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HomeMy WebLinkAbout2017-485-E Finance - Bridge II Sports - Outside Agency Performance Agreement DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 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 Bridge II Sports, a not-for-profit corporation, located at 3729 Murphey School Road, Durham,NC 27705 ("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 Bridge II Sports agree as follows: 1. 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 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 5438 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 1359.5. 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. (Bridge II Sports) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 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. (Bridge II Sports) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 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. (Bridge II Sports) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 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 Bridge II Sports 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: (Bridge II Sports) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 County: Finance &Administrative Services Provider: Bridge II Sports Orange County 3729 Murphey School Road Post Office Box 8181 Durham,NC 27705 Hillsborough,NC 27278 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable,it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. 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 a i-o9?c� ell of the Provider S tMaS 8/31/2017 07A241CBD61441C_. Date (Bridge II Sports) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 E f Orange County Government otAAA,tf, A-eomok (sLui 9/5/2017 06379949755E477... Bonnie Hammersley, County Manager Date (Bridge II Sports) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 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 mNltl rd � WSII➢ 11 , 1111111 11,10 1111111111 11111111 1111111111 '''''''1111111111"00 1111111 III kr� r 1 1*h 00 11 ° 01 CO. - 11„ 1111111111 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION INFORMATION Each year, Orange County Government, the Town of Carrboro and the Town of Chapel Hill invite program funding requests from non-profit providers that support the delivery of vital community services. The application process is very competitive and not all applicants will be awarded funding. Recommendations for funding may be for an award amount less than that requested by the applicant. Agencies that are currently receiving funds from Orange County, the Town of Carrboro, or the Town of Chapel Hill local governments, and are also applying for new funds, must be in compliance with all terms of their current agreement(s) and must not have any outstanding audit findings, monitoring findings or concerns as determined by the municipality. Recipients are required to submit written progress reports on their SMART easures that include: goals, description of activities/challenges, revisions of timelines/budgets, and other relevant information Funded projects will be monitored for progress and performance, financial and administrative management, and compliance with the terms of Performance/Development Agreement(s). Monitoring may involve site and/or office visit(s). Once applications are received, they are reviewed by staff for completeness and eligibility. The applications are presented to a specific application review group, depending on the funding source. The review group will make a recommendation, based on available funding and the priorities identified by the participating jurisdiction. The recommendation is presented to the appropriate Board/Council for consideration and approval. The Board/Council approves/adopts the final allocations. TIMELINE November 15 Funding Application Posted on Websites November 29 Funding Application Workshop Held October 18-January 23 Agency Prepares Application January 10 Q&A Session Held nu ry 31 A III III III urc ul uir m.m I urr o s s urn uris re 00 hie March - May Application Review & Agency Presentations June Agency Funding Approval by Board/Council July Contracts Executed & Programs Begin DO NOT SUBMIT THIS PAGE 1/27/2017 3:48:29 PM P a g e 2 of 2G DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION SUBMITTAL INFORMATION Welcome to the Outside Agency Common Funding application for local/general funds, which will be distributed through this competitive application process. All entities or organizations requesting funds must complete and submit this application prior to the deadline to be considered for FY 2017-2018 funding. The Application Submittal Deadline is: Tuesday, January 31, 2017 5:00 PM In the event of inclement weather, check the website for each Town/County you are applying to, for further instructions. Please note that late, handwritten, or incomplete applications will not be accepted. (Applications not signed by the Chair or President of the Board of Directors, are considered incomplete.) An application orientation workshop will tentatively be held on Tuesday, November 29, 2016 at 9 AM to Noon to review the application and submittal requirements. SUBMITTAL REQUIREMENTS FOR EACH MUNICIPALITY Human ervice Town arr oro Applications are accepted once a year and reviewed by the Town's Human Services Advisory Commission, which makes a recommendation for funding to the Board of Aldermen for final approval. For more information about the Town of Carrboro Human Services program, see here. Questions and submittals should be directed to: Annette Stone, 301 W. Main Street Carrboro, NC 27510 919-918-7319 astone(ctownofcarrboro.or Submission: ➢ We strongly encourage applications to be single-spaced, with 12-point anal font and normal margins. ➢ Application: One (1) original plus Two (2) paper copies of the application must be hand delivered or mailed to Annette Stone, 301 West Main Street, Carrboro, NC 27510; AND ➢ One Application and Attachments files must be submitted by email. Any .pdf files must be accompanied by the original file format of .doc, .xls, etc. DO NOT SUBMIT THIS PAGE 1/27/2017 3:48:29 PM I ' ago 3 of 2G DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Human ervice Town a el Hill In 1982, the Town established local funding to support local nonprofit organizations that carry out human service work throughout the community. Applications are accepted once a year and reviewed by the Town's Human Services Advisory Board, which makes a recommendation for funding to the Town Council for final approval. For more information about the Town of Chapel Hill Human Services program, see here. Questions and submittals should be directed to: Jackie Thompson 405 Martin Luther King Jr. Blvd. Chapel Hill, NC 27514 919-969-5081 