0 X b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? 0 X c) Current beneficiaries of the program for which funds are being requested? 0 X 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. NON-DISCRIMINATION 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. Signature: - 30 - i 7 Executive Director Date Signature-ALAA / -3(7 - Beard C -irperson Date AGENCY INFORMATION 1/27/2017 10:08:56 AM Page 7 of 22 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 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): 33 years in operation; incorporated November 30, 1983 b) Agency's Purpose/Mission (no more than a few sentences): Creating opportunities for students and teachers c) Types of Services the Agency Provides (bullet format): • The Chapel Hill-Carrboro Public School Foundation (PSF) is both a fundraiser and a grant-maker. • In order to fund our grant programs, we apply for grants that we can then re- grant, receive donations from local businesses and donors, and also have endowments that generate funds for our five grant categories. • Over $180,000 was distributed to teachers, principals, and staff in our school district last year through the grant programs. • PSF also hosts a number of fundraising events, including a Walk for Education, which mobilizes community support and enables schools to generate funds for their needed programs. Through the Walk for Education, over $100,000 was raised by individual schools in the Chapel Hill-Carrboro City Schools District in 2015-16 for their own use. We operate a Teacher Supply Store in partnership with the East Chapel Hill Rotary Club and provide free school supplies to teachers for use by their students in the classroom—a $75 value to each teacher who participates. Our 5K for Education targets teachers and staff, in addition to parents, students, and community members, and generates funds for CHCCS schools and PSF grants. The "Teachers First Breakfast and Roses" kicks off Teacher Appreciation Week every year with a wonderful breakfast for teachers and staff. Funds raised--over $90,000 last year--are used for teacher programs. • PSF has eleven endowed teaching chairs that allow us to recognize our outstanding teachers annually. • Additionally, we received funds through annual Board Campaigns and direct mail campaigns. d) Agency's History with Providing These Services: The Public School Foundation submits and receives grants for numerous educational programs annually and acts as the overseeing agent for the implementation of these programs. Specifically, PSF has funded after school tutoring at various Chapel Hill-Carrboro city Schools on some level since the creation of our Achievers' Fund in 2011. e) Other Pertinent Agency Information: The Chapel Hill-Carrboro Public School Foundation (PSF) is the only independent, non-profit organization that is dedicated to mobilizing community support for the Chapel Hill-Carrboro City Schools. We are fundraisers and grant makers. We believe that all students deserve the best possible education and that teachers are our most valuable resource. PSF is the fiscal agent for the Blue Ribbon Mentor Advocate Program, but does not have authority over the programming. 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 Equivalent for all recorded volunteer hours using the following: Agency Information 1/27/2017 11:05:52 AM Page 8 of 2 2 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Total Volunteer Hours=Volunteer FTE 2,080 # of FTE - Full-Time Paid Positions: 1 # of FTE - Paid Part-Time Positions: 3 # of Volunteers: 30 # 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? Yes If no, please explain. Agency Information 1/27/2017 10:08:56 AM Page • of 22 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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) Yes 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 FY17-18 Source Award Request Family Reading Partners $2874 $0 Chapel Hill-CDBG Grant `Add rows or attach additional page, if needed. ii. 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). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues o Private Donations o Program Generated Revenue o Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services Agency Information 1/27/2017 10:08:56 AM Page 1 0 of 2 2 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Orange County Other(DO NOT Include HOME funding here) o Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG/HOMEIetc.) • Private Foundation Grants o Other Revenue • Expenditures o Compensation o Rent & Utilities o Supplies & Equipment o Travel &Training o Other Expenses iii. Does your agency budget show a Surplus or Deficit? No Is there a significant change? Yes/No No Please provide a brief explanation for Surplus or Deficit, and significant changes. iv. What is your agency's fiscal year? July 1, 2016 through June 30, 2017 (Example: July 1, 2016 through June 30, 2017) Agency Information 1/27/2017 10:08:56 AM Page 1 1 of 2 2 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Chapel Hill-Carrboro Public School Foundation Actual Estimated Projected Percent AGENCY REVENUE 201646 2016-17 1 201748 Change Private Donations $315,740.00 $284,000.00 $310,000.00 9% Agency Generated Revenue(fees) $12,488.00 $7,000.00 $8,000.00 14% Local Government Grants: 111111111111111111111111111111111 Human Services-Town of Carrboro $0.00 $0.00 $840.00 0 Other-Town of Carrboro $0.00 $0.00 $0.00 0 Human Services-Town of Chapel Hill $0.00 $0.00 $11,160.00 0 Other-Town of Chapel Hill $0.00 $2,847.00 $0.00 -100% Human Services-Orange County $0.00 $0.00 $0.00 0 Other-Orange County $0.00 $0.00 $0.00 0 Other-Town of Hillsborough $0.00 $0.00 $0.00 0 Other Government Grants 11.1111111111111 Triangle United Way $0.00 $0.00 $0.00 0 State Government $0.00 $0.00 $0.00 0 Federal Government(CDBG/HOME/etc.) $0.00 $0.00 $0.00 0 Private Foundation Grants $0.00 $0.00 $0.00 0 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIMIII Other Revenue $27,977.00 $30,000.00 $25,000.00 $ 0.17 Total Agency Revenue $ 356,205 $323,847.00 $355,000.00 10% AGENCY EXPENSES Compensation $ 113,561 $ 123,000 $ 128,000 4% Rent& Utilities $ 838 $ 900 $ 1,200 33% Supplies& Equipment $ 1,401 $ 1,500 $ 2,000 33% Travel &Training $ 1,200 $ 1,000 $ 1,500 50% Other Expenses: $ 209,443 $ 198,200 $ 217,800 10% Total Agency Expenses $ 326,443 $ 324,600 _ $ 350,500 8% SURPLUS/(DEFICIT) FOR PERIOD: $ 29,762 I $ (753)J $ 4,500 I 698%l FY 2015-16 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Youth Afterschool Tutoring Program for Economically Disadvantaged Students Who Need Assistance in Reading and/or Mathematics Program Primary Contact and Title: Nancy Zeman Telephone Number: 919-967-8211 x28376 E-Mail: nzeman@chccs.kl2.nc.us a) Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area #1: safety-net services for disadvantaged residents X❑ 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 Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare Education X Family Resources Jobs/Jobs Training Food Transportation Other: Afterschool 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. • PSF coordinates with the Chapel Hill-Carrboro City School District (CHCCS) to provide the services. Students are identified by teachers/staff and receive instruction afterschool by certified staff at their home school facilities. • PSF is a partner with Family Success Alliance and collaborates to identify students in Zone 6 schools who need tutoring assistance in math and/or reading. 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 PROGRAM INFORMATION 1/27/2017 11:05:26 AM Page 1 2 of 2 2 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Town/County priority/goal? The afterschool tutoring program specifically addresses the following priority: To fund education, mentorship, and afterschool programming, for about 85 youth facing a variety of challenges. The youth who will be served in this program are ones who come from low-income families and who are non-proficient or borderline proficient in reading and/or mathematics. By providing them with small group tutoring afterschool sessions, the hope is that these students will gain skills that will make them proficient in subject areas for their grade level by the end of the 2017-18 school year. 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 Board Priorities, 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. The Chapel Hill Human Services Needs Assessment lists education as one of the top six human services needs. The report states that, while Chapel Hill-Carrboro is known for its excellent public school system, participants in the assessment felt "the education system and network of family services is not meeting the needs of all children and families. The report further outlines, under the "Quality, equitable education for all" section that the "public school system is not adequately equipped to effectively teach and support at-risk youth and LEP [Limited English Proficient] students". The Town of Chapel Hill Goals state that "creating a place for everyone" and "nurturing our community" are two priorities. The Carrboro Board of Aldermen outlined that their ultimate goal is "creating and maintaining Carrboro as a sustainable community that is a highly desirable place to live". By providing free afterschool tutoring with certified teachers to at-risk students in their home schools, this program will address the needs and goals outlined above. The smaller student-to-teacher ratio in the afterschool settings will provide for a nurturing environment where instruction can be better adapted to individual student learning styles. Tutoring will increase proficiency levels in reading and mathematics for these struggling students, making them more successful academically, and ultimately making them more qualified for college and/or jobs in the future. Data show that success in school is a key indicator for success and happiness in life as an adult, a dream we have for all the children in our community. 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 for this program is at-risk students who are one or more grades below their peers in reading and math abilities. The majority of these children will be from low-income households, from minority populations, and many will be from homes where English is not the main language that is spoken. Students will be identified by their teachers, guidance counselors, or other school staff as ones who would benefit from additional afterschool instruction. The majority of PROGRAM INFORMATION 1/27/2017 11:04:56 AM P - ge 13 of 2 2 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION students will be in elementary school; some will be middle school students. Standardized test scores and reporting will be used as indicators. 