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HomeMy WebLinkAbout2017-586-E Finance - Piedmont Wildlife Center - Outside Agency Performance Agreement DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 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 Piedmont Wildlife Center, a not-for-profit corporation, located at 364 Leigh Farm Rd., Durham,NC 27707 ("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 Piedmont Wildlife Center 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 4475 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 1118.75. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Piedmont Wildlife Center) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 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. (Piedmont Wildlife Center) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 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. (Piedmont Wildlife Center) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 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 Piedmont Wildlife Center 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: (Piedmont Wildlife Center) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 County: Finance &Administrative Services Provider: Piedmont Wildlife Center Orange County 364 Leigh Farm Rd. Post Office Box 8181 Durham,NC 27707 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 ? l#fof the�Provider y041144,0.10. "411:np 10/13/2017 1E2F37B620C4497.. Date (Piedmont Wildlife Center) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 For a /f'of Orange County Government 150V�,V,tt, kominkU SL 10/23/2017 06379949755E477... Bonnie Hammersley, County Manager Date (Piedmont Wildlife Center) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 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 F 11)✓lu fr y ,gy� , F dp 4es� 0 ' '` t 4O\ m � i 1Q 4 i i iffilli.11111 1,00 11 1/12/2017 2:56:42 PM Page 1 .f 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FOR OFFICE USE ONLY Agency _Peidmont Wildlife Center Received By Program(s) (1)Earthkeepers Afterschool Date/Time / (2)Youth & Teen Nature Day Camp 1. Cover Page a. ❑Applicant Contact Information b. ❑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 1/12/2017 2:56:42 PM I:' 2 lr 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. Program Information a. ❑ Human Services Needs Priority b. ❑Type of Program Afterschool Program C. ❑Agency Collaboration d. ❑Summary of Program e. ❑Description of Identified Need f. ❑Description of Population to be Served g. ❑Program Staffing, Capacity, & Expertise h. ❑Program Implementation Timeline i. ❑Value of Investment j. ❑Impact of Reduced/No Allocation k. ❑Other Pertinent Information I. ❑Target Population/Beneficiary Chart m. ❑Work Statement n. ❑Program Budget, Detail, & Cost per Individual 3A. Program Information 0. ❑Human Services Needs Priority p. ❑Type of Program Day Camp Program. q. ❑Agency Collaboration r. ❑Summary of Program S. ❑Description of Identified Need t. ❑Description of Population to be Served u. ❑Program Staffing, Capacity, & Expertise v. ❑Program Implementation Timeline w. ❑Value of Investment x. ❑Impact of Reduced/No Allocation y. ❑Other Pertinent Information z. ❑Target Population/Beneficiary Chart aa. ❑Work Statement bb.❑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 1/12/2017 2:56:42 PM I:' 3 ,r 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Piedmont Wildlife Center Applicant Organization's Physical Address: 364 Leigh Farm Rd; Durham, NC 27707 Applicant Organization's Mailing Address: same as physical address Applicant Organization's Web Address: www.piedmontwildlifecenter.org Executive Director: Gail Abrams Telephone Number: 919-489-0900 E-Mail: director @piedmontwildlifecenter.org Tax ID Number: b) Funding Request List all FY17-18 Human Services (HS) Funding Being Requested — For All Procirams) and the Proposed Use of Funds (2-3 lines or less) Program Carrboro Chapel Orange Total - HS Hill -HS County- HS Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 Afterschool Program Coordinator salary and materials for youth activities and projects Youth Afterschool Program at Carrboro $2,500 $2,500 Elementary School - PWC program salaries, materials, travel; teacher training; and incentives Summer Camp Program - staff salaries, $2,000 $10,000 $12,000 materials,travel, and incentives allowing us to offer up to 46 partial and full scholarships Totals $2,500 $2,000 $5,500 $14,500 c) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: Gail Abrams 1/30/2017 Executive Director Date Signature: Martha Wewer 1/30/2017 Board Chairperson Date 1/12/2017 2:56:42 PM II I:' 4 ,r 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 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 ❑ x a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ x b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ x c) Current beneficiaries of the program for which funds are being requested? ❑ x d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. NON-DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity/expression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: Gail Abrams 01/30/2017 Executive Director Date Signature: Martha Wewer 01/30/2017 Board Chairperson Date 1/12/2017 2:56:42 PM Page 5 •f 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 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): 14 yrs, 12/2002 b) Agency's Purpose/Mission (no more than a few sentences): Inspiring people to develop a positive lifelong connection with the natural world & encouraging active engagement in conservation. We accomplish this mission through a community oriented approach to nature education, leadership development and conservation science. c) Types of Services the Agency Provides (bullet format): • Outdoor education Fall, Winter, Spring, and Summer week-long and day- camps • Outdoor afterschool programs at elementary schools, and at our Durham location • Counselor-in-Training and Outdoor Leadership program for teens • Homeschool programs, ages 5-17 • Community programs using science experts to gather data on species diversity in the Piedmont. • Community partnerships offering nature education, earthskills and community building. • Internships in administration, education and conservation • Family nature programs including camping and camping skills learning • Field trips and at-school programs from