jhompsontownofchapelhill.orp Submission: ➢ We strongly encourage applications to be single-spaced, with 12-point anal font and normal margins. ➢ Application: Two (2) paper copies of the application with ORIGINAL signatures must be hand delivered or mailed to Jackie Thompson, 405 Martin Luther King, Jr. Blvd., Chapel Hill, NC 27514; AND ➢ Attachments: The application submittal must be accompanied by a flash drive with the application and all attachment files in electronic format. Any .pdf files must be accompanied by the original file format of .doc, .xls, etc. Human ervice Orange County For more information about the Orange County Human Services program, see here. Questions and submittals should be directed to: Allen Coleman PO Box 8181 Hillsborough, NC 27278 (919) 245-2151 acoleman(c,oran ecountync. ov Submission: ➢ Email application and ALL Attachments prior to the deadline. Any .pdf files must be accompanied by the original file format of .doc, .xls, etc. Please request a delivery receipt of email with application and attachments. DO NOT SUBMIT THIS PAGE 1/27/2017 3:48:29 PM P g c 1 of 2 6 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION j FOR OFFICE...USE O NLY Agency Bridge II Sports Received By Program(s) _Boccia & Wheelchair Basketball _ Date/Time / wrr,rraA14f 14f 14f 144f 144f 144f 144f 14f 14f 14f J14f 14f 14f 14f 14f 14f 14f 14f 14f 14f 14f 144f 144f 144f 144f 14rJ14f 14f 144f 144f 144f 14f 14f J14f 14f 144f 144f 144f 144f 14f 144f 144f 14f 14 Section Subsection 1. Cover Page 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. ® 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. ® Description of Population to be Served g. ® Program Staffing, Capacity, & Expertise h. ® Program Implementation Timeline i. ® Value of Investment j. ® Impact of Reduced/No Allocation k. ® 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 3:48:29 PM Pago 5 of 2G I DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION I. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Ashley Thomas Applicant Organization's Physical Address: 3729 Murphey School Road, Durham, NC 27705 Applicant Organization's Mailing Address: 3729 Murphey School Road, Durham, NC 27705 Applicant Organization's Web Address: wwvv.bridge2sports.org Executive Director: Ashley Thomas Telephone Number:j866) 880-2742 E-Mail: ashley(@bridge2sports.orq Tax ID Number: b) Funding Request List all FYI 7-18 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 Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 Afterschool Program Coordinator salary and materials for youth activities and projects Adapted sport programming in boccia and $5,000 $10,000 $6,500 $21,500 wheelchair basketball for individuals with disabilities. I Totals $5,000 $10,000 $6,500 $21,500 Funding is used to maintain boccia and wheelchair basketball programs for children and adults with disabilities. Both programs have served residents of Orange County, NC for 10 years. Qualified staff, travel costs, and equipment produce quality programming, creating positive outcomes for individuals with disabilities, as well as communities. 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.1 . .0.1,4 4 i , A Signature. Arahm :1,4. , -- LOA OF 4 -1 ,„,,,, \ ll In Executive BA ector Date Signature: L harrnot b flq le44 .01/01711 i Board Chairperson Date AGENCY INFORMATION 1/26/2017 4:20:31 PM Page 6 of 25 I DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 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 1] a a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? I• .6. 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? 111 I 1 c) Current beneficiaries of the program for which funds are being requested? 111 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: 0 - ' 4 1 i 71 I 1 Exec _ 1 • --hie Di ctor Date /14/1 Signature: ittril ' 1(43 //g2t701- Board Chairperson Date AGENCY INFORMATION 1/26/2017 4:20:31 PM Pngo / of 25 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 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): 10 years in operation; 02/2007 b) Agency's Purpose/Mission (no more than a few sentences): At Bridge II Sports (BITS), our mission is to educate, develop, and implement opportunities for youth and adults with physical disabilities to play individual, team and recreational sports. c) Types of Services the Agency Provides (bullet format): • Adapted sport programming to children and adults with physical disabilities • Trainings, clinics, competitions to engage athletes and coaches in higher levels of competitive play • Statewide school initiative educating students about acceptance, compassion, and inclusive play • Disability etiquette/diversity in the workplace trainings for businesses and corporations • Municipal and university partnerships to empower communities on the importance and need of accessibility d) Agency's History with Providing These Services: 10 years of boccia and wheelchair basketball programming provides seasonal recreation opportunities for individuals with disabilities in Orange County. Athletes and community members experience adapted practices, clinics, trainings and competitions. Our partnerships with municipality groups and UNC-Chapel Hill grows our programs within the County, simultaneously maintaining sustainability. 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?) BIIS implemented the #EverybodyPlaysNC educational initiative, helping to serve over 5,000 students across NC since June 2016. Surveys are distributed to gain insight into students' views, illustrating the learned concepts towards acceptance of disability. f) Schedule of Positions (For Entire Agency): # of FTE - Full-Time Paid Positions: 8 # of FTE - Paid Part-Time Positions: 1 # of Volunteers: 897 # of FTE -Volunteers: 4,548 g) Living Wage Does this agency pay permanent employees a minimum living wam e?Yes If yes, is this agency an Orange County Living Wage Certified Employer? No If no, please explain. BIIS has submitted an Employer Application for the Orange County Living Wage Certified Employer program and is awaiting results. All employees at BIIS earn $12 or more per hour with healthcare. Agency Information 1/27/2017 3:48:29 PM P gf 2 6 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 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) 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 FY17-18 Source Award Request Ex: Affordable Rental 0 $20,000 Carrboro -Affordable Housing Rehabilitation Ex: Agency Administration $15,000 $15,000 Carrboro—Other Ex. Total $15,000 $35,000 Carrboro Total Funding *Add rows or attach additional page, if needed. ii. Submit your agency's 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, and in a similar format, as requested in the provided template). Please refer to the attachment titled "BITS Agency and Program Budgets" to view the agency budget. In this document, we have provided our full agency budget, as well as the revenue portion of the budget worksheet template provided within the grant application. iii. Does your agency budget show a Surplus or Deficit? Surplus Is there a significant change? Yes/No No Please provide a brief explanation for Surplus or Deficit, and significant changes. Our 2017 budget shows a surplus of less than $1,000, indicating that we intend to generate revenue and appropriately use funding so that we are not left with a deficit. iv. What is your agency's fiscal year? January 1, 2017 - December 31, 2017 (Example: July 1, 2016 through June 30, 2017) Agency Information 1/27/2017 3:48:29 PM II ' ago 9 of 2G DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Boccia Program Primary Contact and Title: Ashley Thomas, Founder& Executive Director Telephone Number: (866) 880-2742 E-Mail: Ashley @bridge2sports.