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 Public School Foundation Program Services Manager (PSM) will oversee the requests for specific funding from different schools for the afterschool tutoring funding. The current PSM has been in this position for over a year and has been a grant proposal reviewer and implementer for over 20 years. The teachers/staff who will implement the afterschool tutoring programs at the individual schools are all state-certified elementary and middle school educators. Many have specific training, especially in literacy (ex. Understanding by Design, Institute for Learning-Principles of Learning, Reading Recovery, Augustine Literacy training). h) Describe the specific period over which the activities will be carried out and include an implementation timeline. A request for proposals for afterschool programming for the 2017-18 will have three deadlines: April 30, 2017; September 30, 2017; and January 31, 2018. Afterschool programs will occur throughout the 2017-18 school year, with evaluations and reports due June 2018. 1) 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) In a recent publication in the NY Times (April 2016), the Chapel Hill-Carrboro City School District was reported to have the second highest achievement gap (i.e., the gap between academic achievements of white students versus students of color) in the nation. In 2014-15, 42 percent of black students and 47 percent of Latino students passed end-of-grade and end-of-course tests, compared to over 90 percent of white students in the CHCCS District. Research analyzing data from across the country confirms that socio-economic status plays the biggest role in predicting how students will do in school. Research further shows that purposeful afterschool tutoring is a good way to help at-risk students connect the classroom to the real world, build relationships with school staff, and extend their limited experiences—all things that can work to narrow the achievement gap. By providing tutoring opportunities to these children, narrowing the achievement gap, and having our most fragile students be successful in school, we create a more equitable community. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. If funding is not awarded (or if a reduced allocation is recommended) then the PROGRAM INFORMATION 1/27/2017 11:04:56 AM Page 14 of 22 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION struggling, at-risk students from low-income households in our community would have limited opportunity for outside support beyond what they are receiving in school. These students would likely stay non-proficient or borderline proficient as they progress through school; have a reduced chance for success in school and for college attendance; are at an increased risk to drop out of school; will have reduced self-confidence and self-esteem as the timeframe of their lack of academic success is extended; and have a more limited range of career/job opportunities in their futures. k) Include any other pertinent information. PROGRAM INFORMATION 1/27/2017 11:04:56 AM Page 15 of 22 DocuSign Envelope ID: oo-98o*3oe55r3Ao8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Proqram Information I) Target Population Complete the following tabiee, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Actual Estimated Projected 2015'10 2010-17 2017-18 Gender Male 27 35 45 Female 23 31 40 Total 50 66 85 Ethnicity African-American 16 20 28 American Indian or Alaska Native 0 Asian 15 20 25 Caucasian 2 3 5 Native Hawaiian or other Pacific Islander Other: specify_Hispanic 17 23 27 Total 50 68 85 Of the above, how many Hispariic/Latino 17 23 27 Of the above, how many non-Hispanic/Latino 33 43 58 Total 50 66 85 Age 0-5 years 6-18 years 50 66 85 19-50 years 51+ years Total 0 0 0 Geographic Location Alamance County Chatham County Durham County Wake County Orange County Breakdown Chapel Hill Public Housing °20 25 35 Town of Chapel Hill (Non-Public Housing) °28 37 44 Town of Carrboro *4 4 6 Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) • A guestimate Total ~50 66 85 PROGRAM INFORMATION 1/27/2017 11:04:11 AM Page 1 � of 2 2 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 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 learn 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. (i.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 Youth Afterschool Tutoring 1. Program Activity Name Provide afterschool tutoring to low-income, at-risk students Program Goal At least 85 children will be served over the course of the school year Performance Measures We will track the number of students served Previous Year Program Results At least 50 children served Current Year Estimated Results At least 66 children served Next Year Projected Results At least 85 children served 2. Program Activity Name Increase proficiency of low performing students Program Goal At least 75% of students in the program will be proficient in reading and/or math by the end of the program. Performance Measures Standardized tests Previous Year Program Results Not available Current Year Estimated Results At least 75% of students in the program will be proficient in reading and/or math by the end of the program. Next Year Projected Results At least 75% of students in the program will be proficient in reading and/or math b the end of the •ro•ram. 3. Program Activity Name Show growth in subject areas for all students Program Goal All students will show growth in their math and/or reading abilities Performance Measures Standardized tests Previous Year Program Results Not available Current Year Estimated Results 1 All students will show growth in their math and/or reading abilities Next Year Projected Results All students will show growth in their math and/or reading abilities 4. Program Activity Name Increase self-confidence of low-performing students Program Goal Increase confidence of all students in their reading and/or math skills Performance Measures Anecdotal evidence from tutors and teachers Previous Year Program Results Not Available