elementary to college age • Scholarships to help underserved attend programs • Restore and enhance wildlife habitat in local area, community backyards and schoolyards • Connect citizens to wildlife needs and conservation projects • Volunteer opportunities in education, administration, grounds maintenance, programming, marketing, development, animal care, conservation, and citizen science projects • Volunteer run wildlife hotline referring citizens with wildlife issues to the appropriate source of care, humane removal, or advice • Participate in statewide box turtle project collaborating with other scientists and institutions to study populations and habits. Partner with organizations to improve citizen data collection process. • Offer environmental leadership awards to youth, adults, and businesses who are nominated by those in the community for excellent leadership and involvement in conservation, education, environmental best practices • Collaborate with other area non-profits through membership in Triangle Third Sector Alliance and by other means. 1/12/2017 2:56:42 PM I:' 6 •r 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION d) Agency's History with Providing These Services: We have been providing afterschool programs in some Durham Public Schools, Chapel Hill Carrboro Community schools, and a Hillsborough school for the past 5 years, and a 27-week homeschool program at our Durham location for ages 5 to 17 for 4 years. Our camp program has grown each year and has been in operation for 12 years. We offer summer and intersession/track out camps in Durham, Orange and Wake counties. Each year requests for scholarships have increased. Our conservation program has been doing school programs, outreach events, and citizen science projects for 12 years, and the hotline has been in operation for 8 years. We have an average of 4 interns, 20 counselors-in-training, and 72 volunteers throughout the year. In 2016 we awarded 134 combined full and partial scholarships for all our educational programs. We have been awarding Environmental Leadership awards for the past 3 years. e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? Is there a new Executive Director?Are there new initiatives?) We have received a request from Carrboro Elementary school to bring our afterschool program back.. The teachers have implemented several of the activities we taught them during 2014-15 and feel comfortable leading but would like additional support and activities for their entire afterschool program. For the past several years, we have received grants from Durham County that provided $7000 allowing us to grant 27 full scholarships. Durham is no longer offering their non-profit grant program. We will now have to participate in an RFP process and it is less likely that we will fit into their new format. Two of the buildings we currently use for storage and classroom space at our location in Durham need to be torn down due to safety and structural reasons. Consequently, we need to secure alternative classroom, office, and storage space. This was not part of our current budget so we need to reallocate funds. f) Schedule of Positions (For Entire Agency) • Full Time Equivalent (FTE) staff will be noted as 1.00; half-time as .50; quarter time as .25, etc. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 2,080 # of FTE - Full-Time Paid Positions: 6.00 # of FTE - Paid Part-Time Positions: 4.12 1/12/2017 2:56:42 PM II I:' 7 lr 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION # of Volunteers: 72 # of FTE -Volunteers: 2.06 g) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes/No) Yes If yes, is this agency an Orange County Living Wage Certified Employer? No If no, please explain. We were just able to bring all of our permanent staff up to a living wage. Although some staff live in Orange County and we do programming there, our organization home base is in Durham County. 1/12/2017 2:56:42 PM Page 8 .f 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION h) Agency Budget i) Is your agency currently receiving and/or requesting other(non-Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes/No) No If yes, please list below: Include all programs that have funding requests/awards/totals from Carrboro, Chapel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FY16-17 FY17-18 Source Award Request Ex: Affordable Rental 0 $20,000 Carrboro -Affordable Housing Rehabilitation Ex: Agency Administration $15,000 $15,000 Carrboro—Other Ex. Total $15,000 $35,000 Carrboro Total Funding *Add rows or attach additional page, if needed. i. 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 program year, current program year, and next program year for the following categories: • Revenues o Private Donations o Program Generated Revenue i) Local Government Grants • Carrboro Human Services • Carrboro Other 1/12/2017 2:56:42 PM I:' 9 lr 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • 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 ii. Does your agency budget show a Surplus or Deficit? Surplus Is there a significant change? Yes/No No Please provide a brief explanation for Surplus or Deficit, and significant changes. We had a surplus of$27,100 in 2015/16 due to our efforts to decrease expenses and to increased enrollment in our day camp programs. We work every year to produce a surplus that goes into our cash reserve fund. This fund helps with cash flow during the year as our revenue comes in on a seasonal basis and then is depleted each season as we pay salaries to operate our camp, afterschool and homeschool programs. iii. What is your agency's fiscal year? July 1, 2016 through June 30, 2017 (Example: July 1, 2016 through June 30, 2017) 1/12/2017 2:56:42 PM Page 10 •f 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: EarthKeepers Afterschool Program at Carrboro Elementary School Program Primary Contact and Title: Karen McCall, Education Director Telephone Number: 919-489-0900 E-Mail: karenm.pwc(cgmail.com a) Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area #1: safety-net services for disadvantaged residents x Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ❑Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Yout Public Housing Program Category h Adult Elderly Disabled Neighborhoods/R esidents Affordable Housing Affordable Healthcare Education X Family Resources Jobs/Jobs Training X Food Transportation Other: Please specify Outdoor activities - nature connection X c) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated/collaborative efforts. Chapel Hill Carrboro Community Schools - We ran an outdoor program at 3 of their elementary after-school programs, and held a continuing education training for teachers that provided them with tools to mentor and connect kids to nature, and assist our staff in executing the activities. The Carrboro Elementary Afterschool Manager reached out to ask if we could come back because staff and students missed us and really benefitted from our partnership. They have been using what they remember of the activities and routines we taught them, but would like more support and training. Global Giving Foundation - We have a "Help 30 students become EarthKeepers" project through this foundation which help raises funds so we can provide programming. 1/12/2017 2:56:42 PM Page 11 .f 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT 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? Piedmont Wildlife Center staff travel to Carrboro Elementary School once a week,2 hrs/day, for 20 weeks during the 2017-18 school year. We would hold a 2-hour continuing education training for teachers so they can help facilitate activities, get more teaching tools, and develop their own nature connection. Our nature connection program would positively engage all students enrolled in the Community School afterschool program at Carrboro Elementary. Because our program is outdoors and active, we help improve the health of those who participate. According to ProPublica.org, 37% of students at Carrboro elementary are eligible to receive free or discounted lunches. Our program would address the Human Service Needs priority goal #2: education, mentorship and afterschool programming for youth that may be facing a variety of challenges at no cost to families. 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. Our afterschool program would address the goals and assessments described in the Chapel Hill 2020 plan's section of Nurture Our Community which states: "Chapel Hill strives to live in harmony with the natural world, sustaining its present community, and preserving its quality of life for the future." They benefit from "a commitment to stewardship through a healthier ecosystem and the many opportunities to enjoy natural areas and recreation for all ages and abilities within the community." We lead children in hands-on, outdoor activities, storytelling, nature-themed games and explorations that stimulate curiosity and awaken enthusiasm for the natural world. When we are able to work with youth over a long period of time, their connection to nature and community strengthens. They are positively engaged and apt to be better stewards of their environment and encourage family and friends to do the same. Since Carrboro Elementary is a Title 1 school with 37% of students eligible for free or reduced-price lunch, participants would include those from low-income and possibly at-risk households. This is a direct need described on page 6 of the Human Service Needs in Chapel Hill document prepared in 2012. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? Our target population is elementary school children, grades K-5, enrolled in the afterschool program at Carrboro Elementary school. The Afterschool Manager requested that we come back and work with all their students. Our staff will travel to the school to conduct the program. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) 1/12/2017 2:56:42 PM I:' 12 ,r 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Karen McCall, Education Director, B.S. in Mathematics from UNC-Wilmington with 14 years of experience as a naturalist and program coordinator. She has led the afterschool program for 4 1/2 years. Morgan Freese, Durham Program Coordinator, B.A. in Environmental Studies w/ minor in Marine Sciences from UNC, started as an APPLES intern with us teaching in the afterschool and camp programs. She has been a camp counselor for a 5 years, and is a Certified Interpretive Guide through the NIA. We train volunteers and teachers in awareness routines to navigate through nature, and methods of mentoring that keep students' curiosity peaked by asking questions promoting a desire to delve deeper in the exploration of what sparked their curiosity. Volunteers and teachers become our students and learn by participating in the activities like their students will, igniting their own curiosity and inspiring them to help. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. This program will take place during the 2017-18 school year. A teacher training will be held for 2 hours the week before we begin the program with the students. The student program will be 2 hours a day, one day a week, for 8 weeks during the fall semester and 12 weeks during the spring semester. The fall session operates October - December, and the spring semester operates February - May, with a two week break in April. Timeline: -Sept. 6, 2017, Develop program curriculum, decide start and end dates, times -Sept. 11, 2017, Contact the After school manager and Community Schools Director to get approval for curriculum, confirm day of week to hold the program -Sept. 8, 2017, Once curriculum approved, design teacher training -Sept. 15 Submit teacher training to Community Schools director for continuing education credit approval -Sept. 18 - 30, hold teacher training for 2 hours -Dec. End the program by mid month, establish start date for the following semester -Feb, 2018, begin Winter semester; meet consecutively as possible for 6 weeks -April, 2018, begin second 6 week session -May end program and assess 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) Our outdoor programs are designed to instill an awareness and deeper appreciation for nature and the wildlife that share our environment. Through direct mentoring, we give 1/12/2017 2:56:42 PM I:' 13 ,r 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION young children and teenagers experiences in nature to foster confidence, natural curiosity, a deepening awareness of the intricacies of the world around them and a chance to develop into leaders and mentors in our community. Investing in the youth of the community by funding our program, strengthens their connections to each other, nature, and their outdoor and leadership skills. This provides a better quality, more sustainable way of life making for happier kids. This ripples through the community making it a more enjoyable place to live, which is part of the Carrboro 2020 Vision. Getting kids outside and active addresses the problem we have nationwide with childhood obesity and the alarming and increasing rate Type II diabetes as a result of sedentary lifestyles. Since this is a school program intended for all after school participants free of charge, it gives Community Schools after school program value, and in turn the community. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. The ability to work with an entire after school program reaching students that would not participate in our programs due to financial constraints, limited transportation, or lack of experience with outdoor activities, is unique. At our other after school programs, parents must pay an additional fee. We have funds for scholarships but only enough to grant a dozen, so only a few students benefit. Because of our need to reallocate funds for the next few years, we do not have additional funding in our budget to provide a free program. k) Include any other pertinent information. Research has shown that on average, children spend 4.5 hours a day on the internet, playing video games and/or watching TV. Offering sufficient outdoor time improves the overall health of our children while lengthening attention spans, diminishing aggressiveness, improving test scores and ultimately advancing learning. A plethora of research has indicated that hands-on environmental education has a measurably positive impact not only on student achievement in science, but also in reading, social studies, and mathematics. Outdoor activity has also been proven to improve eyesight, provide Vitamin D for strong bones and healthy hearts, lower and help children maintain safe body weight, and has been shown to reduce attention deficit symptoms. A 2009 study by researchers Andrea Taylor and Frances Kuo found that twenty minutes in a park setting was sufficient to elevate attention performance relative to the same amount of time in other settings. These findings indicate that environments can enhance attention not only in the general population but also in ADHD populations. "Children with attention deficits concentrate better after walk in the park." Journal of Attention Disorders, 12, 402-409. Studies also show that children with more participatory learning experiences have a greater aptitude for leadership, vision and inspired action. 1/12/2017 2:56:42 PM I:' 14 ,r 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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 436 43 173 Female 304 27 110 Total 740 70 283 Ethnicity African-American 61 6 24 American Indian or Alaska Native 0 0 0 Asian 68 12 27 Caucasian 611 52 232 Native Hawaiian or other Pacific Islander 0 0 0 Other: specify Total 740 70 283 Of the above, how many Hispanic/Latino 157 6 61 Of the above, how many non-Hispanic/Latino 583 64 122 Total 740 70 283 Age 0-5 years 90 17 68 6-18 years 650 53 215 19-50 years 51+ years Total 740 70 283 Geographic Location Alamance County 1 Chatham County Durham County 168 68 85 Wake County 1 Orange County Breakdown Chapel Hill Public Housing ? ? ? Town of Chapel Hill (Non-Public Housing) 406 2 3 Town of Carrboro 162 195 Town of Hillsborough 2 City of Mebane(Orange County) Orange County(Outside Municipalities) Total 740 70 283 1/12/2017 2:56:42 PM Page 15 .f 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement 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 EarthKeepers Afterschool Program 1. Program Activity Name Perform 1 two-hour continuing education credit for teachers Program Goal Teachers get trained on nature mentoring and continuing ed credit Performance Measures Training approved by Community Schools Director, teacher participant sign in sheet used Previous Year Program Results Mary Roberts approved continuing ed; 10 teachers attended Current Year Estimated Results not applicable (N/A) Next Year Projected Results Community Schools Director approves continuing ed credit, 4 teachers attend 2. Program Activity Name Afterschool Teachers will be able to facilitate program activities Program Goal Afterschool teachers will be able to incorporate their teacher training and assist or lead activities Performance Measures PWC staff will observe teachers facilitating activities with the students Previous Year Program Results 100% of the teachers helped facilitate the activities Current Year Estimated Results N/A Next Year Projected Results 90% of the teachers will help facilitate the activities 3. Program Activity Name 2-hour programs are taught during three 7 week sessions in the 2017-18 school year to an average of 195 afterschool students Program Goal Teach 8 weeks in the fall, 2 - 6 week sessions in the 1/12/2017 2:56:42 PM II I:' 16 lr 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION spring; 2 hours/week Performance Measures Keep a log with date and times program held Previous Year Program Results 2-hour programs were taught in 3 sessions of 7 weeks each; 162 students participated Current Year Estimated Results not applicable (n/a) Next Year Projected Results A 2-hour program is taught for 3 sessions, each approx 7 week long, to an average of 195 students 4. Program Activity Name Students will gain a greater knowledge in their environment through sensory awareness activities that heighten use of their senses Program Goal To increase observation skills Performance Measures Teachers will keep track of the percentage of students that are successful at the activities we use to test awareness and observation skills and ask questions to test how well students observed an area Previous Year Program Results N/A Current Year Estimated Results N/A Next Year Projected Results 30% of students will increase their sensory awareness skills 5. Program Activity Name Students will gain a greater proficiency in using tools to study wildlife Program Goal Students will be better able to use naturalist tools used to study wildlife Performance Measures Challenges will be given to students in order to observe how well they can use the tools and what their findings are. Teachers will record % of students successful at getting correct answers/using tools correctly Previous Year Program Results N/A Current Year Estimated Results N/A Next Year Projected Results 30% of students will be able to use tools to study wildlife that interests them 6. Program Activity Name Students will increase their time spent outside other than just in our program Program Goal Students will spend time outside at home or with family and friends Performance Measures We will ask students if they spent time outside since our last meeting, teachers will record percentage of students that say yes Previous Year Program Results 50% of the students spent time outside away from our program Current Year Estimated Results N/A Next Year Projected Results 55% of students will report spending time outside when not in our program 1/12/2017 2:56:42 PM II I:' 17 ,r 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 7. Program Activity Name Parents will report back on the positive effects our program had on their child(ren) Program Goal Parents will answer and submit a survey about how well the program affected their child(ren)'s connection to and knowledge about nature Performance Measures We will use SurveyMonkey to capture responses to show how big an impact our program had on their child(ren)'s connection and interest in nature since participating in the program Previous Year Program Results Two parents answered our survey. Three parents verbally shared how important the program was for their kids and hoped we would continue it the following year Current Year Estimated Results N/A Next Year Projected Results 15 to 20% of the parents will submit the survey showing positive changes in their children's knowledge and connection to nature if they receive incentive money 1/12/2017 2:56:42 PM I:' 18 •t 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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. Survey incentives of a $5 gas card will be given to the first 50 parents that answer our parent evaluation at the end of the session. We are hoping to receive more parent feedback by offering these incentives. 3. This program budget represents what percent of the agency budget? 1.75% 4. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2015-16 Estimated 2016-17 Projected 2 017-18 Total Cost of Program 39,489 9,224 11,510 Total # of Individuals 740 70 283 Cost Per Individual 53.36 131.77 40.67 1/12/2017 2:56:42 PM Page 19 •f 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Youth and Teen Nature Day Camp Program Primary Contact and Title: Karen McCall, Education Director Telephone Number: 919-489-0900 E-Mail: karenm.pwc( gmail.com a) Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area #1: safety-net services for disadvantaged residents x Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges Priority Area#3:programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Yout Adult Elderl Disabled Public Housing h y Neighborhoods/Residents Affordable Housing Affordable Healthcare Education X Family Resources Jobs/Jobs Training X X Food Transportation X Other: Please specify Outdoor activities - nature connection X c) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated/collaborative efforts. • Orange County Parks and Rec - We have continued our partnership this year to run 8 camps this summer, one in spring 2017 and one in fall 2018 at Blackwood Farm Park • Send a Kid to Camp through the Triangle Community Foundation - awards us funding to offer scholarships to families in need • Global Giving Foundation - we have a "Send 70 Kids to Nature Camp" project through this foundation helping Piedmont Wildlife Center raise needed funds to provide scholarships. 1/12/2017 2:56:42 PM Page 20 •f 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town/County priority/goal? Piedmont Wildlife Center proposes to offer up to 46 full or partial scholarships to Orange county families in need so their children could attend camps. These camps address a town of Chapel Hill goal of addressing services for youth. We offer summer camps for ages 5 to 17, and intersession/semester break camps throughout the school year at Leigh Farm Park in Durham, and Blackwood Farm Park in Orange County. We also offer exclusive camps for teens all summer at our Durham location. Teen camps include an Outdoor Leadership program, two destination backpacking camps, and several others that provide challenges, teach outdoor skills, and connect teens with nature and their peers. By providing camps that get kids active outside while learning about nature, they develop an affection for their parks, want to take care of them, and bring families and friends to enjoy them. This meets Chapel Hill's desire "to live in harmony with the natural world, sustaining its present community and preserving its quality of life for the future. Its commitment to preserve and maintain its natural beauty, recreational opportunities, and environment are understood and supported by the community," ("Nurture Our Community" theme, 2016-18 Chapel Hill Council Goals) and goal (NOC.3), "Support the Parks and Recreation Master Plan and the Greenways Master Plan to provide recreation opportunities." Our Counselor-in-Training (CIT) program provides an opportunity for local teens to receive training to become leaders in the community, work with children, be able to create educational activities, and learn from expert naturalists and counselors. Participating in this program gives teens skills and a hand up to secure jobs in the future. e) Describe the community need or problem to be addressed in relation to the Chl2gl llilLIIHlurnan Services Needs Assessme nt, rLa_n e County CC Goals end Priorities, Town of Cha el Il lill Council oals, 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. By working with Piedmont Wildlife Center, Orange county meets a goal of supporting and collaborating with a local business/non-profit that is expanding and gives youth a connection to their parks. In Orange County's Parks and Recreation Needs and Assessments, they noted that the public responded to surveys stating that summer camps were on top ten programs they would like to see offered or expanded. A focus group discussed current nature and environmental programs offered by the County and by the Orange Soil and Water Conservation District to the schools. A number of different ideas for future programs were identified, including: signage in parks, collaborate with other jurisdictions and entities; consider creating programs that teach people how to live 1/12/2017 2:56:42 PM I:' 21 00 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION in harmony with nature and basic skills (e.g., flint making); and programs on plants (e.g., edible plants). We teach children and adults all of those concepts. Our collaboration with Blackwood Farm is to work with them to develop interpretive signs. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? Youth, ages 5 to 17 years old, that reside in Orange County. Camps in Durham are for ages 5 to 17 year olds, with exclusive teen camps for ages 13 - 17. Camps offered at Blackwood Farm Park will be for youth, 7 to 12. Scholarships are offered through an application process. We can determine who is from Orange county and what their financial needs are. Parents fill out an application and include a $25 application fee and the first page of their tax returns. Those in need of financial aid that live beyond 5 miles from the camp location will be offered gas cards or cab fare for the camp week if enough funds are available. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) • Karen McCall, Education Director, B.S. in Mathematics from UNC-W with 14 years of experience as a naturalist and program coordinator. Camp and program coordinator at Piedmont Wildlife Center for 4 years. • Hannah Royal, B.A. Interdisciplinary Studies-Environmental Studies with focus on Wildlife and Fisheries Science from Univ. of TN, Off-Site Program Coordinator. • Other staff will be hired in the next few months that are naturalists, teachers, biology or ed majors hired as counselors or college interns • Teen Counselors-in-training providing teens an opportunity to practice leadership skills and assist adult counselors. • We train interns and teens in our Counselor-in-Training program by coaching them on how to work with children of varying ages; give them the chance to develop and/or lead age appropriate activities; they receive feedback and are challenged so they become confident potential leaders in our community. Teens who are new to the program must attend our Outdoor Leadership Camp or "shadow" on of our exemplary veterans and get counselor feedback before becoming a CIT in our camps. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. Camps will be offered for week-long sessions, from 9:00 a.m. to 3:00 p.m. with extended care options. Camps begin June 12, 2017 and run through August 25, 2017. Timeline: - Open registration for camps and get advertising out by Jan 1, 2017 - Applications are accepted for scholarship needs Jan 2, 2017 -Offer scholarships after all paperwork and administration fees have been received by office 1/12/2017 2:56:42 PM II I:' 22 •r 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION manager, and amount determined, rolling dates until all scholarship money allocated. - Spring camps begin March 27,2017, end April 14, 2017 - Summer camps begin June 12, 2017, end August 25, 2017 - Fall camps begin Sept. 18, 2017, end Oct. 13, 2017 -Winter camps begin Dec 26, 2017, end Jan 12, 2018 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) Our partnership with Orange County Parks and Rec is providing visibility for their new park by bringing environmental education programs to the park. Environmental Education programs were listed as a main attraction to park facilities by their focus group (p. 6-11, OCPR Needs and Assessments). The focus group also stated the need to expand camp programs. The Counselor-in-Training program offers a wonderful opportunity for teens to develop into future leaders and have skills to use to teach, spark an interest in our environment providing them with a possible direction to a career they want to pursue. Our organization also has a conservation division offering outreach programs for all ages, helps educate our communities on conservation which brings awareness to the importance of living a sustainable lifestyle. Several of our staff have nature museum experience and could be a great partner and resource for development of a nature center. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Financial aid requests increase yearly. Families are turned away and the chance to connect that child with nature and forming a deep and lasting bond with their surroundings is diminished. Holding camps in several locations, allows us to better serve our surrounding communities, reaching more kids. Without additional funding, our desire and ability to offer the same ratio of scholarships for all of our camp locations will not be possible. We would have to reduce the amount of scholarships per venue impacting families in several counties. k) Include any other pertinent information. Please refer to section K, page 14 of this application. Feedback from our parent surveys from campers who attended Blackwood Farm camps last summer: "This is a wonderful program, and so perfectly located for parents in Hillsborough. I think Mr. Jarl did an amazing job, and I hope Piedmont Wildlife has camps available in future summers at this locale!"; "Both my husband and I are outdoorsy people, but it has been so fun and rewarding experiencing Blackwood Farm Park with our child. Our son has really enjoyed being the 'expert' on our hikes there, which has been incredibly rewarding for all of us.“; "The kids being out in nature. It was peaceful and inspiring for them.” 1/12/2017 2:56:42 PM Page 23 .f 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 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 Projected 2015-16 2016-17 2017-18 Gender Male 946 965 985 Female 609 644 656 Total 1555 1609 1641 Ethnicity African-American 94 89 102 American Indian or Alaska Native 1 1 0 Asian 60 67 68 Caucasian 1,400 1,452 1,471 Native Hawaiian or other Pacific Islander Other: specify Total 1555 1609 1641 Of the above, how many Hispanic/Latino 60 84 77 Of the above, how many non-Hispanic/Latino 1495 1525 1,564 Total 1555 1609 1641 Age 0-5 years 34 36 40 6-18 years 1521 1573 1601 19-50 years 51+ years Total 1555 1609 1641 Geographic Location Alamance County 1 2 2 Chatham County 38 41 43 Durham County 814 838 853 Wake County 237 248 250 Other 28 30 34 Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non-Public Housing) 317 325 331 Town of Carrboro 60 62 63 Town of Hillsborough 40 41 42 City of Mebane(Orange County) 1 2 2 Orange County(Outside Municipalities) 19 20 21 1/12/2017 2:56:42 PM Page 24 .f 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Total 1555 1609 1641 Work Statement m) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and Time-bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday-Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program Youth & Teen Nature Day Camp 8. Program Activity Name Scholarship recipients from Orange County will participate in at least one day camp Program Goal Award 14 full camp scholarships to Orange County residents Performance Measures Keep a daily attendance sheet at camp to show that recipients attended camp Previous Year Program Results Not applicable (N/A) Current Year Estimated Results 16 full scholarships were used to attend camp Next Year Projected Results 30 full scholarships 9. Program Activity Name Give transportation financial assistance to those in need (up to 10 families over the summer) Program Goal provide gas cards or cab fare for one family living further than 5 miles from the camp location to cover transportation costs to get child(ren) to camp for a week Performance Measures Track who received transportation financial aid and 1/12/2017 2:56:42 PM Page 25 •f 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION confirm camper attendance on sign in sheet Previous Year Program Results N/A Current Year Estimated Results N/A Next Year Projected Results 1 family per week receives transportation funding 10. Program Activity Name Teach campers about flora and fauna of our area, and/or outdoor skills (using field guides, survival skills) Program Goal Campers will feel more confident in knowledge of local flora and fauna and/or outdoor skills Performance Measures Counselors will observe campers sharing what they have learned and share it in a summary at the end of camp. Previous Year Program Results N/A Current Year Estimated Results Counselors reported a 32% average of students showing a drastic increase in knowledge of flora, fauna, and outdoor skills Next Year Projected Results 36% of campers will show increase in knowledge of flora, fauna, and outdoor skills 11. Program Activity Name Offer camps that connect students to nature Program Goal Deepen inborn sense of wonder Performance Measures Campers will be curious about something they are drawn to in nature and ask questions about it. Counselors will record observations. Previous Year Program Results N/A Current Year Estimated Results Counselors reported a 32% average of campers showing a large improvement in connecting with nature Next Year Projected Results 36% of campers will show an improved connection with nature 12. Program Activity Name Parents will report back on the positive effects our program had on their child(ren) Program Goal Parents will submit a completed survey evaluating their child(ren)'s connection and interest in nature since participating in the program. Performance Measures We will use SurveyMonkey to capture responses to show how big an impact our program had on their child(ren)'s connection and interest in nature since participating in the program Previous Year Program Results Current Year Estimated Results 12% surveys submitted, 99% positive results Next Year Projected Results 20% surveys submitted, 99% positive results 1/12/2017 2:56:42 PM II I:' 26 ,r 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 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. a. Survey incentives of a $5 gas card will be given to the first 200 parents that answer our parent evaluation at the end of the session. We are hoping to receive more parent feedback by offering these incentives. $5 x 200 parents=$1,000 b. Transportation for parents to get their child to camp. cost is $30/day for 5-day camp=$150 per child. Given to 10 children = $1,500. 3. This program budget represents what percent of the agency budget? 44.4 % 4. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2015-16 Estimated 2016-17 Projected 2017-18 Total Cost of Program 223,702 276,334 291,258 Total # of Individuals 1,555 1,609 1,641 Cost Per Individual 144 172 177 1/12/2017 2:56:42 PM Page 27 •f 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Actual Estimated Projected Percent AGENCY REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 56,562 $ 57,625 $ 58,777 2% Agency Generated Revenue (fees) $ 444,812 $ 502,804 $ 532,190 6% Local Government Grants: Human Services-Town of Carrboro $ 2,200 $ 2,500 $ 3,500 40% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ - 0 Other-Town of Chapel Hill $ 1,000 $ 1,000 $ 1,000 0% Human Services- Orange County $ 2,000 $ 3,500 $ 10,000 186% Other- Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 Durham County $ 8,190 $ 8,190 $ - -100% Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government (CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ 10,000.00 $ 10,000.00 $ 10,000.00 $ - Other Revenue $ 41,276 $ 43,000 $ 40,000 $ 0.07 Total Agency Revenue $ 566,040 $ 628,619 $ 655,467 4% AGENCY EXPENSES Compensation $ 397,031 $ 458,453 $ 477,003 4% Rent& Utilities $ 47,251 $ 52,655 $ 57,498 9% Supplies & Equipment $ 55,233 $ 76,115 $ 77,674 2% Travel & Training $ 926 $ 1,500 $ 2,000 33% Other Expenses: $ 28,383 $ 39,896 $ 41,292 3% Total Agency Expenses $ 528,824 $ 628,619 $ 655,467 4% SURPLUS/(DEFICIT) FOR PERIOD: $ 37,216 I $ - I $ - I 0 FY 2015-16 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME: Earthkeepers Afterschool Program Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 1,681 $ 1,370 $ 1,260 -8% Program Generated Revenue $ 12,588 $ 6,664 $ 7,750 16% Local Government Grants: Human Services-Town of Carrboro $ 2,200 $ 2,500 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ - 0 Other-Town of Chapel Hill $ 1,000 $ - $ - 0 Human Services- Orange County $ 2,000 $ - $ - 0 Other- Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 other-Durham County $ 8,190 $ 1,190 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government (CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ 10,000.00 $ - $ - 0 Other Revenue $ - $ - $ - 0 Total Program Revenue $ 37,659 $ 9,224 $ 11,510 25% PROGRAM EXPENSES Compensation $ 38,076 $ 8,533 $ 10,500 23% Rent& Utilities $ 315 $ 141 $ 160 13% Supplies & Equipment $ 1,007 $ 450 $ 350 -22% Travel & Training $ 91 $ 100 $ 250 150% Other Expenses: survey incentives $ - $ - $ 250 0 Total Program Expenses $ 39,489 $ 9,224 $ 11,510 25% SURPLUS/(DEFICIT) FOR PERIOD: I $ (1,830) $ - $ - 0 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME: Youth & Teen Nature Day Camp Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 3,106 $ 1,500 $ 1,260 -16% Program Generated Revenue $ 247,696 $ 260,834 $ 272,998 5% Local Government Grants: Human Services-Town of Carrboro $ 2,500 $ - -100% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ - 0 Other-Town of Chapel Hill $ 1,000 $ 2,000 100% Human Services- Orange County $ 3,500 $ 10,000 186% Other- Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 other-Durham County $ 7,000 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government (CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ - $ - $ 5,000.00 0 Other Revenue $ - $ - $ - 0 Total Program Revenue $ 250,802 $ 276,334 $ 291,258 5% PROGRAM EXPENSES Compensation $ 191,731 $ 229,944 $ 241,441 5% Rent& Utilities $ 10,561 $ 24,552 $ 25,043 2% Supplies & Equipment $ 19,637 $ 20,030 $ 20,430 2% Travel & Training $ 1,773 $ 1,808 $ 1,844 2% Other Expenses: survey incentives & camper transport $ - $ - $ 2,500 0 Total Program Expenses $ 223,702 $ 276,334 $ 291,258 5% SURPLUS/(DEFICIT) FOR PERIOD: $ 27,100 I $ - I $ - I 0 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 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. 1/12/2017 2:56:42 PM I:' 28 •t 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 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 $2 million Aggregate Injury Property $2 million Aggregate Damage Limit Automobile Not Applicable $1 million Each Occurrence $500,000 Each Liability Occurrence Professional $1 million Each Liability Not Applicable Not Applicable Occurrence $2 million Aggregate 1. Visit the NC Industrial Commission's website for more information regarding Coverage A. Also, note that if an agency uses subcontractors, it must require subcontractors to have workmen's compensation insurance. 2. Bodily Injury by Disease (BID) 3. Please visit Orange County's contracts webpage for more information about the County's risk assessment procedures. f) List of Board of Directors Provide the following information about each board of director's member: name, telephone number, address, occupation or affiliation of each member and the list must identify the principal officers of the governing body, and length of term. g) Solid Waste Program Fee (SWPF) Verification This fee finances Orange County's recycling and waste reduction program. Submit either a.) proof of payment of the agency's FY 2016-17 Solid Waste Program Fee, OR b.) a statement on agency letterhead indicating exemption and specify the person(s), business, etc. that is responsible for paying this fee. 1/12/2017 2:56:42 PM II I:' 29 ,t 29 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 EXHIBIT`B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Piedmont Wildlife Center Program Name: Youth and Teen Nature Day Camp Funding Award: $4475 Outline how the agency will spend Orange County's funding award. Expense Description Amount Staff salaries to allow us to offer up to 14 full camp scholarships $3640 Materials for camp program $200 Travel for families in need $500 $5 gas card incentives for parents to fill out surveys $135 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Summer and intersession camps: week long day camps strengthening kids connections with nature and community through naturalist and survival skills and outdoor play • Send out a survey to parents and offer gas card for filling them out so we can collect more data for better program evaluation • Have parents fill out a scholarship application and supply first page of tax returns to determine amount of scholarship needed and if transportation help is needed. 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 Keep a daily attendance sheet at camp to show that scholarship recipients attended camp 14 Recipients of transportation financial will get campers to camp 3 Campers will share or demonstrate their gained knowledge of survival and/or naturalist skills 36% (counselors last year reported a 32%average of campers showing an increased knowledge of flora and fauna of 18 scholarship recipients in the 2016-17 fiscal year) More than a 12%return of surveys from 14 parent/guardiams(amount received last year)with 30% incentives offered Executive Director DocuSigned by: [9044troa,Zd, 9`a4,4su0 10/13/2017 Certified by: 1E2F37B62oc4497.._ Title: Executive Di rector Date: (Provider's Signature) DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 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: [9044troet,Zd 10/13/2017 Certified b Title: Executive Di rector Date: y• t��zRe�nraasz_ (Provider's Signature) (Piedmont Wildlife Center) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 ACC?R°J CERTIFICATE OF LIABILITY INSURANCE 09/13/2016 L.,.r 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 Chris Rubish HIGH & RUBISH INSURANCE AGENCY PHONE FAX 6015 FARRINGTON ROAD (A/C,No,Ext): 919-913-1144 (A/C No): 919-913-1155 PO BOX 3040 Mass: chrisr©highandrubish.com CHAPEL HILL NC 27515 INSURER(S)AFFORDINGCOVERAGE NAIC# INSURERA: NAUTILUS INSURANCE COMPANY 17370 INSURED INSURER B: PIEDMONT WILDLIFE CENTER, INC. INSURER C: 364 LEIGH FARM ROAD INSURERD: INSURER E: DURHAM NC 27707 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. INSR TYPE OF INSURANCE ADDL INSR SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DD/YYYY) (MM/DD/YYYY) GENERAL LIABILITY X NN706894 09/01/2016 09/01/2017 EACH OCCURRENCE $1 , 000 , 000 A X COMMERCIAL GENERAL LIABILITY PR S RENTED PREMISES((Ea occurrence) $100 , 000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $5, 000 PERSONAL&ADV INJURY $1 , 000 , 000 GENERAL AGGREGATE $2, 000 , 000 GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $INCLUDED X POLICY PRO- JECT LOC $ 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 WC STATU- OTH- AND EMPLOYERS LIABILITY Y/N TORY LIMITS 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 (Attach ACORD 101,Additional Remarks Schedule,if more space is required) WILDLIFE PER FORM L805 TS L805 (5/09) . HIREDAAUTOION, 000 , 000/$1 , 000 , 000; NON OWNED AUTO $1 , 000 , 000/$1 , 000 , 000 . CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ORANGE COUNTY GOVERNMENT AUTHORIZED REPRESENTATIVE PO BOX 8181 HILLSBOROUGH, NC 27278 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD