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2017-558-E Finance - Voices Together - Outside Agency Performance Agreement
DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF 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 Voices Together, a not-for-profit corporation, located at 5007 Southpark Drive, Suite 230, Durham,NC 27713 ("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Voices Together agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 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 17500 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 4375. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Voices Together) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF 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. (Voices Together) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement,insurance: i. Worker's Compensation. For protection from claims under workers' or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury,including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance,including hired and non-owned vehicles,if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury,bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE • Worker's Compensation Limits for Coverage A - Statutory State NC& Coverage B -Employers Liability $500,000 each accident, disease policy limit and disease each employee • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $500,000 Combined Single Limit • Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability)required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough,NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. (Voices Together) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF 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 Voices Together provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (Voices Together) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF County: Finance &Administrative Services Provider:Voices Together Orange County 5007 Southpark Drive, Suite 230 Post Office Box 8181 Durham,NC 27713 Hillsborough,NC 27278 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable,it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. 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 ° hau fIof the Provider �aS�Mi1M. ObLi 10/11/2017 nAnanl A9AP'7a7A Date (Voices Together) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF For a E oa�olzlfof Orange County Government 01A,UUt. �Aa,1144U'S�,t,1? 10/12/2017 F3.79aeg7_55E477... Bonnie Hammersley, County Manager Date (Voices Together) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT 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 1,1111111110 $fpi; 11100 1111111110 1, 111111 I 11111 1011110h 11111 111111111 11 i II 011100111111111111,1,110 1101 u j, II 0 0011 1111111111111111111111, 1,00.000000.0 izzto \lb 101111,111,11111111111 C 041111,1* DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMIF'age 1 •r 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT 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 Measures 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 A IIIIII IIIurc tol n Submossol alas re IIII . e DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AK'age 2 r 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION March - May Application Review & Agency Presentations June Agency Funding Approval by Board/Council July Contracts Executed & Programs Begin 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 DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMIII'age 3 r 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 919-918-7319 astone(@,townofcarrboro.orq 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. 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 jhompson(@townofchapelhill.orcr 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 DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMIII'age 4 ,t 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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 acolemanorangecountync.gov 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 1/26/2017 11:10:15 AMII'age 5 lr 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Voices Together Program(s) _Voices Together in Education 1. Cover Page a. ❑Applicant Contact Information b. El Funding Requests c. ❑Signed Application Cover Page d. ❑signed Disclosure of Conflicts of Interest and Clause e. 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 DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMII'age 6 ,r 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. Program Information a. El Human Services Needs Priority b. El Type of Program A separate Section 3 is c. ❑Agency Collaboration required for each d. ❑Summary of Program program. e. ❑Description of Identified Need f. El Description of Population to be Served g. ❑Program Staffing, Capacity, & Expertise h. El Program Implementation Timeline i. ❑Value of Investment j. El Impact of Reduced/No Allocation k. ❑Other Pertinent Information I. El Target Population/Beneficiary Chart m. ❑Work Statement n. El 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 DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMII'age 7 r 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Voices Together Applicant Organization's Physical Address: 5007 Southpark Dr., Ste. 230, Durham, NC 27713 Applicant Organization's Mailing Address: 5007 Southpark Dr., Ste. 230, Durham, NC 27713 Applicant Organization's Web Address: www.voicestogether.net Executive Director: Yasmine White Telephone Number: 919-942-2714 E-Mail: yasmine(cvoicestogether.net 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 Carrbo Chapel Orange Total ro - HS Hill - County- HS HS Ex. Youth Afterschool Program $10,00 $15,00 $5,000 $30,000 Afterschool Program Coordinator salary and 0 0 materials for youth activities and projects VT in Education program in four Orange $20,000 $20,000 County exceptional children's classrooms for Music Therapist salary and materials Totals DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMIII'age 8 •t 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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. 7 Signature: 1/30/17 Executive Director Date Signature: 1 ,/ 4 1/30/17 Board Chairperson Date DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMIII'age 9 .f 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT 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 ❑ LI la) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ❑—b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ J) Current beneficiaries of the program for which funds are being requested? ❑ JId) 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. DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMIII'age 10 r 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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 qrant awarded. Signature: 7 1/30/17 Executive Director Date Signature: � , 1/30/17 Board Chairperson Date DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMIII'age 11 ,D 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT 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): Nine years in operation, Date of Incorporation: March 06, 2007 b) Agency's Purpose/Mission (no more than a few sentences): The mission of Voices Together is to empower individuals with developmental disabilities to transform their lives. Voices Together address critical life skills that enable students to make a healthy transition to an independent adulthood. c) Types of Services the Agency Provides (bullet format): • Voices Together in the Community: programming for individuals in the community • Voices Together in Education: programming for students in special education classrooms • Voices Youth Connection: programming for individuals who are at-risk for emotional trauma and behavioral issues. Using a specialized music therapy approach, Board Certified Music Therapists use music as a tool to help improve social, cognitive, and emotional health to effect positive change in people's lives. Agency's History with Providing These Services: For a decade, Voices Together has provided weekly programming for students across seven districts in Central North Carolina. Music Therapy is the clinical and evidence-based use of music interventions to accomplish non-musical goals. Public schools, agency administrators, and academic partners have all labeled Voices Together a best practice. Last spring, June Atkinson, the State Superintendent of NC Public Schools wrote, "Students with exceptional needs struggle with language, socialization and emotional development, which directly impact their ability to learn. Across our state, the number of children with intellectual disabilities continues to increase and teachers are struggling to find new and innovative methods to support these students and help them gain critical functional skills they need in their classrooms and in their daily lives. Voices Together is a dynamic best practice and offers unique tools for teaching critical skills to our students. It offers new ways for our teachers to teach and for our students to learn." In 2014, Voices Together began a strong collaborative partnership with Dr. Geraldine Dawson of Duke University. Bass Connections, a Duke research team, worked to measure the efficacy of the Voices Together program in public school special education classrooms. Findings of the 2014-15 study were published in the journal Autism Research and Treatment: https:OOwww.hindawi.com0iournals0aurt02016012647900 The study in 2015-16 showed significant increases in not only communication, but also socialization. There are three to four more academic articles in process and the Duke DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMIII'age 12 •t 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION University research team continues their work on the Voices Together program for the 2016- 17 year. d) 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?) Our organization continues to work to bring this important program to every student in Orange County with exceptional needs. Each year, the number of students with special needs increases while resources decrease. We strive to provide this important program to all classrooms for exceptional children in Orange County in order to help each student reach their maximum potential. Our organization has strengthened this last year in the following ways: • We hired a strong Development Director for our sustainability. • We continued to work to expand our reach in preschools and elementary and early childhood programming in order to reach children early in their development. • We continued to work to develop methods to replicate our program model so we are able to reach more students. • We worked to develop tools for caregivers of adults with developmental disabilities that will offer strategies from some of our weekly programing in order to build pre- vocational skills such as self-advocacy and self-management. e) 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: Total Volunteer Hours = Volunteer FTE 2,080 # of FTE - Full-Time Paid Positions: 5 # of FTE - Paid Part-Time Positions: 1 # of Volunteers: 30 # of FTE -Volunteers: 0 f) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes / No) Yes DO NOT SUBMIT THIS PAGE 1/26/2017 1 1:1 0:1 5 AMI'age 13 •r 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION If yes, is this agency an Orange County Living Wade Certified Employer? No If no, please explain. We are headquartered in Durham County and therefore have not applied to be an Orange County Certified Employer. We have always valued our staff, always paid a living wage, and will continue to do so. DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMII'age 14 .131 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION g) 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- FY17-18 Source 17 Reques Award t 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). Agency Budgets are required to define budget amounts for the previous DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMII'age 15 lr 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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 Is there a significant change? Yes/No No Please provide a brief explanation for Surplus or Deficit, and significant changes. N/A iii. What is your agency's fiscal year? Oct 1, 2017 - Sept 30, 2018 (Example: July 1, 2016 through June 30, 2017) DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMII'age 16 •r 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Voices Together in Education Program Primary Contact and Title: Yasmine White, CEO Telephone Number:919-942-2714 E-Mail: yasmine(cvoicestogether.net a) Indicate the type of Human Services Needs Priority, if program applicable: ❑ Priority Area #1: safety-net services for disadvantaged residents x altkattcriitynknelettlp, 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) Public Housing Program Category Yout Adult Elder! Disabled Neighborhoods/Resident Affordable Housing Affordable Healthcare Education x x Family Resources Jobs/Jobs Training Food Transportation Other: Please specify 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. DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMIII'age 17 r 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Duke University Bass Connections: Research partnership to measure the efficacy of the Voices Together program model. • Our partnership with the Orange County School District, Director of Exceptional Children, and classroom teachers are imperative to the success we have experienced throughout our eight years in the district. Program Description (3 pages OR LESS) Over the last 12 years, the prevalence of developmental disabilities (DDs) in U.S. children has increased 17.1%—that's about 1.8 million more children with DDs compared to a decade earlier. Orange County Schools identified approximately 1,036 students with DDs, or 13.7% of the student body. Developmental disabilities are a diverse group of severe chronic conditions that are due to mental and/or physical impairments. People with developmental disabilities have problems with major life activities such as language, mobility, learning, self-help, and independent living. This dramatic jump in the number of Exceptional Children's students increased the financial burden on our schools and families without the proportionate increases in federal special education appropriations or state education spending necessary. Students with disabilities often face additional challenges with regards to school readiness and long-term academic success. To begin with, it's difficult to overcome the adverse educational effects of some disabilities. Other potential causes include the association between disability and poverty, rigid testing policies and practices, misallocation of resources, lack of staff training or effectiveness, or failures in service delivery. Families of students with a disability face complex financial challenges. Insufficient financial resources and/or inadequate access to intervention services often prohibit these families from receiving specialized therapy services. The partnership between Voices Together and the Orange County Schools will help close the achievement gap and help children from these families succeed academically and into adulthood. Voices Together in Education is designed to advance education and student achievement by increasing the development of students' social-emotional skills and building a foundation to improve and expand communication and language capabilities. Social and emotional skills are defined as the ability to understand, manage, and express the social and emotional aspects of one's life in ways that enable the successful management of life tasks such as learning, forming relationships, solving everyday DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMII'age 18 •0 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION problems, and adapting to the complex demands of growth and development. Numerous research studies have shown that: • Students who are more self-aware and confident about their learning capacities try harder and persist in the face of challenges (Durlak et al., 2011). • Students who have self-discipline motivate themselves, manage stress, and organize their approach to work, learn more, and get better grades. • Students who use problem-solving skills to overcome obstacles and make responsible decisions about studying and completing homework perform better academically (Durlak et al., 2011). As these students age out of the public schools, their ability to find jobs and keep those jobs can depend on their ability to work with others, express their needs and wants, understand their strengths and challenges and self-manage themselves. Our program addresses all of these areas and gives each student a safe and motivating space to learn and practice these skills, ultimately leading to self-advocacy and more independence in their lives. Voices Together in Education has the following SMART goals for each classroom that we work with: • Provide weekly Voices Together music therapy sessions for students in selected Exceptional Children's classrooms resulting in an increase in students' verbal language and speech skills. We will administer pre-test and post-tests to teachers to measure the success of the objectives. • Voices Together will promote learning in classrooms receiving weekly music therapy sessions by working to increase a student's ability to remain seated and engaged in a group setting and teach positive coping skills students can use that will decrease the number of emotional or physical outbursts. We will administer pre-test and post- tests to teachers to measure the success of the objectives. • Voices Together will support the development of student's communication and social skills by increasing their ability to initiate conversation, speak so others can understand them, and engage in active listening. We will administer pre-test and post-tests to teachers to measure the success of the objectives. Approximately 100 more students with developmental challenges have been able to participate in this program and gain lifetime skills because of previous Orange County Outside Agency funding. While offering this program to the students in classrooms, this program has also benefitted teachers as our music therapists work closely with them. Teachers have learned new strategies, ideas, and teaching structures from our weekly DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMII'age 19 •r 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION sessions that they have used in their own classroom instruction for maximum outcomes. The proposed funding for 2017-18 will help us bridge the gap in funding and bring this program to all classrooms in the Orange County Schools Exceptional Children area. It will enable Voices Together to continue to provide our program to students that desperately need intervention services such as ours. Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town/County priority/goal? The Voices Together program aligns with the County's goal of ensuring a high quality of life and lifelong learning that champions education at all levels. It was carefully designed to be closely aligned with the Extended Content Standards. It has been such an effective intervention in the school setting precisely because its techniques help teachers and students meet goals established by the state and federal governments. A key part of the Extended Common Core Standards in every subject in the K-12 curriculum is the development of speaking, listening, and language skills. Voices Together is based in music therapy and music is a key part of the program, offering a motivating and universal tool that facilitates generalized learning. The innovative program method was developed by combining educational and therapeutic techniques for optimal outcomes. Special attention was paid to speech and language areas, basic educational learning techniques, and social/ emotional learning techniques. Every Voices Together session offers continual interactive communication techniques that were developed specifically to prompt and cue neural and language response. The Voices Together curriculum meshes so effectively with the NC Extended Common Core standards because it targets three main core areas of growth: communication, social learning, and emotional learning. For this reason, Voices Together participants acquire life skills that they apply to every subject and, as a result, the outcomes are remarkable. 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. DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMII'age 20 .t 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION The well-being of and quality of life for individuals with developmental challenges depends on opportunities they will have in their classrooms and communities. As they age out of public schools, vocational opportunities will depend on their ability to fully function with others and within a job setting. Without the services to build critical skills, this population will be at risk of being isolated from our communities, creating more dependent members of our community, and more individuals dependent on public funding. Skills such as the ability to tell someone what they think, feel, or need at any given time could greatly help them find jobs that will suit them and keep jobs once they have them. This will lead to more inclusive opportunities, independence and more productive lives. Basic communication and socialization skills are at the core of every person's ability to fully function and thrive. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? Working with the Exceptional Children's Department of Orange County Schools, the Voices Together in Education Program Manager alongside the Director of the Exceptional Children's Department will select four classrooms or a total of approximately 45-50 students to participate in the program from September through April. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) All Voices Together Music Therapists have a Bachelor's or Master's degree in Music Therapy, have completed a college-approved internship, and are Board Certified. They have also completed the Voices Together specialized training. The Program Manager, currently Voices Together's Senior Music Therapist, has all of these credentials as well as three to four years experience in program implementation and an understanding of management requirements in the organization. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. Programmatic Timeline for 2017-18 The comprehensive Voices Together program consists of two months of preparation and development, seven (7) months of direct services to students and two follow-up months that include a district wide performance and evaluation wrap up: • July & August: Meet with district EC Director to plan and discuss classrooms for the fall and distribute baseline evaluations. Voices Together certified therapists and OCS teachers collaborate to set individual student and overall Voices Together goals. Music Therapist and teachers decide on weekly schedule. • September 2017—April 2018: direct student instructional services • May: District wide performance • May 2018: Voices Together will compile data from assessment forms. DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMIII'age 21 •0 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • May-June: Summary assessment results for the year 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) In our schools, teachers are struggling to reach children with special needs who have difficulty speaking, expressing and organizing their thoughts, connecting with their peers and identifying their emotions. Resources for educators are dwindling and teachers are searching for innovative ways to help their students learn. The extended core curriculum for special education is annually modified to try to address specific areas of challenge for these students. Teachers are searching to find new methods to teach socialization, emotional learning, and communication. Teaching basic communication and social/emotional skills is different from traditional academics. Due to the nature of this type of learning, the need for a dynamic, spontaneous, and interactive method is crucial. Our program provides a much-needed bridge for this gap. With this scientifically proven method, students in special education classrooms can have a chance at the same opportunities as their peers to live functioning and purposeful lives. They can have the same opportunities to learn and become mainstreamed with their peers and to have jobs when they age out of school. It is essential that we don't forget these individuals in our communities and help them thrive. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. The goal for Voices Together and for The Exceptional Children's department of OCS is to be able to offer this specialized programming to all classrooms in Orange County. Without this support funding, we would have difficulty reaching that goal. k) Include any other pertinent information. We appreciate your continued support that has made such an impact on our ability to serve the students with exceptional needs in Orange County since 2012. Last year, we were able to offer this program in all of the K-12 Exceptional Children's classrooms in OCS, however, we could not offer this in any of the preschool classrooms. With your continued support this DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMII'age 22 •r 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION year, we will continue our goal to reach every classroom that needs this program and hope to expand the program to preschools so that we can continue to impact children that are in that early childhood development stage. DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMII'age 23 r 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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, Program Target Population Demographics Actual Estimated Projecte 2015-16 2016-17 d 2017-18 Gender Male 50 50 55 Female 25 25 30 Total 75 75 85 Ethnicity African-American 15 14 18 American Indian or Alaska Native Asian Caucasian 43 44 45 Native Hawaiian or other Pacific Islander Other: specify 17 17 22 Total 75 75 0 Of the above, how many Hispanic/Latino 12 15 18 Of the above, how many non-Hispanic/Latino 63 Total 75 75 85 Age 0-5 years 0 25 40 6-18 years 67 44 38 19-50 years 7 6 7 51+ years Total 75 75 85 Geographic Location Alamance County 100 95 120 Chatham County 90 0 0 Durham County 120 110 125 Wake County 0 15 45 DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMIII'age 24 r 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non-Public Housing) Town of Carrboro Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) 75 75 85 Total 385 295 420 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 1. Program Activity Specialized music therapy program that teaches Name communication and social/emotional skill building Program Goal Increase in students' social/emotional learning Performance Measures Percentage of students able to tell someone how they feel Previous Year Program 43% Results Current Year Estimated 47% Results DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMIII'age 25 •r 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Next Year Projected 35% Results 2. Program Activity Specialized music therapy program that teaches Name communication and social/emotional skill building Program Goal Increase students' ability to self-regulate their behaviors Performance Measures The number of students who are able to use self- regulation/coping strategies to decrease the number of emotional or physical outbursts. Previous Year Program 40% Results Current Year Estimated 45% Results Next Year Projected 35% Results 3. Program Activity Specialized music therapy program that teaches Name communication and social/emotional skill building Program Goal Increase students ability to initiate social communication Performance Measures The number of students who will initiate verbal or non- verbal social conversation with peers. Previous Year Program 32% Results Current Year Estimated 30% Results Next Year Projected 30% Results 4. Program Activity Specialized music therapy program that teaches Name communication and social/emotional skill building Program Goal Increase students ability to self-advocate Performance Measures Number of students who are able to ask for help Previous Year Program 29% Results Current Year Estimated 33% Results Next Year Projected 30% Results DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMII'age 26 lr 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT 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. Professional fees and business expenses (marketing, insurance, etc.). 3. This program budget represents what percent of the agency budget? 7.5% DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMII'age 27 •r 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Voices Together Actual Estimated Projected Percent AGENCY REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 26,224 $ 75,250 $ 100,000 33% Agency Generated Revenue (fees) $ 143,350 $ 122,500 $ 175,000 43% Local Government Grants: Human Services-Town of Carrboro $ - $ - $ - 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ - 0 Other-Town of Chapel Hill $ - $ - $ - 0 Human Services- Orange County $ 10,000 $ 15,000 $ 20,000 33% Other- Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Local Government (Durham Co.) $ 11,250.00 $ 11,250.00 $ 1 5,000.00 $ 0.33 State Government $ - $ 15,000.00 $ 15,000.00 $ - Federal Government (CDBG/HOME/etc.) $ - $ - $ 175,000.00 0 Private Foundation Grants $ 331,132.00 $ 161,000.00 $ 100,000.00 $ (0.38) Other Revenue $ 40,519 $ - $ - 0 Total Agency Revenue $ 562,475 $ 400,000 $ 600,000 50% AGENCY EXPENSES Compensation $ 418,581 $ 337,500 $ 440,000 30% Rent& Utilities $ 39,020 $ 36,767 $ 42,000 14% Supplies & Equipment $ 40,452 $ 10,600 $ 48,000 353% Travel & Training $ 8,425 $ 3,700 $ 10,000 170% Other Expenses: $ 29,435 $ 11,433 $ 35,000 206% Total Agency Expenses $ 535,913 $ 400,000 $ 575,000 44% SURPLUS/(DEFICIT) FOR PERIOD: $ 26,562 I $ - I $ 25,000 I 0 FY 2015-16 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME: Voices Together Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ - $ - $ - 0 Program Generated Revenue $ 5,000 $ 20,000 $ 20,000 0% Local Government Grants: Human Services-Town of Carrboro $ - $ - $ - 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ - 0 Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 15,000 $ 15,000 $ 20,000 33% Other-Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ 15,000.00 $ 5,000.00 $ 5,000.00 $ - Other Revenue $ - $ - $ - 0 Total Program Revenue $ 35,000 $ 40,000 $ 45,000 13% PROGRAM EXPENSES Compensation $ 27,350 $ 31,500 $ 35,625 13% Rent& Utilities $ 2,365 $ 2,400 $ 2,475 3% Supplies & Equipment $ 850 $ 1,000 $ 1,200 20% Travel &Training $ 500 $ 700 $ 900 29% Other Expenses: $ 3,935 $ 4,400 $ 4,800 9% Total Program Expenses $ 35,000 $ 40,000 $ 45,000 13% SURPLUS/(DEFICIT) FOR PERIOD: $ - I $ - I $ - I 0 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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- Estimated 2016- Projected 2 017 16 17 18 Total Cost of Program 35,000 40,000 35,625 Total # of Individuals 75 75 85 Cost Per Individual 466.66 533.33 419.12 DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMIII'age 28 .0 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT 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 ( 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 1/26/2017 11:10:15 AMI 'age 29 .t 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT 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 Damage Liability $1 million Each Liability $1,000,000 Bodily $1 million Each Occurrence Occurrence Injury Property $2 million Aggregate ry and Pro p y $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 webpaqe for more information about the County's risk assessment procedures. DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMII'age 30 t 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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 1/26/2017 11:10:15 AMII'age 31 r 31 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF EXHIBIT"B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Voices Together Funding Award: $17,500 Outline how the agency will spend Orange County's funding award. Expense Description Amount Personnel Expenses—Salaries&Benefits 16000 Programmatic Expenses-Supplies 1500 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Provide weekly Voices Together music therapy sessions for students in select Orange County School Exceptional Children's classrooms resulting in an increase in student's verbal language and speech skills. • Support the development of student's communication skills by increasing their ability to speak so other's can understand them and in their ability to actively listen. • Promote learning in the classrooms — receiving weekly music therapy sessions by working to remain seated and engaged in a group setting, and teach positive coping skills student can use that will decrease the number of emotional or physical outbursts. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results Percentage of students who are able to tell someone how they feel using verbal or visual cues. 25% Percentage of students who are able to use self-regulation/coping strategies. 25% Percentage of students who are able to acknowledge others by using appropriate communication 20% skills. Percentage of students who will initiate verbal or non-verbal social conversation with peers. 40% Percentage of students who can ask for help. 45% -----DocuSigned by:11rr Gf MO/lint. U)LIk- ceo 10/11/2017 DAO4O1828F.00 Certified by: Title: ( O Date: 7 - 2 % -/7 (Provider's Signature) DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF 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. PDocuSigned by:11rr ASO% OiA , ti ceo 10/11/2017 Certified by: DA0401828F37476... Title: Date: U (Provider's Signature) 1 1 L (Voices Together) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF ACC30RD® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 7/21/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Amber Simpson Nonprofit Insurance Services (A/c,NNo,Ext): (717)630-1030 (p/C,No): (717)630-1188 195 Stock Street, Suite 118 aoDRless:amber @insureanonprofit.com P.O. Box 933 INSURER(S)AFFORDING COVERAGE NAIC# Hanover PA 17331 INSURERAANI-RRG 10023 INSURED INSURER B: Voices Together INSURERC: 5007 Southpark Dr. , Suite 230 INSURERD: Suite 230 INSURERE: Durham NC 27713 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1772126525 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 TO RENTED 500,000 A CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ X 2016-35634 10/10/2016 10/10/2017 MED EXP(Any one person) $ 20,000 PERSONAL&ADVINJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Increased Aggregate $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE$ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Orange County, its officers, official agents and employees are an additional insured on the General Liability Policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County, Attn: Risk Management THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 South Cameron Street ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE Brian Barrick/AS ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(2014011 DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF ADDITIONAL COVERAGES Ref# Description Coverage Code Form No. Edition Date Improper Sexual Conduct ISC Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 1,000,000 3,000,000 $1,148.00 Ref# Description Coverage Code Form No. Edition Date Add'I for policy minimum premium APMP Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium $581.00 Ref# Description Coverage Code Form No. Edition Date Social Service Prof Liab SSP Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 1,000,000 3,000,000 $840.00 Ref# Description Coverage Code Form No. Edition Date Liquor Liability LIQUR Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 1,000,000 1,000,000 Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium OFADTLCV Copyright 2001,AMS Services,Inc.