PROGRAM INFORMATION 1/27/2017 10:08:56 AM Page 17 of 2 2 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Current Year Estimated Results All students show increased confidence in math and/or reading Next Year Projected Results All students show increased confidence in math and/or reading PROGRAM INFORMATION 1/27/2017 10:08:56 AM Page 18 of 22 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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: • Revenues o Private Donations o Program Generated Revenue o Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other(DO NOT Include HOME funding here) o Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG/HOME/etc.) • Private Foundation Grants o Other Revenue • Expenditures o Compensation o Rent & Utilities o Supplies & Equipment o Travel & Training o Other Expenses 2. Program Budget Detail — Provide description of"other" budget items, not defined. 3. This program budget represents what percent of the agency budget? 3.3% 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. Actual 2015-16 Estimated 2016-17 Projected 2017-18 _Total Cost of Program $10,000 $12,000 Total #of Individuals 66 85 Cost Per Individual $151.51 $141.18 PROGRAM INFORMATION 1/27/2017 10:08:56 AM Page 1 9 of 2 2 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Afterschool Tutoring Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $0.00 $0.00 $0.00 0 Program Generated Revenue $0.00 $0.00 $0.00 0 Local Government Grants: Human Services-Town of Carrboro $0.00 $0.00 $840.00 0 Other-Town of Carrboro $0.00 $0.00 $0.00 0, Human Services-Town of Chapel Hill $0.00 $0.00 $11,160.00 0 Other-Town of Chapel Hill $0.00 $0.00 $0.00 0 Human Services-Orange County $0.00 $0.00 $0.00 0 Other-Orange County $0.00 $0.00 $0.00 0 Other-Town of Hillsborough $0.00 $0.00 $0.00 0 Other Government Grants Triangle United Way $0.00 $0.00 $0.00 0 State Government $0.00 $0.00 $0.00 0 Federal Government(CDBG/HOME/etc.) $0.00 $0.00 $0.00 0 Private Foundation Grants $0.00 $0.00 $0.00' 0 Other Revenue $0,00 $0.00 $0,00 0 Total Program Revenue $0.00 $0.00 $12,000.00 0 PROGRAM EXPENSES Compensation $0.00 $0.00 $12,000.00 0 Rent& Utilities $0.00 $0.00 $0.00 0 Supplies&Equipment $0.00 $0.00 $0.00 0 Travel &Training $0.00 $0.00 $0.00 0 Other Expenses: $0.00 $0.00 $0.00 0 Total Program Expenses $0.00 $0.00 $12,000.00 0 SURPLUS/(DEFICIT) FOR PERIOD: $ - I $ - I $ - I 0 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Blue Ribbon Youth Leadership Institute Program Primary Contact and Title: Lode L. Clark, Blue Ribbon High School Specialist Telephone Number: 919-918-2170# 2 E-Mail: Iclark(a�chccs.k12.nc.us a) Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area #1: safety-net services for disadvantaged residents X 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 Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare Education X Family Resources Jobs/Jobs Training Food Transportation Other: Youth Leadership/ Mentoring 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. • Chapel Hill-Carrboro City Schools —all students are enrolled in CHCCS • Habitat For Humanity—students volunteer for various projects with Habitat, especially A Brush with Kindness which focuses on local repair. • Rogers-Eubanks Neighborhood Association (RENA) — Students have participated in various service events at RENA. Ongoing projects include the Fall Festival, Spring and Community Festival. • Dignity in Schools —focuses on school-to-prison pipeline issues and advocacy training for students PROGRAM INFORMATION 1/27/2017 2:16:38 PM Page 1 1 o f 2 2 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 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? Blue Ribbon seeks funding assistance for the Youth Leadership Institute (YLI) which will address Priority Area #2. Our mission is to improve the achievements of students of color. YLI targets African-American and Latino students. We also serve a small group of Burmese/Karen students; however, the program is open to all high school students including White, Asian, Middle Eastern, Pacific Islander, Native Americans and other multiracial students. Students in Blue Ribbon Mentor-Advocate program are required to participate in YLI in high school. Students have support from mentors and advocacy through our program to help them become global leaders. In many cases, YLI appeals to students who do not otherwise have positive extracurricular engagement. YLI provides a positive and safe environment where students can develop their voice, learn advocacy and leadership skills, and experience a positive atmosphere with like-minded peers. Our program takes place during students' lunch period, afternoons, evenings, weekends, and teacher workdays. We also host a summer leadership weekend camp for students. We provide two separate camps and our goal is to train at least 100 high school students in leadership areas. 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 Board Priorities, 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. The Blue Ribbon Mentor-Advocate program targets African-American and Latino (currently we serve a small number of Burmese/Karen) students in the Chapel Hill- Carrboro City Schools where our district has a significant achievement gap. Blue Ribbon begins working with students in 4th grade until their first year in college. YLI students have been examining the discipline disparity for students of color. According to the Department of Education's Civil Rights Data Collection, students in one of the CHCCS high schools has the following statistics: Enrolled: White - 54%, Black (African American) - 12%, Hispanic - 13.9% In School Suspensions: White — 33%, Black (African American) - 37.8%, Hispanic —24.4% Out of School Suspensions: White — 25.0%, Black (African American) — 47.7%, Hispanic — 18.2% (Department of Education Civil Rights Data Collection- http://ocrdata.ed.gov/Page?t=s&eid=238948&syk=7&pid=732&Report=6) Youth Leadership Institute is an expansion of Blue Ribbon-Mentor Advocate and allows us to serve high school students who are not in the mentoring program. Students in our program often are identified as having great potential but may not possess the skills, confidence, or opportunities to create change. One of the PROGRAM INFORMATION 1/30/2017 9:04:17 AM Page 12 of 22 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION methods to address these challenges is to engage students in on-going leadership and service-learning opportunities. Opportunities are provided to students through leadership training and local service-learning. Students are able to assume leadership roles in this organization that they may not participate in otherwise. Service-learning activities give students social and cultural exposure experiences to find real-world relevance for things they are learning in school, and give them meaningful experiences to share on their college applications. We believe that providing students with these opportunities will allow them to become successful in school and beyond. These opportunities allow them to develop leadership skills within their schools and communities. The program has been operating successfully since 1999. 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 Youth Leadership Institute serves high school students of color and specifically targets African American and Latino students (we serve a small amount of Burmese/Karen students). However, the program is open to all high school students and includes White, Asian, Middle Eastern, Pacific Islander, and multiracial students. All high students in Blue Ribbon Mentor-Advocate participate in YLI. Other students are referred to the program through school family specialists, counselors, community members, and parents. Students are also recruited through school club recruitment fairs. Any student who wishes to participate in the YLI program may do so. Students will participate in a summer youth leadership weekend camp at Camp New Hope, Chapel Hill, NC. Students will develop leadership skills that will empower them to use their voice and create change for all students. Once the school year begins, students will meet bi-monthly at their school during lunch. Each month, students are encouraged to participate in a local service-learning project. Students who attend at least 10 YLI meetings during lunch and complete at least 10 YLI service-learning projects are eligible for the alternative spring break trip outside of North Carolina. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Lorie Clark, the BRMA High School Specialist, plans and implements activities for Youth Leadership Institute. There is also an AmeriCorps Member who is employed full-time through the AmeriCorps program who assists with programming for students and supervises an evening tutorial at a local community center. Both provide workshops to students during their lunch periods and check in with students as they progress towards post-secondary opportunities. They provide mentoring and support to high school students. Additionally, they plan college tours, an alternative spring break trip, and cultural and enrichment opportunities for students. Activities are carried out at all four CHCCS district high schools and service sites. PROGRAM INFORMATION 1/30/2017 9:08:16 AM Page 13 of 2 2 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION h) Describe the specific period over which the activities will be carried out and include an implementation timeline. Each year students complete 12-15 service-learning projects in the local community. Students identify these areas of community need during their summer institute. Staff plans the logistics for the project along with the community partner. Students use their leadership skills to implement the project. 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) When we invest in the education and enrichment of students, we are creating global leaders and civic-minded citizens. Many of our students receive free-or-reduced lunch. Sometimes it is not possible for them to pay the $75 registration fee for summer leadership camp. For many students this is the first time they have attended an overnight camp. Although summer camp is only a weekend, it provides rich resources and options for extending summer opportunities and growth. Students who become a part of the YLI community have access to a number of local, national and international opportunities. Once they leave camp, they feel empowered and ambitious. They have a better understanding of the issues in our community, how to identify needs, and the value of partnering with agencies. Without the support of this grant, Blue Ribbon would not be able to provide partial and full scholarships to students in need. Ninety percent of the students who attend camp request some type of funding to support their participation. When students learn I-CAR (integrity, compassion, accountability, responsibility) principles taught at YLI camp, they realize the value of making sure their community is a great and safe place to live; they are invested and see the impact of making a difference. Funding would also support our annual alternative spring break trip. Over 85% of our YLI students have never