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 Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare Education X X X Family Resources X X X X Jobs/Jobs Training X X X Food Transportation Other: Please specify Health & Fitness X 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. • Chapel Hill Parks and Recreation —We collaborate to use the Chapel Hill Community Center for practices, clinics, trainings and competitions. • UNC Chapel Hill —We accomplish programming, volunteer opportunities and experiential learning skills for UNC students and faculty members. • Disabled Sports USA —As a member of DSUSA, we have low-cost insurance that is required to safely execute program objectives for athletes, volunteers and supporters. • Chapel Hill/Carrboro local businesses and organizations — Donate raffle and auction items • Chapel Hill Chamber of Commerce —Work together to network and promote BIIS services for sponsorship engagement Program Description (3 pages OR LESS) PROGRAM INFORMATION 1/27/2017 3:48:29 PM Pago 10 of 2 6 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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? Individuals with cerebral palsy, or those whose limbs are severely affected can engage in recreational and competitive boccia. Athletes with more severe disability and secondary health issues compete where the playing field among athletes is equal, safe and designed to meet their specific needs. Bridge II Sports provides adapted equipment and memberships at low prices with scholarship opportunities. Youth and adult teams give athletes a chance to be part of regional, statewide and national competitions. Programming improves the physical, mental and social health of the disabled population within Orange county, while also providing community members with the opportunity to learn inclusion, compassion and acceptance. 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. Lack of programming for individuals with disabilities leads to a decrease in physical, mental and social development. BIIS promotes the lives impacted by disability through empowering athletes to embrace their ability. This creates positive outcomes for the Board of Orange County Commissioner's #1 Goal to promote the well-being of all residents. Championing those living with disability allows us to help them to reach health goals and ultimately creates a higher quality of life for this vulnerable population. Our programming instills value to county residents, fostering a community that accepts diversity and innovates with inclusion in mind. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? Individuals living in NC who have Cerebral Palsy, Muscular Dystrophy, a traumatic brain injury, a visual impairment or low-vision, stroke, and wheelchair users can participate in boccia. Youth and adult potential athletes are connected to BIIS through the #EverybodyPlaysNC school initiative, rehabilitation and physical therapy departments, hospital clinics/programs, our boccia clinics, BIIS Paralympic experience programming through business/organization collaboration, university collaboration projects, and social media and marketing platforms. 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 program manager is a Certified Therapeutic Recreation Specialist who is also certified in program planning. Other key staff have college degrees/specialties in Park, Recreation and Tourism, Sport Management, and Kinesiology, as well as a master's degree in Adapted Physical Education. All program staff have certification in: Darkness to Light, CPR/First Aid, Concussion training by the CDC, SafeSport PROGRAM INFORMATION 1/27/2017 3:48:29 PM P a g e 11 of 2G DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION training by Team USA, and Positive Coaching certifications (see "k" for more details). Tier 1 volunteers, who work closely with athletes of all ages, are also required to have a background check, as well as these certifications: Darkness to Light, CPR/First Aid, Concussion training by the CDC, SafeSport training by Team USA. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. Boccia is a weekly, year-round and seasonal sport that takes place at Bond Park Community Center (BPCC) and the Chapel Hill Community Center (CHCC). Residents living in Orange County/Chapel Hill/Carrboro are members of both programs. BIIS provides 40 practices annually and hosts one tournament. BIIS collaborates with UNC Chapel Hill's "Bridge The Gap" tournament by providing qualified staff, equipment and event guidance. BIIS coached two boccia athletes to nationals in 2016. 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) BIIS enhances all community populations by cultivating opportunities for an underserved population. We emphasize the need for better health options for the disabled community while simultaneously serving adapted sports programs. Programming, events, competition and outreach opportunities enhance the future for these individuals by giving them tools to access success. Through sports, our athletes gain tenacity, confidence and joy to help them independently navigate and succeed in life. BIIS also emphasizes the need for civic participation in helping to bridge the gap for a more inclusive, dynamic community. By engaging county residents and students in our services, volunteers and supporters gain firsthand experience and knowledge into how to empower those living with disabilities. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Without BIIS programming, there are few to no opportunities for individuals with disabilities to engage in health related activities. BIIS benefits the disabled community by offering the only adapted sports programming in the Triangle. Without requested funding, programs would not be able to run and people with physical disabilities would not be able to participate in accessible programs. k) Include any other pertinent information. BIIS has a $3Million child molestation insurance policy BIIS staff and coaches: • Working with children are background screened PROGRAM INFORMATION 1/27/2017 3:48:29 PM P g c 12 of 2 6 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Are trained and certified in the SafeSport program created by the USA Olympic/Paralympic Committee • Are trained and certified in concussion training by the Centers for Disease Control (CDC) • Are trained and certified in Positive Coaches Alliance • Are trained and certified in Red Cross First Aid and CPR Additional Program Information I) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, The athlete numbers provided below include only those athletes who are considered paid members of Bridge II Sports. The numbers below exclude the following: athletes considered nonmembers, athletes competing with BITS from external teams, athletes and participants competing in BITS tournaments, athletes and participants who actively engage and obtain benefit from BITS community events and outreach activities, disabled Veteran athletes who competed in the 2016 Valor Games Southeast boccia tournament held in Chapel Hill, UNC experiential learning experiences in boccia programming, and #EverybodyPlaysNC school initiative boccia programming. The total number of all BITS boccia athletes who are paid members, plus the number of people mentioned in the categories above who are not included in the Program Target Population Demographics below, equates to 239 people in 2016. Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male 7 8 9 Female 6 7 8 Total 13 15 17 Ethnicity African-American 2 3 4 American Indian or Alaska Native Asian 2 3 3 Caucasian 9 9 10 Native Hawaiian or other Pacific Islander Other: specify Total 13 15 17 Of the above, how many Hispanic/Latino 0 0 0 Of the above, how many non-Hispanic/Latino 13 15 17 Total 13 15 17 Age PROGRAM INFORMATION 1/27/2017 3:48:29 PM Pago 13 of 2 6 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 0-5 years 6-18 years 6 6 7 19-50 years 6 7 7 51+years 1 2 3 Total 13 15 17 Geographic Location Alamance County 1 1 1 Chatham County Durham County 2 2 2 Wake County 5 5 6 Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non-Public Housing) 4 6 7 Town of Carrboro Town of Hillsborough City of Mebane (Orange County) Orange County(Outside Municipalities) Other 1 1 1 Total 13 15 17 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: Bridqe II Sports Chapel Hill Boccia 1. Program Activity Name Boccia Physical Development: Skills Test Program Goal Practices are structured to develop the physical health and sport specific skills of athletes. Performance Measures During each season, execute a skills development test at the start, middle, and end of each season. Skills will test endurance, distance, and accuracy. Previous Year Program Results 100 %of athletes completed a skills test for each sport season. PROGRAM INFORMATION 1/27/2017 3:48:29 PM P g o of 2G DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Current Year Estimated Results 100% of athletes will perform a skills test during each season. Next Year Projected Results 100 %of athletes will perform a skills test in each season and will record growth between seasons. 2. Program Activity Name Boccia Personal/Social Development: Goal Cards Program Goal Practice will be structured to provide an avenue for social development: communication, self-understanding, and the opportunity for community engagement. Performance Measures Participants will create goal cards outlining academic, personal, skills, and team goals which will be checked every four weeks to evaluate progress and outcomes. Previous Year Program Results 100%Athletes created, maintained and completed season-end analysis of goal cards. Current Year Estimated Results 100%Athletes will create, maintain and compete season-end analysis of goal cards. Next Year Projected Results 100%Athletes will create, maintain and complete season-end analysis of goal cards and records growth between seasons. 3. Program Activity Name Boccia Participants Program Goal Increase number of participants Performance Measures We will increase athlete participation by 5-7 individuals as we partner with local schools through our school initiative campaign and by targeting a new age demographic with the Durham VA. Previous Year Program Results Current Year Estimated Results 5-7 new athletes are recruited to boccia program Next Year Projected Results 5-8 new athletes are recruited to boccia program 4. Program Activity Name Boccia Tournaments Program Goal Tournaments are organized to apply sport specific skills and team solidarity. Performance Measures Host 1-2 local tournaments in the Triangle area to facilitate social networking and physical competition among peers with similar disabilities. Previous Year Program Results Hosted 1 tournament in Triangle are while assisting with external local and national competitions. Current Year Estimated Results Host 2 tournaments in Triangle area; 15 athletes served; 20 college students volunteer; bring awareness to 30 community members. Next Year Projected Results Host 2 tournaments &one clinic in Triangle area; 20 athletes served/25 students volunteer; bring awareness to 35 community members PROGRAM INFORMATION 1/27/2017 3:48:29 PM Pago 15 of 2G DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 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). Please refer to the attachment titled "BITS Agency and Program Budgets" to view the boccia program budget. 2. Program Budget Detail — Provide description of "other" budget items, not defined. We do not have "other" budget items provided in our boccia program budget. 3. This program budget represents what percent of the agency budget? 1.7% 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 $15200 $15960 $16758 Total # of Individuals 239 251 264 Cost Per Individual $64 $64 $63 PROGRAM INFORMATION 1/27/2017 3:48:29 PM P g c 1G of 2G DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Wheelchair Basketball Program Primary Contact and Title: Ashley Thomas, Founder& Executive Director Telephone Number: (866) 880-2742 E-Mail: Ashley @bridge2sports.org o) 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 p) 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 X X Family Resources X X X X Jobs/Jobs Training X X X Food Transportation Other: Please specify Health and Fitness X X X X q) 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. • Local Church —We collaborate to use the Church for practices and competitions. • UNC Chapel Hill — We accomplish programming, volunteer opportunities and experiential learning skills for UNC students and faculty members. • Disabled Sports USA —As a member of DSUSA, we have low-cost insurance that is required to safely execute program objectives for athletes, volunteers and supporters. • Chapel Hill/Carrboro local businesses and organizations — Donate raffle and auction items • Chapel Hill Chamber of Commerce —Work together to network and promote BIIS services for sponsorship engagement PROGRAM INFORMATION 1/27/2017 3:48:29 PM P g I "'/ of 2 6 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Description (3 pages OR LESS) Please provide the following information about the proposed program: r) Summarize the program services proposed and how the program will address a Town/County priority/goal? Wheelchair basketball enables those with spinal cord injuries, amputees or able- bodied individuals to engage in weekly opportunities of physical activity. Community members living in Orange County who have a disability benefit from safe and accessible programming lessons and adapted equipment to live healthy lifestyles. Youth and adult teams offer all people the chance to learn new skills, meet others living with disability, compete in tournaments, and achieve goals. Adaptive sport programming gives this group a chance to develop physical, mentally and socially. The high energy sport is offered at a low-cost membership fee and scholarship opportunities are available. s) 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. BITS enhances the community as the Town of Chapel Hill's Council Goals suggests in "Creating a Place for Everyone." Without BITS, individuals with disability have no activity that positively impacts their health and well-being. Adaptive sports programming provides those with disability a safe and accessible space to engage. Volunteer assistance from county residents and UNC Chapel Hill students creates sustainable and supported programming that educates everyone on the idea of inclusivity improvement and growth that is imperative to the future of the Orange County community. Bridge II Sports is a niche organization that enables civic participation among athletes, participants and community members of all ages. t) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? People living in NC who have spinal cord injuries, Cerebral Palsy, Spina Bifida, amputees, or little people participate in wheelchair basketball. Our youth and adult participants are connected to BI IS through our#EverybodyPlaysNC school initiative, rehabilitation and physical therapy departments, hospital clinics/programs, halftime programs at college basketball games, Paralympic experience programming through business/organization collaboration, university collaboration projects, and social media and marketing platforms. u) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) PROGRAM INFORMATION 1/27/2017 3:48:29 PM Pago of 2G DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION The BITS Program Manager is a Certified Therapuetic Recreation Specialist who is also certified in Program Planning. Other key staff have college specialties in Park, Recreation and Tourism, Sport Management, and Kinesiology, as well as a master's degree in Adapted Physical Education. All program staff have certification in: Darkness to Light, CPR/First Aid, Concussion training by the CDC, SafeSport training by Team USA, and Positive Coaching certifications (see "k" for more details). Tier 1 volunteers, who work closely with athletes of all ages, are also required to have a background check, as well as these certifications: Darkness to Light, CPR/First Aid, Concussion training by the CDC, SafeSport training by Team USA. v) Describe the specific period over which the activities will be carried out and include an implementation timeline. Wheelchair basketball is a weekly, year-round and seasonal sport that takes place at a local church. BITS hosts 46 practices annually and two tournaments. One tournament will be a day-long competition while the other will be a two-day competition. BITS also provides demos at UNC Chapel Hill, collaborates with the student led project "Bridge The Gap," and collaborates with Orange County schools to bring students adapted sports education days. w) 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) BITS enhances all community populations by cultivating opportunities for an underserved population. We emphasize the need for better health options for the disabled community while simultaneously serving adapted sports programs. Programming, events, competition and outreach opportunities enhance the future for these individuals by giving them tools to access success. Through sports, our athletes gain tenacity, confidence and joy to help them independently navigate and succeed in life. x) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Without BITS programming, there are few to no opportunities for individuals with disabilities to engage in health related activities. BIIS benefits the disabled community by offering the only adapted sports programming in the Triangle. Without requested funding, programs would not be able to run and people with physical disabilities would not be able to participate in accessible programs. y) Include any other pertinent information. BI IS has a $3Million child molestation insurance policy BI IS staff and coaches: • Working with children are background screened • Are trained and certified in the SafeSport program created by the USA Olympic/Paralympic Committee PROGRAM INFORMATION 1/27/2017 3:48:29 PM Pago 19 of 2 6 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Are trained and certified in concussion training by the Centers for Disease Control (CDC) • Are trained and certified in Positive Coaches Alliance • Are trained and certified in Red Cross First Aid and CPR PROGRAM INFORMATION 1/27/2017 3:48:29 PM Page 20 of 26 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Proclram Information a) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, The athlete numbers provided below include only those athletes who are considered paid members of Bridge II Sports. The numbers below exclude the following: athletes considered nonmembers, athletes competing with BITS from external teams, athletes and participants competing in BITS tournaments, athletes and participants who actively engage and obtain benefit from BITS community events and outreach activities, UNC experiential learning experiences in wheelchair basketball programming, and #EverybodyPlaysNC school initiative wheelchair basketball programming. The total number of all BITS wheelchair basketball athletes who are paid members, plus the number of people mentioned in the categories above who are not included in the Program Target Population Demographics below, equates to 373 people in 2016. Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male 15 16 16 Female 7 8 10 Total 22 24 26 Ethnicity African-American 5 6 6 American Indian or Alaska Native 1 1 2 Asian 0.5 1.5 1.5 Caucasian 14 14 14 Native Hawaiian or other Pacific Islander 1 Other: specify 1.5 1.5 1.5 Total 22 24 26 Of the above, how many Hispanic/Latino 0.5 1.5 2.5 Of the above, how many non-Hispanic/Latino 21.5 22.5 23.5 Total 22 24 26 Age 0-5 years 6-18 years 15 16 16 19-50 years 2 3 4 51+years 5 5 6 Total 22 24 26 Geographic Location Alamance County Chatham County Durham County 6 6 6 PROGRAM INFORMATION 1/27/2017 3:48:29 PM Pago 21 of 2 6 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Wake County 7 7 7 Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non-Public Housing) 1 1 Town of Carrboro 1 2 Town of Hillsborough 1 1 1 City of Mebane (Orange County) Orange County(Outside Municipalities) 1 Other 8 8 8 Total 22 24 26 Work Statement b) 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 Wheelchair Basketball 5. Program Activity Name Wheelchair Basketball Practices Program Goal Practices develop sport skills, communication, teamwork, independence and physical activity for cross disabilities. Performance Measures Weekly: Coaching plans executed; reflection/assessment of practices; 4 individual goals tracked. Previous Year Program Results Held 24 practices in 2017; served 22 athletes &20 college students; Raised awareness to audience size of 1,600. Current Year Estimated Results Hold 24 practices in 2017; serve 24 athletes & 25 college students; Raise awareness to audience size of 2,000. Next Year Projected Results Hold 24 practices in 2018; serve 26 athletes & 30 college students; Raise awareness to audience size of 2,200. 6. Program Activity Name Wheelchair Basketball Tournaments Program Goal Tournaments are organized to apply sport skills, leadership, sportsmanship, and confidence in competition. Performance Measures East Coast team registration allows for social networking and physical competition of peers with similar disabilities. PROGRAM INFORMATION 1/27/2017 3:48:29 PM Pago 22 of 2 6 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Previous Year Program Results BITS hosted 1 tournament that served 70 unique athletes and 60 college students, with an audience size of 300 people. Current Year Estimated Results 2 tournaments are organized in 2017 by BITS coaches; Serves 150 unique athletes &75 college students Next Year Projected Results 2 tournaments are organized in 2018 by BITS coaches; Serves 150 unique athletes &75 college students 7. Program Activity Name Wheelchair Basketball Clinic Program Goal Clinics to develop skills for athletes and coaches. Performance Measures Host clinic to educate: skills, drills, goal setting, rules, and disability etiquette. Previous Year Program Results BITS did not host a clinic for wheelchair basketball in 2016. Current Year Estimated Results Host 2017 clinic; invite PE &Adapted PE teachers to learn; serve 30 unique athletes &coaches (combined). Next Year Projected Results Host 2018 clinic; invite PE &Adapted PE teachers to learn; serve 35 unique athletes &coaches (combined). 8. Program Activity Name Student/Parent/Caregiver Goal Setting & Evaluation Program Goal BITS programs provide access to social development & community engagement Performance Measures Programs provide capacity to communicate independently and as a team; Athletes understand/follow directions and achieve goals. Previous Year Program Results 100% of athletes/parents/caregivers practiced setting goals, documenting goals, &determined positive outcomes of program. Current Year Estimated Results 100%of athletes&parents/caregivers will practice goal setting,goal tracking and evaluation. Next Year Projected Results 100%of athletes&parents/caregivers will practice goal setting,goal tracking and evaluation. Goals from different seasons are compared. PROGRAM INFORMATION 1/27/2017 3:48:29 PM Pago 23 of 2G DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION c) Program Budget 5. 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). Please refer to the attachment titled "BITS Agency and Program Budgets" to view the wheelchair basketball program budget. 6. Program Budget Detail — Provide description of "other" budget items, not defined. We do not have "other" budget items provided in our boccia program budget. 7. This program budget represents what percent of the agency budget? 2.1% 8. 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 $21,006 $22,056 $23,159 Total # of Individuals 373 392 412 Cost Per Individual $56 $56 $56 PROGRAM INFORMATION 1/27/2017 3:48:29 PM P g c 21 of 2G DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Bride II Sports Agency & Program Budgets BITS Agency Budget Bridge II Sports Budget Comparison - Current r"evisi.on Organiza.tion Totals Annual Iudget Annual Budget Revenue Contributions:Business/Coq) $ 192,500.00 $ 198,275.00 Contributions: Individual $ 25,030.00 $ 25,780.90 Event: Registration 350.00 $ 360.50 Grant:. Business/Corporate $ - $ Grant:. Foundation $ 211,000..00 $ 217,330.00 Grant:. Govermnent $ 510,000..00 $ 525,300.00 Contract Service:. Busiii.essDenno $ 3,500..00 $ 3,605.00 Equipment Rental Luc 500.00 $ 515..00 Uniform Rental 300.00 $ 309..00 Interest Income $ 100.00 $ 103.00 Team Fundraising $ 500.00 $ 515..00 Progra.m..Incoine $ 10,650.00 $ 10,969..50 Team Fundraising Processing Fee (15% $ 500.00 $ 515..00 Total Revenue $ 954,930..00 $ 98.3,577.90 xpenses Salary.& Wages $ 421,830.00 $ 434,484.90 Salary&'Wages -Veteran Support $ 2,674.00 $ 2,754.2.2 Website Ma.intenatace $ 15,000.00 $ 15,450.00 Health Insurance $ 8,000.00 $ 8,240.00 Payroll Processing Fees 600.00 $ 618.00 Payroll.Tax $ .38,192.00 $ 39,337.76 Audit $ 8,500.00 $ 8,755.00 Awards & Trophies $ 6,700.00 $ 6,901.00 Background checks 400.00 $ 412.00 Bank fees & charges 200.00 $ 206.00 Bookkeeping $ 30,000.00 $ 30,900.00 Books., SubscriptionJr e.ference„Publica.t $ 1,000.00 $ 1,030..00 Computer& Technology $ 10,000.00 $ 10,300.00 Conference, convention 750.00 $ 772.50 Consultants $ 10,000.00 $ 10,300.00 Copier $ 3,750.00 $ 3,862.50 Equipment $ 16,900.00 $ 17,407.00 Equipment Maintenance $ 6,550.00 $ 6,746.50 Event Food $ .23,750.00 $ 24,462.50 Depreciation'Expense $ DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Bride II Sports Agency & Program Budgets Fundraising Upfront Costs 720.00 5 741.60 Insurance: Auto/Truck $ 5,000.00 5 5„150.00 Insurance: Board&Officer 800.00 5 824.00 Insurance: Commercial 5 6,800.00 5 7 004.00 Insurance: Programming 100.00 5 103.00 Insurance: Content $ 1,200.00 5 1,236.00 Marketing,Advertising,Promo 5 35,000.00 5 36,050.00, Moving - Meal: Business $ 1,43146 5 1,474.40 Membership dues $ 2,095.00 5 2„157.85 Merchant Account Fees 700.00 5 721.00 Finance and interest charges - $ Mileage Reimbursement $ 10,950.00 $ 11,278.50' Supplies $ 35,775.04 5 36,848.30, Postage& Shipping $ 1,350.00 $ 1,390.50 Printing $ 1,170.00 5 1,205.10 Rent: Office $ 18,000.00 5 18,540.00 Rent: Venue $ 30,300.00 $ 31,209.00 Registration:Teams $ 1,050.00 $ 1,081.50 Staff Coach Development $ 11,800.00 5 12,154.00 Board Development $ 500.00 5 515.00 Tournament Costs $ 1,240.00 5 1,277.20 Travel: Airfare $ 16,700.00 5 17,201.00' Travel: Car Rental $ 3,420.00 $ 3,522.60 Travel: Gasoline for Truck $ 3,625.00 5 3,733.75 Travel: Lodging $ 66,000.00 $ 67,980.00, Travel: Meals $ 53,560.00 5 55,166.80' Travel: Tolls 50.00 $ 51.50 Travel: Parking 100.00 5 103.00 Travel: Gasoline for Bus, $ 3,500.00 $ 3.605.00 Truck and Trailer Maintenance $ 2,000.00 5 2,060.00 Bus Maintenance $ 2,000.00 $ 2,060.00 Uniforms $ 4,200.00 $ 4,326.00' Utilities: Electric $ Utilities: Internet 5 2,400.00 $ 2,472.00 Utilities: Phone &Fax $ 3,500.00 $ 3,605.00 Secunty 700.00 $ 721.00 Warehouse Supplies 550.00 $ 566.50 Total Expenses $ 954,082.50 $ 9611,074.98 Excess(Deficit)of 1!.'evelaue over Expel $ 847.50 $ 22,502.93 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Bride II Sports Agency & Program Budgets Agency Budget Operafing Budget.for Entire.Agency AGENCY NAME: Bridge VI Sports Actual Estimated Projected 1Percent AGENCY REVENUE 201546 20116-17 217-118 Change, Private Donations $ 1.U00 S - $ 0. Agency Generated Revenue(fees), 5 - S - $ 0 Local Government Grants::: Human Services-Town of Carrboro $ 3,500 5 4,000 $ 4,500 13% Other-Town of Carrboro 5 - $ - $ - 0 Human Services•-Town of Chapel Hilt $ 5,000 $ 5,750 $ 6,250 Other-Town of Chapel H11111 5 - $ 2,250 $ -100%. Homan Services-Orange County $ 5,000 $ 5,250 $ 5,500 5% Other-Grange County 5 - $ - $ 01 Other-Town of Hillsborough 5 - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ 0 State Government $ - $ - $ 0 . Federal Government(CDBGIHOMEletc.) $ - $ - $ - 0 . Private Foundation Grants imi.- $ 5,000.00 $ - $ (1..0D) LD) Other Revenue 5 - $ - $ Total Agency Revenue $ 14,500 $ 22250 $ 16,250, -27% DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Bride II Sports Agency & Program Budgets BITS Boccia Program Budget Program Itudget Operating Itudget!for!Program IPROGRAM NAME: =!crocia Pietua 11 Estimated 17,1„,.jeldeed percerti PROGRAM REVENUE !"..ii(1846, 25111,&17 201748 Change Rival*Donations $ 500 $ - $ .. 0 Program Generated!Revenue Local Government Grants: Human Services-Town of Can-1mm $ 1,750 $ 2,000 $ 2.250 13% Other-Town of Candor° $ - $ - $ 0 Human Semices-Town Of Chapel HI $ 2,500 $ 2$75 $ 312,5 Other-Town of Chapel HE $ - $ 1„125 $ -1015% Human Sernees-Orange County $ 2,500 $ 2„505 $ 2750 511: Other-Orange CUE* $ - $ - $ 0 Other-Town of IHillaborough $ - $ - $ 1 0 Other Government Grants Triangle United Way 5 0 State Government 5 -. $ - 0 Federal Government fC11(341HOOMEeitc.) 5 - $ - $ .. 0 Private Foundation Grants 5 - $ 2,500.00 $ (1..00) Other 1,..-_ ,Ariue, 5 0 Total' Program Revenue $ 7„250 $ 11,125, $ B,125 -27% PROGRAM EXPENSES Compensation 5 12,000 5 12,500) $ 13,230 5% Rent&Utilities 5 200 • 210 I 221 5% Supplies&Equipment 5 2,000 $ 2,100 $ 2,205 5% Travel&.Training S 1,000 $ 1,050 $ 1103 511: Other Expensesr S - 5 - $ 0 T,05:1 1] r0 giaim E "o.'7".'nee's $ 15,200 $ 15,960 $ 16,758 5% SUR PLUSADEHICIT) FOR PERIOD: $ (7„95011 $ 04,8351 $ ,(0',19,3311 -79% DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Bride II Sports Agency & Program Budgets BITS Wheelchair Basketball Program Budget !Program tiulidgell Operating Budget for IProgram PROGRAM N ''E 'Wheelchair IBasketbaill Actual Estiir :-..:14 proio., Percent PROGRAM REVENUE 2$9,15-16 213116-11 213111,40 Change Pt-hate!Donations $ 5.00, $ - $ ., Et !Program Generated!Revenue $ - $ - $ _. U !Local Government Grants,: Human Services-Tom of Carnbom $ 1,750 $ 2,066 $ 2,25C 13% Jr-Town of Carrboro $ _, $ _, $ - U Human Services-Town of Chape4IHRI $ 2,500, $ 2,875 $ 3,125 lg% Other-Town of Chapel Hal $ - $ 1,125 $ ., Human Services•-Orange County $ 2,5ft $ Z625 $ 2,750: Other ,Orange Courty $ - $ - $ ., El Other-Town of Hillsborough $ - $ - $ - U ,Other Government Grants Triangle United Way $ - $ - $ ., D State,Government $ - $ - $ ., 13 Federal Government(ODISGAHOMEretc„,) $ _, $ -, $ - 0 Private,!Foundation Grants $ - $ 2,500.00 $ - 5 u1.DU) Other Revenue $ - $ - $ ., 0 TRAM Provarn Revenue $ 7,250 $ 11025 $ 8,425 -27% PROGRAM EXPENSES, Compensation 5 12410: 5 13,053 5 13,750 5% Rent&Utilities 5 3,W0 5 3,150 5 3,3ca 5% Supplies&Equipment 3 2,875 5 2,5136 5 2,625 Trawl&Training! 5 1,241, 5 1,260 5 1,323 5%: 0th er Expenses: 5 - 5 - $ ., U Titait IRrogram Expenses $ 18,985 $ 19„,973 $ 2114106 5% SURPLUSIIDEFICITI FOR PERIOD: $ (11,735)1 i (8034811 $ (1,2,(3811)1 -46%1 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4. ATTACHMENTS Description of Required Attachments a) Financial Audit A recent financial audit that should cover CY 2015, for calendar year agencies, and FY 2015- 16, for fiscal year agencies. For agencies with prior year revenues totaling $500,000 or more a financial audit, prepared by a certified public accountant is required. Agencies with prior year revenues of less than $500,000 may submit a completed Schedule of Receipts and Expenditures form (see application materials), in lieu of an audit/report. Agencies with a certified audit/report should not complete the form. b) IRS Federal Form 990 A copy of the agency's 2014 Form 990 is required. The specific form depends upon the agency's financial activity. Review the IRS' table guide, for more details. For Form 990-N (e- postcard) filers, include a copy of the postcard, with the agency's application materials. c) NC Solicitation License A copy of the agency's current solicitation license is required. Organizations that solicit contributions in North Carolina, directly or through a third party, must renew their licenses annually. For more details, refer to the NC Secretary of State's licensing website and its Frequently Asked Questions Guide (P F), about exemptions. If exempt per N.C.G.S. § 131 F- 3, include a copy of the exemption letter with the agency's application materials. d) IRS Federal Tax-Exemption Letter A copy of the agency's IRS tax-exempt letter that confirms its nonprofit status is required. An agency can request a copy of its letter from the IRS' Customer Account Services. e) Certificate of Liability Insurance A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker's Compensation compliance, include a statement explaining why, with the agency's application materials. *Note: If Approved for Funding: Approved agencies must provide an updated insurance certificate. The update should reflect the funding jurisdiction as an additional insured party and certificate holder and provide coverage for the duration of the funding period(July 1 —June 30). Renewal certificates must be sent to the jurisdiction 30 days prior to any expiration date, cancellation or modification of any stipulated insurance coverage. DO NOT SUBMIT THIS PAGE 1/27/2017 3:48:29 PM P a g e 25 of 2G DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Table 1. Forms of Liability Insurance and Minimum Policy Amounts Required INSURANCE TOWN OF CARRBORO TOWN OF CHAPEL HILL ORANGE COUNTY3 Worker's Limits for Coverage Compensation' A - Statutory State Limits for Coverage A - Limits for Coverage A - NC, for each Statutory State NC, for Statutory State NC, for employee each employee each employee Limits for Coverage Limits for Coverage B - Limits for Coverage B - B - Employers Employers Liability of: Employers Liability of: Liability of: $100,000 Each Occurrence $500,000 each $1 million Each $100,000 BID for each accident, $500,000 Occurrence employee BID for each employee $1,000,000 BID2 $500,000 BID limit $500,000 for BID limit limit Commercial $100,000 Property General Liability Damage Liability $1 million Each Occurrence $1 million Each $1,000,000 Bodily $2 million Aggregate Occurrence Injury and Property $2 million Aggregate Damage Limit Automobile Not Applicable $1 million Each Occurrence $500 000 Each Liability Occurrence Professional $1 million Each Liability Not Applicable Not Applicable Occurrence $2 million Aggregate 1. Visit the NC Industrial Commission's website for more information regarding Coverage A. Also, note that if an agency uses subcontractors, it must require subcontractors to have workmen's compensation insurance. 2. Bodily Injury by Disease (BID) 3. Please visit Orange County's contracts webpape for more information about the County's risk assessment procedures. f) List of Board of Directors Provide the following information about each board of director's member: name, telephone number, address, occupation or affiliation of each member and the list must identify the principal officers of the governing body, and length of term. g) Solid Waste Program Fee (SWPF) Verification This fee finances Orange County's recycling and waste reduction program. Submit either a.) proof of payment of the agency's FY 2016-17 Solid Waste Program Fee, OR b.) a statement on agency letter head indicating exemption and specify the person(s), business, etc. that is responsible for paying this fee. DO NOT SUBMIT THIS PAGE 1/27/2017 3:48:29 PM P g c 2G of 2G DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 EXHIBIT `B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Bridge II Sport Program Name: Adapted sport programming in boccia and wheelchair basketball for individuals with disabilities. Funding Award: $5438 Outline how the agency will spend Orange County's funding award. Expense Description Amount Program Staff to implement Boccia,Wheelchair Basketball,and other adapted sports outreach in 5438 Orange County Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • One full season of Boccia will happen in Orange County to include one competition attended/hosted for athletes. • One full season of wheelchair basketball will be hosted by BIIS so that Orange county residents can participate • Host VGSE Event in Orange county serving military injured. 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 BIIS will increase numbers of Orange County Residents served 17 served BIIS will implement survey pre and post season to capture outcomes by individuals 50%Survey completed BIIS will host VGSE in Orange county engaging residents as volunteers 10 new Orange county volunteers ---DocuSigned by: VII �r�� 8/31/2017 Certified by: 07n241CBD61441c_. Title: Executive Di rector Date: (Provider's Signature) DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 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: QSIt,It1 1.614, .S Executive Di rector 8/31/2017 Certified by: Title: Date: a,*241 oeQ6-ra41 c_. (Provider's Signature) (Bridge II Sports) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/25/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: American Specialty Insurance&Risk Services, Inc. (a//c,Nr o,Ext): 260-969-5203 AAA/c,No): 260-969-4729 E-MAIL ADDRESS: 7609 W.Jefferson Blvd.,Suite 100 INSURER(S)AFFORDINGCOVERAGE NAIC# Fort Wayne IN 46804 INSURERA: Greenwich Insurance Company 22322 INSURED INSURER B: Disabled Sports USA, Inc. INSURER C: Bridge II Sports INSURERD: 451 Hungerford Drive,Suite 100 INSURERE: Rockville MD 20850 INSURER F: COVERAGES CERTIFICATE NUMBER: 1001354674 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE RENTE CLAIMS-MADE X OCCUR PREMISES O(Ea occur ence) $ 1,000,000 MED EXP(Any one person) $ Excluded A N ASG089703602 12/01/2016 12/01/2017 PERSONAL&ADVINJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $ 5,000,000 X OTHER: CLUB $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE N N ASX089704002 12/01/2016 12/01/2017 AGGREGATE $ 5,000,000 DED RETENTION$ PROD-COMP WK HAZ AGG $ 5,000,000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) -Evidence of coverage as respects to BRIDGE II SPORTS. -Coverage available under policy#SRPO-50219-203 is on file with the policyholder. Excess Accident Medical for Class 1 &2-$25,000 with a$250 deductible per injury per covered accident.Accidental Death&Dismemberment is$10,000 per person per accident.Class 3&4-$100,000 with a$250 deductible per injury per covered accident.Accidental Death&Dismemberment is$10,000 per person per accident. CERTIFICATE HOLDER CANCELLATION DISABLED SPORTS USA, INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. BRIDGE II SPORTS AUTHORIZED REPRESENTATIVE 3729 MURPHEY SCHOOL ROAD Durham NC 27705 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 AGENCY CUSTOMER ID: LOC#: A 0 ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED American Specialty Insurance&Risk Services, Inc. Disabled Sports USA, Inc. POLICY NUMBER Bridge II Sports ASG089703602 451 Hungerford Drive,Suite 100 CARRIER NAIC CODE Rockville, MD 20850 Greenwich Insurance Company 22322 EFFECTIVE DATE: 12/01/2016 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE-Certificate#1001354674 -With regards to the Excess Accident Medical Coverage,Class 1 &3 is all registered/approved participants and volunteers of the Participating Organization and its Chapters with respect to sponsored and approved activities including direct travel to and from the activity and home, not including overnight trips. -With regards to the Excess Accident Medical Coverage,Class 2&4 is all registered/approved participants and volunteers of the Participating Organization and its Chapters with respect to sponsored and approved overnight trips including direct travel to and from the activity and home. ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD