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Home My WebLink About2018-507-E Finance - Club Nova outside agency agreementDocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 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 Club Nova Community, Inc., a not - for - profit corporation, located at 103 D. West Main Street, Carrboro, NC 27510 ( "Provider "). 1.iIMy�1�LXy�lly 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 Club Nova Community, Inc. 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 $16,250 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. c. The Provider shall be paid in four equal installments in the amount of $4,062.50. 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. (Club Nova Community, Inc.) Orange County Outside Agency Performance Agreement Revised 712018 Page 1 of 9 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 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. (Club Nova Community, Inc.) Orange County Outside Agency Performance Agreement Page 2 of 9 Rev. 7118 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 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. (Club Nova Community, Inc.) Orange County Outside Agency Performance Agreement Page 3 of 9 Rev. 7118 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 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 Club Nova Community, Inc. 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: (Club Nova Community, Inc.) Orange County Outside Agency Performance Agreement Page 4 of 9 Rev. 7118 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 County: Finance & Administrative Services Orange County Post Office Box 8181 Hillsborough, NC 27278 Provider: Club Nova Community, Inc. 103 D. West Main Street Carrboro, NC 27510 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. For pocu5ignedby" ``7eProvider Viti�l JA, 04AC9278265F493... For E6Q OcuSigned by, r :'ounty Government Nwmt yi Fi3799d6755E477... Bonnie Hammersley, County Manager (Club Nova Community, Inc.) Orange County Outside Agency Performance Agreement Rev. 7118 8/27/2018 Date 8/28/2018 Date Page S of 9 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Club Nova Community, Inc. Applicant Organization's Physical Address: 103 -D W Main St, Carrboro, NC 27610 Applicant Organization's Mailing Address: 103 -D W Main St Carrboro NC 27610 Applicant Organization's Web Address: www.clubnova.orq Executive Director: Karen Kincaid Dunn Telephone Number: 919- 968 -6682 Tax ID Number: 27- 0103430 E -Mail: adminRclubnova.org 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 Ch_ apel Hill - HS Orange Count -HS Total -HS Ex. Youth Afterschool Program Afterschool Program Coordinator salary and materials for youth activities and projects $10,000 $15,000 $5,000 $30,000 Critical Safety Net— Health and Wellness $20,000 $20,000 Critical Safety Net - Operating $20,000 $20,000 Employment/Education; Transportation: expenses and salary; Critical Safety Net $120,000 $120,000 Totals $170,000 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 applicant. Signature:�� Executive Director Date Signature: Al, RJKI.14 AE3Vard Chairperson Date Agency Information 1/23/2018 1:00:30 PM Page 8 of 3,1 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 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? JZ ❑ 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. As part of our inclusive governance, Club Nova has two members of Club Nova on the Club Nova Community, Inc. Board of Directors. 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: t roc.^) ,' rl�' ecutive Dire for -- Signature: tAfv'(7 card Chairperson Date J Datc Agency Information 1122/2018 4:17:50 PM Page 9 of 31 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 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): August/2004 Club Nova was founded July 1, 1987. Our founding members were at the core of our inception. Club Nova has been in operation for almost 30 years, operating for 19 years under the auspices of OPC Area Authority. Club Nova Community, Inc. incorporated on August 23, 2004. On May 21, 2006, Club Nova was divested and came under the governance of Club Nova Community, Inc. We have operated as a private non - profit for over 10 years. b) Agency's Purpose /Mission (no more than a few sentences): Club Nova provides opportunities for individuals living with severe and persistent mental illness to lead meaningful and productive lives of their choice in the community. Club Nova focuses on members' strengths and potential rather than their illness. c) Types of Services the Agency Provides (bullet format): • The Basic Components of Clubhouse: Community Support • Members get help with acquiring and keeping affordable and dignified homes. • Members get help with government disability and pension benefits. • The Basic Components of Clubhouse: Supported Housing o Club Nova is committed to securing a range of choices of safe, decent and affordable housing including independent living opportunities for all members. o Members choose the location of their housing and their roommates. o The level of support increases or decreases in response to the changing needs of the members. The Basic Components of Clubhouse: Health and Wellness • Club Nova provides 13 affordable, nutritious meals each week. • Members receive help accessing and navigating the social and healthcare services they require. • Members get help with averting crisis and crisis intervention. • Members have opportunities to participate in weekly wellness programming. The Basic Components of Clubhouse: Outreach o Reach -out call or visit is made when a member does not attend or is hospitalized. o Outreach provides an early warning system for members experiencing difficulties. o Through routine contact, a crisis, hospitalization or worse, is often prevented. The Basic Components of Clubhouse: The Work Ordered Day • Members and staff work together as colleagues to carry out all the critical work necessary to sustain Clubhouse functions. • Through participating and contributing, members regain skills, a sense of purpose, self- worth, and confidence working in the Clubhouse • The Basic Components of Clubhouse: The Employment Programs o People with SMI have the lowest employment rates of any disability. o Return to paid employment is a right of membership and a priority of Clubhouse o Members are given opportunities for paid employment in integrated work settings. Agency Information 1/23/2018 1:58:29 PM Page 10 of 31 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION • Three types of employment programs: Transitional, Supported, and Independent • Employment is at the employer's place of business and pays the prevailing wage for the required work. The Basic Components of Clubhouse: Education • Often education has been interrupted by SMI. Our Supported Education assists with admissions, financial aid, and utilization of disability offices. • The Clubhouse provides opportunities and assistance helping members complete or start their certificate or degree programs at colleges and universities. • The Basic Components of Clubhouse: Evening, Weekend, Holiday Program o Evening, Weekend, Holiday Program reduces isolation and gives members a sense of social connectedness and belonging. + The Basic Components of Clubhouse: Transportation • Access is essential for members' participation in Club Nova's full range of opportunities. • Transportation operates morning and evening routes throughout Orange County. d) Agency's History with Providing These Services: Club Nova offers solutions to the challenges our members and our community face on a daily basis. For 30 years, Club Nova has been saving and changing lives and making a positive impact on the health of our community. We have 30 years of experience in providing the full range of supports and opportunities that define the Model and are in our funding request. The Model operates on proven standards and has been replicated effectively with over 320 Clubhouses worldwide. A rigorous accreditation process assures fidelity to the standards of the Model. Club Nova holds a 3 Year Accreditation and is one of six accredited Clubhouses in North Carolina. The Clubhouse Model is included in the Substance Abuse and Mental Health Services Administration (SAMHSA) registry for Evidence -Based Practices. In 2017 the Conrad N. Hilton Foundation, one of the world's most prestigious humanitarian prizes, chose the Clubhouse International /Fountain House Clubhouse Model as the answer to alleviating worldwide human suffering for individuals living with mental illness. Our dedication to our members and this community have earned Club Nova the 2016 GlaxoSmithKline Impact Award and Employee Choice Award, 2016 Chamber of Commerce Business Excellence Award for Community Impact, 2016 Faith Connections Community Servant Award and recognition by Towns of Carrboro and Chapel Hill for being a Model of Excellence in mental health. With Club Nova's current plans for expansion, we look forward to the next 30 years. e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? Is there a new Executive Director? Are there new initiatives?) While Club Nova has not experienced any major changes in the past year, we have continued to provide employment services despite elimination of state funds - as well as retaining members who receive other services which Club Nova cannot be reimbursed for (ACTT services) despite the two services' being complementary of each other. While no major changes have occurred, we are always aware the Medicaid state funds could shift without much notice. Agency Information 1/23/2018 1 :58.291 PM P a g e 1 1 o f 3 1 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 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: 10 # of FTE - Paid Part -Time Positions: 4 (these are Y4 time positions) # of Volunteers: 104 # of FTE - Volunteers: 0 g) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes /No) Yes If yes, is this agency an Orange County Living Wage Certified Employer? No If no, please explain. Club Nova Community has strived to give our employees living wages. All our full -time employees are paid above the living wage amount, and in 2017 -2018 we reached our goal of paying our 4 part time employees (114 time) for transportation the living wage set in 2017 of $13.15 per hour. However, with the new Living Wage rate for 2018 we now fall short for those 4 part -time employees. With the low Medicaid reimbursement rates and exclusions of services we cannot be reimbursed for, our budget cannot currently handle another increase to the 2018 Living Wage amount for our part -time transportation staff after a 16% increase for 2017 -2018. We will continue to work to gradually increase wages for all staff, with a goal of increased funding to raise staff wages to a living wage across the board. 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. Club Nova is currently working with Orange County, Town of Carrboro, Town of Chapel Hill regarding financial or in -kind support for Club Nova expansion. If yes, please list below: Include aH programs that have funding requests /awards /totals from Carrboro Chapel Hill, and Orange Count governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FY17 -18 Award FY18 -19 Request Source Ex: Affordable Rental Rehabilitation 0 $20,000 Carrboro - Affordable Housing Ex: Agency Administration $15,000 $15,000 Carrboro — Other Ex. Total $15,000 $35,000 Carrboro Total Funding *Add rows or attach additional page, if needed. Agency Information 1/23/2018 1:58 :29 PM P a g e 1 2 o f 3 1 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION ii. Submit your agency's budget. You may complete the provided template (separate xis file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: Revenues • 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 (CDBG /HOME /etc.) • Private Foundation Grants • Other Revenue Expenditures • Compensation • Rent & Utilities • Supplies & Equipment • Travel & Training • Other Expenses iii. Does your agency budget show a Surplus or Deficit? Yes Is there a significant change? Yes /No No Please provide a brief explanation for Surplus or Deficit, and significant changes. As seen in the budget worksheet, the surplus for actual, estimated and projected are minimal. Last year's actuals had a surplus of $34,951 due to 2 unapplied for grants and 1 unexpected gift.. iv. What is your agency's fiscal year? July 1, 2018 through June 30, 2019 (Example: July 1, 2016 through June 30, 2017) Agency Information 1123/2018 1 :58:29 PM P a g e 1 3 o f 3 11 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: AGENCY REVENUE Private Donations Club Nova Community, Inc 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 /HOM'E /etc.) Private Foundation Grants Other Revenue ' "This budget excludes Capital Campaign revenue Total Agency Revenue AGENCY EXPENSES Compensation Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: Include the following: Payroll taxes, Benefits, Consultinglprofessional Services, Legal Counsel, IT, accreditation and certification, dues and membership 'This budget excludes Capital Campaign revenue Total Agency Expenses SURPLUS/(DEFICIT) FOR PERIOD: FY 2018 -19 Agency Budget $ 34,9511 $ 5,665 1 $ 10,000 1 77% Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Percent Change $ 114,456 $ 115,000 $ 115,000 0% $ 463,598 $ 483,000 $ 483,000 0% $ 13,500 $ 19,000 $ 20,000 5% $ - $ - $ - 0 $ 16,000 $ 19,000 $ 20,000 5% $ - $ - $ - 0 $ 95,000 $ 107,500 $ 120,000 12% $ - $ - $ - 0 $ - $ - $ - 0 $ 44,990.00 $ 11,247.00 $ 10,000.00 $ (0.11) $ - $ - $ - 0 $ - $ - $ - 0 $ 25,000.00 $ 20,000.00 $ 20,000.00 $ - $ 127,647 $ 130,000 $ 130,000 $ - $ $ 900,191 485,080 $ $ 904,747 500,123 $ $ 918,000 506,000 1% 1% $ 35,957 $ 37,000 $ 38,000 3% $ 67,745 $ 70,000 $ 72,000 3% $ 60,333 $ 60,000 $ 62,500 4% $ 216,125 1 $ 231,959 1 $ 229,500 -1 $ 865,240 $ 899,082 $ 908,000 1 1% $ 34,9511 $ 5,665 1 $ 10,000 1 77% DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME: Club Nova Community, Inc. - O.C. Funding for Transportation 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 (CDBGIHOMEletc.) Private Foundation Grants Other Revenue Total Program Revenge PROGRAM EXPENSES Compensation: Drivers, wage increase, and Transport Coordinator Rent & Utilities Supplies & Equipment: Travel & Training Other Expenses: Total Program Exponses Vehicles ExpenseslMaintenance SURPL,USI(DEFICIT) FOR PERIOD: 1 $ (26,741) $ (31,080) $ (36,000) -16% Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Percent Change $ - $ $ 0 $ - $ $ 0 $ $ $ - 0 $ $ - $ - 0 $ - $ - $ - 0 $ $ - $ 0 $ 55,000 $ 62,500 $ 65,000 4% $ - $ - $ - Q $ 0 $ $ $ - 0 $ - $ $ Q $ - $ $ 0 $ - $ - $ Q $ - $ $ - 0 $ 55,000 $ 62,500 $ 65,000 4% $ 50,500 $ 58,580 $ 63,000 8% $ - $ - $ - 0 $ 31,241 $ 35,000 $ 38,000 9% $ - $ - $ 0 $ - $ - $ 0 $ 81,741 $ 93,580 $ 101,000 8% SURPL,USI(DEFICIT) FOR PERIOD: 1 $ (26,741) $ (31,080) $ (36,000) -16% DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Club Nova Community, Inc. - Orange County Funding - PSR Services -ACTT Members 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 (CDBG /HOME /etc.) Private Foundation Grants Revenue: MCO County Allocations i Total Program Revenue PROGRAM EXPENSES Compensation: Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: # of hours at PSR Reim. Rate Total Program Expenses SURPLUS /(DEFICIT) FOR PERIOD: 1 $ (21,596) $ (44,500) $ (49,500) -11 90 Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Percent Change $ - $ - $ - 0 $ - $ - $ - 0. $ - $ - $ 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ 15,000 $ 15,000 $ 17,500 17% $ - $ - $ - 0 $ - $ - $ - 0 - $ - $ - 0 $ - $ - $ _ 0 $ - $ - $ - 0 $ - $ $ - 0 $ 68,000 $ 68,000 $ 68,000 $ - $ $ 83,000 - $ $ 83,000 - $ $ 85,500 3% 0 $ - $ - $ - 0 $ - $ - $ 0 $ - $ - $ - 0 $ 104,596 $ 127,500 $ 135,000 6% $ 104,596 1 $ 127,504 $ 135,000 6% SURPLUS /(DEFICIT) FOR PERIOD: 1 $ (21,596) $ (44,500) $ (49,500) -11 90 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION PROGRAM NAME PROGRAM REVENUE Program Budget Operating Budget for Program Club Nova Community, Inc. - Orange County Funding for Critical Safety Net 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 dill Human Services - Orange County Other - Orange County Other - Town of Hillsborough Other Government Grants Triangle United Way State Government Federal Government (CDBGIHOMEletc.) Private Foundation Grants Other Revenue Total Program Revenue PROGRAM EXPENSES Compensation: Includes Wage Increase Rent & Utilities Supplies & Equipment: Food & Provisions Travel & Training Other Expenses: Total Program Expenses SURPLUSI(DEFICIT) FOR PERIOD: $ (486,170) $ (479,624) $ (496,000) -3% Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Percent Change $ - $ - $ - 0 $ - $ - $ - 0 $ 13,500 $ 19,000 $ 20,000 5 %Q $ - $ - $ - 0 $ 10,000 $ 19,000 $ 20,000 5% $ - $ - $ - 0 $ 10,000 $ 15,000 $ 15,000 0% $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ 0 $ - $ $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ $ 33,500 484,270 $ $ 53,000 495,624 $ $ 55,000 510,500 4% 3 % $ - $ - $ - 0 $ 35,400 $ 37,000 $ 40,500 9% $ - $ - $ - 0 $ - $ - $ - 0 $ 519,67Q $ 532,624 $ 551,000 3% $ (486,170) $ (479,624) $ (496,000) -3% DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Club Nova Community, Inc. - Orange County Funding for Employment PROGRAM REVENUE Private Donations Program Generated Revenue Local Government Grants: Human Services - Town of Carrbora 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 Program Revenue PROGRAM EXPENSES Compensation: salaries, FICA, Fringe Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: Total Program Expenses SURPLUSI(DEFICIT) FOR PERIOD: 1 $ (25,865) $ (34,342) $ (37,500) "I"ll Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 percent Change $ $ - $ - 0 $ - $ - $ _ 0 $ - $ - $ - 0. $ - $ - $ - 0 $ $ - $ - 0 $ - $ _ $ - 0 $ 15,000 $ 20,000 $ 22,500 13% $ - 0 $ - $ - $ - 0 $ $ - $ - 0 $ - $ - $ - 0 $ - $ - $ _ D $ - $ - $ - 0 $ - $ - $ - 0 $ $ 15,000 40,865 $ $ 20,000 54,342 $ $ 22,500 60,000 13% 10% $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ 40,865 $ 54,342 $ 60,000 10% SURPLUSI(DEFICIT) FOR PERIOD: 1 $ (25,865) $ (34,342) $ (37,500) "I"ll DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Club Nova Program Primary Contact and Title: Steven Warnock, Associate Director of Program Telephone Number: 919- 968 -6682 E -Mail: admin(@,clubnova.org a) Indicate the type of Human Service Needs Priority, if program applicable: M 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) * *Club Nova works with adults 78+ who live with serious mental illness. 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. Mental health Care Services- Club Nova Community, Inc. coordinates its' services with other agencies involved with our members. For example, some of our members receive outpatient services from the UNC Center for Excellence in Mental Health. When members and staff create their person centered plan, we include the psychiatrist and therapist's input in the plan. The psychiatrist will sign the Person Centered Plan for our service order, meaning the psychiatrist agrees that our services are needed. We maintain periodic contact to review progress and to exchange any needed information. Some of our partners include: ■ UNC Center for Excellence in Mental Health, including Assertive Community Treatment Team (ACTT), STEP, and Oasis UNC Department of Psychiatry and Walk -In Clinic PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 1 4 o f 31 Public Housing Program Category Youth Adult Elderly Disabled Neighborhoods /Residents Affordable Housing X Affordable Healthcare X Education X Family Resources Jobs /Jobs Training X Food X Transportation X Other: Please specify Crisis Prevention and Intervention - Outreach - Benefits and Entitlements -Supported Housing X * *Club Nova works with adults 78+ who live with serious mental illness. 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. Mental health Care Services- Club Nova Community, Inc. coordinates its' services with other agencies involved with our members. For example, some of our members receive outpatient services from the UNC Center for Excellence in Mental Health. When members and staff create their person centered plan, we include the psychiatrist and therapist's input in the plan. The psychiatrist will sign the Person Centered Plan for our service order, meaning the psychiatrist agrees that our services are needed. We maintain periodic contact to review progress and to exchange any needed information. Some of our partners include: ■ UNC Center for Excellence in Mental Health, including Assertive Community Treatment Team (ACTT), STEP, and Oasis UNC Department of Psychiatry and Walk -In Clinic PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 1 4 o f 31 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION • Lutheran Family Services — (ACTT) • Referring Organizations and Agencies • Private Psychiatrists • Community Resource Court • Freedom House • Crisis Prevention and Intervention Work - CNCI staff maintain contact with the following agencies when a member is in crisis and needs to be evaluated for harm to self or others and /or checked on if the member has not been seen or heard from in a couple of days. Some of these partners include: • UNC Emergency Department • Freedom House • UNC On -Call Psychiatry • Carrboro and Chapel Hill Police Departments — Wellness Checks are highly effective • County Sheriff's Department • Chapel Hill Police Department Crisis Unit i Lutheran Family Services, XDS and other ACT Teams — intense collaboration especially during crisis. • Primary and Other Health Care - CNCI staff assist members in obtaining quality health care. With the life expectancy of people living with serious mental illness being 25 years shorter than the general population, it is critical that our members receive quality health care. We may help coordinate the care needed and accompany members to medical appointments to provide a support person to help listen, help provide information and ask questions, process the information for decision making, and provide support during the decision making process. Numerous members have faced life threatening diseases and have had to make difficult decisions. Providing emotional support is imperative. Staff will attend appointments and communicate with the providers as needed. Some of these partners include: • Physicians (Primary Care, Specialists) • Piedmont Health Services • UNC Healthcare • Emergency Department • UNC Family Medicine • Cancer Hospital • Department of Psychiatry • UNC Center of Excellence • Neurosciences Hospital • UNC Dental School • SHAC (UNC - Student Health Action Coalition) ■ Other Private Providers • Food Access and Healthy Living - The partnerships held by Culinary Program at CNCI highlight the power of community partners: we are able to offer our members nearly 1000 affordable, nutritious, and tasty plates each month through relationships with local food organizations. Some of these partners include: ■ Farmer Foodshare Donations Station and POP Market PROGRAM INFORMATION 1/23/2018 1:58:29 PM P a g e 1 5 o f 3 1 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION • Chapel Hill Farmers' Market • Carrboro Farmers' Market • Orange County Solid Waste - Composting • Sysco and Ecolab • Housing - CNCI assists members in locating, securing, and maintaining safe, dignified, affordable housing. We collaborate with group homes and CASA to support our members and advocate as needed if a member's residency is in jeopardy. Some of these partners include: • CASA (Manages Club Nova apartments) • Interfaith Council • Alberta Services — Homestead Place and Booth Road (Group Homes) • New Destinations - Hillsborough (Group Horne) • Overlook Apartments • Orange County Housing Authority • Empowerment • Landlords • Securing Other Benefits and Entitlements - CNCI assists members with securing benefits and entitlements such as applying for Medicaid, Medicare, & Social Security. All of these applications and re- certifications can be overwhelming. Some of these partners include: • Orange County Department of Social Services — Medicaid and SNAP • Social Security Administration • Veterans Administration • Partnerships with Local Business Community — CNCI has an employment program that helps members return to paid work at local businesses in the community. Our employment program helps members move toward economic stability and independence. Our local business partners in our Transitional Employment Program include: • Town of Carrboro • Cafe Driade • Open Eye Cafe • National Mail Service • Tarheel Lodging II LLC (Hampton Inn) • Supported Education — We assist members in their educational pursuits through our Supported Employment. As examples, we offer assistance with application process and getting connected with the Disabilities Office. Some of these partners include: • Durham Tech • Central Carolina Community College • University of North Carolina • Alamance Community College • Job Link • Orange County Literacy Council • Community Empowerment Fund PROGRAM INFORMATION 1/23/2018 1:58:29 PM P a g e 1 6 o f 3 1 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION m Academic and Community Education Partnerships - We partner with students and community members to educate the public and future mental health providers about living with mental illness, the mental health system, the Clubhouse Model and dismantling stigma. We have an ongoing relationship with the University of North Carolina and are part of the academic curriculum for numerous departments, hosting many interns throughout the year at the Clubhouse. This relationship is beneficial to the students who gain relevant and meaningful experiences to facilitate their classroom learning as well as to our members who are social practitioners imparting knowledge to students and develop positive relationships. We also speak to civic and community organizations. Some of these partners include: ■ University of North Carolina • Occupational Science and Occupational Therapy • School of Nursing • School of Medicine • Psychology • Dental School o School of Social Work • School of Public health • School of Journalism • School of Pharmacy • Allied health — Rehabilitation Counseling • UNC Student Affairs ■ North Carolina State University o School of Social Work (Masters and Bachelors Programs) ■ East Carolina University o Occupational Therapy ■ Community Education Partnerships/ Collaborations • Crisis Intervention Training— CIT • Police Academy • The Johnson Service Corp • Faith based communities o Civic Groups o Orange County, Chapel Hill, Carrboro High Schools o Local Business Community — Over 50 Contacts for Job Development ■ Research • University of Massachusetts School of Medicine • University of North Carolina • Veterans Administration (VA) • Clubhouse International Advocacy Partnerships- CNCI works to raise awareness about the needs of individuals navigating the mental health system on a local, state, and national policy level. By partnering with others we create a unified voice for change. Some of these partners include: PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 17 of 3'1 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION • North Carolina Clubhouse Coalition (NCCC) • United States Clubhouse Coalition • Clubhouse International • Caramore Community, Inc. • Josh's Hope Foundation • Alberta Services • Threshold • NAMI -NC • Annual Legislative Breakfast on Mental Health • NC Council of Community Programs • State Consumer Family Advisory Council (CFAC) ■ Seymour Center • Local, State, and Federal Government — CNCI works with various local, state and Federal entities to advocate for positive changes in the rules, regulations and treatment of persons living with mental illness. Some of these partners include: • Orange County, Town of Chapel Hill, Town of Carrboro, Town of Hillsborough • North Carolina General Assembly • US Congressional Offices • Managed Care Organizations (MCOs) — Cardinal and Alliance • Centers for Medicare and Medicaid (CMS) • NC Department of Health and Human Services including Division of Mental Health and Division of Medical Assistance • Social Engagement —CNCI works with various private and public funded entities in the arts and entertainment community to help provide social activities that enable positive engagements to people living with mental illness, and provide a means to reduce isolation and interact with others in the greater community. Some of these partners include: UNC Athletic Department ■ Ackland Art Museum ■ UNC Planetarium ■ Transactors Improv ■ Carrboro ArtsCenter ■ Carrboro Music Festival Carrboro Film Festival ■ NC Museum of History ■ NC Museum of Natural Sciences ■ Raleigh Little Theater ■ UNC Playmakers ■ Tarheel Lodging II LLC (Hampton Inn) ■ NC Theatre ■ North Carolina Museum of Art ■ Nasher Art Museum ■ Piedmont Farm • INC Botanical Gardens ■ Eno River Festival PROGRAM INFORMATION 1/23/2018 1:58:29 PM P a g e 18 of 3 1 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION ■ North Carolina Zoo ■ American Dance Festival ■ Hog Day /Hillsborough ■ Cedar Creek Gallery 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? Priorities Addressed by Club Nova: Critical Safety Net, Health and Nutrition, and Quality of Life The Clubhouse Model is one of the most comprehensive, integrated programs in the United States offering persons with mental illness access to the supports and opportunities needed to rebuild their lives. Club Nova addresses the risks of mental illness while providing supports and opportunities to live meaningful lives of one's choice in the community. Specifically, we provide the following: Community Support • Assistance in accessing and navigating quality healthcare. Addresses shorter life expectancy and serious health problems. Housing supports to secure and maintain safe, affordable, dignified housing. Averts homelessness. 100 % of Club Nova members maintained housing in 2017. • Crisis prevention and intervention. Saves lives and avoids costly ER and hospitalization costs. • Assistance in securing and maintaining benefits and entitlements. Provides more economic security. • Health and wellness with nutritious, affordable meals that are prepared by members and staff. Addresses hunger and helps mitigate health problems. • Outreach. Combats isolation and reduces risk of crisis, ER visits, and hospitalization. • Transportation. Essential in members accessing Club Nova and the full range of opportunities and supports. • Employment. Addresses high unemployment for our members and increases economic security. • Supported Education. Addresses education that has been interrupted by mental illness. • Work Ordered Day. Provides a sense of community, common purpose, and opportunities to contribute. Builds confidence, self- worth, and skills. • Evening /Weekend /Holiday Program. Addresses isolation and social connectedness. 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. Orange County Board of County Commissioners: Supporting affordable housing; providing affordable and healthy meals; providing transportation to low income residents living with mental illness especially those unable to access public transportation; bridging the gaps in quality of aging and mental health; connecting students to community colleges; partnering with local civic organizations, local governments, local businesses, and other support services; creating a safe community and reducing stigma and social inequity; creating employment opportunities for those living with mental illness. Town of Chapel Hill Town Council: Supporting affordable housing and healthcare; Jobs and jobs training, and education supports; Affordable and healthy food options; Increased access to services through PROGRAM INFORMATION 1/23/2018 1 :58:29 PM Page 19 of 31 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION coordination and communication; Increased community engagement. Town of Carrboro Board of Aldermen: Enhance and sustain quality of life /place for everyone. Maintain Carrboro's unique identity. Help develop a human environment that promotes trust, mutual respect, acceptance, happiness and well- being. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? Club Nova works with Orange County adults living with serious mental illness (SMI), primarily schizophrenia and bipolar disorder. All members are beneficiaries. Beneficiaries are identified through outreach, community education, other providers and organizations, families, and members of the community. Our referral process ensures that Club Nova is preserved for the intended beneficiaries — adults living with serious mental illness. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) All staff must have the following trainings in order to maintain our Mental Health License, be accredited by CARF, and in order to bill for Medicaid services: • CPR and First Aid — Annually • Client Rights • Confidentiality • HIPAA • Infectious Diseases and Bloodborne Pathogens • Alternatives to Restrictive Intervention and Crisis Management The following are our kev staff related to the program and their credentials: Karen Kincaid Dunn, Executive Director, BA, QP, 30+ years of direct mental health experience working with individuals living with serious mental illness through work at John Umstead Hospital and Club Nova. Club Nova Director for 24 years with 11 years in non-profit leadership' Steven Warnock, Associate Director of Program, M.Div., QP, 12 years of direct mental health experience and 21 years of non- profit programming and leadership. Marsha Pate, Associate Director of Community Relations, MEd, QP, 6 years of direct mental health experience, plus 30 years of non-profit programming and leadership Peter Mazzei, Coordinator of Membership, MSW, QP, 9 years director mental health experience and leadership. Sadie Brooks, Associate Director of Administration, 4 years direct mental health experience and 18 years administrative operations. Volunteers go through a Club Nova orientation, and are trained directly by an Associate Director and members. They are required to have confidentiality and Clubhouse Model trainings. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. Implementation Timeline: Club Nova has been fully operational for 30 years. • We are open six days per week and all major holidays on the holiday. We are open 55 + hours per week. • Community Supports are provided on a daily, ongoing, and as needed basis. • Nutritious, Affordable Meals: 5 Breakfasts (Mon -Fri), 6 Lunches (Mon -Sat), 2 Dinners (Mon & Thurs), Holiday Meals. Serve 12,000 + meals annually. Members are involved in planning and preparation. • Employment, Supported Education, and Outreach are provided on a daily, ongoing basis. • Transportation: Operates two routes a day (morning and evening) Mon -Sat and major holidays. • Work Ordered Day operates Mon -Fri 8 AM -6 PM and Sat 10 AM -5 PM. PROGRAM INFORMATION 1123/2018 1:58:29 PM Page 20 of 31 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION -Evening, Weekend, Holiday Program is provided on Thurs 4 PM -8 PM and Sat typically from 11 AM - 4 PM. Holiday hours vary depending on the holiday. We are typically open 5 hours on holidays. i) Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) The lesson that is repeatedly reaffirmed is that relationships, inclusion, and opportunities are interwoven with and at the heart of a healthy community. Club Nova can serve a member for an entire year, for what it cost for less than a week in the hospital. There is a positive impact on alleviating human suffering that people with mental illness are at risk for such as suicide, homelessness, incarceration hospitalization and isolation Evidence substantiates the fact that clubhouses provide communities with a cost effective solution for dealing with the devastating impact that mental illness has on society, and for helping people living with serious mental illness achieve their full potential in their communities. As we attempt to affirm what we know from our moral principles – that we are all in this together and if anybody is diminished, if anybody is left behind, if anybody is marginalized, then we are all diminished —I hope we can commit to making that something we live by. It is something Club Nova embodies every day." -- NC Congressman David Price j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. We are filling a critical need in our community that would otherwise go unmet. Club Nova requires a healthy blend of public and private dollars. We are in need of more robust local funding given the challenges in the NC Mental Health System. Without county and municipal funds, Club Nova would have to lay off staff and reduce the number of members accepted and served which would cause our program and members to suffer. North Carolina has one of the lowest reimbursement rates for Clubhouses of any other state in the nation. In a national survey conducted by the University of Massachusetts School of Medicine, representing 30 states, the average hourly reimbursement rate is $23.96 per hour. Our current hourly reimbursement rate is $13.36. With the continuing changes in mental health, Club Nova has stepped up to meet more of the critical needs of members that historically other services were available to help support. Additionally, services we used to be reimbursed for have been eliminated or now have exclusions that result in Club Nova providing in excess of $100,000 in services that are not reimbursed. This amount does not include the elimination of state funding for our Employment Program. Our Employment Program with job development, job training, and ongoing support is an essential facet of Club Nova. k) What percentage of your target population is low- moderate income? 100% of our target population are low- moderate income. 1) What efforts do you make to seek feedback about your program from your target population (e.g. survey, evaluations, etc. ?) We conduct annual surveys with our membership. We also have weekly House Meetings where all members and staff discuss the happenings of Club Nova and are provided an opportunity for feedback about our program. m) Include any other pertinent information. PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 2 1 of 3 1 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program 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, I Program Target Population Demographics I Gender Male Female Total Ethnicity African- American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Other: specify Middle Eastern Total Of the above, how many Hispanic /Latino Of the above, how many non - Hispanic /Latino Total Age 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) Actual Estimated Projected 2016 -17 2017 -18 2018 -19 79 86 94 33 39 47 112 125 141 21 30 38 0 0 0 1 2 3 89 91 97 0 0 0 1 2 3 112 125 141 6 8 10 106 117 131 112 125 141 0 0 0 0 1 1 63 68 72 49 56 68 112 1 125 141 0 0 0 8 10 10 3 3 3 0 0 0 14 11 15 32 29 35 43 62 67 11 8 9 1 2 2 0 0 0 Total 1 112 125 1 141 PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 22 of 3 1 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement 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 (�jpecific, 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 elderlyldisabled 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 Club Nova Community, Inc. 1. Program Activity Name Club Nova offers a round trip ride for members throughout Orange County six days a week, and on holidays. Transportation is offered with no out -of- pocket charge to members. Club Nova's transportation service ensures each member has equal access to all of our opportunities. Club Nova transportation serves members who live in areas not accessible to public transportation or are unable to utilize the bus system for various reasons (including symptoms related to diagnoses like paranoia) and need viable transportation to Club Nova. Club Nova transportation staff receives necessary training and certification. Staff maintains vehicles. Program Goal Club Nova will maintain a full transportation program that employs and trains 100% of a team of drivers, maintains its vehicles, and provides our membership with approximately 65,000 miles of transportation to and from Club Nova (plus socials and occasional medical appointments) throughout Orange County six days a week and on all major holidays. Performance Measures Club Nova will: • Maintain logs in each vehicle to track ridership and mileage for all trips • Maintain vehicle logs, tracking overall mileage and gas expenditures • Document of certification of all trainings received by drivers (in CPR, AED, 1st Aid, Blood Borne Pathogens, etc.) • Maintain log of social and community events attended by Club Nova members through Club Nova transportation Previous Year Program Results Club Nova provided 64,456 miles of unreimbursed transportation services to members, • 100% of members had access to our transportation services and therefore had access to the rest of our services. (0% were unable to participate due to lack of transportation.) • 80% of Club Nova members utilized transportation opportunities, PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 23 of 3 1 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 24 of 3 1 • 100% of drivers attended all needed trainings. • Transportation continued to facilitate enhanced engagement by members in the larger community. Current Year Estimated Results Club Nova will provide approximately 66,000 miles of unreimbursed transportation services to members. • 100% of members will have access to our transportation services and therefore have access to the rest of our services. (0% will be unable to participate due to lack of transportation.) • 80% of Club Nova members will utilize transportation opportunities. • 100% of drivers will attend all needed trainings. * Transportation will continue to facilitate enhanced engagement by members in the larger community. • All drivers will receive a 2017 "living wage" of at least $13.15 per hour Next Year Projected Results Club Nova will provide approximately 68,000 miles of unreimbursed transportation services to members. • 100% of members will have access to our transportation services and therefore have access to the rest of our services. (0% will be unable to participate due to lack of transportation.) • 80% of Club Nova members will utilize transportation opportunities. • 100% of drivers will attend all needed trainings. • Transportation will continue to facilitate enhanced engagement by members in the larger community. 2. Program Activity Name Club Nova offers the spectrum of services to ACTT members regardless of our ability to receive payment for these services, due to ACTTfPSR exclusion, which amounts to roughly $120,000 annually. Club Nova actively collaborates with the ACTT providers to coordinate care and ensure the health and safety support of these members. Program Goal 22 current members who receive Assertive Community Treatment Team (ACTT) non - billable services (typically those members that experience the most disabling effects of mental illness) will continue to receive full access to the supports and opportunities provided by Club Nova. Performance Measures Club Nova will: • Monitor our provision of services to ACTT members through calculating monthly participation and attendance hours. • Write monthly service notes on each member receiving ACTT services. Previous Year Program Results 100% of Club Nova members who received ACTT services, maintained their Club Nova membership, and received supports and services provided through Club Nova. Current Year Estimated Results 100% of Club Nova members who receive ACTT services will maintain their Club Nova membership, and receive supports and services provided through Club Nova. Next Year Projected Results 100% of Club Nova members who receive ACTT services will maintain their Club Nova membership, and receive supports and services provided through Club Nova, . 3. Program Activity Name Club Nova builds relationships with businesses throughout the county, resulting in structured Transitional Employment (TE) sites. We provide on -site training and support, absence coverage, job skill development, transportation to and from, and ongoing communication with the employers. Club Nova also assists with skill- building and educational opportunities, PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 24 of 3 1 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION PROGRAM INFORMATION 1/23/2018 1 :58 :29 PM Page 25 of 31 resume writing, benefit counseling and goal -- planning. We hold a weekly employment support meeting with employment staff to go over goals, progress and skills. Program Goal 30 Club Nova members will return to paid employment in the community through our Transitional (TE) and Supported Employment (SE) Programs. Performance Measures Club Nova will: • Maintain logs of member participation in employment programs • Maintain logs of members attending weekly Employment meetings -Maintain logs of the number of TE & SE sites available through Club Nova Previous Year Program Results 100% of Club Nova members had access to our TE and S£ services, as well as, educational and /or job skills opportunities. 32 members returned to paid employment through these supports. These services led to the following outcomes: • Increased financial stability & independence • Increased self- esteem • Reduced community stigma « Increased member civic engagement Current Year Estimated Results 100% of Club Nova members will have access to our TE and SE services, as well as, educational and /or job skills opportunities. An estimated 32 members will return to paid employment through these supports. These services will lead to the following outcomes: • increased financial stability & independence • Increased self - esteem • Reduced community stigma • Increased member civic engagement Next Year Projected Results 100% of Club Nova members will have access to our TE and SE services, as well as, educational and /or job skills opportunities. A projected 35 members will return to paid employment through these supports. These services will lead to the following outcomes: • Increased financial stability & independence • Increased self- esteem • Reduced community stigma • Increased member civic engagement 4. Program Activity Name Club Nova provides high - quality programming related to housing, employment, wellness and social engagement to members living in Orange County and the townships within. Club Nova maintains necessary staff to execute programming. Program Goal Club Nova will operate six days a week, 54 -60 hours per week and on all major holidays, to provide our members the full range of programming and safety -net services, such as housing support, crisis prevention and intervention, and access to healthcare, inherent in a Clubhouse Model. Club Nova will: -Ensure housing supports to secure and maintain safe, affordable, dignified housing for members, and to avert homelessness. • Provide crisis prevention and intervention to save lives and avoid costly ER and hospitalization costs. • Assist in accessing and navigating quality healthcare, including access to primary care. Performance Measures Data on our general operating costs are maintained in our financial books. We will track costs of utilities, payroll, and other daily supplies via receipts and Quickbooks to reflect the basic expenses of Clubhouse programming. We will keep record of all paper invoices /receipts. PROGRAM INFORMATION 1/23/2018 1 :58 :29 PM Page 25 of 31 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 26 of 3 1 Club Nova will keep records and statistics via our member database and progress notes. Club Nova will: • Track the housing security of membership • Track hospitalization and re- hospitalization of members • Survey members, yearly, on housing security, hospitalization, access to healthcare including primary care, dentistry, and supportive care. Previous Year Program Results Club Nova was open 6 days a week, 54 -60 hours per week, and had the necessary assistance to pay the cost of utility bills, staff compensation and benefits (including payroll taxes and insurance), and necessary programming supplies and training. The following are results for the year: 90% of Club Nova members will report having safe, secure, and affordable housing, with 0% homelessness. 87% of Club Nova members will report no re- hospitalization due to psychiatric concerns. 100% of Club Nova members will report access to healthcare with 50% reporting access to primary care. Current Year Estimated Results Club Nova will remain open 6 days a week, 54 -60 hours per week, and will have the necessary assistance to pay the cost of utility bills, staff compensation and benefits (including payroll taxes and insurance ), and necessary programming supplies and training. The following are estimated for the year: 92% of Club Nova members will report having safe, secure, and affordable housing, with 0% homelessness. 81% of Club Nava members will report no re- hospitalization due to psychiatric concerns. 100% of Club Nova members will report access to healthcare with 60% reporting access to primary care. Next Year Projected Results Club Nova will remain open 6 days a week, 54 -60 hours per week, and will have the necessary assistance to pay the cost of utility bills, staff compensation and benefits (including payroll taxes and insurance), and necessary programming supplies and training. The following are projected for the year: 95% of Club Nova members will report having safe, secure, and affordable housing, with 0% homelessness. 87% of Club Nova members will report no re- hospitalization due to psychiatric concerns. 100% of Club Nova members will report access to healthcare with 60% reporting access to primary care. 5. Program Activity Name Club Nova partners with local food organizations to secure approximately 750 pounds of fresh, local produce and meat monthly. Members and staff cook from scratch and address individual dietary needs in our meals. Club Nova members and staff prepare and serve 13 meals per week. Members are be given opportunities to engage in every step of the process, including menu planning, grocery shopping, cooking and cleaning. Club Nova uses its garden as an educational and wellness activity and engages community experts for workshops and trainings related to wellness. Staff work closely with members who have individual goals specifically related to healthy eating and increased wellness to ensure they have the supports needed. PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 26 of 3 1 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Program Goal Club Nova will address food insecurity and diet related disease by providing at least 12,000 healthy, affordable meals, engaging at least 80`Y of membership in Clubhouse meals, and providing education and training related to cooking, nutrition, obtaining and growing food. Performance Measures Club Nova will: • Maintain records of the number of meals served daily. • Maintain daily records of individuals eating at the Clubhouse. • Survey its membership yearly to evaluate the achieved health and food security benefits of our healthy, affordable meal program and nutrition education. • Staff will closely monitor specific individuals' wellness goals through progress notes. Previous Year Program Results 100% of Club Nova members had access to an average of 13 healthy, well- balanced meals each week (5 breakfasts, 6 lunches and 2 dinners), with 12,015 meals served for the year. 85% of Club Nova members participated in meals. This service led to: • Decreased food insecurity for members • increased knowledge of culinary skills, nutrition, and gardening • Increased knowledge in the health benefits related to a healthy diet • Decreased incidence of nutrition - related diseases Current Year Estimated Results 100% of Club Nova members will have access to an average of 13 healthy, well- balanced meals each week (5 breakfasts, 6 lunches and 2 dinners), with an estimated 12,100 meals served for the year. An estimated 85% of Club Nova members will participate in meals. This service will lead to: • Decrease in food insecurity for members • Increase in knowledge of culinary skills, nutrition, and gardening • Increase in knowledge in the health benefits related to a healthy diet • Decrease in incidence of nutrition- related diseases Next Year Projected Results 100% of Club Nova members will have access to an average of 13 healthy, well- balanced meals each week (5 breakfasts, 6 lunches and 2 dinners), with 12,200 meals served for the year. At least 85% of Club Nova members will participate in meals. This service will lead to: • Decrease in food insecurity for members • Increase in knowledge of culinary skills, nutrition, and gardening • Increase in knowledge in the health benefits related to a healthy diet • Decrease in incidence of nutrition- related diseases PROGRAM INFORMATION 1/23/2018 1:58:29 PM P a g e 2 7 of 3 1 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION p) Program Budget 1. 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). 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 • Focal 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 (CDBGfHOMEfetc.) • Private Foundation Grants • Other Revenue Expenditures o Compensation o Rent & Utilities • Supplies & Equipment • Travel & Training • Other Expenses 2. Program Budget Detail — Provide description of "other" budget items, not defined. 3. This program budget represents what percent of the agency budget? 100% 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. PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 28 of 31 Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Total Cost of Program $865,240 $899,082 $908,000 Total # of Individuals 112 125 141 Cost Per Individual $7,725 $7,192 $6,439 PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 28 of 31 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 Nii 1.`117 l': Scope of Services FY 2018 -19 Outside Agency Performance Agreement Agency Name: Club Nova Community, hie Program Name: Club Nova Community, Inc Funding Award: $16,250 )utline how the agency will spend Orange County's funding award. Expense Description Amount Transportation (fuel, travel, etc) $16,250 Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2018. o Members Receiving ACTT Services: Provide opportunities and support to our members who are also receiving Assertive Community Treatment Team services. Employment: Continue to support and assist members who desire to return to paid employment in the community. The Transitional and Supported Employment Programs will maintain and strive to increase the number of placements available to members and the number of members who work in the community. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons /units served within Orange County, only (all Towns and municipalities). if you use percentages, you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results Club Nova Drivers will be trained in CPR /15tAid, APD, NCI -A 4 Drivers Club Nova maintains its vehicles, and provides our membership with transportation to and from Club Nova (plus socials and occasional medical appointments) throughout Orange County six days a week and on all major holidays. 80,000 Miles Docusigned by: Anal, Vl AJA, Executive Director 8/27/2018 04AC92782B5F403... Certified by: Title: Date: . (Providers Signature) DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 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. Docu5ign d by: 611. VWAJA, Certified by: _ 04AC9278265F493... _ (Provider's Signature) Title: Executive Director Date: 8/27/2018 (Club Nova Community, Inc.) Orange County Outside Agency Performance Agreement Page 9 of 9 Rev. 7118 DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973DO39 OP 1D: KR DATE IMMIDDIYYYYi CERTIFICATE OF LIABILITY INSURANCE 06/2612018 THIS CERTIFICATE I5 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS ER THE COVERAGE AFFORDED BY THE POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALT 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). HTA T PRODUCER HA E: Kim Rhodes CITIZENS INSURANCE AGENCY PHONE e� 262-492 -4061 iuc NO: P 0 BOX 109 a MA L HENDERSON, NC 27536 ADDRESS: kirn�ncagent.cam W PRODUCER_, CLUBN -2 nus9 Account/Joel T. Cheatham ,, INSURED Club Nava Community, lr P.O. Box 1345 Carrboro, NC 278104346 CO 3VERAGES %,CM I Imam I c nuniw� .-- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD T TO WHICH THIS INDICATED. NOTWITHSTANDING ANY REOUIREMENT, TERM oft CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPEC CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, e—%i , ,a,n,,ec eun rrlummnN.r, nF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- IiT� TYPHOFINSURANCE FACH OC%fJJUR S RFNERAL WBILrrY 07101/2018 0710112019 A X COMMERCIAL GENERAL LIABILITY P'' X I CLAIMS -MADE 0 OCCUR S x Retro 5113106 PERSONRY S GEN'L AGGREGATE LIMITAPPLIES PER GENE- AE S X POLICY Q PRO LOC AUTOMOBILE LIABILITY PRODUCAGG S 3 B X ANY AUTO F S ALL OWNED AUTOS COMBINED SINGLE LIMIT 5CHEOULEO AUTOS HP K1642347 0710112016 0710112019 X H €RED AUTOS S F B X NGN- OWNEDAUTOS BODILYINJURY(Peraxidonll S 1 UMBRELLA LU+B OCCUR PROPERTY DAMAGE S HPK1842347 EXCESS LtAe CLAIMS M4OE 0710`112018 (PERACCIDElrr) oVOUCT1BL6 HPK1842347 071o112o1B 07101/2019 MedPay RETENTION WORKERS COMPENSATION s _ AND EMPLOYERS' UABILM YIN ANY pROPRMTOR1PARTHER/BXECUT\!£ r } N 1 A OFFICERtMEMBER EXCLUDED? {Mandatary le NHI Iles , descnAe under DCRIPTION OF OPERATIONS below A Professional Liab. Claims Made RETRO 5113106 DESCRIPTION OF OPERATIONS! LeCA110N8 r VEHIOLBS (AtUch ACORD 101, AddWanal R11rd4*6 Bahrdult, It man coca +la nqulnd) I E L DISEASE - EA EMPLOYEE) S 3,00 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 13E DELIVERED IN Orange County ACCORDANCE WITH THE POLICY PROVISIONS. 200 S Cameron St Hillsbarough, NC 27278 Au O R6PR98%y�ATIYE Buse counU oat T. Cheatham E d 1988.2005 ACORD COftpeMTION. All rights reserved. ACORD 26 (2009108), The ACORD name and logo are registered marks of ACORD FACH OC%fJJUR S 4PK1842347 07101/2018 0710112019 PREMISEee S MED E XP on) S PERSONRY S GENE- AE S PRODUCAGG S 3 S COMBINED SINGLE LIMIT S HP K1642347 0710112016 0710112019 IEa eccidenl ) BODILY INJURY (Per parson) S BODILYINJURY(Peraxidonll S PROPERTY DAMAGE S HPK1842347 0710112018 0710`112018 (PERACCIDElrr) HPK1842347 071o112o1B 07101/2019 MedPay S UM1U1141 s _ Claims Made RETRO 5113106 DESCRIPTION OF OPERATIONS! LeCA110N8 r VEHIOLBS (AtUch ACORD 101, AddWanal R11rd4*6 Bahrdult, It man coca +la nqulnd) I E L DISEASE - EA EMPLOYEE) S 3,00 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 13E DELIVERED IN Orange County ACCORDANCE WITH THE POLICY PROVISIONS. 200 S Cameron St Hillsbarough, NC 27278 Au O R6PR98%y�ATIYE Buse counU oat T. Cheatham E d 1988.2005 ACORD COftpeMTION. All rights reserved. ACORD 26 (2009108), The ACORD name and logo are registered marks of ACORD