experience travel outside of North Carolina. Spring break travel--although a reward for participation--is much more than that! Spring break travel consists of: college tours, service-learning projects and enrichment. Blue Ribbon typically tours a PWI (Predominately White Institution); HBCU (Historically Black College or University); and a private institution. (Blue Ribbon sponsors at least two other college tours within our state each year.) Over 75% of students who attend the alternative spring break trip request partial and full scholarships. YLI students will request data on the number of students enrolled in AP (Advanced Placement) and Honors classes, and will work to increase those numbers. Students who develop their voice, whose eyes are open to issues and injustices, become caring and committed to changing the environment in which they live. Finally, the funding supports our service projects. Once students identify a need, we partner with local agencies in the area to fulfill their needs. Students have volunteered in urban gardens, food banks and protected environmental parks. Blue Ribbon believes that enrichment is vital to learning. We plan to include museum tours, walking tours, and exploring local eateries as part of their exposure experiences. PROGRAM INFORMATION 1/30/2017 9:08:16 AM Page 1 4 of 2 2 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION YLI is a magical journey, a sure way to make a difference and give back. Kyesha Clark, Senior, Carrboro High School i) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. If Blue Ribbon does not receive funding, we would not be able to take the anticipated number of students on the spring break trip (40) or have funding for our goal of training at least 100 students at the summer leadership camp. j) Include any other pertinent information. Blue Ribbon Mentor-Advocate is a comprehensive support program for students of color in the Chapel Hill-Carrboro City Schools (CHCCS). Our program identifies students in fourth grade and provides them with academic and enrichment support through high school graduation and enrollment in post-secondary education. In response to the CHCCS district's significant achievement gap, Blue Ribbon Mentor-Advocate targets low-income African-American, Latino, Burmese, and Karen students in our schools. Unfortunately, race and socioeconomic status are two of the strongest predictors of student achievement in the school district. While 97% of white students in grades 3-8 are proficient in reading and math, only 66% of African American students and 70% of Latino students score at the proficient level. While 91% of white high school students are proficient in state End-of-Course tests, only 46% of African American students and 60% of Latino students match that level. Graduation rates from high school follow a similar trend with Whites graduating at a rate of about 95%, and only about 75% for African Americans and Latinos. This affects a significant percentage of our student population overall as about 50% of the 11,900 students in the CHCCS district are racial and ethnic minorities this school year. Mentoring is at the core of our program's intervention model, and we have learned how to create long-lasting, successful mentoring relationships. Our model emphasizes starting early with students and supporting them through high school graduation and college enrollment. Over 90% of our mentoring relationships last at least two years. More than 60% of our graduates have had the same mentor from enrollment in 4th grade through their high school graduation. We provide extensive training and support to all of our mentors. We monitor their progress with an evaluation that compares the quality of each mentoring relationship to nationally recognized benchmarks for quality and effectiveness. Over the nine years that students are involved with BRMA, the program provides an array of enrichment experiences designed to help students explore and develop strengths that will move them toward post-secondary education. These activities include social and cultural enrichment, academic support, college and career PROGRAM INFORMATION 1/30/2017 9:08:16 AM Page 15 of 22 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION exposure, and leadership development. When the students graduate from high school, BRMA provides them with a college scholarship that is supported by over 150 local donors. In general, we bring in an average of 20 new students per year, with about 2/3 of those students being female because the pool of female mentors is larger (we only make same-gender mentor-mentee matches). Given the documented success of BRMA and our current plans for program development, we believe continued funding from the Human Services grants will help us to make significant impacts on the lives of individual students while simultaneously improving district success indicators such as high school graduation and post-secondary enrollment rates. Additional Program Information k) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male 40 45 45 Female 60 55 55 Total 100 100 100 Ethnicity African-American 30 35 40 American Indian or Alaska Native 0 0 0 Asian 10 10 10 Caucasian 10 10 10 Native Hawaiian or other Pacific Islander 0 0 0 Other: specify Multiracial 50 45 40 Total 100 100 100 Of the above, how many Hispanic/Latino 40 50 50 Of the above, how many non-Hispanic/Latino 60 50 50 Total 100 100 100 Age 0-5 years 0 0 0 6-18 years 100 10 100 19-50 years 0 0 0 51+ years 0 0 0 Total ^ 100 100 100 Geographic Location Alamance County 0 0 0 Chatham County 0 0 0 PROGRAM INFORMATION 1/30/2017 9:08:16 AM Page 16 of 22 DocuSign Envelope ID: oo-98o*3oe55r3Ao8E5 EXHIBIT A PROVIDERS OUTSIDE AGENCY APPLICATION Durham County 0 0 0 Wake County 0 0 0 Orange County Breakdown Chapel Hill Public Housing 3 5 5 Town of Chapel Hill (Non-Public Housing) 64 58 55 Town of Carrboro 23 25 25 Town of Hillsborough 0 City of Mebane (Orange County) 0 Orange County (Outside K8unicipm|ities) 10 12 _ 15 Total 100 100 100 Work Statement I) 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, Measurab/e, Achievable, Relevant, and Time-bound. Click on SMART Goals to learn 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. (i.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 rnet, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program Blue Ribbon Mentor-Advocate Youth Leadership Institute 1. Program Activity Name Youth Leadership Summer Camp Program Goal Students will receive leadership training that will give them the skills and confidence to participate in a myriad of school and civic youth clubs/organizations. Performance Measures 100 students will actively participate in YLI and either a school club or community organization Students will understand and adhere to the mission and goals of such organizations. Previous Year Program Results Students shared information about the benefits of participating in various clubs and organizations Current Year Estimated Results More students of color will participate in school and civic clubs. For example, take a leadership role in student and class councils and town advisory boards. Next Year Projected Results More students of color will have a presence in school o|uba, councils and to n adviso boards 2. Program Activity Name YLI Alternative Spring Break Program Goal Students will be exposed to providing service outside of North PROGRAM INFORMATION 1/30/2017 9:08:16 AM H G g B 1 7 of 2 2 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Carolina and touring colleges Performance Measures Students will actively participate in YLI to meet the leadership requirements to attend the alternative spring break trip. Previous Year Program Results Over 30 students participated in the alternative spring break trip to Washington, DC Current Year Estimated Results At least 30 students will participate in the alternative spring break trip, understand the college process and understand the benefits of campus tour, develop an appreciation of enrichment activities. Next Year Projected Results Blue Ribbon will increase the number of students participating in YLI and the alternative s•rin. break tri.. 3. Program Activity Name Student Voice/Advocacy Program Goal Students will use their voice and experiences regarding injustices in their school community. Performance Measures Students will request data from central office and their school; survey students and make recommendations. Previous Year Program Results Students will share information with their peers; create a plan for more students of color to enroll in Honors & AP classes and present recommendations to the School Board. Current Year Estimated Results More students of color will enroll in Honors and AP classes Next Year Projected Results Increased enrollment will decrease the sense of isolation that the few students of color feel in Honors &AP classes 4. Program Activity Name Solutions Not Suspensions --- ------------- Program Goal To reduce ISS/OSS for students of color Performance Measures Students will review the district suspension data Previous Year Program Results Students will modify the student code of conduct and make recommendations to the School Board. Current Year Estimated Results Students who are suspended at high rates will receive less punitive punishments and more classroom instruction. Next Year Projected Results Reduce ISS and OSS by implementing Restorative Discipline Practices PROGRAM INFORMATION 1/30/2017 9:08:16 AM Page 1 8 of 22 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION m) Program Budget 1. Submit your program 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, 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: • Revenues o Private Donations o Program Generated Revenue o Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT include HOME funding here) o Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG/HOME/etc.) • Private Foundation Grants o Other Revenue • Expenditures o Compensation o Rent & Utilities o Supplies & Equipment o Travel &Training o Other Expenses 2. Program Budget Detail— Provide description of"other" budget items, not defined. 3. This program budget represents what percent of the agency budget? 5% 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. Actual 2015-16 Estimated 2016-17 Projected 2017-18 Total Cost of Program $10,500 $17,500 $18,000 Total # of Individuals 90 100 100 Cost Per Individual $116.67 $175 $180 PROGRAM INFORMATION 1/27/2017 2:13:43 PM Page 19 of 22 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Blue Ribbon Youth Leadership institute Actual Estimated : Projected Percent PROGRAM REVENUE . 