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2017-560-E Finance - Boys & Girls Club of Durham & Orange Counties - Outside Agency Performance Agreement
DocuSign Envelope ID:FCA96EA6-6080-4E8E-8EFF-B03ECA597827 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 Boys & Girls Club of Durham & Orange Counties, a not-for-profit corporation, located at 808 East Pettigrew Street; PO BOX 446, Durham, NC 27702 ("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 Boys & Girls Club of Durham&Orange Counties 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 6500 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 1625. 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. (Boys&Girls Club of Durham &Orange Counties) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID:FCA96EA6-6080-4E8E-8EFF-B03ECA597827 d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 —December 31; January 1 —March 31 and April 1 - June 30. Reports are due on January 12,April 13, and July 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 (Boys&Girls Club of Durham &Orange Counties) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID:FCA96EA6-6080-4E8E-8EFF-B03ECA597827 Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of 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 (Boys&Girls Club of Durham &Orange Counties) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID:FCA96EA6-6080-4E8E-8EFF-B03ECA597827 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to 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 Boys & Girls Club of Durham & Orange Counties 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 (Boys&Girls Club of Durham &Orange Counties) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID:FCA96EA6-6080-4E8E-8EFF-B03ECA597827 required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: County: Finance &Administrative Services Provider: Boys & Girls Club of Durham& Orange County Orange Counties Post Office Box 8181 808 East Pettigrew Street; PO Hillsborough,NC 27278 BOX 446 Durham,NC 27702 16. E ntire 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 and on behalf of the Provider (Boys&Girls Club of Durham &Orange Counties) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID:FCA96EA6-6080-4E8E-8EFF-B03ECA597827 O DocuSigned by: s)Voibwtt. btAiuSt1 10/10/2017 `—1nB7oCE i e4u24zE... Date E1Albow For s��6lfof Orange County Government bl abut, tk'GUMwtt-rS(LL 10/12/2017 Bonnie Hammersley, County Manager Date (Boys&Girls Club of Durham &Orange Counties) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 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 4 C 7. i . f *0- i rf • i CARiz %i w " ' Ur, x j� � '.% S'i ! 1III111U� ,,,,,,..,.„A,Vy 'k CiLt6 ',,, ,.. 'E ,Vs' fJ DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 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 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 M1mmArmM1/rnM1M1M1 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 January 31 Application Submissions are Due March - May Application Review &Agency Presentations ,ranp rrrnrmrrnm nM1mm ffl mmM1 nanM1M1M1M1nmmM1M1 mrlrmmw r *M1M14M1M1 m rrn June Agency Funding Approval by Board/Council vrwawrmM1 IhrM1M1M1.4..r myymMMA July Contracts Executed & Programs Begin SUBMITTAL INFORMATION DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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 Services—Town Of Carrboro 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 astoneAtownofcarrboro.orq Submission: > We strongly encourage applications to be single-spaced, with 12-point arial 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 .doci ,x1s, etc. Human Services —Town Of Chapel Hill In 1982, the Town established local funding to support local nonprofit organizations that carry out human service work throughout the community. DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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 jthompson@townofchapelhili.orq Submission: • We strongly encourage applications to be single-spaced, with 12-point anal font and normal margins. A 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 Services—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 acolemanoranqecountync.00v 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. DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Boys & Girls clubs of Durham and Orange Counties Program(s) Chapel Hill Program for Impact Section Subsection 1. Cover Page a. ®Applicant Contact Information b. Funding Requests c. 11 Signed Application Cover Page d. /'1Si s ned Disclosure of Conflicts of Interest and Clause 2. Agency Information a. Agency's Years in operation b. ®Agency's Purpose/Mission c. /1 Agency's Types of Services Provided d. ®Agency's Experience with Programs e. /1 Other Pertinent Agency Information f. Schedule of Positions g. /1 Living Wage 3. Program Information a. ® Human Services Needs Priority b. ® Type of Program A separate Section 3 is c. I1 Agency Collaboration required for each program. d. ®Summary of Program e. 1/ Description of Identified Need f. /1 Description of Population to be Served g. ►„1 Program Staffing, Capacity, &Expertise h. /:1 Program Implementation Timeline i. /,;1 Value of Investment j. `1 impact of Reduced/No Allocation k. Other Pertinent Information 1. Target PopulationlBeneflciary Chart m. /`1 Work Statement 4. Attachments a. /1 Audit: Organizations receiving $300,000 or more in Federal financial assistance, and/or organizations with more than$500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ►1 IRS Federal Form 990 c. /1 NC Solicitation License d. IRS Federal Tax-Exemption Letter e. 11 Certificate of Insurance f. F1 List of Board of Directors DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Boys & Girls Clubs of Greater Durham, soon to be Boys & Girls Clubs of Durham and Orange Counties (in the process of making this legal change) Applicant Organization's Physical Address: 808 East Pettigrew Street, Durham, NC 27701 Applicant Organization's Mailing Address: PO Box 446, Durham, NC 27702 Applicant Organization's Web Address: www.durhambgc.org Executive Director: Jerome Levisy Telephone Number: 919-687-4517,X20 E-Mail:jlevisy©durhambgc.org Tax ID Number: b) Funding Request List all FY17-118 Human Services (HS) Funding Being Requested– For All Proorams) and the Proposed Use of Funds (2-3 lines or less) Program Carrboro Chapel Hill Orange ' Total H$ HS County- H; yr,/ 05.00f .10M/#“000,0 00.6 00u00mmurfarn The BGCDOC Community Impact Program in $10,000 $10,000.00 $10,000.00 $30,000.00 Chapel Hill. Funds for salaries and benefits for the full time Program Director,two part-time program assistants who provide program services to the youth In the program. 111.1111. rnr rnr. rnr. rnr n mvhr.Av.,/07.1.01 1, 4/ 01,00,. r mnemrr Totals $10,000.0 $10,000.00 $10,000.00 $30,000.00 0 c) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: Ex utive Director Date / 041111roP Signature: 1 ' i/27//i- Board Chairperson 44f) Date AGENCY INFORMATION 1/26/2017 14:54:11 al/pi Page 6 of 22 DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION (3) 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 L ❑ a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ■ b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ® c) Current beneficiaries of the program for which funds are being requested? El ® 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. The two part time assistants are teachers employed by the Chapel Hill-Carrboro School district during the school day but are employees of the Boys & Girls Club Program for Impact during the Club after-school hours. We are applying for funds to help pay the salaries/benefits of the two part-time employees as well as for the Program Director (who is not employed by the schools- is 100% employed by BGCDOC) 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. /7 , ,„,,„ :- "f*,'z�. '.y' �,,,.TY.rC"', , i ,,f q A N / do,/ Signature: _ Ec Live Director Date �� i2'l `�i' '� Signature: A �` ' / /z7/-7.-- Board Chairperson U Date AGENCY INFORMATION 1/26/2017 14:54:11 al/pi P a g e 7 of 22 DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 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): Years in Operation, Date of Incorporation (Month/Year): 77 years in operation; incorporated in 1942 Agency's Purpose/Mission (no more than a few sentences): Mission:To inspire and enable all young people, especially those who need us most, to reach their full potential as productive, caring and responsible citizens. Purpose:To instill a sense of competence, a sense of belonging and a sense of having power and influence, especially over their own lives as well as in the community. Types of Services the Agency Provides (bullet format): • Help with homework (Power Hour) with goal of academic success and graduation from high school • Character development through volunteer programs, healthy interaction with peers and adults, and opportunities to get involved throughout the community • Health education (both mental and physical) that incorporates age-appropriate lessons to ensure that Club members are able to make positive choices. Programs include: Smart Moves, Healthy Habits, Smart Girls, and Passport to Manhood. • Summer camp that helps children continue to engage in educational activities between spring and fall school semesters Agency's History with Providing These Services: The Durham Club has been successfully operating for 77 years and the Chapel Hill Program for Impact has been successfully operating for three years. 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?) The BGC Program for Impact in Chapel Hill (formerly part of the BGCEP)merged with the BGC of Greater Durham in August of 2016 with the composite new name of Boys & Girls Clubs of Durham and Orange Counties; legal name change is in process. The CEO of the Durham Club, Jerome Levisy, is now the CEO of the combined Boys & Girls Clubs of Durham and Orange Counties. The BGCEP Club in Slier City merged, at the same time, with the BGC Club in Sanford, Lee County. Everyone believes these mergers are in the best interest of all parties involved. Agency Information 1/26/2017 14:54:11 a1/p1 Page Bof 22 DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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: 3 FTE #of FTE - Paid Part-Time Positions: 5.5 FTE # of Volunteers: 50 1,040 FTE Living Wage Does this agency pay permanent employees a minimum living wage? (Yes/No) If yes, is this agency an Orange County Living Wage Certified Employer? If no, please explain. The Boys & Girls Clubs of Greater Durham and BGCEP recently merged, and pay was determined prior to merger. Now that we have merged, everyone's hourly wage is under review for the 2017 budget. We will always attempt to provide our employees with what they need. Agency Information 1/26/2017 14:54:11 a1/p1 Page 9of 22 DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Ad. 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/N2 Our agency is not receiving nor requesting any other(non human services) local (Carrboro, Chapel Hill, Orange County)government funding. If yes, please list below: Include all programs that have funding requests/awardsltotals 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 FY1?-18 Source Award Re uest 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 wumemmynnrorrvmmv Nn *Add rows or attach additional page, if needed. Agency Information 1/26/2017 14:54:11 a1/p1 Page g 10 of 22 DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Ail. Submit your agency's budget. You may complete the provided template (separate xis file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues o Private Donations o Program Generated Revenue o Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other(DO NOT include CDBG funding here) • Orange County Human Services • 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 A.iii. Does your agency budget show a Surplus or Deficit? Surplus from 2016 Is there a significant change?Yes/No Please provide a brief explanation for Surplus or Deficit, and significant changes. There is a change in our budget due a new management team, a recent focus on stewardship, and the merger of the Durham and Chapel Hill Boys & Girls Clubs. Orange county budget information is not fully represented in our full 2016 budget due to a late fall merger. However, they are included in 2017. A.iv. What is your agency's fiscal year? (Example: July 1, 2016 through June 30, 2017) The previous Chapel Hill organization (Boys & Girls Club of Eastern Piedmont)operated from July 1, 2016. However, the Boys & Girls Clubs of Durham and Orange Counties operates January 1, 2017 to December 31, 2017. Agency Information 1/26/2017 14:54:11 al/pi Page 11 of 22 DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: The Chapel Hill Community Impact Program under the auspices of Boys & Girls Clubs of Durham and Orange Counties (BGCDOC), Program Primary Contact and Title: Jerome Levisy, CEO Telephone Number: 919-687-4517, ext. 20 E-Mail: jlevisy©durhambgc.com a) Indicate the type of Human Service Needs Priority, if program applicable: O Priority Area#1: safety-net services for disadvantaged residents 14 Priority Area#2: education, mentorship, and afterschool programming for youth facing a variety of challenges O 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 a..1 to this profram j 1 Public Housing Program Category Youth Adult Elderly Disabled 1 • Neighborhoods/Residents ........ . Affordable Housing Affordable Healthcare , I Focus on those who need Education X us most. „„.„.. 1 Emily_Resources Jobs/Jobs Training _ 1 Food / Tranagitation other: Please specify Focus on those who need Character us most. development, good citizenship and healthy life styles X 1 1 1 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. • We sought collaboration with the CHAPEL HILL-CARRBORO CITY SCHOOLS in late 2014 and secured space for one classroom to serve 17 youth beginning on January 5, 2015 in Northside Elementary School. The Northside School officials said they were "delighted" to have our program back in Fall 2015 in two large, sunny classrooms with 32 children enrolled (K-5) for the school year of 2015-16. With the continuing success of the BGC Community Impact Program, the Northside School has offered three rooms in 2016-17 for the program to expand to 50 children enrolled. Referrals to the program are primarily PROGRAM INFORMATION1/26/2017 14:54:11 al/p1 P a ge 12 o f 22 DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION through the school social worker and teachers. The CEO, staff, and board are working to continue to expand the program throughout Orange County. • New partnership with Chapel Hill school district program, "School Reading Partners," which will train volunteers to work with BGC students twice per week at Northside. This will actively increase reading and comprehension. • New partnership with Power Crunch. They will be planning events and activities throughout the year. • In January 2016, Ron Reeves of Bridge Buildings at UNC, which focuses on work with at risk children in grades 3-6, started work with our program. This is a group of 20-30 African- American men who are employees of UNC in departments associated with athletics and in professions including graphic design, training, business, fund raising, ticket sales and coaching. They desire to serve as role models and build bridges to adulthood, provide field trips to the UNC campus to encourage kids to see themselves as future students on campus. They tutor and help kids with their homework, as well. This program continues this year. • We are collaborating with the Kidzu Museum to arrange field trips to their museum for low or no cost. • UNC APPLES PROGRAM,There are many other opportunities through the Apples program at UNC which provide volunteers and support to our Program. • The UNC Autograph Basketball Program has granted our Program $15,000 this year and has steadily supported our Program in many past years. They wish to support the youth, in part, recognizing that some star athletes may arise from the Program and attend UNC. • TWIG gift store in Chapel Hill supports us each year at Christmas time with 20% of purchases donated when the buyer requests the donation to go to the BGC. Their support program will take place in May 2017, this year. • We are members of the Chapel Hill-Carrboro Chamber of Commerce. The Chamber featured our program as the non-profit-of-the month in May 2016 at their After-Hours Program. We are negotiating a month in 2017 to be spotlighted. As members. we make use of the monthly non-profit roundtable program and the After-Hours Program. • THE WALKING CLASSROOM. The Program for Impact engaged the Walking Classroom tapes during the summer 2016 program. This will continue into 2017. • KAPPA ALPHA PSI -African American fraternity on campus talking about volunteering with homework/recreation as well as taking the Northside Program on as a service project. PROGRAM INFORMATION1/26/2017 14:54:11 al/pi Page 13 of 22 DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town/County priority/goal? The Community Impact Program addresses the goal to ensure a community network of basic human services and infrastructure that maintains, protects, and promotes the well-being of all county residents, and priority four which aims to review services to identify and protect 'safety net' programs and services. The program supports the Chapel Hill goal of creating a place for everyone, all children can attend an after-school Program regardless of income. Our agency provides youth from kindergarten through twelfth grade with an after-school youth development program focused on three main goals or outcomes as follows: The PRIORITY OUTCOMES are: 1.Academic success in school with end-goal to graduate from high school ready for college, trade school, military or employment; 2. Good character and citizenship-to become an engaged citizen involved in the community, register to vote and model strong, positive character; 3. Healthy life style- to adopt a healthy diet, practice good lifestyle choices and make a lifelong commitment to fitness. While all children are eligible to join, the Club focuses on the population who "needs us most," those unable to access other Chapel Hill-Carrboro after-school programs, even on scholarship, which often have waiting lists and which present transportation problems. Providing after school academic enrichment and development to children who currently are poorly served or served not at all, centrally fills the stated Goal of maintaining, protecting and promoting the well-being of all of our county residents with this 'safety net' program. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment)to support the need for this program. A needs survey found that, although there are many activities for children in the Chapel Hill- Carrboro area, most of them have waiting lists, have costs that prohibit low income children from taking part and are not open long enough or often enough to be helpful to and useful for our target population, to achieve and maintain the goals of the Program for the youth enrolled. Over the years, approximately 35% of the student population in the Chapel Hill Carrboro Schools are currently qualified for free or reduced lunch. In addition, 600 families in Chapel Hill/Carrboro live on $15,000/year or less and children in these families cannot afford any of the programs offered after school, even on scholarship. After-school programs have consistent waiting lists and also pose transportation difficulties. These kids are left to wander the streets during the most dangerous hours for kids (3pm-7pm) when either they commit crimes or crimes are committed against them. PROGRAM INFORMATION1/26/2017 14:54:11 a1/p1 Page 14 of 22 DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION The goal to 'nurture our community'or'provide high quality life' is described in all the governmental needs assessment documents. Orange County's Goal, "High Quality of Life," describes two education goals: close the achievement gap and end school to prison pipeline. The Chapel Hill-Carrboro City Schools have been struggling for years to close the achievement gap. A Boys & Girls Club, with its emphasis on school success, can be instrumental in helping to close that gap. in addition, because the club program continues through the summer months, children will not lose the gains they have made in the past year as they often do if they have no enrichment over the summer. Because of the strong attention the Club gives to understanding and finishing homework each day, with the goal of success in school, it is expected that the Community Impact Program will have a positive effect on the achievement gap. Over 70% of adults who attended Boys & Girls Clubs say that the Club saved their lives. Studies show that Boys & Girls Clubs work to reduce drug, gang and early sexual involvement, and to increase the likelihood of graduating from high school. The program will end the school to prison pipeline for those who attend. A father of twins who attend the program starting from January 2015 said that he saw a difference in his boys immediately and that they are now "interested in math! Of all things!" As District Court Judge Joe Buckner says, regarding the Boys & Girls Club in Chapel Hill, "There is no greater need." It is clear that the Impact of the BGC Program corresponds closely with many of the goals set forth by governments and will greatly enhance the quality of life in Chapel Hill. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? The population we will serve encompasses all children from K-5 (hoping to expand to K-8) in Orange County who wish to belong. The program at this time can only accommodate 50 children at any one time at the Northside Elementary School, from kindergarten- 591 grade. We do not discriminate while at the same time our target population is youth "who need us most." At the present time, all of our Club members are from the Northside School and are referred into the program by the school Social Worker and teachers. Our long term plans are to expand to other schools, especially middle schools, so that the youth who graduate from 5th grade will not be deprived of continuing Club membership through high school. 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 management team comprises three educated and experienced individuals. The CEO, Jerome Levisy, has worked with Boys & Girls Clubs for nearly two decades. The Development Director, Benay Hicks, has her master's degree from Boston University and a Certificate in Nonprofit Management from Duke. The Program Director, Regina Lindsay, has her degree in criminal justice, speaks Spanish fluently, and has worked with BGC programming for several years. In addition, the program coordinator in Chapel Hill, Brittney Goldston, has a college degree and has been the Program Director at the Siler City Club for five years and at the Chapel Hill Community Impact Program for three years. The two assistants in Chapel Hill are full time teachers in the Chapel Hill Carrboro City Schools and have worked in the program for three years, since it opened. All program leaders and management staff undergo consistent training with the Boys & Girls Clubs of American. This includes webinars, in-person trainings, and conferences. PROGRAM INFORMATION1/26/2017 14:54:11 a1/p1 Page 15 o f 22 DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Volunteers go through an orientation, background check, and placement process. They are reviewed and managed accordingly. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. The Chapel Hill program is an after-school and summer camp program, and is currently being carried out at the Northside School from 2:30- 6pm, Monday through Friday during the school year. A summer program was provided in 2016 and will continue in summer of 2017. The rate of educational programs is increasing, and will continue to increase throughout 2017. The new, larger, management team will oversee new program implementation, ensuring that children in Orange County are getting the most out of their education throughout the school year and during the summer. 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) The Boys & Girls Club helps at-risk children in Orange County reach their potential through academic and life-skills programming. These kids do better in school, behave well at home, and are able to plan for their future. Each child has a ripple effect within the community as they beomce leaders among their peers and in their families. Teach them to read, and they will teach their siblings and cousins to read. Teach them about healthy lifestyles and they will encourage their parents/guardians to buy healthier food and stop smoking. Each individual child the Boys & Girls Club helps will contribute to a more positive Orange County.A Florida study shows that BGCs even help enhance the tax base since these youth grow up to be gainfully employed, tax-paying citizens who do not need juvenile justice services in their youth. The $10 per school year membership fee for each child means no child will be turned away. Now ALL children our community will have a safe and nurturing place to be after school, without regard to income. a) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. If funding is not awarded, we will find additional sources for support. In the Durham Club's 77 years, the doors have never been closed. This will be the case for Orange County as we do whatever we can to continue to provide the excellent programming we offer. The program, both in Chapel Hill and Durham, is currently supported by ongoing individual donors, corporate donations, and grants. However, the funds that come through the Outside Agency Grant will enable our programs to be stronger and more fulfilling and we hope for increased support in future as we extend our excellent record of accomplishment. b) Include any other pertinent information. Funding from this grant would go specifically to the program in Chapel Hill. The organizational budget lists both Durham and Orange County programs—many are combined, but funding remains separate when necessary. PROGRAM INFORMATIONI/26/2017 14:54:11 a1/p1 Page 16 o f 22 DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information c) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male 284 290 Female 169 200 Total 0 453 490 Ethnicity African-American 386 386 American Indian or Alaska Native Asian Caucasian 6 29 Native Hawaiian or other Pacific Islander Other: specify hispanic, other 51 75 Total 0 453 490 Of the above, how many Hispanic/Latino 50 75 Of the above, how many non-Hispanic/Latino 403 415 Total 0 453 490 1 Age 0-5 years 0 6-18 years 453 490 19-50 years 51+years Total 0 453 490 PROGRAM 11VORMATION1/26/2017 14:54:11 alipl Pa g e 17 of 22 DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Geographic Location ,I,MVPMMVP,,,M71,TIOMM,,",,,, irin ininiiiininnnnornin mini, Alamance Count 1 iinnnininian*M...iniann n Si maw, (........M . Mr6v,./ ''..1 Chatham Count!) ! 1 1 Durham Count!, 382 ! 400 Wake Count , ! Orange County Breakdown 71 90 - , Chapel Hill Public Housing . ......... , Town of Chapel Hill (Non-Public Housing 10 10 _.. Town of Carrbors 15 ! 20 VinOnn,iiiiiii.nnininVII 0 n,,, 1...Min _ Town of Hillsboroug 5 City of Mebane(Orange County 1 Orange County(Outside Municipalities!' ! Total 0 453 490 Work Statement d) 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. (L 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.) PROGRAM INFORMATION1/26/2017 14:54:11 a1/p1 Pa g e 18 o f 22 DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement Chart for Program Chapel Hill Program for Impact 1. Program Activity Name Provide homework&tutoring assistance for at-risk youth Program Goal To increase grades in reading and/or math by I point(scale 1-4) for 20%of youth members. Performance Measures Report card indicators Previous Year Program Results Met goal Current Year Estimated Results Already exceeded by 24%over goal Next Year Projected Results Expect to reach or exceed goal. 2. Program Activity Name Monitor personal&social skills of youth members Program Goal 75%of youth members will meet standards set by school in four categories. Performance Measures Report card indicators: 1. Follows classroom rules. 2. Takes responsibility for behaviors & actions. 3. Respects & cooperates with others. 4. Follows directions. Previous Year Program Results Met goal. Current Year Estimated Results 92%success in reaching goal so far and expect goal will be fully met. Next Year Projected Results Expect to reach or exceed goal, 3. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 4. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results DO NOT SUBMIT THIS PAGE 1/26/2017 15:32:56 a1/p1 Page 19 o !r 22 DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION e) Program Budget 1. Submit your program budget.You may complete the provided template (separate xis file) or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template). Program Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues O Private Donations O Program Generated Revenue • Local Government Grants • Carrboro Human Services • Carrboro Other I 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 I Triangle United Way • State Government I Federal Government(CDBG/HOME/etc.) • Private Foundation Grants • Other Revenue * Expenditures • Compensation O Rent& Utilities • Supplies & Equipment O Travel &Training • Other Expenses 2. Program Budget Detail—Provide description of"other" budget items, not defined. Other budget items include event revenues and expenses, fees and grants associated with our affiliation with Boys & Girls Clubs of America, and professional fees (audit and consulting). 3. This program budget represents what percent of the agency budget? 25% 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 nil Actual 201if Projected 2017-18 Total Cost of Program $529,520 I $570,695 $661,700 Total#of Individuals I 453 490 Cost Per Individual $1,260 $1,350 DO NOT SUBMIT THIS PAGE 1/26/2017153256 al/pi F" n g a 20 1 22 DocuSign Envelope ID:FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Boys & Girls Clubs of Durham and Orange Counties Actual Actual Projected Percent AGENCY REVENUE 2015 2016 2017 Change Private Donations $ 210,894 $ 225,641 $ 302,000 34% Agency Generated Revenue (fees) $ 23,441 $ 20,554 $ 22,700 10% 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 $ - $ - $ - 0 Other- Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ 56,501.00 $ 60,833.00 $ 65,000.00 $ 0.07 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ 130,100.00 $ 182,133.00 $ 212,000.00 $ 0.16 Other Revenue $ 69,526 $ 90,740 $ 60,000 $ 0.34 Total Agency Revenue $ 490,462 $ 579,901 $ 661,700 14% AGENCY EXPENSES Compensation $ 340,287 $ 359,239 $ 416,480 16% Rent& Utilities $ 65,467 $ 58,740 $ 57,600 -2% Supplies & Equipment $ - $ 21,990 0 Travel &Training $ - $ - $ 16,850 0 Other Expenses: $ 123,766 $ 152,716 $ 148,780 -3% Total Agency Expenses $ 529,520 $ 570,695 $ 661,700 16% SURPLUS/(DEFICIT) FOR PERIOD: $ (39,058)1 $ 9,206 1 $ - I -100% FY 2015-16 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID:FCA96EA6-6080-4E8E-8EFF-B03ECA597827 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME: Chapel Hill Program for Impact Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016 2017 Change Private Donations $ - $ 119,750 $ 110,000 -8% Program Generated Revenue $ - $ 2,000 $ 2,000 0% Local Government Grants: nan Services-Town of Carrboro $ - $ 1,250 $ - -100% Other-Town of Carrboro $ - $ - $ - 0 an Services-Town of Chapel Hill $ - $ 2,000 $ - -100% Other-Town of Chapel Hill $ - $ - $ - 0 luman Services-Orange County $ - $ 5,000 $ - -100% Other-Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government (CDBG/HOI $ - $ - $ - 0 Private Foundation Grants $ - $ - $ 12,000.00 0 Other Revenue $ - $ - $ 15,000 0 Total Program Revenue $ - $ 130,000 $ 139,000 7% PROGRAM EXPENSES Compensation $ - $ 48,087 $ 60,580 26% Rent& Utilities $ - $ 1,000 $ 500 -50% Supplies & Equipment $ - $ 6,164 $ 4,090 -34% Travel &Training $ - $ 2,250 $ 600 -73% Other Expenses: $ - $ 55,499 $ 51,190 -8% Total Program Expenses $ - $ 113,000 $ 116,960 4% SURPLUS/(DEFICIT) FOR PERIOD: $ - I $ 17,000 I $ 22,040 I 30% EXhIBIT"B" Scope of Services---FY 2017-18 Outside Agency Performance Agreement Agency Name: Boys & Gtris Ciun ot CurLars & OrarBje Co Program Name: Funding Award: $6,500 Outline how the agency will spend Orange(:.`tmnty's funding award, Elpense Description Amount Salaries and benefits kir a full-time Prtsram Manager and twoprt-time assistants $6,500 Program Services hit l Me the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • 'Ihe Community Impact Program will provide tutoring assistance tbr at-risk youth to improve academic outcomes • The program will monitor personal and social skills of youth members to measure the increase of positive development and behaviors. Anticipated Outcomes The Anticipated Results colt MU/must include quantifiable results in the Ruin of number of persons/units served within Ora nit (ounty, only fall 'fawns and mon,icapaVities). If'you use percentages, you Must also provide the total rtumber of participants within that measure's description or thr an earlier performance measure. Anticipated Performance Measures Results At least 15 youth members will increase a grade in a core subject by 1 point(scale of 1-4) 35% Approximately 30 members will meet the standards set by the schools in at least 4/14 categories. • 4- .1 Certified by „4/4i!> el Title: Date: /A /7 " /(Provider's Signature: DocuSign Envelope ID:FCA96EA6-6080-4E8E-8EFF-B03ECA597827 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: Dt%Oi1t, (PU9L1 CEO 10/10/2017 Certified by: B807BCE1C48242E_, Title: Date: (Provider's Signature) (Boys&Girls Club of Durham &Orange Counties) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 DocuSign Envelope ID:FCA96EA6-6080-4E8E-8EFF-B03ECA597827 20BOYSGIR2 ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)11/03/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Terrie G. Roberts NAME: BB&T Insurance Services, Inc. PHONE 919 281-4500 FAx 8887468761 (A/C,No,Ext): (A/C,No): Post Office Box 13941 MAILS: roberts@bbandt.com ADDRESS: tgroberts@bbandt.com Durham, NC 27709 INSURER(S)AFFORDING COVERAGE NAIC# 919 281-4500 River port Insurance Company 36684 INSURERA: p p y INSURED INSURER B:FirstComp Insurance Company 27626 Boys&Girls Club of Greater Durham INSURER C:Travelers Indemnity Company 25658 PO Box 446 INSURER D: Durham, NC 27702-0446 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. ILTR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DD/YYYY) (MMIDDIYYYY) A X COMMERCIAL GENERAL LIABILITY 13242855 09/09/2016 09/09/2017 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED occurrence) $1 00,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY JECOT LOC PRODUCTS-COMP/OPAGG $3,000,000 OTHER: $ A AUTOMOBILE LIABILITY 13242855 09/09/2016 09/09/2017 (E°acBC debt)INGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) A x UMBRELLA LIAB OCCUR BINDER13242856 09/09/2016 09/09/2017 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DED RETENTION$ $ B WORKERS COMPENSATION MWC005544003 09/09/2016 09/09/2017 PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? Y N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 C D&0/Empl Prac 105991654 09/09/2014 09/09/2017 1,000,000 A Professional Liab 13242855 09/09/2016 09/09/2017 1,000,000/3,000,000 A Sexual Abuse 13242855 09/09/2016 09/09/2017 1,000,000/3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) **Workers Comp Information** Other States Coverage Proprietors/Partners/Executive Officers/Members Excluded: Jerome Levisy, CEO (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION Orange County Risk Manager SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g y g er THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 8181 ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE 74416 ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 2 The ACORD name and logo are registered marks of ACORD #S17079500/M16784881 TGR DocuSign Envelope ID:FCA96EA6-6080-4E8E-8EFF-B03ECA597827 DESCRIPTIONS (Continued from Page 1) Orange County is named as Additional Insured with respects to General Liability as required in a written agreement. SAGITTA 25.3(2014/01) 2 of 2 #S17079500/M16784881