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2018-473-E Finance - Bridge II Sports outside agency agreement
DocuSign Envelope ID: E30588DE- A1BC- 443D- A5C4- 3BE790331500 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2018, ( "Effective Date ") by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ( "County") and Bridge II Sports, a not - for - profit corporation, located at 3729 Murphey School Road, Durham, NC 27705 ( "Provider "). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners. NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Bridge II Sports agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2018 to June 30, 2019. 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 A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of $6,272. b. All funds appropriated shall be used for purposes described in Exhibit A. 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. The Provider shall be paid in four equal installments in the amount of $1,568. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Bridge II Sports) Orange County Outside Agency Performance Agreement Revised 712018 Page 1 of 9 DocuSign Envelope ID: E30588DE- A1BC- 443D- A5C4- 3BE790331500 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. £ 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 11, April 12, and July 12 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services, upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as "default "), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider, the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten (10) business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. (Bridge II Sports) Orange County Outside Agency Performance Agreement Page 2 of 9 Rev. 7118 DocuSign Envelope ID: E30588DE- A1BC- 443D- A5C4- 3BE790331500 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 • Worker's Compensation • Commercial General Liability • Automobile Liability • Professional Liability MINIMUM REQUIRED COVERAGE Limits for Coverage A - Statutory State NC & Coverage B - Employers Liability $500,000 each accident, disease policy limit and disease each employee $1,000,000 Each Occurrence $2,000,000 Aggregate $500,000 Combined Single Limit $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability) required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough, NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. (Bridge II Sports) Orange County Outside Agency Performance Agreement Page 3 of 9 Rev. 7118 DocuSign Envelope ID: E30588DE- A1BC- 443D- A5C4- 3BE790331500 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 $ 14.25 per hour. To the extent possible, Orange County recommends that Bridge II Sports provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (Bridge II Sports) Orange County Outside Agency Performance Agreement Page 4 of 9 Rev. 7118 DocuSign Envelope ID: E30588DE- A1BC- 443D- A5C4- 3BE790331500 County: Finance & Administrative Services Orange County Post Office Box 8181 Hillsborough, NC 27278 Provider: Bridge II Sports 3729 Murphey School Road Durham, NC 27705 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. a. 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. 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. 18. 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. Fi UocuSignedby: 'r " heProvider l�S 07A241CBD61441C... Fo; Docusignad by: County Govern m en t 0637994B755E477... Bonnie Hammersley, County Manager (Bridge II Sports) Orange County Outside Agency Performance Agreement Rev. 7118 8/22/2018 Date 8/23/2018 Date Page S of 9 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Bridge II Sports Applicant Organization's Physical Address: 3729 Murphey School Road, Durham, NC 27705 - Applicant Organization's Mailing Address: 3729 Murphey School Road, Durham, NC 27705 Applicant Organization's Web Address: www.bridge2sports.org Executive Director: Ashley Thomas Telephone Number: (866) 880 -2742 E -Mail: ashleyCcDbridge2sports.org Tax ID Number: 20- 8577055 b) Funding Request List all FY18 -19 Human Services (HS) Funding Being Requested - For All Programs) and the Proposed Use of Funds (2 -3 lines or less) Program Carrboro Chapel Orange Total - HS Hill - HS County-HS Ex. Youtli:Afterschovl Program : $10,000 $15,000 ". $5;000 130,000. Afterschool Program Coordinator salary and materials for.youth activities and projects : " Host 3 Adapted sport competitions to be held $5,000 $10,000 $6,000 $21,000 in Orange County to include Valor Games SE, utilizing UNC, students and the community at large. Adapted Sports Programs serving youth and $5,000 $10,000 $5,000 $20,000 adults with disabilities to include Boccia, Archery, Air Rifle, Wheelchair Basketball. Program Coordinator salary, equipment, and materials for activities. Totals $10,000 1 $20,000 1 $11,000 1 $41,000 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 applica Signature: Signature nt. , Executive Director Board Chairperson Date Date AGENCY INFORMATION 1/22/2018 10:12:15 AM Page 7 of 30 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 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 ❑ ® a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ® b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ® c) Current beneficiaries of the program for which funds are being requested? ❑ ® 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. . i V Executive Dire for Date c Signature: s�' �`'� � (� fLZ� � b Board Chairperson Date AGENCY INFORMATION 1/22/2018 10:12:15 AM Page 8 of 30 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 2. AGENCY INFORMATION (Be Very Brief and Concise) Please provide the following information about your agency (2 pages OR LESS): a) Years in Operation, Date of Incorporation (Month/Year): 11 years in operation; 0212007 b) Agency's Purpose /Mission (no more than a few sentences): Bridge Il Sports (BIIS), mission is to educate, develop, and implement opportunities for youth and adults with physical disabilities to play individual, team and recreational sports developing independence and inclusion. c) Types of Services the Agency Provides (bullet format): • Adapted