2015-16 2015-17.:' 2017-18 '' -.Change Private Donations $0.00 $2,000.00 $2,500.00 25% Program Generated Revenue $3,000.00 $3,000.00 $3,000.00 0% Local Government Grants: IIMIIIIIIIMIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Human Services-Town of Carrboro $0.00 $1,500.00 $1,875.00 25% Other-Town of Carrboro $0.00 $0.00 $0.00 0 Human Services-Town of Chapel Hill $0.00 $4,500.00 $4,500.00, 0% Other-Town of Chapel Hill $0.00 $0.00 $0.00 0 Human Services-Orange County $0.00 $1,000,00 $1,125.00 13% Other- Orange County $0.00 $0,00 $0,00 0 Other-Town of Hillsborough $0,00 $0.00 $0.00 0 Other Government Grants IIIIIIIIIIIIIIIIIOIIIIIIIIIIIMIIIMIMMIMMIIIMIIMII Triangle United Way $0.00 $0,00 $0.00 0 State Government $0.00 $0.00 $0.00 0 Federal Government(CDBG/HOME/etc.) $0.00 $0.00 $0.00 0 Private Foundation Grants $7,500.00 $5,000.00 $5,000.00 $ - Other Revenue $0.00 $0.00 $0.00 0 IMIMIMIIIIIIMIIIIIIMMIIIIIIIIIIIIMR Total Program Revenue $10,500.00 $17,000.00 $18,000.00 6% PROGRAM EXPENSES Compensation $0.00 $0.00 $0.00 0 Rent& Utilities $3,000.00 $4,000.00 $4,500.00 13% Supplies&Equipment $2,500.00 $3,000.00 $3,500.00 17% Travel &Training $5,000.00 $10,000.00 1 $10,000.00 0% Other Expenses: $0.00 $0.00 $0.00 0 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIMIMIMIMM Total Program Expenses $10,500.00 $17,000.00 $18,000.00 6% SURPLUS/(DEFICIT) FOR PERIOD: $ - I $ - I $ - I 0 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 EXHIBIT `B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Chapel Hill-Carrboro Public School Foundation Program Name: Blue Ribbon Youth Leadership Institute Funding Award: $563 Outline how the agency will spend Orange County's funding award. Expense Description Amount Youth Leadership Summer Camp $250 YLI Alternative Spring Break $313 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Students will receive leadership training that will give them the skills and confidence to participate in a myriad of school and civic youth clubs/organizations • Students will be exposed to providing service outside of North Carolina and touring colleges • Students will use their voice and experiences regarding injustices within their school community • Students will work on ways to reduce In-School and Out-of-school suspensions for students of color 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 Forty high school students participated in the YLI Summer Leadership Camp in June All students Ten students served as peer mentors will participate in YLI during the 2017-18 school year. Students traveled to Charleston, SC during spring break. Students volunteered in Lumberton,NC Twenty to provide relief for Hurricane Matthew and at the Simmons Pickney Middle School in students Charleston, S.C. Students toured UN C-Pembroke; Savannah College of Art&Design; Savannah attended the State. alternative spring break. Certified by: `, Title: Blue Ribbon High School Specialist Date: 7/5/17 (Provider's Signature) DocuSign Envelope ID:F9ADA870-944A-40DD-9800-3DB55F3AD8E5 Students will continue to develop leadership skills and engage in local service learning projects. MSAN Students presented"A Classroom in Color"during the Summer Institute for Professional Students will Learning and for CHCCS Leadership staff during Leadership Week as requested by continue to Superintendent Dr. Baldwin Nine students facilitated sessions that provided strategies for more provide equitable solutions to disparities and classroom discipline. facilitation& conversations with faculty, staff and administrators. YLI&MSAN students have worked all year on examining,analyzing and researching the Students will local student code of conduct and reviewing how other public school districts have implemented continue to change. Students presented to recommendations to the Board of Education in June. work on the student code of conduct until policies are changed. DocuSigned by: OC298F75CF68475_. Executive Director 8/31/2017 Certified by: `, Title: Blue Ribbon High School Specialist Date: 7/5/17 (Provider's Signature) DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 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: dltk A\Certified by: ds,\MKAA Title: Executive Di rector Date: 8/31/2017 y• OC7 RF75CF6R475 (Provider's Signature) (Chapel Hill-Carrhoro Public School Foundation) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 JIIII „nN ,„,n,����,����,����,�,�,,,�,n,�,,,,.,nN���,,,,.,nN„�.;�N�,,,,;�//r�rall�J14���1�Sl� �. Association Insurance Management, Inc. your partner for insurance and risk solutions MEMBER CERTIFICATE OF INSURANCE 7/5/17 Thank you for purchasing your insurance from AIM. This is your Member Certificate and should be kept with your permanent records. Insured#: NC073365 NAMED INSURED MEMBER: Named Insured&Mailing Address PRODUCER NAME Chapel Hill-Carrboro Public School Foundation Education Support Purchasing Group AIM Association Insurance Attn:Lyan Lehmann or Current Officer do AIM Management,Inc. PO Box 877 P.O.Box 674051 PO Box 674051 Carrboro, NC 27510 Dallas TX,75267-4051 Dallas TX,75267-4051 Company/Coverage Policy# Effective Dates Deductible Limits of Insurance Tudor Insurance Company/ PTP0006097 10/19/16-10/19/17 $0 Each Occurrence $1,000,000 Commercial General Liability General Aggregate $2,000,000 Products-COMP/OPS Aggregate $1,000,000 Personal&Advertising Injury $1,000,000 Fire Damage(any one fire) $50,000 Tudor Insurance Company/ PTP0006097 10/19/16-10/19/17 $0 Any One Person $5,000 Medical Payments Aggregate $5,000 Tudor Insurance Company/ PTP0006098 10/19/16-10/19/17 $ 1,500 Aggregate $1,000,000 Non-profit Prof Liability(Officers Liability)* Retro-active Effective Date: 10/19/14 Orange County,NC is added as an additional insured to the general liability policy only. Event:Human Services Grant Programs Certificate Holder: This member certificate,together with the common policy conditions,coverage part(s),coverage form(s),and endorsements,if any,complete the above numbered Orange County, NC policy. Copies of the Master Policies are available upon request or may be printed at PO Box 8181 www.aim-companies.com Hillsborough,NC 27278 AUTHORIZED REPRESENTATIVE ,.."'"-:::-'",..__,----e.._4: