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2017-616-E Finance - Kidzu Children's Museum - Outside Agency Performance Agreement
DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1 C 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 Kidzu Children's Museum, a not-for-profit corporation, located at 201 South Estes Drive Suite A9, Chapel Hill,NC 27514 ("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 Kidzu Children's Museum 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 10460 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 2615. 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. (Kidzu Children's Museum) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1 C 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. (Kidzu Children's Museum) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1 C 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. (Kidzu Children's Museum) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1 C 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 Kidzu Children's Museum 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: (Kidzu Children's Museum) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1 C County: Finance &Administrative Services Provider: Kidzu Children's Museum Orange County 201 South Estes Drive Suite A9 Post Office Box 8181 Chapel Hill,NC 27514 Hillsborough,NC 27278 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable,it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. 18. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php). Any violation of this requirement is a breach of the Agreement and County may immediately terminate this Agreement without further obligation on part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 19. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For a apbalvabfof the Provider jtSa. Ualt UMaln, 10/12/2017 gaaaza277c54475... Date (Kidzu Children's Museum) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1 C r F if of Orange County Government 01AILit, A AA144,V'SLt,1? 11/13/2017 063799eg-55E477... Bonnie Hammersley, County Manager Date (Kidzu Children's Museum) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID: 0E0892A5-AB8C-4E61-8B53-2125B8922B1C 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 IL f I �O IO O �� C' yes �F� c LEE'oy+ Ny,11 CAR()11` yA A E I.N‘ DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XH I BIT A PROVIDER'S OUTSIDE AGENCY APPLICATION INFORMATION Each year, Orange County Government, the Town of Carrboro and the Town of Chapel Hill invite program funding requests from non-profit providers that support the delivery of vital community services. The application process is very competitive and not all applicants will be awarded funding. Recommendations for funding may be for an award amount less than that requested by the applicant. Agencies that are currently receiving funds from Orange County, the Town of Carrboro, or the Town of Chapel Hill local governments, and are also applying for new funds, must be in compliance with all terms of their current agreement(s) and must not have any outstanding audit findings, monitoring findings or concerns as determined by the municipality. Recipients are required to submit written progress reports on their SMART Measures that include: goals, description of activities/challenges, revisions of timelines/budgets, and other relevant information Funded projects will be monitored for progress and performance, financial and administrative management, and compliance with the terms of Performance/Development Agreement(s). Monitoring may involve site and/or office visit(s). Once applications are received, they are reviewed by staff for completeness and eligibility. The applications are presented to a specific application review group, depending on the funding source. The review group will make a recommendation, based on available funding and the priorities identified by the participating jurisdiction. The recommendation is presented to the appropriate Board/Council for consideration and approval. The Board/Council approves/adopts the final allocations. TIMELINE November 15 Funding Application Posted on Websites November 29 Funding Application Workshop Held October 18-January 23 Agency Prepares Application January 10 Q&A Session Held January 31 Application Submissions are Due March - May Application Review & Agency Presentations June Agency Funding Approval by Board/Council July Contracts Executed & Programs Begin DO NOT SUBMIT THIS PAGE 2/9/2017 1:27:17 PM Page 2 of 3 0 DocuSign Envelope ID: 0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION SUBMITTAL INFORMATION Welcome to the Outside Agency Common Funding application for local/general funds, which will be distributed through this competitive application process. All entities or organizations requesting funds must complete and submit this application prior to the deadline to be considered for FY 2017-2018 funding. The Application Submittal Deadline is: Tuesday, January 31, 2017 5:00 PM In the event of inclement weather, check the website for each Town/County you are applying to, for further instructions. Please note that late, handwritten, or incomplete applications will not be accepted. (Applications not signed by the Chair or President of the Board of Directors, are considered incomplete.) An application orientation workshop will tentatively be held on Tuesday, November 29, 2016 at 9 AM to Noon to review the application and submittal requirements. SUBMITTAL REQUIREMENTS FOR EACH MUNICIPALITY Human 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 astone(a�townofcarrboro.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 .doc, .xls, etc. DO NOT SUBMIT THIS PAGE 2/9/2017 1 :27:17 PM Page 3 of 3 0 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Human ervice Town a el Hill In 1982, the Town established local funding to support local nonprofit organizations that carry out human service work throughout the community. Applications are accepted once a year and reviewed by the Town's Human Services Advisory Board, which makes a recommendation for funding to the Town Council for final approval. For more information about the Town of Chapel Hill Human Services program, see here. Questions and submittals should be directed to: Jackie Thompson 405 Martin Luther King Jr. Blvd. Chapel Hill, NC 27514 919-969-5081 jhompsontownofchapelhill.orq Submission: ➢ We strongly encourage applications to be single-spaced, with 12-point arial font and normal margins. ➢ Application: Two (2) paper copies of the application with ORIGINAL signatures must be hand delivered or mailed to Jackie Thompson, 405 Martin Luther King, Jr. Blvd., Chapel Hill, NC 27514; AND ➢ Attachments: The application submittal must be accompanied by a flash drive with the application and all attachment files in electronic format. Any .pdf files must be accompanied by the original file format of .doc, .xls, etc. Human ervice Orange County For more information about the Orange ount Y uman Services rvices p r g ram see here. Questions and submittals should be directed to: Allen Coleman PO Box 8181 Hillsborough, NC 27278 (919) 245-2151 aco11 m h ,c„ir hT3cc„su� ir:.Y!! : ,g y Submission: ➢ Email application and ALL Attachments prior to the deadline. Any .pdf files must be accompanied by the original file format of .doc, .xls, etc. Please request a delivery receipt of email with application and attachments. DO NOT SUBMIT THIS PAGE 2/9/2017 1:27:17 PM Page 4 of 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FOR OFFICE USE ONLY Agency Kidzu Children's Museum Received By Program(s) "Community Connections" Date/Time / I RRRrRRRRRREFFEEFFERRr RRRREFFERRRRRRRRRRfiRRRRRRRRREFFERRRRRr7RRRRRRRRRRRRRRREFFE RRRRRRRRRRRRRREFFEfiRRRRRRRRRRRRRRRRRRRRr7REFFERRRE Section Subsection 1. Cover Page a. ❑ Applicant Contact Information b. ❑ Funding Requests c. ❑ Signed Application Cover Page d. ❑Signed Disclosure of Conflicts of Interest and Clause 2. Agency Information a. ❑ Agency's Years in operation b. ❑ Agency's Purpose/Mission c. ❑ Agency's Types of Services Provided d. ❑ Agency's Experience with Programs e. ❑ Other Pertinent Agency Information f. ❑ Schedule of Positions g. ❑ Living Wage h. ❑ Agency Budget 3. Program Information a. ❑ Human Services Needs Priority b. ❑ Type of Program A separate Section 3 is c. ❑ Agency Collaboration required for each program. d. ❑ Summary of Program e. ❑ Description of Identified Need f. ❑ Description of Population to be Served g. ❑ Program Staffing, Capacity, & Expertise h. ❑ Program Implementation Timeline i. ❑ Value of Investment j. ❑ Impact of Reduced/No Allocation k. ❑ Other Pertinent Information I. ❑ Target Population/Beneficiary Chart m. ❑ Work Statement n. ❑ Program Budget, Detail, & Cost per Individual 4. Attachments a. ❑ Audit: Organizations receiving $300,000 or more in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ❑ IRS Federal Form 990 c. ❑ NC Solicitation License d. ❑ IRS Federal Tax-Exemption Letter e. ❑ Certificate of Insurance f. ❑ List of Board of Directors g. ❑ Solid Waste Program Fee (SWPF)Verification Application Submittal Checklist 2/9/2017 1:27:17 PM Pago 5 of DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Chapel Hill/ Carrboro Children's Museum (aka Kidzu Children's Museum) Applicant Organization's Physical Address: 201 S. Estes Drive, Suite A-9, Chapel Hill, NC, 27514 Applicant Organization's Mailing Address: 201 S. Estes Drive, Suite A-9, Chapel Hill, NC, 27514 Applicant Organization's Web Address: www.kidzuchildrensmuseum.orq Executive Director: Lisa Van Deman Telephone Number: 919.933.1455 E-Mail: vandeman©kidzuchildrensmuseum.orq Tax ID Number: b) Funding Request List all FY17-18 Human Services (HS) Funding Being Requested — For All Programs) and the Proposed Use of Funds (2-3 lines or less) Program Carrboro Chapel Orange Total - HS Hill - County- HS HS Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 Afterschool Program Coordinator salary and materials for youth activities and projects Outreach STEM Programs — community based $3,000 $9,275 $9,935 $22,210 (Outreach Coordinator (PT) salary, STEM educator, materials for academic enrichment activities during out-of-school time) Access STEM Programs — Kidzu based $1,922 $7,836 $10,984 $20,742 (STEM and museum educator compensation, academic enrichment program materials, family engagement materials, outreach marketing) Totals $4,922 $17,111 $20,919 $42,952 AGENCY INFORMATION 2/9/2017 1:27:17 PM Pago G of 30 DocuSign Envelope ID: 0E0892A5-AB8C-4E61-8B53-2125138922B1C (HI BIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Totals a) 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 applica t Signature: /,C\ Executive Director Date Signature: I - ( Board Chairperson Date DocuSign Envelope ID: 0E0892A5-AB8C-4E61-8B53-2125138922B1C (HI BIT A PROVIDER'S OUTSIDE AGENCY APPLICATION b) 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 r, 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? El r c) Current beneficiaries of the program for which funds are being requested? 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 1„,3111'1".' 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 confOct may resul in the termination of any grant awarded. jyr Signature: Executive Director Date „ Signature: / (1'e: 1/ Boa El Chairperson Date DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C 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): 10 years and 10 months Agency's Purpose/Mission (no more than a few sentences): With focus on S.T.E.M., the arts, child health and wellness and emerging literacy, Kidzu's mission is "to inspire children and the adults in their lives to learn through creative and purposeful play." Types of Services the Agency Provides (bullet format): • Kidzu Children's Museum, located in University Place, includes 9 hands-on interactive exhibit areas, including the only dedicated makerspace in the Carolinas designed specifically for young children, and a recently opened outdoor learning garden focused on native plants and pollinators. Kidzu hosts focused learning field trips for school groups and special programs for children and adults. • The museum's expert education staff facilitate a rich year-round calendar of programming focused on the arts, S.T.E.M (science, technology, engineering and math), emerging literacy and child health and wellness. The programming takes place in the museum and throughout the community through our"museum in a box" initiatives. • Kidzu works with many outside individuals and organizations to provide supplemental enrichment activities for community events and out-of-school time programs. Kidzu has a roster of over 100 community partners representing academic, scientific, artistic and civic facets of our community. • Kidzu provides multiple programs targeted towards supporting underserved communities. Programs include: once monthly "open access" day at the museum (free admission to all), STEM and arts based enrichment activities during community celebrations such as Hargraves Family Fun Day, STEM and arts based programming for out-of-school time programs, scholarship opportunities for museum based programs and free family memberships and visitor passes. b) Agency's History with Providing These Services: Since 2006, Kidzu has been the leading and primary early learning cultural institution in Chapel Hill. Since re-locating to University Place in February, 2014, Kidzu has served over 90,000 visitors annually in the museum and reached over 5,000 children and families through targeted outreach programming in the community. c) 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?) Kidzu moved into its current location in April, 2015. We expect to stay at this location for the near future as we determine the location for the museum's permanent, right sized home. Lisa Van Deman became Kidzu's current Executive Director in January, 2016 after serving as Interim Executive Director through 2015. Lisa Van Deman has a 20-year career leading children's museums and is passionate about the impact a children's museum can have on the quality of life and education of all children and families in our community. Agency Information 2/9/2017 1:27:17 PM Pago 9 of 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION d) 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 # of FTE - Paid Part-Time Positions: 41 # of Volunteers: 100 (25 volunteer hours per volunteer) # of FTE - Volunteers:1.2 e) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes/No) No If yes, is this agency an Orange County Living Wage Certified Employer? If no, please explain. Many of our employees are undergraduate students and our base pay rate matches that of the work study students ($10.10) which is already in the second highest tier of WS pay rates. Agency Information 2/9/2017 1:27:17 PM Page 10 of 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION f) Agency Budget i. Is your agency currently receiving and/or requesting other(non-Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes/No) Yes. If yes, please list below: Include all programs that have funding requests/awards/totals from Carrboro, Chapel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FY16-17 FY17-18 Source Award Request 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 Kidzu Enrichment Activities $10,000 - Chapel Hill/ Parks and Recreation performance agreement (after school programming, visitor passes and family memberships) Agency Information 2/9/2017 1:27:17 PM 0:' g 11 of i DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate xls file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous 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 iii. Does your agency budget show a Surplus or Deficit? Surplus Is there a significant change? Yes/No No Please provide a brief explanation for Surplus or Deficit, and significant changes. In 2016 Kidzu did not complete any major exhibit updates and focused spending on program and outreach improvements. This balance resulted in a surplus. iv. What is your agency's fiscal year? January 1,2017 — December 31, 2017 (Example: July 1, 2016 through June 30, 2017) Agency Information 2/9/2017 1:27:17 PM Pago 12 of 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Community Connections Program Primary Contact and Title: Rose Cuomo, Outreach Coordinator Telephone Number: 919.933.1455 E-Mail: Cuomo kidzuchildrensmuseum.orq a) Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area #1: safety-net services for disadvantaged residents ® Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ❑ Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare Education X X X Family Resources X X X Jobs/Jobs Training Food Transportation Other: Please specify c) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated/collaborative efforts. Since its inception in 2006, Kidzu has collaborated with hundreds of community partners including local title one schools, social service agencies, non-profits, community groups and individuals. For the "Community Connections" program Kidzu will strengthen both Outreach and Access programs including the following partners: • Cedar Grove Community Center • Fairview Child and Family Center • Orange County Partnership for Young Children (OCPYC) • New Hope Elementary School • Family Success Alliance • Ella Baker Women's Center for Leadership and Community Activism PROGRAM INFORMATION 2/9/2017 1:27:17 PM Pago 13 f 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Description of coordinated/ collaborative efforts below: Outreach Programs Partner Agencies/ When Schools "Museum in a box" STEM based activities. Cedar Grove Summer (July 2017 E.g. Simple Machine Building: Children learn Community Center and June 2018). how catapults work, design their own and test Once per month, 2 machines for accuracy and precision. Children hour educational follow the design thinking process (empathize, program. define the problem, ideate, prototype, and New Hope School year test). Elementary (September 2017- May 2018) during after school programming. 1 hour activity. Fairview Child and School year Family Center (September 2017- May 2018) during morning pre-school programming. 1- hour activity. Parents and caregivers invited to participate in activity. Mentoring and Leadership training -- Kidzu Ella Baker School year will provide mentorship / leadership training to Women's Ctr. for (September 2017 2-3 high school-aged girls from the Ella Baker Leadership and through May 2018). Women's Center and facilitate application of Community Students will these skills during monthly STEM focused Activism participate in 3 "museum in a box" programs at New Hope professional Elementary and/ or Cedar Grove Community development Center. The student must be from the S. sessions throughout Hillsborough community and will receive a the school year. stipend upon completion of the program. Dates TBD. Kidzu has a long history of supervising HS aged students from Empowerment and other local institutions. PROGRAM INFORMATION 2/9/2017 1:27:17 PM Pago 11 of 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION MOBILE STEM Night -- Kidzu will provide New Hope Date TBD. Evening one mobile STEM Night for families from New Elementary/ Family program starting at Hope Elementary and other families/agencies Success Alliance 5pm. working with the Family Success Alliance. partner agencies/ This program allows working families to learn schools/ families alongside their children through a variety of programs focused on STEM. When entering the program each child is handed a "passport" (see Appendix 1.) This passport will be their guide through the evening and encourage children to participate in each STEM station placed around the facility. Children have the opportunity to co-curate special activities with Kidzu staff and special community experts, ask questions, record their"stats" at each station, and engage in a unique learning experience alongside caretakers as well as fellow children. Caregiver educational info sessions offered in English and Spanish. Dinner will be provided. Access Programs Family Memberships and Visitor Passes — Cedar Grove Memberships and Kidzu will provide six family memberships per Community visitor passes will partner agency for families to utilize from July Center, Family be valid from July 1, 2017 through June 2018. Kidzu will also Success Alliance, 2017 to June 30th, provide 150 of day visitor passes for families New Hope 2018 of age appropriate children to utilize during Elementary, the same period. Fairview Child and Family Center SUMMER ENRICHMENT Camp Kidzu -- Cedar Grove Scholarship camp During June of 2018, Kidzu will provide 6 Community sessions run weekly Camp Kidzu scholarships to children enrolled Center, Family through June 2018 in partner agencies and participating in Success Alliance, (and are designed Kidzu's outreach programs. Fairview Child and to culminate Family Center involvement in all of Kidzu's outreach programs). Camp sessions are one week in length. PROGRAM INFORMATION 2/9/2017 1:27:17 PM Pago 15 of 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION ON-SITE STEM Night— This program allows Cedar Grove We will run one working families to enter the museum for free Community STEM Night in 2017 and learn alongside their children through a Center, Family and one in 2018. variety of programs focused on STEM. When Success Alliance, Dates TBD. STEM entering the museum each child is handed a Fairview Child and Nights are three "passport" (see Appendix 1.) This passport Family Center hours in length and will be their guide through the evening and start at 5.30pm. encourage children to participate in each Dinner will be STEM station placed around the museum. provided. Children have the opportunity to co-curate special activities with museum staff and special community experts, ask questions, record their "stats" at each station, and engage in a unique learning experience alongside caretakers as well as fellow children. Dinner will be provided. Transportation TBD but possible partnerships with local churches may results in donated bus services. STEM Open Access Sunday -- Kidzu opens Cedar Grove First Sunday of the its doors for free one Sunday per month. In Community month. Date TBD. collaboration with our partners we will provide Center, Family 11am-5pm specific programming and transportation Success Alliance, opportunities to enable families from our Fairview Child and partner agencies/ schools to enjoy a day at Family Center, the museum free of charge. Attendees from New Hope partner agencies will have the opportunity to Elementary School participate in special programming and a healthy brunch one hour prior to the museum public opening hours (12-5pm) 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? Inclusiveness is at the heart of everything Kidzu stands for, and the museum supports Orange County's goal to "Ensure a high quality of life and lifelong learning that champions diversity, education for all....". In order to be truly inclusive the museum has, in the past, engaged program partners to complement learning for young people and help identify and serve those who, because of economic, cultural or language barriers, haven't been able to take advantage of Kidzu's benefits. With that said, Kidzu recognizes the need to continue providing new services to the 3,820 children in Orange County living in poverty (U.S Census Bureau, 2013) in order to maximize reach and effectiveness. PROGRAM INFORMATION 2/9/2017 1:27:17 PM Pago 1G of 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Kidzu's proposed "Community Connections" program will unite multiple community partners to support what the Harvard Family Research Project refers to as "Complementary Learning." As communicated, "Complementary learning refers to the idea that school and life success requires an array of learning supports. These learning supports include families, early childhood programs, schools...health and social service agencies...museums, and other community-based institutions. To be most effective, these supports should complement one another, moving out of the silos and working together to create an integrated, accessible set of community-wide resources that support learning and development." (Weiss, H.B. Complementary Learning. The Evaluation Exchange. Vol XI, No. 1. Spring, 2005. Harvard Family Research Project.) To achieve this goal Kidzu's "Community Connections" program will follow a two-pronged approach: 1. Outreach: Provide specialty STEM based programs supplementing existing pre- school, after school and summer programs working in underserved communities. 2. Access: Provide opportunities for family engagement through special programs at the museum, free access to the museum and out-of-school time program scholarships. These programs will target families from partner agencies engaged in our outreach programming. For the specific program services for Orange County see above table. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. The need for quality out-of-school time enrichment programming is particularly great for the 13.4% of children who live in poverty in Orange County. Family income is an important determinant of access to quality education, with children from working poor families typically having the least access (Child Care Services Association (2005). North Carolina Early Childhood Systems Study.). North Carolina children from low income backgrounds fare worse than their economically advantaged peers in many regards. They tend to have poorer health, are less likely to be read to as young children, are less likely to take part in after-school activities, and are more likely to repeat a grade (North Carolina Child Advocacy Institute. (Dec. 2005) "Outcomes by Income: Low-income children fare worse on many indicators."). For this segment the quality of early education settings varies greatly (particularly in pre-schools and child care settings) and they do not have equal access to high quality education. In North Carolina, working poor families and those with limited English proficiency are most likely to be receiving inadequate early education opportunities (Child Care Services Association (2005). Ibid). Addressing Orange County's need to provide education opportunities for at-risk children, Kidzu plans to deepen its existing outreach, targeting specific neighborhoods and invest in relationship-building with families living in these neighborhoods to help them better access PROGRAM INFORMATION 2/9/2017 1:27:17 PM P g 1 "' of 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION the kinds of unique and valuable learning opportunities that a children's museum inherently provides. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? The target population is children aged 0-12 years and their caregivers living in underserved communities, specifically students enrolled at New Hope Elementary and families participating in programs at the Cedar Grove Community Center, Fairview Child and Family Center and engaged with the Family Success Alliance. We estimate over 340 children will have access to Kidzu through our outreach programs and over 800 children and adults will access Kidzu through our special programs at the museum on STEM Nights and Open Access Sundays. The outreach programs will operate as "push-in" academic activities in the existing after school programs at each location therefore, participants will already be identified and registered in the program. If the Kidzu "push-in" programs create interest with young people not registered in the programs Kidzu will work with the families to register each child in the appropriate 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.) Kidzu Children's Museum senior staff have decades of experience in creating effective collaborative partnerships and in designing and presenting programs and activities that engage a range of learning styles and developmental levels. Specific staff have nationally recognized experience in working directly with underserved families to involve their children in the life of the museum and understand that relationship-building is the key to having long-term impact. The staff is also very seasoned in managing grant-funded programs and meeting the goals and objectives laid out in grant applications. Kidzu's full-time Community Program Manager has been working in the museum field for over 5 years, holding a Master's Degree in Museum Education and a Bachelor's Degree in Art History. The Community Program Manager has been with Kidzu for 1.5 years and has planned and facilitated over 200 programs with children and community partners during this time. In 2016, her outreach efforts reached 5,000 families in the Chapel Hill/Carrboro area strengthened existing partnerships with the OCPYC and grew the museum's collaborations with community artists, scientists, and makers by 35%. The Community Program Manager manages and staffs all outreach programs for Kidzu, as well as selects appropriate and innovative STEM and Arts programming for each outreach event. For these outreach efforts to expand, Kidzu plans to hire a bilingual Community Outreach Coordinator. This position would assist the Community Programs Manager in building new multi-cultural partnerships and strengthen relationships with existing community partners. This coordinator would also be responsible for the translation of outreach/program materials, guides, as well as being the lead translator at onsite community-wide programs and caregiver information sessions. This new position would also assist in the coordination of a diverse outreach volunteer core as well as lead volunteer training sessions. Kidzu will also allocate 5% of time from the museum's STEM lead educator to ensure high quality program content and delivery. PROGRAM INFORMATION 2/9/2017 1:27:17 PM Page 1 of 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Community Outreach Volunteers before assisting in off-site outreach programs are required to undergo a 1-hour training session with the Community Program Manager, as well as a background check from Kidzu. Community Outreach Volunteers will leave the training session with strategies how to manage behavior, engage children at offsite programs, how to share their enthusiasm for Kidzu and STEM education, how to foster learning environments and how to model effective ways to lead engaging programs in a variety of outreach settings. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. The 'Community Connections' programs will operate from July 2017 through June 2018. The programs run during out-of-school time in the summer and school year. Access to Kidzu via family membership and/or day visitor passes will be year-round from July 1, 2017 to June 30, 2018. See below for implementation timeline: Implementation Timeline: June, 2017: Summer enrichment and after school program plans created/ schedules confirmed with partner agencies/ orientation/ training session with Ella Baker leadership students/begin search and interview process for Outreach Coordinator July, 2017: Human Services contract executed/ summer enrichment programs begin at Cedar Grove Community center/press release distributed/ promote STEM nights and Open Access Sunday with Cedar Grove community/ Fall activity lesson plans and outlines complete/finalize hiring of Outreach Coordinator/ family memberships and visitor passes distributed August, 2017: Promote STEM nights and Open Access Sunday with partners/ finalize schedules and activity plans for out-of-school time programs September - December, 2017: STEM "museum in a box" programs launched/ second leadership training sessions with Ella Baker students October, 2017: Conduct first STEM night for families from Cedar Grove CC and Fairview Child and Family Ctr. December, 2017: Review programs with partners — discuss successes and challenges and plan for necessary changes for Spring series. January— May, 2018: STEM programs continue/third leadership training sessions with Ella Baker students/ promote the second STEM Night, the mobile STEM Night and Open Access Sunday March, 2018: Conduct mobile STEM Night at New Hope Elementary and second STEM Night at the museum for families from Cedar Grove, Family Success Alliance and Fairview Child and Family Ctr. PROGRAM INFORMATION 2/9/2017 1:27:17 PM Pago 19 f 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION April, 2018: Begin planning summer enrichment activities/ conduct Open Access Sunday/ promote and register students for Camp Kidzu June, 2018: Conduct summer enrichment programs at Cedar Grove/ review and evaluate all after school programs — plan improvements for 2018/19/ one-week summer camp programs begin 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. Access to Kidzu is our primary goal. Funding this program will address three critical needs: 1. Parents and other primary caregivers need greater access to educational resources and community services to help support their children's healthy development 2. All children in our community need access to complementary learning experiences to supplement the educational offerings of local child care centers, preschools and public elementary schools 3. All young children in our community from under-served neighborhoods are particularly in need of enriched, engaging educational experiences to help prepare them for success in schools Additionally, the "Community Connections" programs will place a focus on STEM education, providing necessary 21st century skills needed for tomorrow's leaders. Early exposure to STEM-based learning supports a child's academic growth, develops early critical thinking and problem-solving skills and nurtures later interest in STEM study and careers. STEM learning is a natural organizer to the way very young children approach the world: "Young children are avid STEM investigators, eager to explore and invent...as their own natural curiosity leads them towards STEM inquiry."(Successful STEM Education/Nurturing STEM Skills in Young Learners, 2014). j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Kidzu is committed to providing its unique, academically enriching programming to more youth and adults living in underserved communities in the county in 2017 and 2018. In this application, we have presented a menu of program offerings designed to nurture long-term relationships with individual neighborhoods and individual families with the goal of creating meaningful engagement with the museum regardless of an individual's ability to pay for services. Whilst we passionately believe in the continuum of the Community Connections program as described, we recognize the funding source is limited and there are many non- profits in our community providing valuable services. If the full award cannot be granted, we would urge the HSAC to fund the outreach portion of our application. Doing so gives Kidzu the opportunity to, at minimum, strengthen its foundation for long-term impactful relationships with targeted underserved children and provides them with meaningful learning activities during out-of-school time. PROGRAM INFORMATION 2/9/2017 1:27:17 PM Pago 20 of 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION k) Include any other pertinent information. PROGRAM INFORMATION 2/9/2017 1.27.17 PM Page 21 of 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Proclram 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 Projected 2017-18 Actual Estimated (Orange 2015-16 2016-17 County (program in (program in Chapel Hill) Chapel Hill) programming only) Gender Male 462 288 399 Female 924 578 800 1,199 Total 1,386 866 Ethnicity African-American 485 303 223 American Indian or Alaska Native Asian 155 95 115 Caucasian 469 295 683 Native Hawaiian or other Pacific Islander Other: specify Hispanic/Latino 277 173 178 Total 1,386 866 1,199 Of the above, how many Hispanic/Latino 277 173 178 Of the above, how many non-Hispanic/Latino 1,109 693 1,021 Total 1,386 866 1,199 Age 0-5 years 429 379 485 6-18 years 732 321 378 19-50 years 150 111 260 51+years 75 55 76 Total 1,386 866 1,199 Geographic Location Alamance County 7 Chatham County 7 Durham County 122 40 Wake County 78 2 Orange County Breakdown Chapel Hill Public Housing 800 315 508 Town of Chapel Hill (Non-Public Housing) 219 193 93 PROGRAM INFORMATION 2/9/2017 1:27:17 PM Pago 22 of 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Town of Carrboro 26 11 Town of Hillsborough 15 2 100 City of Mebane (Orange County) Orange County(Outside Municipalities) 498 Total 1,386 I 866 1,199 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 _Kidzu Children's Museum "Community Connections" 1. Program Activity Name STEM "museum in a box" activities Program Goal Provide monthly, hour long STEM activities to youth aged 1- 12 in three sites (Cedar Grove Community Ctr SUMMER ONLY, New Hope Elementary, Fair View Child and Family Ctr). Serve upwards of 150 children between three sites. Promote STEM education and design thinking process. Performance Measures Program attendance, tracking ages, ethnicity and residence; formative and summative quantitative survey data measuring understanding and educational value of key STEM learning concepts. Serve 65 children at Cedar Grove, 50 children at New Hope Elementary and 25 children at Fairview Child and Family Ctr. Previous Year Program In 2016 Kidzu worked with an average of 15 children per site Results (in a similar program in the S. Estes community in Chapel Hill, for example, and 60 children at Hargraves Community Center) PROGRAM INFORMATION 2/9/2017 1.27.17 PM Pago 23 of 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Current Year Estimated In June 2017 Kidzu expects to work with an average of 20-25 Results children per site (in S. Estes and Hargraves Community Center) and for participants to "significantly" increase their understanding of the design thinking process and STEM topics. Next Year Projected Results Through increased interest in the program we expect to work with 5-10 more children per site. 2. Program Activity Name Mentoring and Leadership training Program Goal Kidzu will support leadership training for 2-3 high school aged students from the Ella Baker Women's Ctr. Each participant will be from S. Hillsborough and familiar with the work of the community partners. The ultimate goal for this program is for each participating student to develop leadership skills, mentor their younger peers attending Kidzu's "museum in a box" programs and generate facilitation skills to teach STEM education. Each participant must attend three training sessions and all after school programs for one community partner. A stipend will be awarded upon completion of the program. Performance Measures Program attendance (Participants must attend all three training sessions and 80% of out-of-school programs). Formative and summative participant surveys will be administered measuring the educational value of this internship and leadership preparedness. Previous Year Program n/a (we have significant experience running a similar Results program with Empowerment HS students, however, this is our first running this program in partnership with the Ella Baker Women's Ctr.) Current Year Estimated n/a Results Next Year Projected Results We expect three students to successfully "graduate" from this program with a better core understanding of STEM principles and leadership skills. 3. Program Activity Name STEM Nights (3) Program Goal Our goal is to welcome 150 children and adults to a museum or site based STEM Night, 75% of attendees reporting knowledge of at least one new STEM topic and 90% of PROGRAM INFORMATION 2/9/2017 1.27.17 PM Pago 21 of 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION caregivers reporting they are "somewhat, very, or extremely likely" to access programs at Kidzu CM. Performance Measures Program attendance and visitor evaluations measuring understanding of key STEM learning principles and value of this programming. Previous Year Program Kidzu ran a STEM Night for children and families from Results OCPYC agencies. We welcomed 55 children and 35 adults. Attendees attested to the value of this programming and, on average, participants indicated it was "extremely true" that the program was educationally valuable to both children and caregivers. Current Year Estimated We ran one STEM Night in partnership with OCPYC. We met Results above program goals for this pilot program. Next Year Projected Results Serve 150 children and adults per STEM Night. 4. Program Activity Name Open Access Sunday Program Goal Welcome over 250 visitors from partner agencies and over 65% of said attendees reporting they learned something new through the exhibits and special programs Performance Measures Program attendance (tracking child ages, ethnicity and residence) and visitor surveys measuring the educational value of open access museum days. Previous Year Program In 2016 we served an average of 250 visitors during Open Results Access Sundays. We have not targeted specific community groups to attend, therefore, we do not have specific previous year program results. Current Year Estimated As above Results Next Year Projected Results In 2017/18 we plan to target specific community groups and work with groups to provide transportation to enable attendance at program. 5. Program Activity Summer Enrichment Camp Kidzu Name Program Goal 90% of participants report they "learned something new every day" during camp and report they feel "somewhat, very, or extremely confident" in applying the information to PROGRAM INFORMATION 2/9/2017 1.27.17 PM Pago 25 of 0 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION their school work. Performance Measures Program attendance and visitor evaluations measuring value of summer enrichment at Kidzu Previous Year Program n/a (in past years we have not provided scholarships to Results partner agencies. This funding stream provides this opportunity to the community for the first time.) Current Year Estimated n/a Results Next Year Projected Results Serve 6 children for 6, week long camp sessions. All camp sessions located at Kidzu. This piece of the program serves as a culmination to the "Community Connections" initiatives in the targeted communities. 6. Program Activity Family Memberships and visitor passes Name Program Goal Welcome over 300 visitors from partner agencies and over 65% of said attendees reporting they learned something new through the exhibits and special programs Performance Measures Program attendance and visitor evaluations measuring value of summer enrichment at Kidzu. Provide 150 visitor passes and 6 family memberships Previous Year Program n/a (this type of programming was included in the 2016 Parks Results and recreation program agreement but passes have not yet been distributed, therefore, results are unavailable. Current Year Estimated n/a Results Next Year Projected Results In 2017/18 we plan to support community groups and work with partner agencies to provide transportation to enable access to the museum. PROGRAM INFORMATION 2/9/2017 1.27.17 PM Pago 2G of 30 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C 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. Included in the "other" budget item is as follows: • Overhead costs such as— administrative costs, outreach marketing, PR • Curriculum development • Leadership program stipends ($250 per student) • Museum exhibit maintenance • Food 3. This program budget represents what percent of the agency budget? 1.9% 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 $14,742 $17,242 $20,920 PROGRAM INFORMATION 2/9/2017 1:27:17 PM P g 2 / of 0 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Total # of Individuals 1,386 866 1,199 Cost Per Individual $10.64 $19.90 $17.44 PROGRAM INFORMATION 2/9/2017 1:27:17 PM 11""") age 2 of DocuSign Envelope ID: 0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Kidzu Children's Museum Actual Estimated Projected Percent AGENCY REVENUE 2016 2017 2018 Change Private Donations $ 70,254 $ 81,375 $ 81,375 0% Agency Generated Revenue (fees) $ 324,225 $ 366,415 $ 366,415 0% Local Government Grants: Human Services - Town of Carrboro $ - $ - $ 4,921 0 Other- Town of Carrboro $ - $ - $ - 0 Human Services - Town of Chapel Hill $ - $ - $ 17,111 0 Other- Town of Chapel Hill $ 10,000 $ 10,000 $ - -100% Human Services - Orange County $ - $ - $ 20,920 0 Other- Orange County $ - $ - $ - 0 Other- Town of Hillsborough $ - $ - $ - 0 Other Government Grants State Government $ - $ 101,000.00 $ 50,000.00 $ (0.50) Private Foundation Grants $506,340.00 $440,000.00 $ 450,000.00 $ 0.02 Other Revenue 0 Total Agency Revenue $ 910,819 $ 998,790 $ 990,742 -1% AGENCY EXPENSES Payroll $ 671,950 $ 691,840 $ 691,840 0% Operations $ 72,464 $ 155,061 $ 155,061 0% Exhibits & Programs $ 47,726 $ 77,360 $ 76,360 -1% Professional Fees $ 29,997 $ 24,200 $ 24,200 0% Special Events $ 33,530 $ 42,300 $ 42,300 0% Total Agency Expenses $ 855,666 $ 990,761 $ 989,761 0% SURPLUS/(DEFICIT) FOR PERIOD: $ 55,152 I $ 8,029 I $ 981 I -88% FY 2015-16 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Kidzu Children's Museum Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 4,742.00 $ 7,242.00 $ - -100% Program Generated Revenue $ - $ - $ - 0 Local Government Grants: Human Services-Town of Carrboro $ - $ - $ - 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ - 0 Other-Town of Chapel Hill $ 10,000 $ 10,000 $ - -100% Human Services-Orange County $ - $ - $ 20,920 0 Other-Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ - 0 Other Revenue $ - $ - $ - 0 Total Program Revenue $ 14,742 $ 17,242 $ 20,920 21% PROGRAM EXPENSES Compensation $ 7,574 $ 8,694 $ 10,580 22% Rent& Utilities $ 1,861 $ 2,111 $ 1,825 -14% Supplies& Equipment $ 3,207 $ 3,344 $ 4,686 40% Travel & Training $ 692 $ 762 $ 932 22% Other Expenses: $ 1,408 $ 2,331 $ 2,897 24% Total Program Expenses $ 14,742 $ 17,242 $ 20,920 21% SURPLUS/(DEFICIT) FOR PERIOD: $ - I $ - I $ - I 0 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION %, NEE FAMILY SUCCESS ALLIANCE January 30th, 2017 Dear Selection Committee, I am delighted to offer support for the Kidzu Children's Museum's Orange County Human Services grant application. We are thrilled to partner with Kidzu Children's Museum and support the promotion of STEM-based learning and engaging, educational workshops for our children and families. One of the primary focuses of the Family Success Alliance (FSA) is to provide the appropriate supports for "children to succeed in school and in life". Collaborating with community experts enables us to move towards meeting this goal. Through the proposed partnership, Kidzu Children's Museum will provide expert led STEM (science, technology, engineering and math) based learning modules during out-of-school time programs at New Hope Elementary and create family engagement opportunities through the special evening program "New Hope's STEM Night". New Hope, an FSA zone 4 school, is especially well-positioned to benefit from this type of program since geographically it is further away from the rich array of programs and resources offered in other parts of Orange County. We are thrilled to partner with Kidzu Children's Museum and we look forward to supporting the growth of our community through this innovative project. Sincerely, Meredith McMonigle, MSW Family Success Alliance http://www.orangecountync.govidepartments/health/FSA.php 919.245.2071 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8853-212588922B1C (HI BIT A PROVIDER'S OUTSIDE AGENCY APPLICATION „ V 1 yy7 GOV; 11 Cedar Grove Neighborhood Association Ploy Grow and Learn Togothor January 19'h, 2017 Dear Human Service Advisory Committee, As a new community partner of Kidzu Children's Museum, and as a dedicated supporter of community collaborations and enriching educational programming for all children in our community, we are delighted to provide a letter of support for Kidzu Children's Museum's Orange County Human Services application. The Cedar Grove Community Center hosts multiple youth programs for children living in the N. Hillsborough community. The children and family members accessing programs at the Center are in dire need of supplemental services. Through the proposed partnership with Kidzu Children's Museum we will be able to provide expert led STEM (science, technology, engineering and math) programs for elementary and middle school aged youth throughout the summer months and special access programs at Kidzu Children's Museum for children and families throughout the school year. Such programming is essential for our youth especially during the summer school break. According to the National Summer Learning Association "High-quality summer learning programs have been shown to improve reading and math skills, school attachment, motivation and relationships with adults and peers." Kidzu's process of uniting STEM topics with innovative programming techniques creates engaging learning experiences for our children. Alongside access to the museum for STEM Nights and Open Access Sundays we can create multi-level family engagement experiences and support the growth of our community in multiple ways. We are thrilled to partner with Kidzu Children's Museum and we look forward to starting the program in July, 2017. Sincerel 14- /Dr. Sue Florence, President Cedar Grove Neighborhood Association 919-218-6745 (cell) 919-245-2640 (Cedar Grove Community Center) 5800 NC Highway 86 NorthHilisborough, North Carolina 27278 919-245-2640 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C 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 a Ili of IReceii„y.. airman„ II ii ii „ilJij ii' form (see application materials), in lieu of an audit/report. Agencies with a certified audit/report should not complete the form. b) IRS Federal Form 990 A copy of the agency's 2014 Form 990 is required. The specific form depends upon the agency's financial activity. Review the IRS' table guide, for more details. For Form 990-N (e- postcard) filers, include a copy of the postcard, with the agency's application materials. c) NC Solicitation License A copy of the agency's current solicitation license is required. Organizations that solicit contributions in North Carolina, directly or through a third party, must renew their licenses annually. For more details, refer to the NC Secretary of State's licensing website and its Frequently Asked Questions Guide ( F), about exemptions. If exempt per N.C.G.S. § 131 F-3, include a copy of the exemption letter with the agency's application materials. d) IRS Federal Tax-Exemption Letter A copy of the agency's IRS tax-exempt letter that confirms its nonprofit status is required. An agency can request a copy of its letter from the IRS' Customer Account Services. e) Certificate of Liability Insurance A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker's Compensation compliance, include a statement explaining why, with the agency's application materials. *Note: If Approved for Funding: Approved agencies must provide an updated insurance certificate. The update should reflect the funding jurisdiction as an additional insured party and certificate holder and provide coverage for the duration of the funding period (July 1 — June 30). Renewal certificates must be sent to the jurisdiction 30 days prior to any expiration date, cancellation or modification of any stipulated insurance coverage. DO NOT SUBMIT THIS PAGE 2/9/2017 1:27:17 PM Page 29 t 3 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C 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 te III° i ca it ul m II (SWPF) Verification This fe ,,,,,,,,,,,���,, fee finances Orange County's recycling and waste reduction program. Submit either a.) proof of payment of the agency's FY 2016-17 Solid Waste Program Fee, OR b.) a statement on agency letter head indicating exemption and specify the person(s), business, etc. that is responsible for paying this fee. DO NOT SUBMIT THIS PAGE 2/9/2017 1:27:17 PM I:) a 3 e 3 0 t 3 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C EXHIBIT "B" Scope of Services —FY 2017-18 Outside Agency Performance Agreement Agency Name: Kidzu Children's Museum Program Name: Community Connections Funding Award: $10,460 Outreach Coordinator (part time) 1,500 STEM Educator(part time) $2,160 Sus sort Staff(wa_es and FICA) $2,560 Program materials (for children and caregivers) $3,144 Food (for STEM Night particiapants) $250 Facility Rental(for STEM Night activity) $500 Admin .(includes office supplies, copying,outreach,) $346 $10,460 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Museum in a Box programs (4) -- STEM box programs at Cedar Grove community Center's summer camp, Fairview Child and Family Ctr, New Hope Elementary. Each STEM box provides interactive, rigorous and FUN STEM programming during partner agency's out of school time initiatives. • STEM Night (1)— Family engagement evening encouraging STEM learning. The STEM Night takes place at New Elope Elementary school and provides food for all families. • Open Access Sunday (1) — to culminate the Community Connections program Kidzu will open its door for free on the first Sunday in June 2108. All families from Cedar Grove Community Center, Fairview Child and Family Ctr, New Hope elementary and Family Success Alliance will enjoy a full day of programming at Kidzu for FREE! 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. Anticipated Performance Measures Results Museum in a Box attendance(4 programs throughout OC) 205 STEM Night attendance(1 night). Children and caregivers 150 Open Access Sunday attendance 250 DoLuSlyneu-br Significantly incrits; p r ici,‘ ts u r erstanding of STEM learning concepts 85% if 7 : • % ,A, 5 „. Executive Di rector Certified by _ lip I , \kr--- 71itle: i----- , (--'"-"T-1"- A , 1011777017— Date: --) '2 1 ± (Provider's Signature) 1 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1 C 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: �,ISA UA�I VUMalA, Executive Director 10/12/2017 Certified by: 9BB8EB277C5A475_. Title: Date: (Provider's Signature) (Kidzu Children's Museum) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C OP ID: DS ACORCr CERTIFICATE OF LIABILITY INSURANCE DA 01/27DD/YYYY) �►.--""' 01/27/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT High&Rubish Insurance Agency PHONE FAX P.O.Box 3040 (A/C,No,Ext): (A/C,No): 6015 Farrington Rd.Ste 101 E-MAIL Chapel Hill,NC 27517 PRODUCER Jeffrey A.Rubish CUSTOMER ID#:KIDZU-1 INSURER(S)AFFORDING COVERAGE NAIC# INSURED Kidzu Children's Museum INSURERA:Philadelphia Insurance Co 201 S Estes Dr, Ste A9 INSURER B:Hartford Insurance Company Chapel Hill, NC 27514 INSURER C: INSURER D: 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. INSR A POLICY EFF POLICY EXP LTR TYPE OF INSURANCE I W INSR VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY PHPK1590484 02/20/2017 02/20/2018 DAMAGE TO RENTED 300,000 PREMISES(Ea occurrence) $ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- JECT $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PHPK1590484 02/20/2017 02/20/2018 PROPERTY DAMAGE A X HIRED AUTOS (PER ACCIDENT) A X NON-OWNED AUTOS $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ A PHUB569172 02/20/2017 02/20/2018 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER Y/N B ANY PROPRIETOR/PARTNER/EXECUTIVE 22WECNY6264 04/10/2016 04/10/2017 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101 Additional Remarks Schedule,if more space is required) Childrens Museum/located at University Place,201 Estes Drive Suite B2/B3 Chapel Hill, N C 27514 CERTIFICATE HOLDER CANCELLATION ORANG-3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County Human Services THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g y ACCORDANCE WITH THE POLICY PROVISIONS. Program C/O Allen Coleman P.O. Box 8181 AUTHORIZED REPRESENTATIVE Hillsborough, NC 27278 \.mo Vta2S ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1 C KIDZU-1 PAGE 2 NOTEPAD INSURED'SNAME Kidzu Children's Museum OP ID: DS Date 01/27/2017