sport programming to children and adults with physical disabilities • Trainings, clinics, competitions to engage athletes and coaches in higher levels of competitive play • Statewide school initiative educating students about acceptance, compassion, and inclusive play • Disability etiquette /diversity in the workplace trainings for businesses and corporations • Municipal and university partnerships to empower communities on the importance and need of accessibility d) Agency's History with Providing These Services: 11 years of a variety of adapted sports Programming provides seasonal recreation opportunities for individuals with disabilities in Orange County. Athletes and community members experience adapted practices, clinics, trainings and competitions. Our partnerships with municipality groups and UNC- Chapel Hill grows our programs within the County, simultaneously maintaining sustainability. e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? is there a new Executive Director? Are there new initiatives ?) BIIS implemented the #EverybodyPlaysNC educational initiative in June 2016, helping to serve over 5,000 students across NC. Surveys are distributed to gain insight into students' views, illustrating the learned concepts towards acceptance of disability. 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: 8 # of FTE - Paid Part -Time Positions: 2 # of Volunteers: 1,250 g) Living Wage # of FTE - Volunteers: 125 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? Yes If no, please explain. Agency Information 1/22/2018 10:12:15 AM Page 9 of 30 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION h) Agency Budget i. Is your agency currently receiving and/or requesting other (non -Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes /No) No If yes, please list below: Include all programs that have funding requests /awards /totals from Carrboro Chapel Hill, and Oran a Count governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FYI 7-18 Award FYI 8-19 Request Source Ex: Affordable Rental Rehabilitation:,: 0 $20,000 Carrboro:- Affoidable Housing Ex: Agency Administration $15,000 $15,000` Carrboro .Other Ex. Total $151000 $35,000" Carrboro Total "Funding *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate As file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Please see attachment BIIS Agency Budget for our entire agency budget. Please refer to attachment BIIS Budget Worksheets 2018 -2019 for the Revenue portion of our Agency Budget to include funds received from Carrboro, Chapel Hill and Orange County Human Services. .... ............................... Agency Information 1/22/2018 10:12:15 AM Page 10 of 30 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 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 • Private Donations • Program Generated Revenue • 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) • Other Government Grants • Triangle United Way • State Government • Federal Government (CDBGIHOMEIetc.) • Private Foundation Grants • 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? Breakeven — No Surplus or Deficit Is there a significant change? Yes /No No Please provide a brief explanation for Surplus or Deficit, and significant changes. Our 2018 budget is a breakeven budget, indicating that we intend to generate revenue and appropriately use funding to serve the needs of the disabled community. iv. What is your agency's fiscal year? January 1, 2018 — December 31, 2018 (Example: July 1, 2016 through June 30, 2097) Agency Information 1/22/2018 10:12:15 AM Page 11 of 30 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Adapted Sport Programing Program Primary Contact and Title: Ashley Thomas, Founder & Executive Director Telephone Number: (866) 880 -2742 E-mail: ashle brid e2s orts.or 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. Housirlg Neigh borhoodslResidents Affordable Housing Affordable Healthcare Education X X X Family Resources X X X X Jobs /Jobs Training X X X Food Transportation Other: Please specify Health & Fitness X X X X c) Provide a bulleted list of other agencies, if any, with which your agency coordinates /collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated /collaborative efforts. • Chapel Hill Parks and Recreation — We collaborate to use the Chapel Hill Community Center for practices, clinics, trainings and competitions. • UNC Chapel Hill — We accomplish programming, volunteer opportunities and hands -on learning skills for UNC students and faculty members. • Disabled Sports USA — As a member of DSUSA, we have low -cost insurance that is required to safely execute program objectives for athletes, volunteers and supporters. • Chapel Hill /Carrboro local businesses and organizations — Donate raffle and auction items. • Chapel Hill Chamber of Commerce — Work together to network and promote BI IS services for sponsorship engagement. Agency Information 1/22/2018 10:12:15 AM Page 12 of 30 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town /County priority /goal? Individuals with cerebral palsy, or those whose limbs are severely affected can engage in recreational and competitive adapted sport. Athletes with more severe disability and secondary health issues compete where the playing field among athletes is equal, safe and designed to meet their specific needs. Bridge II Sports provides adapted equipment and memberships at low prices with scholarship opportunities. Youth and adult teams give athletes a chance to be part of regional, statewide and national competitions. Programming improves the physical, mental and social health of the disabled population within Orange county, while also providing community members with the opportunity to learn inclusion, compassion and acceptance. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro 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. Lack of programming for individuals with disabilities leads to a decrease in physical, mental and social development. BIIS promotes the lives impacted by disability through empowering athletes to embrace their ability. This creates positive outcomes for the Board of Orange County Commissioner's #1 Goal to promote the well -being of all residents. Championing those living with disability allows us to help them to reach health goals and ultimately creates a higher quality of life for this vulnerable population. Our programming instills value to county residents, fostering a community that accepts diversity and innovates with inclusion in mind. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? Individuals living in NC who have Cerebral Palsy, Muscular Dystrophy, a traumatic brain injury, a visual impairment or low- vision, stroke, and wheelchair users can participate in adapted sport. Youth and adult potential athletes are connected to BIIS through the #EverybodyPlaysNC school initiative, rehabilitation and physical therapy departments, hospital clinicslprograms, 4 adapted sports, BIIS Paralympic experience programming through businesslorganization collaboration, university collaboration projects, and social media and marketing platforms. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) BIIS Program Staff and Tier 1 Volunteers go through many trainings and are Certified in Darkness to Light, CPR/First Aid, AED, Concussion Training by the CDC, Agency Information 1/22/2018 10:12:15 AM P a g e 13 o f 3 0 DocuSign Envelope ID: E30588DE- A1BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION SafeSport training by Team USA, Background Checked. BIIS staff and Board have a broad variety of expertise from Therapeutic Rec., Sports Management, Marketing, O.T., and more. Perhaps more importantly, we have several staff /coaches who have disability themselves and know the journey from injury to recovery. Creating an inclusive and diverse environment, together, we support the work of Bridge II Sports. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. Boccia is a weekly, year -round and seasonal sport that takes place at Chapel Hill Community Center (CHCC) and the Bond Park Community Center (BPCC). Residents living in Orange County /Chapel Hill /Carrboro are members of both programs. BIIS provides 40 practices annually and hosts one tournament. BIIS collaborates with UNC Chapel Hill's "Bridge the Gap" tournament by providing qualified staff, equipment and event guidance. BIIS coached two boccia athletes to compete at nationals in 2017. Air Rifle and Archery are hosted at the BIIS offices located in Orange County. BIIS provides 40 practices annually and two tournaments in both sports. BIIS would like to expand wheelchair basketball to Orange County, enabling an inclusive program for the community. Accessible space is being researched. i) Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) BIIS enhances all community populations by cultivating opportunities for an underserved population and educating the community at large through inclusive play. We emphasize the need for better health options for the community of people with disabilities while simultaneously serving adapted sports programs. Programming, events, competition and outreach opportunities enhance the future for these individuals by giving them tools to access success. Through sports, our athletes gain tenacity, confidence and joy to help them independently navigate and succeed in life. To date, 92% of our youth attend college or tech school. BIIS also emphasizes the need for civic participation in helping to bridge the gap for a more inclusive, dynamic community. By engaging county residents and students in our services, volunteers and supporters gain firsthand experience and knowledge into how to empower those living with disabilities. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Without BIIS programming, there are few to no opportunities for individuals with disabilities to engage in health- related activities. BIIS benefits the community with disabilities by offering the only adapted sports programming in the Triangle. Without requested funding, programs would not be able to run and people with physical disabilities would not be able to participate in accessible programs. k) What percentage of your target population is low- moderate income? Based on data in our CRM, over 50% are identified as low- moderate income. Agency Information 1/22/2018 10:12:15 AM Page 14 of 30 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 1) What efforts do you make to seek feedback about your program from your target population (e.g. survey, evaluations, etc. ?) In 2018, a survey will be implemented capturing growth pre- and post - season. In addition to the survey, each individual program captures four (4) unique goals from participants to evaluate personal development. Those goals are. Sport specific skill goal, Team goal, Education specific goal (to compete, athlete must be passing with a C or above), and Independent living goal. m) Include any other pertinent information. B11S has a $1 million child molestation insurance policy BIIS staff and Tier 1 Coaches: • Working with children are background screened • Are trained and certified in the SafeSport program created by the USA Olympic /Paralympic Committee • Are trained and certified in concussion training by the Centers for Disease Control (CDC) • Are trained and certified in Positive Coaches Alliance • Are trained and certified in Red Cross First Aid, CPR, and AED • Certified in adapted sport if available Additional Pro ram Information n) 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 2016 -17 2017 -18 2018 -19 Gender Male Female Total Ethnicity African- American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Other: specify Chose not to say Total 80 95 105 46 55 70 126 150 175 41 60 75 2 4 8 55 60 72 5 10 10 2 16 10 F1 26 150 175 Agency Information 1/22/2018 10:12:15 AM P a g e 15 of 3 0 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Age Of the above, how many Hispanic /Latino Of the above, how many non-Hispanic/Latino Total 0 -5 years 6 -18 years 19 -50 years 51+ years _. .... Total Geographic Location Alamance County Chatham County Durham County Wake County Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non - Public Housing) Town of Carrboro Town of Hillsborough. City of Mebane (Orange County) Orange County (Outside Municipalities) Work Statement 7 14 21 119 136 154 126 156 175 5 8 12 75 85 95 31 40 50 20 25 30 126 150= 175 5 8 12 2 10 15 15 20 25 68 70 80 Total 1 100 1 114 1 167 o) 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 900 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 measurable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Agency Information 1/22/2018 10:12:15 AM P a g e 1 6 o f 3 0 3 3 6 1 2 3 2 5 6 7 14 20 Total 1 100 1 114 1 167 o) 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 900 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 measurable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Agency Information 1/22/2018 10:12:15 AM P a g e 1 6 o f 3 0 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement Chart for Program: Bridge II Sports Adapted Sport Programing 7. Program Activity Name Physical Development: Skills Test Program Goal Practices are structured to develop the physical health and sport specific skills of athletes. Performance Measures During each season, execute a skills development test at the start, middle, and end of each season. Skills will test endurance, distance, and accuracy. Previous Year Program Results 6 athletes completed a skills test for each sport season. Current Year Estimated Results 10 athletes will perform a skills test during each season. Next Year Projected Results 15 athletes will perform a skills test in each season and will record growth between seasons. Z. Program Ac #ivifiy Namo' -;' Personal /Social Development: Goal Cards Program Goal Practice will be structured to provide an avenue for social development: communication, self - understanding, and the opportunity for community engagement. Performance Measures Participants will create goal cards outlining academic, personal, skills, and team goals which will be checked every four weeks to evaluate progress and outcomes. Previous Year Program Results 6 Athletes created, maintained and completed season - end analysis of goal cards. Current Year Estimated Results 10 Athletes will create, maintain and complete season - end analysis of goal cards. Next Year Projected Results 15 Athletes will create, maintain and complete season - end analysis of goal cards and records growth between seasons. Program ,c iYy Name `' Partici ants Program Goal Increase number of participants. Performance Measures We will increase athlete participation by 5 -7 individuals as we partner with local schools through our school initiative campaign and by targeting a new age demographic with the Durham VA. Previous Year Program Results Ended season with 6 athletes participating. Current Year Estimated Results Keep current 6 athletes and grow to 10 adding 4 new. Next Year Projected Results Keep 10 athletes and grow to 5 more. 4 Program Actwity Name ' Tournaments Program Goal Tournaments are organized to apply sport specific skills and team solidarity. Performance Measures Host 1 -2 local tournaments in the Triangle area to facilitate social networking and physical competition among peers with similar disabilities. Previous Year Program Results Hosted 2 tournaments in Triangle area while assisting with external local and national competitions. Agency Information 2/20/2018 11:26:09 AM Page 17 of 30 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Current Year Estimated Results Host 2 tournaments & one clinic in Triangle area; 20 athletes served / 25 students volunteer; bring awareness to 35 community members. Next Year Projected Results Host 2 tournaments & one clinic in Triangle area; 23 athletes served / 28 students volunteer; bring awareness to 38 community members. Agency Information 2/20/2018 11-26,09 AM P a g e 1 8 o f 3 0 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION ff) Program Budget 5. Submit your program budget. You may complete the provided template (separate As file) or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template). Please see attached BI IS Budget Worksheet 2018 -2019 Adapted Competition Events Budget. 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 • Private Donations • Program Generated Revenue • 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) • Other Government Grants • Triangle United Way • State Government • Federal Government (CDBGIHOMEIetc.) • Private Foundation Grants • Other Revenue Expenditures • Compensation • Rent & Utilities • Supplies & Equipment • Travel & Training • Other Expenses 6. Program Budget Detail — Provide description of "other" budget items, not defined. Staff and Coach Development, Insurance 7. This program budget represents what percent of the agency budget? 21.7% 8. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. PROGRAM INFORMATION 3/21/2018 5:56:28 PM Page 27 of 30 Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Total Cost of Program $198,122 $230,235 $272,900 Total # of Individuals 632 675 725 Cost Per Individual $313.48 $341.09 $376.41 PROGRAM INFORMATION 3/21/2018 5:56:28 PM Page 27 of 30 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Adapted Competition Events Program Primary Contact and Title: Ashley Thomas, Founder & Executive Director Telephone Number: (866) 880 -2742 E -Mail: ash ley (cbbridge2sports.org q) 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 r) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category', y Youth Adult Elderly Disabled Public Housing Neighborhoods /Residents Affordable Housing Affordable Healthcare Education X X X X Family Resources X X X X Jobs /Jobs Training X X X Food Transportation Other: Please specify Health & Fitness X X X X s) 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. UNC Chapel Hill — We accomplish programming, volunteer opportunities and hands - on learning skills for UNC students and faculty members. • Disabled Sports USA — As a member of DSUSA, we have low -cost insurance that is required to safely execute program objectives for athletes, volunteers and supporters. • Chapel HIII /Carrboro local businesses and organizations — Donate raffle and auction items. 0 Chapel Hill Chamber of Commerce — Work together to network and promote BIIS services for sponsorship engagement. PROGRAM INFORMATION 1/22/2018 10:12:15 AM Page 20 of 30 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Program Description (3 pages OR LESS) Please provide the following information about the proposed program: t) Summarize the program services proposed and how the program will address a Town /County prioritylgoal? Adapted competitive Events enables those with a variety of physical disabilities to engage in competitive events supporting physical activity. Community members living in Orange County who have a disability benefit from safe and accessible adapted sports competition and adapted equipment to empower living healthy lifestyles. Youth and adult teams offer all people the chance to learn new skills, meet others living with disability, compete in tournaments, and achieve goals. Competition allows people with disabilities to develop physically, mentally and socially. Hosting local competition overcomes high cost of travel for the community we serve. Hosting locally also engages the community to serve, learn, and support. u) 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. BIIS enhances the community as the Town of Chapel Hill's Council Goals suggest in "Creating a Place for Everyone." Without BIIS, individuals with disability have no activity that positively impacts their health and well- being. Adaptive sports events provide those with disability a safe and accessible space to engage. Volunteer assistance from county residents and UNC Chapel Hill students creates sustainable and supported programming that educates everyone on the idea of inclusivity improvement and growth that is imperative to the future of the Orange County community. Bridge II Sports is a niche organization that enables civic participation among athletes, participants and community members of all ages. v) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? People living in NC who have spinal cord injuries, Cerebral Palsy, Spina Bifida, a Amputees, Little people, TBIIPTSD, Stroke, and a variety of other disabilities to participate in adapted sport competition. Our youth and adult participants are connected to BIIS through our #EverybodyPlaysNC school initiative, rehabilitation and physical therapy departments, hospital clinicslprograms, halftime programs at college basketball games, Paralympic experience programming through business /organization collaboration, university collaboration projects, and social media and marketing platforms. w) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) PROGRAM INFORMATION 1/22/2018 10:12:15 AM P a g e 2 1 of 30 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION BI IS Program Staff and Tier 1 Volunteers go through many trainings and are Certified in Darkness to Light, CPR /First Aid, AED, Concussion Training by the CDC, SafeSport training by Team USA, Background Checked. BIIS staff and Board have a broad variety of expertise from Therapeutic Rec., Sports Management, Marketing, O.T., and more. Perhaps more importantly, we have several staff /coaches who have disability themselves and know the journey from injury to recovery. Creating an inclusive and diverse environment, together, we support the work of Bridge II Sports. x) Describe the specific period over which the activities will be carried out and include an implementation timeline. BIIS hosts many competitions over the course of a year to include Valor Games SE (UNC), Paddle Lake Crabtree, Winter Classic, Hog Wild, Goal Ball, Boccia, Archery and Air Rifle local competitions. These competitions include community members, students, and people with disabilities in a competitive space educating all on the ability of disability. Some of these events engage large corporations and companies creating opportunity to educate on disability in the workplace. This is a positive and wholistic approach. BIIS also provides demos at UNC Chapel Hill, collaborates with the student led project "Bridge the Gap," and collaborates with Orange County schools to bring students adapted sports education days. y) Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) BIIS enhances all community populations by cultivating opportunities for an underserved population. We emphasize the need for better health options for the disabled community while simultaneously serving adapted sports programs. Programming, events, competition and outreach opportunities enhance the future for these individuals by giving them tools to access success. Through sports, our athletes gain tenacity, confidence and joy to help them independently navigate and succeed in life. z) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Without BIIS programming, there are few to no opportunities for individuals with disabilities to engage in health- related activities. BIIS benefits the community of people with disabilities by offering the only adapted sports competition in the Triangle. Without requested funding, programs would not be able to run and people with physical disabilities would not be able to participate in competition. Without competition, there is no reason to train. These are crucial experiences for the development of a child, or the recovery after injury to see that one can live successfully with independence while having a disability. Competition has been a huge motivation for our injured military community to rediscover their physical ability as a warrior. This has been one area that is most effective for military to engage. aa) What percentage of your target population is low- moderate income? PROGRAM INFORMATION 1/22/2018 10:12:15 AM Page 22 of 30 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Based on data in our CRM, over 50% are identified as low- moderate income. bb) What efforts do you make to seek feedback about your program from your target population (e.g. survey, evaluations, etc. ?) Surveys are sent out after each event. cc) include any other pertinent information. BIIS has a $1 million child molestation insurance policy BIIS staff and coaches: • Working with children are background screened • Are trained and certified in the SafeSport program created by the USA Olympic /Paralympic Committee • Are trained and certified in concussion training by the Centers for Disease Control (CDC) • Are trained and certified in Positive Coaches Alliance • Are trained and certified in Red Cross First Aid and CPR • Many staff and coaches are people with disabilities, understanding the journey and recovery. • Trained it TBI /PTSD Additional Program Information dd)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 2016 -17 2017 -18 2018 -19 Gender Male Female Total Ethnicity (We will collect next time) This is what we did collect African- American Amputee American Indian /Alaska Native Blind/ Low Vision Asian Cerebral Palsy Caucasian Spina Bifida Native Hawaiian /Pacific Islander Spinal Cord Injury Other: TBI /PTSD /Stroke Total Of the above, how many Hispanic /Latino 505 525 550 127 150 175 632 675 725 41 60 70 18 25 30 36 40 45 75 85 95 88 90 100 374 375 385 632 675 725 We will do a Increase Increase better job by 5% by 5% PROGRAM INFORMATION 1/22/2018 10:12:15 AM Page 23 of 30 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Of the above, how many non-Hispanic/Latino Total Age 0 -5 years 6 -18 years 19 -50 years 51f years Total Geographic Location Alamance County Chatham County Durham County Wake County Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non - Public Housing) Town of Carrboro Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) Work Statement capturing this data 10 previous year 258 300 350 a 1 o 1 0 5 10 15 258 300 350 299 275 265 75 100 110 632 675 725 5 10 15 2 4 10 150 175 200 100 125 150 Total 1 393 1 479 1 600 ee) 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 (�2pecific, 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 900 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 measurable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 905 meals per day.) PROGRAM INFORMATION 1/22/2018 10:12:15 AM Page 24 of 30 118 130 150 5 8 15 10 15 30 2 5 3 10 25 Total 1 393 1 479 1 600 ee) 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 (�2pecific, 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 900 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 measurable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 905 meals per day.) PROGRAM INFORMATION 1/22/2018 10:12:15 AM Page 24 of 30 DocuSign Envelope ID: E30588DE- A1l3C- 443D- A5C4- 3l3E790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement Chart for Program: Bridge II Sports Adapted Competition Events 5. Program Activity Name Valor Games SE to prepare we will hold practices to include Program Goal Through Competition, challenge sport skills, communication, teamwork, independence and physical activity for cross disabilities. 125 athletes attend. Performance Measures Event outcomes tracked, awards given, outcomes given to all athletes. Previous Year Program Results 100 athletes attended with above accountability and follow -up survey. Current Year Estimated Results As of 1129118, 100 athletes are registered. Next Year Projected Results Grow the funding support and volunteer support to accommodate 140 athletes, with 25% being new. 6. Program Activity Name'' Paddle Lake Crabtree to prepare we will hold practices to include Program Goal Through Competition, challenge sport skills, independence and physical activity for cross disabilities. 50 athletes attend. Performance Measures Event outcomes tracked, awards given, outcomes given to all athletes. Previous Year Program Results 35 athletes attended with above accountability and follow-up survey. Current Year Estimated Results Organized in 2018 by BITS staff; Supported by community and college students. Next Year Projected Results Grow the funding support and volunteers support to accommodate a sanctioned ACA event in 2019. 7. Program Activity Name Sanctioned Youth Wheelchair Basketball Tournament Program Goal Host Event in Fall of 2018. Performance Measures Register 6 Teams from Southeast. Previous Year Program Results 6 Teams attend for two -day event with serving 150 athletes. Current Year Estimated Results 5 teams attended last year. Opportunity for college student to volunteer. Next Year Projected Results Grow the funding support and volunteers support to accommodate a growth for 4 more teams in 2019. 8. Program Activity Name Host Bridging the Gap Competition at UNC Program Goal Utilizing UNC College Students to organize a Goal Ball /Boccia competition for our youth programs. PROGRAM INFORMATION 1/22/2018 10:12:15 AM Page 25 of 30 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Performance Measures Event outcomes tracked, awards given, outcomes given to all athletes. Students get firsthand experience and education in adapted programming. Previous Year Program Results Completed 3 years of successful event Current Year Estimated Results Complete 2 Bridge the Gap events in 2018 serving two program competitions: Goal Ball and Boccia. Next Year Projected Results Grow event to lay foundation for UNC College Programing. PROGRAM INFORMATION 1/22/2018 10:12:15 AM Page 26 of 30 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION ff) Program Budget 5. Submit your program budget. You may complete the provided template (separate As file) or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template). Please see attached BI1S Budget Worksheet 2018 -2019 Adapted Competition Events Budget. 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 • Program Generated Revenue • 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) • Other Government Grants • Triangle United Way • State Government • Federal Government (CDBGIHOMEIetc.) • Private Foundation Grants • Other Revenue Expenditures o Compensation o Rent & Utilities o Supplies & Equipment • Travel & Training • Other Expenses 6. Program Budget Detail — Provide description of "other" budget items, not defined. Staff and Coach Development, Insurance 7. This program budget represents what percent of the agency budget? 21.7% 8. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. L��W z �►cfia216 °'(7 �'r ' Eet�m01�7 18.sPro�ecte ,. 0j1 �, 8,��✓19�y Total Cost of Program $208,620 $219,050 $230,000 Total # of Individuals 632 625 675 Cost Per Individual $330.09 $350.48 $340.74 PROGRAM INFORMATION 1/22/2018 10:12:15 AM Page 27 of 30 DocuSign Envelope ID: E30588DE- A1BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Bridge II Sports AGENCY REVENUE Private Donations Agency Generated Revenue (fees) Local Government Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services - Town of Chapel Hill Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Town of Hillsborough Other Government Grants Triangle United Way State Government Federal Government (CDBG /HOME /etc Private Foundation Grants Other Revenue Total Agency Revenue AGENCY EXPENSES Compensation Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: Total Agency Expenses Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Percent Change $ 26,630 $ 7,801 $ 46,500 496% $ 14,942 $ 4,000 $ $ 22,279 2,000 1 $ $ 47,250 10,000 j 112% 400% $ - $ - $ - 0 $ 8,000 $ 8,000 $ 20,000 150% $ - $ - $ - 0 $ 5,250 $ 5,438 $ 11,000 102% $ - I $ - I $ - 1 0 i- $ - $ $ - - $ $ - - 0 0 $ - $ - $ - 0 $ 151,000 $ 110,000 $ 110,000 0% $ 282,273 $ 265,153 $ $ 121,100 332,658 $ $ 161,000 652,600 33% 96% $ 757,248 $ 609,276 $ 1,058,350 740%16 $ 298,749 $ 347,364 $ 556,550 60% $ 146,365 $ 52,205 $ 54,200 4% $ 60,716 $ 129,875 $ 77,800 -40% $ 71,271 $ 124,835 $ 228,600 83% $ 108,682 $ 139,186 $ 141,200 1% $ 685,783 1 $ 793,4651 $ 1,058,350 1 33% SURPLUS /(DEFICIT) FOR PERIOD: 1 $ 71,465 1 $ (184,189) $ - 1 100% FY 2018 -19 Agency Budget DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Bridge II Sports Program Budget PROGRAM NAME: Competitions and Events PROGRAM REVENUE Private Donations Program Generated Revenue Local Government Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services - Town of Chapel Hill Other - Town of Chapel Hill Human. Services - Orange County Other - Orange County Other -Town of Hillsborough Other Government Grants Triangle United Way State Government Federal Government (CDBGIHOMEIetc.) Private Foundation Grants Other Revenue Total Program Revenue PROGRAM EXPENSES Compensation Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: Total Program Expenses Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Percent Change $ 1,200 $ 37 $ 1,500 3954% $ $ 382 2,000 $ $ 8,348 1,000 1 $ $ 10,000 6,700 1 20% 570% $ - $ - $ - 0 $ 4,000 $ 4,000 $ 13,400 235% $ - $ - $ - 0 $ 2,625 1 $ 2,7191 $ 7,370 1 171% $ - $ - $ - 0 i- $ - $ $ - - $ $ - - 0 0 $ - $ _ $ _ 0 $ 151,000 $ 110,000 $ 110,000 0% $ 36,873 64,900 $ 52,500 33,0061 $ $ 60,000 43,530 14% 1 32% $ 262,980 $ 211,610 $ 252,500 19% 51,094 48,013 83,100 73 °o 14,785 23,431 19,000 -19% 77,838 70,638 88,900 26% 28,228 43,790 40,250 -8% 26,177 MOM 44,363 41,660 -6% $ 198,122 $ 230,235 $ 272,900 1 19% SURPLUSI(DEFICIT) FOR PERIOD: 1 $ 64,858 1 $ (18,625)1_$ (20,400) -10% FY 2018-19 Program Budget DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Bridge II Sports Program Budget PROGRAM NAME: Adapted Sports Programing PROGRAM REVENUE Private Donations Program Generated Revenue Local Government Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services - Town of Chapel Hill Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Town of Hilisborough Other Government Grants Triangle United Way State Government Federal Government (CDBG /HOME /etc.) Private Foundation Grants Other Revenue Total Program Revenue PROGRAM EXPENSES Compensation Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: Total Program Expenses Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Percent Change $ 524 $ - $ - 0 $ 1,182 $ 3,808 $ 2,000 -47% 0 $ 2,000 $ 1,000 $ 3,300 230% $ - $ - $ - 0 $ 4,000 $ 4,000 $ 6,600 65% $ - $ - $ - 0 $ 2,625 $ 2,719 $ 3,630 34% $ - $ - $ - 0 Is - $ 1 $ - 1 fl $ - $ - $ - 0 $ $ - $ 0 $ - $ - $ - 0 $ - $ 19,500 $ 20,000 3% $ 16,975 $ 15,344 $ 27,470 79% $ 27,306 $ 46,371 $ 63,000 36% $ 54,551 $ 72,169 $ 71,950 0% $ - $ - $ - 0 $ 149 $ 231 $ 21,115 9041% $ 1,432 $ 5,599 $ 2,750 -51% $ 17,674 $ 14,259 $ 17,200 21% $ 73,806 $ 92,258 1 $ 113,015 22% SURPLUSI(DEFICIT) FOR PERIOD: 1 $ (46,500) $ (46,887)L$ (50,015) -9% DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 EXHIBIT "B" Scope of Services — FY 2018 -19 Outside Agency Performance Agreement Agency Name: Bridge II Sports Program Name: Adapted Sports Programming Funding Award: $6,272 Outline how the agency will spend Orange County's funding award. Expense Description Amount Host 3 Adapted sport competitions to be held in Orange County to include Valor Games SE, utilizing UNC, students and the community at large. Expenses include supplies and event costs. 4,000 Adapted Sports Programs serving youth and adults with disabilities to include Boccia, Archery, Air Rifle, Wheelchair Basketball. Program Coordinator salary, equipment, and materials for activities. 2,272 Athletes will attend Valor Games SE in 2019 — event outcomes tracked, awards 100 given, outcomes given to all athletes (# of Athletes registered) Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2019. Host adapted sport competitions, including Valor Games Southeast and Paddle Lake Crabtree • Provide adapted sports programming for youth and adults with disabilities The Anticipated Results column must include quantifiable results in the form of number of persons /units served within Oran$! 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 Adapted Competition Events: Athletes will attend Valor Games SE in 2019 — event outcomes tracked, awards 100 given, outcomes given to all athletes (# of Athletes registered) Athletes to attend Paddle Lake Crabtree in 2018 — event outcomes tracked, 20 awards given, outcomes given to all athletes # of Athletes attend Host youth wheelchair basketball event with disability awareness (# of Athletes 75 registered) Host Bridging the Gap Event at UNC — outcomes tracked, awards given, 50 outcomes given to all athletes (# of Athletes) ,—Docu5igned by: LAU" ' "mas Executive Director 8/22/2018 Certified by: ..a241cBD61441c... _ Title: Date: (Provider's Signature) DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 Performance Measures Anticipated Results Adapted Sport Programming: Athletes will perform a skills test during each season (# of Athletes) 8 Athletes will create, maintain and complete season -end analysis goal cards 8 # of Athletes Increase athlete participation by adding 4 new athletes (# of Athletes keep 10 4 and grow by 4 additional Host 1 -2 events in the Triangle area to facilitate social networking and physical 40 competition and promote disability awareness # of Athletes DOCUSigne- dj-by: S ` ma'S Executive Director 8/22/2018 Certified by: _ 07A241cao61441c... Title: Date: (Provider's Signature) DocuSign Envelope ID: E30588DE- A1BC- 443D- A5C4- 3BE790331500 ATTACHMENT "A" Orange County Certifications — FY 2018 -19 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. DOCU Signed by: Certified by: Q7A2a1CBD61441C... (Provider's Signature) Title: Executive Director Date: 8/22/2018 (Bridge 11 Sports) Orange County Outside Agency Performance Agreement Page 9 of 9 Rev. 7118 DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 ASR °� CERTIFICATE OF LIABILITY INSURANCE FDATE (MMIDDIYYYY) 08/13/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: American Specialty Insurance & Risk Services, Inc. HONE Ext : 260- 969 -5203 FA No): 260 - 969 -4729 E -MAIL COMMERCIAL GENERAL LIABILITY ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # 7609 W. Jefferson Blvd., Suite 100 INSURERA: Arch Insurance Company 11150 Fort Wayne IN 46804 INSURED INSURER B : INSURER C, Disabled Sports USA, Inc. INSURER D: PREM SES (Ea olccur ence ) 451 Hungerford Drive, Suite 608 INSURER E : MED EXP (Any one person) $ Excluded INSURER F: Rockville MD 20850 COVERAGES CERTIFICATE NUMBER: 1001595594 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICYNUMBER POLICY EFF MM /DDIYYYY POLICY EXP MM /DDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR PREM SES (Ea olccur ence ) $ 1,000,000 MED EXP (Any one person) $ Excluded PERSONAL & ADV INJURY $ 1,000,000 A Y SBCGL0408100 12/01/2017 12/01/2018 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000 POLICY ❑ PRO- JECT [::] LOC PRODUCTS - COMP /OP AGG $ 5,000,000 X $ OTHER: CLUB AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 X AGGREGATE $ 5,000,000 A EXCESS LIAB CLAIMS -MADE SBFXS0054000 12/01/2017 12/01/2018 DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN PER OTH- STATUTE ER ANYPROPRIETOR /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 I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Coverage applies to the following chapter: BRIDGE II SPORTS, . The General Liability policy includes Form CG 2133 Exclusion - Designated Products with the following products excluded: Athletic or exercise equipment when manufactured by you or manufactured by others to your specifications. CERTIFICATE HOLDER CANCELLATION Orange County Government SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 200 S Cameron St, PO Box 8181 AUTHORIZED REPRESENTATIVE Hillsborough NC 27278 ©1988 -2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 AGENCY CUSTOMER ID: LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY American Specialty Insurance & Risk Services, Inc. POLICY NUMBER SBCGL0408100 CARRIER Arch Insurance Company ADDITIONAL REMARKS NAMED INSURED Disabled Sports USA, Inc. 451 Hungerford Drive, Suite 608 NAIC CODE Rockville, MD 20850 11150 EFFECTIVE DATE: 12/01/2017 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE -Certificate #1001595594 - The General Liability policy includes Form CG 2116 Exclusion - Designated Professional Services with the following professional services excluded: Providing or failure to provide medical professional services. - The General Liability policy includes Form CG 2144 Limitation of Coverage to Designated Premises or Project, with the following Scheduled Project/Premises limitation: Events, activities, and business operations related to Disabled Sports USA - The General Liability policy includes Form 00 SGL0118 00 Construction Operations Limited Coverage, with the following Construction Operations scheduled: NONE - Coverage available under policy # SRPO- 50219 -203 is on file with the policyholder. Excess Accident Medical for Class 1 & 2 - $25,000 with a $250 deductible per injury per covered accident. Accidental Death & Dismemberment is $10,000 per person per accident. Class 3 & 4 - $100,000 with a $250 deductible per injury per covered accident. Accidental Death & Dismemberment is $10,000 per person per accident. - With regards to the Excess Accident Medical Coverage, Class 1 & 3 is all registered /approved participants and volunteers of the Participating Organization and its Chapters with respect to sponsored and approved activities including direct travel to and from the activity and home, not including overnight trips. - With regards to the Excess Accident Medical Coverage, Class 2 & 4 is all registered /approved participants and volunteers of the Participating Organization and its Chapters with respect to sponsored and approved overnight trips including direct travel to and from the activity and home. - The Certificate Holder is only an Additional Insured with respect to liability caused by the negligence of the Named Insured as per Form 00 SGL0026 00 Additional Insured - Certificate Holders, but only with respect to BRIDGE II SPORTS ADAPTED PROGRAMMING from August 13, 2018 through November 30, 2018. ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 it: I&14111lie]*-`] 4ul4 hill Keli 1 G11[c7*j III awl ;111l6]IIIIIII)WAalill:r-F.`] Ji7:FG101iMI 0401MA POLICY CHANGE As of the effective date hereof, it is hereby understood and agreed that Endorsement Number 01 SEXUAL ABUSE OR MOLESTATION COVERAGE, SCHEDULE, Limits of Insurance is amended to read as follows, but only with respects to Bridge II Sports Chapter: Sexual Abuse Each Occurrence: $1,000,000 Sexual Abuse Aggregate: $1,000,000 Additional Premium Due. $ All other terms and conditions of this Policy remain unchanged. Company: Arch Insurance Company Endorsement Number: 07 Policy Number: SBCGL0408100 Named Insured: Disabled Sports USA, Inc. Endorsement Effective Date: 01/29/18 President Issued by: AK February 6, 2018 00 ML0207 00 11 03 Page 1 of 1