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HomeMy WebLinkAbout2018-637-E Finance - Youth Community Project outside agency agreement DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT,made and entered into the first day of July 2017, ("Effective Date")by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ("County") and Youth Community Project, a not-for-profit corporation, located at 179 East Franklin Street, Chapel Hill,NC 27514("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need,as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth,the County and Youth Community Project agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2017 to June 30, 2018. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit "A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit B, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 7038 b. All funds appropriated shall be used for purposes described in Exhibit B. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of 1759.5. 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. (Youth Community Project) Orange County Outside Agency Performance Agreement Revised 712017 Page I of 7 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 —December 31; January 1 —March 31 and April 1 -June 30. Reports are due on January 12,April 13, and July 13 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services,upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as "default"), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance,incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider,the county may elect to terminate this Agreement,in whole or in part and/or require the Provider to repay the funds within ten(10)business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. (Youth Community Project) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7117 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker's Compensation. For protection from claims under workers'or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury,including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance,including hired and non-owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury,bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents,consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE • Worker's Compensation Limits for Coverage A-Statutory State NC&Coverage B -Employers Liability $500,000 each accident, disease policy limit and disease each employee • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $500,000 Combined Single Limit • Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability)required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough,NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. (Youth Community Project) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7117 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. 11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 12. Non-Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. 13. Non-Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves,their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender,national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee,no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Non-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. 14. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County's living wage is $ 13.75 per hour. To the extent possible, Orange County recommends that Youth Community Project 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: (Youth Community Project) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7117 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 County: Finance&Administrative Services Provider: Youth Community Project Orange County 179 East Franklin Street Post Office Box 8181 Chapel Hill,NC 27514 Hillsborough,NC 27278 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part,term or provision held to be invalid. 18. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php). Any violation of this requirement is a breach of the Agreement and County may immediately terminate this Agreement without further obligation on part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 19. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For DocuSignd by: Provider �04 d�.GG Sf6Vu 1/22/2018 DIMDADMADUD9... Date (Youth Community Project) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7117 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 For an ' oocusignedby'. inty Government Rm&t(,^ 2/12/2018 0�3799d6755E477 Bonnie Hammersley, County Manager Date (Youth Community Project) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7117 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FY 2017-2018 Outside Agency Funding Application HUMAN SERVICES • ORANGE COUNTY • TOWN OF CARRBORO • TOWN OF CHAPEL HILL Orange County (OC) Town of Carrboro (CA) Town of Chapel Hill (CH) 200 S. Cameron Street 301 W. Main Street 405 Martin Luther King, Jr. Blvd. Hillsborough, NC 27278 Carrboro, NC 27510 Chapel Hill, NC 27514 �Lk,a ' �a�¢� ��pF CAR��Q • • 44? DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION INFORMATION Each year, Orange County Government, the Town of Carrboro and the Town of Chapel Hill invite program funding requests from non-profit providers that support the delivery of vital community services. The application process is very competitive and not all applicants will be awarded funding. Recommendations for funding may be for an award amount less than that requested by the applicant. Agencies that are currently receiving funds from Orange County, the Town of Carrboro, or the Town of Chapel Hill local governments, and are also applying for new funds, must be in compliance with all terms of their current agreement(s) and must not have any outstanding audit findings, monitoring findings or concerns as determined by the municipality. Recipients are required to submit written progress reports on their SMART Measures that include: goals, description of activities/challenges, revisions of timelines/budgets, and other relevant information Funded projects will be monitored for progress and performance, financial and administrative management, and compliance with the terms of Performance/Development Agreement(s). Monitoring may involve site and/or office visit(s). Once applications are received, they are reviewed by staff for completeness and eligibility. The applications are presented to a specific application review group, depending on the funding source. The review group will make a recommendation, based on available funding and the priorities identified by the participating jurisdiction. The recommendation is presented to the appropriate Board/Council for consideration and approval. The Board/Council approves/adopts the final allocations. TIMELINE November 15 Funding Application Posted on Websites November 29 Funding Application Workshop Held October 18-January 23 Agency Prepares Application January 10 Q&A Session Held January 31 Application Submissions are Due March - May Application Review & Agency Presentations June Agency Funding Approval by Board/Council July Contracts Executed & Programs Begin DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 2 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION SUBMITTAL INFORMATION Welcome to the Outside Agency Common Funding application for local/general funds, which will be distributed through this competitive application process. All entities or organizations requesting funds must complete and submit this application prior to the deadline to be considered for FY 2017-2018 funding. The Application Submittal Deadline is: Tuesday, January 31, 2017 5:00 PM In the event of inclement weather, check the website for each Town/County you are applying to, for further instructions. Please note that late, handwritten, or incomplete applications will not be accepted. (Applications not signed by the Chair or President of the Board of Directors, are considered incomplete.) An application orientation workshop will tentatively be held on Tuesday, November 29, 2016 at 9 AM to Noon to review the application and submittal requirements. SUBMITTAL REQUIREMENTS FOR EACH MUNICIPALITY Human Services— Town Of Carrboro Applications are accepted once a year and reviewed by the Town's Human Services Advisory Commission, which makes a recommendation for funding to the Board of Aldermen for final approval. For more information about the Town of Carrboro Human Services program, see here. Questions and submittals should be directed to: Annette Stone, 301 W. Main Street Carrboro, NC 27510 919-918-7319 astone(aD_townofcarrboro.org Submission: ➢ We strongly encourage applications to be single-spaced, with 12-point arial font and normal margins. Application: One (1) original plus Two (2) paper copies of the application must be hand delivered or mailed to Annette Stone, 301 West Main Street, Carrboro, NC 27510; AND y One Application and Attachments files must be submitted by email. Any .pdf files must be accompanied by the original file format of .doc, .xIs, etc. DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 3 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Human Services — Town Of Chapel Hill In 1982, the Town established local funding to support local nonprofit organizations that carry out human service work throughout the community. Applications are accepted once a year and reviewed by the Town's Human Services Advisory Board, which makes a recommendation for funding to the Town Council for final approval. For more information about the Town of Chapel Hill Human Services program, see here. Questions and submittals should be directed to: Jackie Thompson 405 Martin Luther King Jr. Blvd. Chapel Hill, NC 27514 919-969-5081 Thompson(o).townofchapelhill.org Submission: We strongly encourage applications to be single-spaced, with 12-point arial font and normal margins. ➢ Application: Two (2) paper copies of the application with ORIGINAL signatures must be hand delivered or mailed to Jackie Thompson, 405 Martin Luther King, Jr. Blvd., Chapel Hill, NC 27514; AND ➢ Attachments: The application submittal must be accompanied by a flash drive with the application and all attachment files in electronic format. Any .pdf files must be accompanied by the original file format of .doc, .xIs, etc. Human Services— Orange County For more information about the Orange County Human Services program, see here. Questions and submittals should be directed to: Allen Coleman PO Box 8181 Hillsborough, NC 27278 (919) 245-2151 acoleman(a)-orangecountync.gov Submission: ➢ Email application and ALL Attachments prior to the deadline. Any .pdf files must be accompanied by the original file format of .doc, .xIs, etc. Please request a delivery receipt of email with application and attachments. DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 4 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FOR OFFICE USE ONLY Agency Youth Community Project Received By Program(s) 1. Youth Organizing and Date/Time / leadership Development, 2. Youth Arts Exhibitions, 3. Reintegration Support Network, 4. LGBTQ Youth Community Building Section Subsection 1. Cover Page a. ® Applicant Contact Information b. ® Funding Requests c. ® Signed Application Cover Page d. ®Signed Disclosure of Conflicts of Interest and Clause 2. Agency Information a. ® Agency's Years in operation b. ® Agency's Purpose/Mission c. ® Agency's Types of Services Provided d. ® Agency's Experience with Programs e. ® Other Pertinent Agency Information f. ® Schedule of Positions g. ® Living Wage h. ® Agency Budget 3. Program Information a. ® Human Services Needs Priority b. ® Type of Program A separate Section 3 is c. ® Agency Collaboration required for each program. d. ® Summary of Program e. ® Description of Identified Need f. ® Description of Population to be Served g. ® Program Staffing, Capacity, & Expertise h. ® Program Implementation Timeline L ® Value of Investment j. ® Impact of Reduced/No Allocation k. ® Other Pertinent Information I. ® Target Population/Beneficiary Chart m. ® Work Statement n. ® Program Budget, Detail, & Cost per Individual Application Submittal Checklist 1/31/2017 12:37:26 PM Page 5 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4. Attachments a. ® Audit: Organizations receiving $300,000 or more in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ® IRS Federal Form 990 c. ® NC Solicitation License (***see note) d. ® IRS Federal Tax-Exemption Letter e. ® Certificate of Insurance (***see note) f. ® List of Board of Directors g. ® Solid Waste Program Fee (SWPF)Verification (***see note) Application Submittal Checklist 1/31/2017 12:37:26 PM Page 6 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Youth Community Project Applicant Organization's Physical Address: 179 E. Franklin St, Chapel Hill, NC 27514 Applicant Organization's Mailing Address: P.O. Box 915, Carrboro, NC 27510 Applicant Organization's Web Address: http://youthcommunityproject.org Executive Director: Christine Abernathy Telephone Number: (704) 277-0043 E-Mail: abernathy.christine @gmail.com Tax ID Number: 46-2369263 b) Funding Request List all FY17-18 Human Services (HS) Funding Being Requested — For All Programs) and the Proposed Use of Funds (2-3 lines or less) Program Carrboro Chapel Orange Total - HS Hill - HS County-HS Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 Afterschool Program Coordinator salary and materials for youth activities and projects 1. Youth Leadership Development: Youth Board $750 $2,250 $4,500 $7,500 and Freedom School 2. Youth Artists Exhibitions $200 $550 $1,250 $2,000 3. Reintegration Support Network $800 $2,200 $10,000 $13,000 4. LGBTQ Youth Community Building Initiatives: $750 $2,000 $4,250 $7,000 Fluid Revolutions, Queer Youth Drop In Totals $2,500 $7,000 $20,000 $29,500 c) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: 01/31/2016 Executive Director Date Signature: 01/31/2016 Board Chairperson Date AGENCY INFORMATION 1/31/2017 12:37:26 PM Page 7 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO ❑ ® 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. 6 Signature: 01/31/2016 Executive Director Date Signature: 01/31/2016 Board Chairperson Date AGENCY INFORMATION 1/31/2017 12:37:26 PM Page 8 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 2. AGENCY INFORMATION (Be Very Brief and Concise) Please provide the following information about your agency (2 pages OR LESS): a) Years in Operation, Date of Incorporation (Month/Year): Received non-profit status 06/15/2016; Articles of incorporation 9/05/2015 b) Agency's Purpose/Mission (no more than a few sentences): YCP is dedicated to creating non-profit, youth-led and run (adult-supervised) spaces, programs and activities for all the high-school age youth of the community - including a safe, relaxed, lively intercultural center/cafe that can hold many diverse youth groups at a time. This will be a place where youth can gather for leisure and feel free to discover and nurture their artistic, advocacy, academic, and vocational interests and passions. We seek programming that can facilitate youth empowerment and promote youth investment in their social health and the health of the community. We work to encourage multicultural collaboration, strive for solidarity in diversity, and work towards good self-governance and monitoring —skills desired for future adult citizens. c) Types of Services the Agency Provides (bullet format): YCP, housed in Chapel Hill's Teen Center, has become • a stable foundation from which youth grow and develop their ideas and organizations; • a safe home where youth and their organizations lay out their issues, needs and desires, and then create proposals for community projects, singly or in collaboration; • a catalyst for youth engagement and leadership — a place for meetings, project launchings and coordination, outreach, publicity and logistics, and recruitment, within which youth and their organizations can share and develop common bonds, interests and resources that might otherwise be insufficient to achieve their aims; • a space for mutual support. Youth have been able to amplify important messages using power in numbers, bring up prevalent youth issues to our towns, and shape individual groups into a stronger network for youth to design, manage, and operate within. d) Agency's History with Providing These Services: In the past year YCP has managed to grow collaborate with over 10 youth-serving organizations with a growing need for more. These have included: The Jackson Center Youth Against Rape Culture Reintegration Support Network Baha'i Youth Group Youth Organizing Institute Sacrificial Poets Beat Making Lab Creative Swag Sisters Street Scene Teen Center Boomerang Immigrant Youth Forum Triangle BikeWorks Transplanting Traditions iNSIDEoUT Herban Garden Changing Our Realities Parents Against Racism Youth Restorative Justice Circles Agency Information 1/31/2017 12:37:26 PM Page 9 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • We've been successful in strengthening our relationship with the Towns of Carrboro and Chapel Hill, and have formed a partnership with the Chapel Hill Youth Council. • We hosted our second annual youth art exhibition and auction to showcase over 50 works of art produced by local youth in partnership with YCP & art clubs at Chapel Hill-Carrboro area high schools • YCP, like the Youth Initiative, has conducted surveys to identify youth interests. Our discussions have suggested substantial overlap. We believe the programs we propose are important developments in responding to those needs. 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?) Other Pertinent Information: Chapel Hill's 2020 Plan has as its stated goal to: Review and refine focus for youth services and begin planning for youth-centered facilities. Further, it calls for both raising youth awareness of the town's current programs and spaces, and collaborating and innovating to develop and deploy new programs and services. YCP is a community leader serving to achieve of these goals. 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: # of FTE - Paid Part-Time Positions: 3 # of Volunteers: 50 # of FTE -Volunteers: 1 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. *** YCP is a very small organization with limited resources for activities outside our core mission. Nonetheless, we have a very strong commitment to the concept of a living wage and substantially exceed living wages for all employees. We will work in the plo coming year to become a certified living wage emyer. 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: Agency Information 1/31/2017 12:37:26 PM Page 10 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Include all programs that have funding requests/awards/totals from Carrboro, Chapel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FY16-17 FY17-18 Source Award Request Ex: Affordable Rental 0 $20,000 Carrboro - Affordable Housing Rehabilitation Ex: Agency Administration $15,000 $15,000 Carrboro—Other Ex. Total $15,000 $35,000 Carrboro Total Funding *Add rows or attach additional page, if needed. 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). 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 o Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) o Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG/HOME/etc.) • Private Foundation Grants o Other Revenue • Expenditures o Compensation o Rent & Utilities • Supplies & Equipment • Travel & Training • Other Expenses iii. Does your agency budget show a Surplus or Deficit? Surplus Is there a significant change? Yes/No No Please provide a brief explanation for Surplus or Deficit, and significant changes. Agency Information 1/31/2017 12:37:26 PM Page 11 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION YCP programs have and continue to operate within budget. While budgets are tight, we always ensure there are sufficient funds to transition from fiscal year to year. There may be a carryover from year to year because of grant funding tied to the calendar year rather than to the July 1 to June 31 outside agency funding year. This does not reflect a surplus. iv. What is your agency's fiscal year? January 1 to December 31 (Example: July 1, 2016 through June 30, 2017) Agency Information 1/31/2017 12:37:26 PM Page 12 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. YOLD 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: 1. Youth Organizing and Leadership Development (YOLD): Youth Board and Freedom School Program Primary Contact and Title: Christine Abernathy, Director Telephone Number: (704) 277-0043 E-Mail: abernathy.christine @gmail.com a) Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area #1: safety-net services for disadvantaged residents ® Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ❑ Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare Education X Family Resources Jobs/Jobs Training Food Transportation Other: Youth Organizing and X Leadership Development 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. • Beat Making Lab worked with YCP program director to create Freedom School and provide a workshop. • Herban Garden worked with YCP program director to provide a workshop. • Sacrificial Poets worked with YCP program director to provide a workshop. • Boomerang provided YCP with a space. • Fight for $15 worked with YCP program director to provide a workshop. • Youth Organizing Institute worked with YCP program director to provide a model, advice for Freedom School, and a workshop. • Street Scene Teen Center worked with YCP program director to create Freedom School. PROGRAM INFORMATION 1/31/2017 12:37:26 PM Page 13 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. YOLD • Youth Restorative Justice Circles including Parents Against Racism, and Creative Swag Sisters have been working with YCP to develop and hold events and trainings. • Triangle Bikeworks participates and collaborates in YCP events; the two organizations share a board member. 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? Youth Community Project will conduct its 2nd annual youth organizing and leadership development camp based on Youth Organizing Institute's Summer Freedom School model with Street Scene Teen Center (SSTC) and Beat Making Lab (BML). The camp will educate youth aged 14 to 18 around four subjects: organizing skills, political analysis, restorative justice and young people's movement history. YCP will run the program for two weeks in July of 2017. This will be executed by YCP's paid staff with limited assistance from YCP's board and paid staff from SSTC and BML. Volunteers, activists, and paid workshop facilitators will be necessary to make the organizing camp a success. Topics will include school to prison pipeline, sexism and homophobia, reproductive justice, Native liberation, and race in the United States. Youth will leave the camp as more confident leaders, qualified speakers on social justice, and experts on leveraging people power. They will become leaders in their social circles or school classes in the fight against racism, bigotry, and homophobia. Organizing camp will have a morning and afternoon workshop, lunch for the youth, and games that build youth confidence. Youth will meet inspiring community members and local leaders in social justice. They will learn both academic information and hard skills to use in a multitude of situations. The organizing camp's goal is that youth leave as organizers, thought leaders, and facilitators of change in their communities. This program addresses funding priority two. The program targets marginalized youth including African Americans, Latino youth, and youth from low income families. These youth are currently underserved and the town has struggled to engage them, politically and otherwise. 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. Racism, homophobia, and marginalization runs deeply through US society. These problems continue because our youth are not socialized with race, class and gender equity in mind. In late 2015, East Chapel Hill High experienced homophobic messages throughout the school. There was no organized response from students. Individuals must be educated to be able to fight these social problems. In March 2016, the NC State Legislature passed and Governor McCrory signed HB2, an open attack by the state government and its supporters on the LGBTQ community and labeled the most anti-LGBTQ legislation in the US. There is currently no youth organizing initiative in Chapel Hill, Carrboro or Orange County that teaches youth hard intersectional skills to use in response to racism, homophobia, or forms of bigotry. These issues are widely PROGRAM INFORMATION 1/31/2017 12:37:26 PM Page 14 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. YOLD understood to be root causes of observed inequities in academic outcomes in our schools, for example. The decades old achievement gap persists and disparities in end-of-grade tests (42% of black and 47% of Latino youth passed vs 90% for whites) and suspensions (8 times as often for Black students compared to whites) are representative of other disparities in service to our community's youth and those at the margins (e.g., those with drug and alcohol addictions, mental health issues, economically disadvantages and learning differences). This relates to Chapel Hill Human Services Needs Assessment's recommendation to strive for social justice and youth support, Orange County's goal to close the achievement gap and end the school to prison pipeline, and Carrboro's priority of creating programs that are reflective of citizens' needs and promote sensitivity to cultural diversity. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? YCP's organizing camp will recruit and serve youth ages 14 to 18. We will target marginalized youth, especially African American, Latino, queer, transgender, and economically disadvantaged youth through our program and partner networks. We will accept youth from all backgrounds to ensure a strong dialogue and discussion at workshops. The camp will benefit multiple groups. First, youth participants are directly empowered and educated. Second, each youth's community and network will be affected as youth take action in their community to eliminate injustice and speak out against intolerant language. Third, marginalized communities will benefit as a critical mass of leaders in the next generation become educated and engaged in social justice. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Christine Abernathy has served as YCP Volunteer, Programmer and Director for over three years. She has demonstrated the knowledge and skills to organize this type of event across organizations. Abby Hylton, Programmer for YCP for over three years, was the recipient of a youth organizing award, attended 2 Freedom Schools in Durham, NC and conducted the YCP initial Freedom School in the summer of 2016. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. YCP paid staff, including our managing director and program director, will execute the organizing camp in July 2017. Board members may provide additional assistance. Staff will hire workshop facilitators and recruit local activists to add guest speakers and facilitators to the camp. The camp will be held at Boomerang in Chapel Hill. The program will be planned and organized from January 2017 to July 2017. This will include building a multi-organizational team including key segments and organizations of the local community, especially those who suffer oppression and are traditionally underserved. This will involve recruitment of both adult leaders/organizers and youth to participate in Freedom School. The school will be conducted in July 2017 (specific weeks yet to be determined). Follow-up evaluations and assessments will engage all parties in August 2017. 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) Every community across the country needs to educate and activate its youth regarding fighting homophobia, misogyny, racism, and other forms of oppression. PROGRAM INFORMATION 1/31/2017 12:37:26 PM Page 15 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1 . YOLD This is even more important for the youth of NC who have experienced the passage of homophobic, transphobic, and anti-worker HB2 and racist Voter ID/Suppression laws. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. YCP is pursuing several funding sources for our second annual Freedom School to be held July 2017. We are applying (Jan 31 st 2017) to Strowd Roses for funding. They helped fund the 2016 school. If this project is funded at a reduced rate, it would reduce the effectiveness of the camp by limiting our ability to cover staff time and/or our ability to learn and develop the program with help from experts; in other words it will likely impact sustainability. Full funding will help establish regular staff and grow the program so that we can sustain Freedom School as an ongoing initiative in our community. Include any other pertinent information. PROGRAM INFORMATION 1/31/2017 12:37:26 PM Page 16 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. YOLD Additional Program Information k) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of y our ability, Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male 2 4 Female 2 6 Transgender 3 5 Total 7 15 Ethnicity African-American 2 5 American Indian or Alaska Native 0 1 Asian 1 2 Caucasian 3 4 Native Hawaiian or other Pacific Islander 0 0 Other: specify 1 3 Total 7 15 Of the above, how many Hispanic/Latino 1 3 Of the above, how many non-Hispanic/Latino 6 12 Total 7 15 Age 0-5 years 0 0 6-18 years 7 14 19-50 years 0 1 51+ years 0 0 Total 7 15 Geographic Location Alamance County 1 1 Chatham County 0 0 Durham County 1 1 Wake County 0 0 Orange County Breakdown Chapel Hill Public Housing 1 2 Town of Chapel Hill (Non-Public Housing) 1 4 Town of Carrboro 2 4 Town of Hillsborough 0 1 City of Mebane (Orange County) 1 1 Orange County(Outside Municipalities) 0 1 Total 7 15 PROGRAM INFORMATION 1/31/2017 12:37:26 PM Page 17 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. YOLD Work Statement 1) 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 100 meals per day, Monday-Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program Youth Organizing and Leadership Development 1. Program Activity Name Freedom School workshops on social justice issues. Program Goal Building youth passion for social justice issues. Performance Measures Create youth organizing leaders on social justice issues that affect youth. Previous Year Program Results Youth recorded lessons from camp and created a system to keep each other accountable on their social justice issues. Current Year Estimated Results Youth will record lessons from camp. Youth will create a monthly reporting system to keep themselves accountable to each other on their social justice initiatives throughout the following year. Next Year Projected Results Youth will have recorded lessons from camp and created a system to keep each other accountable on issues. 2. Program Activity Name Freedom School workshops on social justice issues. Program Goal Educating youth organizing leaders. Performance Measures Develop skills of 15 youth organizing leaders on social justice issues that engage in organizing and action affect their peers in the 12 months following the program. Previous Year Program Results Youth filled out evaluations for workshops, participated in quizzes, went through mock situations, and wrote in journals. One of the trainees is now part of YCP's leadership council. Current Year Estimated Results Youth will evaluate workshops individually for takeaways. Youth will be quizzed on and successfully demonstrate advancement in leadership and organizing skills. Youth will use mock situations to practice and then demonstrate their organizing and assertiveness. Next Year Projected Results Youth will have filled out evaluations for workshops, participated in quizzes, gone through mock situations, and written about their experiences and thoughts in journals. 3. Program Activity Name Training as advocates for themselves and peers. PROGRAM INFORMATION 1/31/2017 12:37:26 PM Page 18 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. YOLD Program Goal Youth participation is measured in service hours, number of events attended where youth spoke or served a prominent leadership role, number of pieces written and published, qualitative feedback gathered about their perception of themselves and their abilities over time and if there was a shift, an increase or decrease in the members of the youth board. Performance Measures 15 youth will demonstrate leadership among their peers and within the greater community and ability to communicate complex social and political issues. Previous Year Program Results Youth have completed 5 collaborative projects with other youth-serving organizations. Youth have created capacity for the YCP including a social justice training curriculum for all staff, board members, and volunteers. Youth have held meetings with community leaders and plan/attend events to educate the community about their needs and advocate for youth. Current Year Estimated Results Youth will complete at least 5 collaborative projects with other youth-serving organizations. Youth will hold meetings with community leaders and plan/attend events to educate the community about their needs and advocate for youth. Youth will build on the previous relationships made and seek opportunities to engage new stakeholders in their advocacy efforts. Next Year Projected Results 4. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results PROGRAM INFORMATION 1/31/2017 12:37:26 PM Page 19 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. YOLD m) Program Budget 1. Submit your program budget. You may complete the provided template (separate xls file) or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template). Program Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues • 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 2. Program Budget Detail — Provide description of"other" budget items, not defined. See attached spreadsheet. 3. This program budget represents what percent of the agency budget? 13.4% 4. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2015-16 Estimated 2016-17 Projected 2017-18 Total Cost of Program $7,909 $7500 Total # of Individuals 7 15 Cost Per Individual $1129 $500 PROGRAM INFORMATION 1/31/2017 12:37:26 PM Page 20 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 2. Youth Artists Exhibitions PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: 2. Youth Artists Exhibitions Program Primary Contact and Title: Christine Abernathy, Director Telephone Number: (704) 277-0043 E-Mail: abernathy.christine @gmail.com a) Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area #1: safety-net services for disadvantaged residents ® Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ❑ Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare Education X Family Resources Jobs/Jobs Training Food Transportation Other: Youth Leadership X Development 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. Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town/County priority/goal? The annual Youth Arts Exhibition at the Arts Center is a month-long showcase of 40 youth artists from the three CHCCS high schools, Orange County (to be added for coming year) and other local schools. This exhibit and the events that lead up to and accompany it announce to the community that new young voices are continually emerging that represent and shape the future of our community. DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 21 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 2. Youth Artists Exhibitions 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. Youth, like everyone, need spaces where they can gather with their peers — organize and create programs, or spend leisure and creative time together. Many such places exist for thousands of our younger children, university students, adults, senior citizens. But Orange County's 6,000+ high-school age youths — five percent of the population — have limited programs available to them, especially cultural arts programs outside of school. The Youth Art Exhibition allows youth artists in Orange County an opportunity to express themselves and create pieces together with their peers and showcase them in a professional way. This falls in line with Chapel Hill Human Needs Assessment and Town of Chapel Hill priorities of youth support and increasing cultural and creative arts. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? Youth Art Exhibitions primary targets are youth artists in Chapel Hill, Carrboro City Schools, Orange County Schools and students of other local high schools. These students are representative of all local teens whose voices are exemplified by their artistic expression. In turn, this project targets our entire community who need to demonstrate that young people are an integral and contributing part of our overall community, to recognize that they have a voice in interpreting their experiences as important to our overall understanding of a holistic civic body. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) The Youth Art Exhibition is organized by the YCP Managing Director, Christine Abernathy. Christine Abernathy has been working directly with Orange County teens for the past five years. She has also worked aboard teaching art-based youth empowerment in Honduras, Hungary, and Malaysia. She focuses on cultivating youth as community leaders and activating them to pursue their passions through advocacy and self-expression. Christine is currently pursuing a Certificate in Nonprofit Management from Duke University. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. The Youth Arts Exhibition will be carried out in the first half of the calendar year as fits with the venue and youth art clubs' calendars. This will involve months of planning and art creation, one month of showing at a gallery yet to be selected and months of exhibition at the YCP space. 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) Teens of Chapel Hill, Carrboro and Orange County are some of the most underserved residents in our community. Solutions to this problem begin with the recognition and honoring of the voices (including artistic expression) of our teenage youth. Absent, robust non-school programming or available modern venues, teens DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 22 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 2. Youth Artists Exhibitions are left to interpret their role in the community as merely secondary. The entire community needs to demonstrate that this is not so if they are to become the visionary future leaders of our community. By bringing them together for a project unified across jurisdictions and boundaries we are showing them how to conceive of a unified supportive community. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Two years of work on the Youth Arts Exhibitions have led us to a point where the youth of our community are taking guiding leadership and programmatic responsibility. In turn, this leadership development will manifest itself in areas beyond art to a broader range of youth projects and initiatives that will grow like this art exhibition over time. This is a monumental development. It is not however, spontaneous and requires the ongoing adult leadership dedicating time and effort that needs and deserves remuneration. A single year's exhibition may go on without this support, however it will only be sustainable with outside financial funding. k) Include any other pertinent information. DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 23 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 2. Youth Artists Exhibitions Additional Program Information 1) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male 5 15 25 Female 30 42 45 Transgender 3 6 10 Total 38 63 80 Ethnicity African-American 9 16 18 American Indian or Alaska Native 0 1 3 Asian 10 13 18 Caucasian 12 23 26 Native Hawaiian or other Pacific Islander 0 0 0 Other: specify 7 10 15 Total 38 63 80 Of the above, how many Hispanic/Latino 7 10 15 Of the above, how many non-Hispanic/Latino 31 53 65 Total 38 63 80 Age 0-5 years 0 0 0 6-18 years 37 62 79 19-50 years 1 1 1 51+ years 0 0 0 Total 38 63 80 Geographic Location Alamance County 1 1 1 Chatham County 2 2 3 Durham County 1 1 2 Wake County 0 0 0 Orange County Breakdown Chapel Hill Public Housing 0 2 2 Town of Chapel Hill (Non-Public Housing) 15 26 30 Town of Carrboro 12 20 25 Town of Hillsborough 2 1 1 City of Mebane (Orange County) 0 1 1 Orange County(Outside Municipalities) 5 9 15 Total 38 63 80 DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 24 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 2. Youth Artists Exhibitions Work Statement m) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART (,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 100 meals per day, Monday-Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program: Youth Artists Exhibition 5. Program Activity Name Planning and executing the exhibition. Program Goal Provide youth with leadership opportunities, concrete skills, and gallery experience necessary for careers in visual art. Increase visibility of youth presence and youth perspectives within the greater community. Increase confidence in expressing themselves, their thoughts, and their struggles to the public through art Performance Measures Involvement at the planning coalition level from students across CHCCS and Orange County Schools. Qualitative feedback from youth regarding what they learned and a shift in their behavior ranking for how likely they would be to submit their work to an art exhibit before and after this experience. Organizers will develop and/or supplement an ongoing list of "lessons learned" related to conducting a successful art exhibition to be used in future ears' exhibitions. Previous Year Program Results 50 art pieces were viewed by 200+ gallery attendees Current Year Estimated Results 50 art pieces will have been viewed by 300+gallery attendees Next Year Projected Results 80 art pieces will be viewed by 400 gallery attendees and youth artists will be further transformed through connections to buyers or to future art projects due to the visibility of their pieces. 6. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 25 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 2. Youth Artists Exhibitions 7. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 8. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 26 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 2. Youth Artists Exhibitions n) 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). 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 (CDBG/HOME/etc.) • 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. See attached spreadsheet. 7. This program budget represents what percent of the agency budget? 3.6% 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. Actual 2015-16 Estimated 2016-17 Projected 2017-18 Number of individuals only includes youth participants and not the greater community that may benefit from attending exhibits or gaining other benefits from the art exhibitions. Total Cost of Program $0 $0 $2,000 Total # of Individuals 38 63 80 Cost Per Individual $0 $0 $25 DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 27 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. Reintegration Support Network PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: 3. Reintegration Support Network Program Primary Contact and Title: Abby Hylton, Program Director Telephone Number: (919) 428-6233 E-Mail: abby.hylton @gmail.com a) Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area #1: safety-net services for disadvantaged residents ® Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ❑ Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare Education X Family Resources X Jobs/Jobs Training X Food Transportation Other: Youth transition to sustained substance abuse X recovery and reduction of recidivism 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. As an aftercare rather than treatment program, RSN collaborates with school justice system and private practice counselors and participates in local coalitions such as Reclaiming Futures/Juvenile Justice Substance Abuse Mental Health Partnership, Juvenile Crime Prevention Council, and the Orange County Community Collaborative, professional social workers among others. These connections provide RSN with guidance and professional support. • Boomerang • Juvenile Crime Prevention • Orange Criminal Justice Council, Orange County Resource Office • Cardinal Innovations • Juvenile Justice, Substance • Orange Partnership for Abuse and Mental Health Alcohol and Drug Free Youth Partnership • Chapel Hill, Carrboro City • NC Department of Public 0 RHA Net Schools Safety • Department of Health and Oasis,A Holistic Network 0 UNC Greensboro, Center for Human Services, Orange Youth Family and Community County Partnerships DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 28 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. Reintegration Support Network • Dispute Settlement Center Orange County Community 0 Volunteers for Youth Collaborative • Freedom House Recovery Orange County Department of e Youth Villages Center Juvenile Justice • Duke University Center for Orange County Schools Adolescent Substance Abuse Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town/County priority/goal? The Reintegration Support Network (RSN) is unique in our community as a program that focuses on aftercare for area youth who have gone through substance abuse and/or mental health treatment programs. The targeted youth often have also been involved with the juvenile justice system or as teens in the adult justice system. RSN surrounds each enlisted youth and their parents/guardians with a circle of supervised, screened adult volunteers (mentors) that use tailored, structured approaches which enable each youth to engage in 8 life domains and build on their strengths to solidify a lasting recovery (goal of 6-8/yr for completion of 52 week program). RSN, a program of the Youth Community Project (YCP), unites families, staff, professionals and communities to create opportunities, routines and networks invested in each youth's healthy future. The needs enunciated above interface well with the aims and priorities developed by the towns and county. Chapel Hill: The findings of Chapel Hill's Key Human Service Needs Assessment lists under Affordable Healthcare substance abuse services, such as alcohol & drug treatment programs. While the area suffers from insufficient services for youth generally in these areas, aftercare, an essential and critical component of youth recovery is especially lacking. Focus groups referenced in Chapel Hill's assessment further identified these needs. Orange County: Orange County's goals and priorities identified among social justice values the creation of a safe community. The disproportionate incarceration of minorities and the poor often begins with encounters with the judicial systems with which RSN interacts and gets many of its referrals. Stemming the tide of mass incarceration begins exactly where RSN is engaged. Additionally, RSN is on target with the county's emphasis on mental health, as virtually every youth RSN works with has a concomitant mental health diagnosis. Carrboro: Carrboro lists among its priorities the enhancement and sustainability of quality of life/place issues for everyone. These must include youth in trouble with substance abuse, mental health and juvenile justice issues. RSN is uniquely situated to address these issues. RSN became a YCP program January 2016. 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. Following months of treatment for addiction, 17 year-old Chapel Hill resident Matt McQuiston returned home happy, healthy and ready to forge a new life. Tragically, without proper aftercare, he soon fell prey to the same circumstances and drugs from DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 29 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. Reintegration Support Network which he had freed himself. The night before re-entering treatment he died of an overdose. Matt was part of an epidemic of unintentional poisoning deaths from misuse of meds and opioids in North Carolina. Over the last 15 years, the number of these deaths has increased by over 320% and males aged 12-25 accounted for 8% of these. Given these facts, the importance of treatment followed by aftercare cannot be overstated. National leaders in the field, Hazelden Betty Ford, Drug Strategies and Reclaiming Futures, all recognize that these programs are essential to success. Nonetheless, aftercare programs, which lower recidivism, are rare. Programs that are low cost, intensive, and tailored to each individual youth are more so. Orange County JJ referred 20 youth to treatment in 2014. Criminal charges related to substance abuse have more than doubled in the last decade on state and national levels; presently 2/3 of US youth charged with delinquency also abuse substances. 75% of youth completing treatment, like Matt, will re-abuse within 3 months. Many of these youth are forced down the school to prison pipeline as many are tried in adult court following recidivism. In the last year, Orange County has become a pilot site for the Criminal Justice Resource Office's Misdemeanor Diversion Program, which attempts to keep 16 and 17 year-olds out of adult court and prison. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? RSN serves youth ages 14-18 typically referred by counselors/social workers from: Chapel Hill, Carrboro City Schools; Orange County Juvenile Justice; the Orange County Criminal Justice Resource Office (for juveniles in the adult court system); or from treatment practitioners such as Youth Villages. Typically these youth have been, or are about to be, referred to substance abuse and/or mental health treatment. In either case, RSN engages with them and their families throughout treatment and then more intensely in aftercare, the latter being the main emphasis of the program. Referrals in the 6 months have come at approximately one per month. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) The senior program director is Thomas McQuiston, M.S., DrPH. He has over 30 years' experience developing, leading and evaluating national public health programs collectively funded at approximately $40 million. Dr. McQuiston will have overall strategic, operational and financial responsibilities for RSN including its goals, policies and funding. He leads staff, coordinates work with contractors; attends and reports on the progress of RSN at all Youth Community Project Board meetings as its treasurer and organizes and attends all RSN Advisory Board meetings. He is responsible for all data analysis, program evaluation and reports; and assists RSN's program director in her duties as needed. RSN's program director, Abby Hylton, has worked for the past five years in crisis response. She oversees the coordination and administration of all aspects of an ongoing program including planning, organizing, training and activities supervision of volunteers and their activities; serves as liaison with cooperating agencies, organizations and professionals; leads each support circle of mentors; coordinates activities and referrals with parents/guardians and others as needed; and coordinates collection of process and outcome data. William Elmore, Outreach and Volunteer Coordinator, has spent years working with Think Smart, a program helping at-risk youth to understand the importance of, and ways to lead, positive, clean lives. With RSN he identifies organizations from which to DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 30 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. Reintegration Support Network enlist support for the program; schedules and makes presentations to the same; recruits individuals to become volunteer support circle members (mentors); gathers and processes volunteer applications; maintains communication and provides updates to individuals and organizations. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. RSN is an ongoing initiative and activities will occur continuously over the period of the grant/funding. 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) RSN is modeled after international programs that lower long-term costs through use of community partnerships and volunteers. RSN will gather evidence that demonstrates that its local aftercare program encourages effective recovery transitions. In turn, these changes are known to reduce recidivism, JJ involvement and social and monetary costs to the community. Just as important, RSN works to reintegrate youth who are often a marginalized and isolated part of our community. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. RSN has, and will seek other sources of funding. If RSN is not funded by the towns and county it will continue operations in a more limited way than would be possible with these funds. However, the program also needs a demonstration that our communities and their leaders are invested in our youth, even those who have experienced substance abuse, like so many others, but have, through no fault of their own, succumbed to the disease of addiction. When youth are unable to sustain their recovery our communities pay not only monetarily but in many other ways. k) Include any other pertinent information. DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 31 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. Reintegration Support Network Additional Program Information 1) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male 3 7 14 Female 6 13 14 Transgender 2 3 Total 9 22 31 Ethnicity African-American 6 12 16 American Indian or Alaska Native 2 2 Asian Caucasian 3 5 8 Native Hawaiian or other Pacific Islander Other: specify_Latin 3 6 Total 9 22 31 Of the above, how many Hispanic/Latino 0 3 5 Of the above, how many non-Hispanic/Latino 9 19 25 Total 9 22 31 Age 0-5 years 6-18 years 4 8 12 5 (parents/ 14 (parents/ 19 (parents/ 19-50 years guardians ) guardians ) guardians ) 51+ years Total 9 22 31 Geographic Location Alamance County 0 0 0 Chatham County 0 0 0 2 (both 0 Durham and 0 Durham County Orange) Wake County 0 0 0 Orange County Breakdown Chapel Hill Public Housing 0 0 4 Town of Chapel Hill (Non-Public Housing) 6 12 15 Town of Carrboro 3 6 6 Town of Hillsborough 0 4 6 City of Mebane (Orange County) 0 0 0 Orange County(Outside Municipalities) 0 0 3 Total 9 22 31 DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 32 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. Reintegration Support Network Work Statement m) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART (Specific, Measurable, Achievable, _Relevant, and _Time-bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday-Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program: Reintegration Support Network 1. Program Activity Name MentorNolunteers Recruitment Program Goal Develop community support networks of RSN staff and trained volunteers to serve in youth-specific support circles that will provide intensive, long-term, at-home and in-community support to youth in solidifying their recovery following successful completion of intensive substance abuse treatment from addiction and co-occurring disorders. Over the next year, the RSN will engage 6 to 8 youth and their parents/guardians. The program will be free for recovering youth and their families. The circle of support will engage with recovering youth weekly for one year. RSN will recruit, screen, train, and supervise 18-40 volunteers (mentors) (3-5 per recovering youth) who will engage in support circles per grant year along with the program director. Performance Measures We will have documented the number of volunteers engaged in supervised recovery support for youth, parents, and program director. Previous Year Program Results Program start-up. No mentors/volunteers recruited. Current Year Estimated Results Will have recruited and engaged 24 mentors/volunteers. Next Year Projected Results Will have recruited and engaged 48 mentors/volunteers. 2. Program Activity Name Recovering Youth Engagement and Enlistment Program Goal Youth completing the program will have solidified sustainable, enriching, healthy routines that enable them to a) achieve and solidify positive coping mechanisms b) gain experiential knowledge and skills that increase their capacities to be self-determining and c) recognize pathways to maintaining a supportive network and sobriety. Performance Measures Collect data from weekly encounter logs from volunteers, youth, parents, and program director as well as pre-and post-assessments from youth using screening and assessment tools. DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 33 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. Reintegration Support Network Previous Year Program Results Program start up. 3 referrals of youth but none completed the program due to relapse and incarceration. Current Year Estimated Results Program will recruit 8 recovering youth 6 of whom will fully engage as mentees in the program. Next Year Projected Results Program will recruit 12 recovering youth 8 of whom will fully engage as mentees in the program. 3. Program Activity Name Partnerships, Collaborations And Support Circles Program Goal RSN will have established effective local partnerships,collaborations and support circles that create sustainable structures that enhance youth recovery and the ability of support circles to operate. This model will be: 1) based on local experiences and pre-existing structures; and 2 created to be flexible and adaptable. Performance Measures Conduct end-of-year interviews with key informants from collaborating agencies and professionals qualitatively assess connectedness, integration of effort, degree of coordination, goal alignment, and mutual support. Previous Year Program Results Networked with over 24 agencies, schools and practitioners Current Year Estimated Results Continued networked with over 24 agencies, schools and practitioners and developed relationships for ongoing referrals. Will have conducted outreach to recruit volunteers from over 12 community organizations and places of worship. Next Year Projected Results Continued networked with over 24 agencies, schools and practitioners and developed relationships for ongoing referrals. Will have conducted outreach to recruit volunteers from over 20 community organizations and places of worship. 4. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 34 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. Reintegration Support Network n) Program Budget 9. 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 • 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 10. Program Budget Detail — Provide description of"other" budget items, not defined. See attached spreadsheet. 11. This program budget represents what percent of the agency budget? 69.6% 12. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2015-16 Estimated 2016-17 Projected 2017-18 Total Cost of Program $34,833 $62,722 $64,000 Total # of Individuals 9 22 31 Cost Per Individual $3,870 $2,853 $2,064 DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 35 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4. LGBTQ Youth PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: 4. LGBTQ Youth Community Building Initiatives: Fluid Revolutions, Queer Youth Drop In (In the 2017-18 program year, LGBTQ YCBI will be come under YCP's 501(c)(3) umbrella as a YCP supported initiative of Fluid Revolutions and Abby Hylton.) Program Primary Contact and Title: Abby Hylton, Program Director Telephone Number: (919) 428-6233 E-Mail: abby.hylton @gmail.com a) Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area #1: safety-net services for disadvantaged residents ® Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ❑ Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare Education X Family Resources Jobs/Jobs Training Food Transportation Other: Youth Leadership X Development, creation of safe spaces 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. • iNSIDEoUT collaborates with QYDI on special events such as dances and socials. • Street Scene Teen Center provides space for QYDI and Fluid Revolutions' political- social discussions. DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 36 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4. LGBTQ Youth 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? As part of its mission to create and support youth leadership, YCP is incubating new initiatives and partnerships for underserved youth. These new initiatives emerge and evolve over time. The program components described here are two that have emerged from the expressed needs of our local youth. They are: 1) Queer Youth Drop In (QYDI) and 2) Fluid Revolutions (FR). 1) Queer Youth Drop In is an open program that fosters friendships among queer and/or transgender youth to break down the sense of isolation and loneliness. QYDI gives youth a supportive environment to have fun and relate their experiences to similar others who can affirm and support them in an atmosphere that moves beyond how hard it is to be queer and/or trans in our community. 2) Fluid Revolutions Queer Youth Circus provides queer and trans youth with a space for artistic expression, athletic activity, and political-social discussion through aerial arts such as silks, trapeze, and Tyra. FR meets weekly for aerial rehearsal and then political discussions. Its goals are to: 1) help youth learn to Be Bold in aerial moves, conditioning, and choreographing in both partner and solo pieces; creating supportive peer environments to build self-confidence and recognition of their capacities to grow beyond their own expectations; connect to and appreciate their bodies, engage in physical activity and expression through movement; and 2) Amplify And Validate Their Voices in relation to often exclusionary systemic structures, develop leadership, increase confidence in expressing views and opinions, and deepen interpersonal relationships based on sharing. These address Priority Area #2 because both programs offer mentorship and afterschool programming to youth that are underserved in our community. In addition, Fluid Revolutions builds in an education component through political-social discussion. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. The youth of our community are underserved. Further, the community's broad sense of tolerance has yet to be transformed to a sense of solidarity and has yet to be demonstrated as equity. The passage of House Bill 2 in North Carolina, recent homophobic incidents and their aftermath, and the fact that there are few specific programs and resources for LGBTQ youth give these youth a sense of marginalization. Queer Youth Drop In and Fluid Revolutions fill the gap in opportunities for LGBTQ youth in our community by creating space for them to gather, make friends, meet mentor figures, have fun, learn new artistic and athletic skills, learn about inequity in our society, and engage in political-social discussion. This relates to Chapel Hill Human Services Needs Assessment's recommendation to strive for social justice and youth support, Chapel Hill's goal to increase cultural and creative arts, and Carrboro's priority of creating programs that are reflective of citizens' needs and promote sensitivity to cultural diversity. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 37 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4. LGBTQ Youth Both Queer Youth Drop In and Fluid Revolutions will target LGBTQ youth through each school's Queer Student Alliance (QSA), the LGBTQ Centers of Raleigh and Durham, and the older LGBTQ community. The programs will also reach out to YCP's extensive network of partners to recruit LGBTQ youth from a diversity of backgrounds. Fluid Revolutions will also engage the community at large by reaching out to and welcoming youth and adults in the surrounding areas to their performances, thereby creating a sense of awareness of LGBTQ issues and culture in the public. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) QYDI and FR are coordinated and supervised by YCP's Program Director, Abby Hylton. Hylton is a queer and transgender activist who has been working with LGBTQ youth in the Orange County area for five years and provides trainings for organizations wishing to become safe and affirming spaces for LGBTQ youth. Hylton is also an aerialist and teaches and performs in Orange and Wake Counties, including teaching at the Flow Jo, Triangle Yoga, and Cirque De Vol. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. Queer Youth Drop In is ongoing with meetings weekly throughout the year plus quarterly additional special events and/or field trips. Fluid Revolutions meets weekly throughout the year, has a spring show open to the public, and a summer camp for queer and transgender youth. 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) LGBTQ youth are at a higher risk for bullying, violence, homelessness and depression than other youth and often develop unhealthy coping mechanisms as a result of feeling a sense of isolation and unworthiness. They are also underserved in our community and lacking supports and programs. QYDI and FR are good investments because they give these youth a place to connect with each other and adults who model healthy behaviors as well as giving them a sense of belonging and self-worth within the community. They also learn how to advocate for themselves and others. The programs also create awareness of LGBTQ issues in our community and engage community members in mutual support and solidarity. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. QYDI and FR would both continue with Hylton in a volunteer position; both programs would continue to seek funding from outside sources including Strowd Roses and attempt to raise money through small crowdsourcing campaigns and performances. k) Include any other pertinent information. DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 38 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4. LGBTQ Youth Additional Program Information 1) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male 3 4 Female 5 6 Transgender 7 10 Total 15 20 Ethnicity African-American 4 6 American Indian or Alaska Native 1 1 Asian 2 3 Caucasian 6 7 Native Hawaiian or other Pacific Islander 0 0 Other: specify 2 3 Total 15 20 Of the above, how many Hispanic/Latino 2 4 Of the above, how many non-Hispanic/Latino 13 16 Total 15 20 Age 0-5 years 0 0 6-18 years 14 18 19-50 years 1 2 51+ years 0 0 Total 15 20 Geographic Location Alamance County 1 1 Chatham County 0 0 Durham County 1 2 Wake County 0 0 Orange County Breakdown Chapel Hill Public Housing 0 0 Town of Chapel Hill (Non-Public Housing) 5 7 Town of Carrboro 4 4 Town of Hillsborough 1 2 City of Mebane (Orange County) 2 2 Orange County(Outside Municipalities) 1 2 Total 15 20 DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM l DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4. LGBTQ Youth Work Statement m) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART (,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 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 LGBTQ Youth Community Building Initiatives: Queer Youth Drop In and Fluid Revolutions 9. Program Activity Name QYDI Weekly Meetings Program Goal To hold 45 90-minute meetings weekly throughout the year plus four additional quarterly special events and/or field trips and a social. Performance Measures QYDI tracks both repeated and one-time attendance. Previous Year Program Results QYDI held 37 90-minute meetings throughout the year plus 2 field trips to Raleigh and Durham and collaborated on a social with iNSIDEoUT. Current Year Estimated Results QYDI will have held 40 90-minute meetings throughout the year plus 1 open game night, 1 dance, and 2 field trips to Durham. Next Year Projected Results QYDI will hold 45 90-minute meetings throughout the year plus 3 field trips to Durham, Raleigh, and Hillsborough and host a winter dance. 10. Program Activity Name FR Queer Youth Circus Camp Program Goal To plan, fundraise for and implement a week-long aerial camp for queer and transgender youth to kick off a weekly circus program. Performance Measures Enrollment of 5 youth in the camp and a half hour long performance for friends and family at the end of the week. Previous Year Program Results Enrollment of 6 youth in the camp and a half hour long performance for friends and family at the end of the week. Current Year Estimated Results Enrollment of 9 youth in the camp and an hour long performance for friends and family at the end of the week. Next Year Projected Results Enrollment of 15 youth in the camp and an hour and a half long performance for friends and family at the end of the week. 11. Program Activity Name FR Weekly Queer Youth Circus lessons Program Goal To help youth learn to be bold in aerial moves, conditioning, and choreographing in both partner and solo pieces; creating supportive peer environments to build self-confidence and recognition of their capacities to grow beyond their own expectations; connect to and DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 40 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4. LGBTQ Youth appreciate their bodies, engage in physical activity and expression through movement. Performance Measures The program director keeps a journal of notes from training and rehearsals documenting each individual's progress. Youth will also choreograph 1-2 pieces for a performance. Previous Year Program Results Each individual advanced from beginner to intermediate skills, choreographed solo and duet performance pieces, and taught the skills learned to adult queer individuals. Current Year Estimated Results Beginner students will have advanced to intermediate while intermediate students become advanced. Youth will have choreographed pieces for a show and performed. Next Year Projected Results Beginner students will advance to intermediate while intermediate students become advanced and advanced students begin helping beginners to learn. Youth will choreographed pieces for a show and will perform. 12. Program Activity Name FR Monthly social-political workshops Program Goal To amplify and validate their voices in relation to often exclusionary systemic structures, develop leadership, increase confidence in expressing views and opinions, and deepening interpersonal relationships based on sharing. Performance Measures Youth will have begun co-leading discussions/workshops with the program director. Social-political issues discussed have been translated into themes for the performance. Previous Year Program Results Youth co-lead discussions and workshops with the program director. Current Year Estimated Results Youth have been leading discussions and workshops on their own and are discussing how to incorporate these themes into their show. Next Year Projected Results Youth will continue leading social-political workshops on their own and will incorporate these themes into their show. DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 41 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4. LGBTQ Youth n) Program Budget 13. 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 • 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 14. Program Budget Detail — Provide description of"other" budget items, not defined. See attached spreadsheet. 15. This program budget represents what percent of the agency budget? 13.4% 16. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2015-16 Estimated 2016-17 Projected 2017-18 Total Cost of Program $5,591 $7500 Total # of Individuals 15 20 Cost Per Individual $372 $375 DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 42 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4. ATTACHMENTS Description of Required Attachments a) Financial Audit A recent financial audit that should cover CY 2015, for calendar year agencies, and FY 2015- 16, for fiscal year agencies. For agencies with prior year revenues totaling $500,000 or more a financial audit, prepared by a certified public accountant is required. Agencies with prior year revenues of less than $500,000 may submit a completed Schedule of Receipts and Expenditures form (see application materials), in lieu of an audit/report. Agencies with a certified audit/report should not complete the form. b) IRS Federal Form 990 A copy of the agency's 2014 Form 990 is required. The specific form depends upon the agency's financial activity. Review the IRS' table guide, for more details. For Form 990-N (e- postcard) filers, include a copy of the postcard, with the agency's application materials. c) NC Solicitation License A copy of the agency's current solicitation license is required. Organizations that solicit contributions in North Carolina, directly or through a third party, must renew their licenses annually. For more details, refer to the NC Secretary of State's licensing website and its Frequently Asked Questions Guide (PDF), about exemptions. If exempt per N.C.G.S. § 131 F- 3, include a copy of the exemption letter with the agency's application materials. *** 2017 Reapplication Submitted to NC Secretary of State 01/31/2017. d) IRS Federal Tax-Exemption Letter A copy of the agency's IRS tax-exempt letter that confirms its nonprofit status is required. An agency can request a copy of its letter from the IRS' Customer Account Services. e) Certificate of Liability Insurance *** The Youth Community Project has experienced difficulties in securing liability insurance because of its need for coverage of its aerial arts program when conducting events out in the community (i.e., not within venues that routinely sponsor aerial arts and already covered by appropriate insurance). YCP has worked with Dominick, Huckabee, Noblin & Trent and the broker Atlantic Specialty to secure a new insurance policy meeting the towns' and county's requirements and will be covered by February 3, 2017 for the coming year. Offsite aerial events will henceforth be conducted only with acquisition of event specific insurance. The new certificate of insurance will be forwarded immediately upon receipt by YCP from the carrier. DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 43 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker's Compensation compliance, include a statement explaining why, with the agency's application materials. *Note: If Approved for Funding: Approved agencies must provide an updated insurance certificate. The update should reflect the funding jurisdiction as an additional insured party and certificate holder and provide coverage for the duration of the funding period(July 1 —June 30). Renewal certificates must be sent to the jurisdiction 30 days prior to any expiration date, cancellation or modification of any stipulated insurance coverage. Table 1. Forms of Liability Insurance and Minimum Policy Amounts Required INSURANCE TOWN OF CARRBORO TOWN OF CHAPEL HILL ORANGE COUNTY3 Worker's Limits for Coverage Compensation' A - Statutory State Limits for Coverage A - Limits for Coverage A - NC, for each Statutory State NC, for Statutory State NC, for employee each employee each employee Limits for Coverage Limits for Coverage B - Limits for Coverage B - B - Employers Employers Liability of: Employers Liability of: Liability of: $100,000 Each Occurrence $500,000 each $1 million Each $100,000 BID for each accident, $500,000 Occurrence employee BID for each employee $1,000,000 BID $500,000 BID limit $500,000 for BID limit limit Commercial $100,000 Property General Liability Damage Liability $1 million Each $1,000,000 Bodily $1 million Each Occurrence Occurrence Injury 2 million Aggregate y and Property p y $2 million Aggregate Damage Limit Automobile Not Applicable $1 million Each Occurrence $500,000 Each Liability Occurrence Professional $1 million Each Liability Not Applicable Not Applicable Occurrence $2 million Aggregate 1. Visit the NC Industrial Commission's website for more information regarding Coverage A. Also, note that if an agency uses subcontractors, it must require subcontractors to have workmen's compensation insurance. 2. Bodily Injury by Disease (BID) 3. Please visit Orange County's contracts webpage for more information about the County's risk assessment procedures. f) List of Board of Directors Provide the following information about each board of director's member: name, telephone number, address, occupation or affiliation of each member and the list must identify the principal officers of the governing body, and length of term. DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 44 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION g) Solid Waste Program Fee (SWPF) Verification This fee finances Orange County's recycling and waste reduction program. Submit either a.) proof of payment of the agency's FY 2016-17 Solid Waste Program Fee, OR b.) a statement on agency letter head indicating exemption and specify the person(s), business, etc. that is responsible for paying this fee. DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 45 of 45 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Youth Community Project Actual Estimated Projected Percent AGENCY REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 44,734 $ 19,773 $ 5,000 -75% Agency Generated Revenue (fees) $ - $ - $ - 0 Local Government Grants: Human Services -Town of Carrboro $ - $ 1,000 $ 2,500 150% Other- Town of Carrboro $ - $ - $ - 0 Human Services -Town of Chapel Hill $ - $ 4,675 $ 7,000 50% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services - Orange County $ - $ 4,675 $ 15,000 221% Other- Orange County $ - 1 $ - 1 $ - 0 Other- Town of Hillsborough $ - 1 $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government (CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ 25,000.00 $ 53,000.00 $ 52,000.00 $ (0.02) Other Revenue $ - $ - $ - 0 Total Agency Revenue 1 $ 69,7341 $ 83,123 1 $ 81,500 -2% AGENCY EXPENSES Compensation $ 52,277 $ 69,000 $ 76,280 11% Rent& Utilities $ 6,816 $ 316 $ - -100% Supplies & Equipment $ 950 $ - $ - 0 Travel &Training $ - $ 3,100 $ 4,500 45% Other Expenses: Adminstrative/Programming $ 8,717 $ 720 $ 720 0% Total Agency Expenses $ 68,760 $ 73,136 1 $ 81,500 1 11% SURPLUS/(DEFICIT) FOR PERIOD: $ 975 $ 9,987 $ - -100% FY 2015-16 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID:3457204A-7765-4E36-8842-227F6F673AF6 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Youth Organizing and Leadership Development Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ - $ - $ - 0 Program Generated Revenue $ - $ - $ - 0 Local Government Grants: Human Services-Town of Carrboro $ - $ 129 $ 750 483% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ 611 $ 2,250 268% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services- Orange County $ - $ 611 $ 4,500 637% Other-Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ - $ 3,000.00 $ - $ (1.00) Other Revenue $ - $ - $ - 0 Total Program Revenue $ - $ 4,350 $ 7,500 72% PROGRAM EXPENSES Compensation $ - $ 3,000 $ 5,400 80% Rent&Utilities $ - $ - $ - 0 Supplies & Equipment $ - $ - $ - 0 Travel &Training $ - $ 1,350 $ 2,100 56% Other Expenses: $ - $ - $ - 0 Total Program Expenses r$ ,- $ 4,350 1 $ 7,500 1 72% SURPLUS/(DEFICIT) FOR PERIOD: 1 $ - I $ - I $ - I 0 DocuSign Envelope ID:3457204A-7765-4E36-8842-227F6F673AF6 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Youth Art Exhibitions Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ - $ - $ - 0 Program Generated Revenue $ - $ - $ - 0 Local Government Grants: Human Services-Town of Carrboro $ - $ - $ 200 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ 550 0 Other-Town of Chapel Hill $ - $ - $ - 0 Human Services- Orange County $ - $ - $ 1,250 0 Other-Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ - $ - $ - 0 Other Revenue $ - $ - $ - 0 Total Program Revenue $ - $ - $ 2,000 0 PROGRAM EXPENSES Compensation $ - $ - $ 1,750 0 Rent&Utilities $ - $ - $ - 0 Supplies & Equipment $ - $ - $ 250 0 Travel &Training $ - $ - $ - 0 Other Expenses: $ - $ - $ - 0 Total Program Expenses r$ ,- $ 1 $ 2,000 1 0 SURPLUS/(DEFICIT) FOR PERIOD: 1 $ - I $ 1 $ - I 0 DocuSign Envelope ID:3457204A-7765-4E36-8842-227F6F673AF6 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Reintegration Support Network Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 5,150 $ 1,000 $ 1,000 0% Program Generated Revenue $ - $ - $ - 0 Local Government Grants: Human Services-Town of Carrboro $ - $ - $ 800 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ 2,200 0 Other-Town of Chapel Hill $ - $ - 0 Human Services- Orange County $ - $ - $ 10,000 0 Other-Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ 26,000.00 $ 51,000.00 $ 25,000.00 $ (0.51) Other Revenue $ - $ - $ - 0 Total Program Revenue $ 31,150 $ 52,000 $ 39,000 -25% PROGRAM EXPENSES Compensation $ 18,733 $ 52,000 $ 38,500 -26% Rent&Utilities $ - $ - $ - 0 Supplies & Equipment $ - $ - $ 500 0 Travel &Training $ - $ - $ - 0 Other Expenses: $ 148 $ - $ - 0 Total Program Expenses 7$ ,M8,8811 $ 52,000 $ 39,000 -25% SURPLUS/(DEFICIT) FOR PERIOD: 1 $ 12,269 1 $ - I $ - I 0 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Youth Community Project Actual Estimated Projected Percent AGENCY REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 44,734 $ 19,773 $ 5,000 -75% Agency Generated Revenue (fees) $ - $ - $ - 0 Local Government Grants: Human Services -Town of Carrboro $ - $ 1,000 $ 2,500 150% Other- Town of Carrboro $ - $ - $ - 0 Human Services -Town of Chapel Hill $ - $ 4,675 $ 7,000 50% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services - Orange County $ - $ 4,675 $ 15,000 221% Other- Orange County $ - 1 $ - 1 $ - 0 Other- Town of Hillsborough $ - 1 $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government (CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ 25,000.00 $ 53,000.00 $ 52,000.00 $ (0.02) Other Revenue $ - $ - $ - 0 Total Agency Revenue 1 $ 69,7341 $ 83,123 1 $ 81,500 -2% AGENCY EXPENSES Compensation $ 52,277 $ 69,000 $ 76,280 11% Rent& Utilities $ 6,816 $ 316 $ - -100% Supplies & Equipment $ 950 $ - $ - 0 Travel &Training $ - $ 3,100 $ 4,500 45% Other Expenses: Adminstrative/Programming $ 8,717 $ 720 $ 720 0% Total Agency Expenses $ 68,760 $ 73,136 1 $ 81,500 1 11% SURPLUS/(DEFICIT) FOR PERIOD: $ 975 $ 9,987 $ - -100% FY 2015-16 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID:3457204A-7765-4E36-8842-227F6F673AF6 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Youth Organizing and Leadership Development Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ - $ - $ - 0 Program Generated Revenue $ - $ - $ - 0 Local Government Grants: Human Services-Town of Carrboro $ - $ 129 $ 750 483% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ 611 $ 2,250 268% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services- Orange County $ - $ 611 $ 4,500 637% Other-Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ - $ 3,000.00 $ - $ (1.00) Other Revenue $ - $ - $ - 0 Total Program Revenue $ - $ 4,350 $ 7,500 72% PROGRAM EXPENSES Compensation $ - $ 3,000 $ 5,400 80% Rent&Utilities $ - $ - $ - 0 Supplies & Equipment $ - $ - $ - 0 Travel &Training $ - $ 1,350 $ 2,100 56% Other Expenses: $ - $ - $ - 0 Total Program Expenses r$ ,- $ 4,350 1 $ 7,500 1 72% SURPLUS/(DEFICIT) FOR PERIOD: 1 $ - I $ - I $ - I 0 DocuSign Envelope ID:3457204A-7765-4E36-8842-227F6F673AF6 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Youth Art Exhibitions Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ - $ - $ - 0 Program Generated Revenue $ - $ - $ - 0 Local Government Grants: Human Services-Town of Carrboro $ - $ - $ 200 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ 550 0 Other-Town of Chapel Hill $ - $ - $ - 0 Human Services- Orange County $ - $ - $ 1,250 0 Other-Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ - $ - $ - 0 Other Revenue $ - $ - $ - 0 Total Program Revenue $ - $ - $ 2,000 0 PROGRAM EXPENSES Compensation $ - $ - $ 1,750 0 Rent&Utilities $ - $ - $ - 0 Supplies & Equipment $ - $ - $ 250 0 Travel &Training $ - $ - $ - 0 Other Expenses: $ - $ - $ - 0 Total Program Expenses r$ ,- $ 1 $ 2,000 1 0 SURPLUS/(DEFICIT) FOR PERIOD: 1 $ - I $ 1 $ - I 0 DocuSign Envelope ID:3457204A-7765-4E36-8842-227F6F673AF6 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Reintegration Support Network Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 5,150 $ 1,000 $ 1,000 0% Program Generated Revenue $ - $ - $ - 0 Local Government Grants: Human Services-Town of Carrboro $ - $ - $ 800 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ 2,200 0 Other-Town of Chapel Hill $ - $ - 0 Human Services- Orange County $ - $ - $ 10,000 0 Other-Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ 26,000.00 $ 51,000.00 $ 25,000.00 $ (0.51) Other Revenue $ - $ - $ - 0 Total Program Revenue $ 31,150 $ 52,000 $ 39,000 -25% PROGRAM EXPENSES Compensation $ 18,733 $ 52,000 $ 38,500 -26% Rent&Utilities $ - $ - $ - 0 Supplies & Equipment $ - $ - $ 500 0 Travel &Training $ - $ - $ - 0 Other Expenses: $ 148 $ - $ - 0 Total Program Expenses 7$ ,M8,8811 $ 52,000 $ 39,000 -25% SURPLUS/(DEFICIT) FOR PERIOD: 1 $ 12,269 1 $ - I $ - I 0 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME LGBTQ Youth Community Building Initiatives Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ - $ - $ - 0 Program Generated Revenue $ - $ - $ - 0 Local Government Grants: Human Services-Town of Carrboro $ - $ - $ 750 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ 264 $ 2,250 752% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ - $ - $ - 0 Other-Orange County 1 $ - 1 $ 2,529 1 $ 4,500 78% Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ - $ - $ - 0 Other Revenue $ - $ - $ - 0 Total Program Revenue $ - $ 2,793 $ 7,500 169% PROGRAM EXPENSES Compensation $ - $ 1,443 $ 5,500 281 Rent& Utilities $ - $ - $ - 0 Supplies& Equipment $ - $ - $ - 0 Travel &Training $ - $ 1,350 $ 2,000 48% Other Expenses: $ - $ - $ - 0 Total Program Expenses $ - $ 2,793 $ 7,500 169% SURPLUS/(DEFICIT) FOR PERIOD: I $ - - Is - 1 0 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 EXHIBIT"B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Youth Community Project Program Name: 1. Youth Leadership Development: Youth Board and Freedom School 2. Youth Artists Exhibitions 3. Reintegration Support Network 4. LGBTQ Youth Community Building Initiatives: Fluid Revolutions, Queer Youth Drop In Funding Award: $7,038 Outline how the agency will spend Orange County's funding award. Expense Description Amount Compensation(YOLD=$1,140;YAE=$385;RSN=$3,384;LGTBQ YCBI=$1,097) $6,006 Rent&Utilities $0 Supplies&Equipment(YAE=$55;RSN=$135) $190 Travel&Training(MOLD=$442;LGTBQ YCBI=$400) $842 Other Expenses: $0 Total $7,038 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Youth Community Project will conduct its 2'annual youth organizing and leadership development camp based on Youth Organizing Institute's Summer Freedom School model with Street Scene Teen Center (SSTC) and Beat Making Lab (BML). The camp will educate youth aged 14 to 18 around four subjects: organizing skills, political analysis, restorative justice and young people's movement history. YCP will run the program for two weeks in July of(altered from original proposal to 2018 to align with other programs and organizations collaborating with this initiative—program will now have a number of activities throughout the year leading up to the July event). This will be executed by YCP's paid staff with limited assistance from YCP's board and paid staff from SSTC and BML. • The annual Youth Arts Exhibition at the Arts Center is a month-long showcase of 40 youth artists from the three CHCCS high schools, Orange County(to be added for coming year)and other local schools. This exhibit and the events that lead up to and accompany it announce to the community that new young voices are continually emerging that represent and shape the future of our community. • The Reintegration Support Network(RSN) is unique in our community as a program that focuses on aftercare for area youth who have gone through substance abuse and/or mental health treatment programs. The targeted youth often have also been involved with the juvenile justice system or as teens in the adult justice system. RSN surrounds each enlisted youth and their parents/guardians with a circle of supervised, screened adult volunteers(mentors)that use tailored, structured approaches which enable each youth to engage in 8 life domains and build on their strengths to solidify a lasting recovery(goal of 6-8/yr for completion of 52 week program). RSN, a program of the Youth Community Project DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 (YCP),unites families, staff,professionals and communities to create opportunities,routines and networks invested in each youth's healthy future. • Queer Youth Drop In is an open program that fosters friendships among queer and/or transgender youth to break down the sense of isolation and loneliness. QYDI gives youth a supportive environment to have fun and relate their experiences to similar others who can affirm and support them in an atmosphere that moves beyond how hard it is to be queer and/or trans in our community. Fluid Revolutions Queer Youth Circus provides queer and trans youth with a space for artistic expression,athletic activity,and political-social discussion through aerial arts such as silks,trapeze, and lyra. FR meets weekly for aerial rehearsal and then political discussions. 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 A caveat: The following is based on 100%of the funding requested. While we will still strive to meet these measures,funding received 45%of requested)may limit results compared to anticipated results. YOLD: Create youth organizing leaders on social Youth will have recorded lessons from camp and justice issues that affect youth. created a system to keep each other accountable on issues. YOLD:Develop skills of 15 youth organizing leaders Youth will have filled out evaluations for workshops, on social justice issues that engage in organizing and participated in quizzes,gone through mock situations, action affect their peers in the 12 months following the and written about their experiences and thoughts in program. journals. YOLD: 15 youth will demonstrate leadership among Youth will complete at least 5 collaborative projects their peers and within the greater community and ability with other youth-serving organizations.Youth will to communicate complex social and political issues. hold meetings with community leaders and plan/attend events to educate the community about their needs and advocate for youth.Youth will build on the previous relationships made and seek opportunities to engage new stakeholders in their advocacy efforts. YAE: Involvement at the planning coalition level from 80 art pieces will be viewed by 400 gallery attendees students across CHCCS and Orange County Schools. and youth artists will be further transformed through Qualitative feedback from youth regarding what they connections to buyers or to future art projects due to learned and a shift in their behavior ranking for how the visibility of their pieces. likely they would be to submit their work to an art exhibit before and after this experience. Organizers will develop and/or supplement an ongoing list of"lessons learned"related to conducting a successful art exhibition to be used in future years' exhibitions. RSN: We will have documented the number of Will have recruited and engaged 48 volunteers engaged in supervised recovery support for mentors/volunteers. youth,parents,and program director. RSN: Collect data from weekly encounter logs from Program will recruit 12 recovering youth 8 of whom volunteers,youth,parents,and program director as well will fully engage as mentees in the program. as pre-and post-assessments from youth using screening and assessment tools. DocuSign Envelope ID:3457204A-7765-4E36-8842-227F6F673AF6 Performance Measures Anticipated Results RSN: Conduct end-of-year interviews with key Continued networked with over 24 agencies,schools informants from collaborating agencies and and practitioners and developed relationships for professionals qualitatively assess connectedness, ongoing referrals.Will have conducted outreach to integration of effort,degree of coordination,goal recruit volunteers from over 20 community alignment,and mutual support. organizations and places of worship. QYD1 tracks both repeated and one-time attendance. QYDI will hold 45 90-minute meetings throughout the year plus 3 field trips to Durham,Raleigh,and HiIlsborou h and host a winter dance. FR Queer Youth Circus Camp: Enrollment of 5 youth in Enrollment of 15 youth in the camp and an hour and a the camp and a half hour long performance for fiends half long performance for friends and family at the and fain il y at the end of the week. end of the week. The program director keeps a journal of notes from Beginner students will advance to intermediate while training and rehearsals documenting each individual's intermediate students become advanced and advanced progress.Youth will also choreograph 1-2 pieces for a students begin helping beginners to learn. Youth will performance. chorea ra hed pieces for a show and will perform. FR Weekly Queer Youth Circus lessons: The program director keeps a journal of notes from training and rehearsals documenting each individual's progress.Youth will also choreograph 1-2 pieces for a performance. FR Weekly Queer Youth Circus lessons:The program Beginner students will advance to intermediate while director beeps a journal ofnotes from training and intermediate students become advanced and advanced rehearsals documenting each individual's progress. students begin helping beginners to learn.Youth will Youth will also choreograph 1-2 pieces for a choreographed pieces for a show and will perform. erfonnance. FR Monthly social-political workshops:Youth will have Youth will continue leading social-political begun co-leading discussions/workshops with the workshops on their own and will incorporate these program director.Social-political issues discussed have themes into their show. been translated into a4-°-°°` -•' ~- ° ~-° anUe, �ocuSigned by. [ � Treasurer 1/2 /2018 o�eaonoso.noaaos... Certified by Title: r ��� ���� [late: glezh7 o rder's Sign tore) DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 ATTACHMENT "A" Orange County Certifications—FY 2017-18 Outside Agency Performance Agreement Chief Contact,Administrators,Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name,title,residential address;phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing,with the name, physical address,mailing address and if possible,phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not,please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. DocuSigned by: 54� 1/22/2018 Certified b Title: Treasurer Date: Y' Di&BDADBDAD44D9... _ (Provider's Signature) (Youth Community Project) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7117 DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 YOUTCOM OP ID: SLS A n° CERTIFICATE OF LIABILITY INSURANCE P03/03/2/ YYYY) 017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER Phone:919-286-7473 NAME, Dominick Huckabee Noblin Trent Fax:919-286-5170 PHONE FAX Insurance Agency A/C No EXt: A/C,No): POBox 52239 E-MAIL Durham,NC 27717-2239 ADDRESS: Sherry Sloan INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Atlantic Specialty Lines, Inc 27154 INSURED Youth Community Project INSURERB: PO Box 915 Carrboro, NC 27510 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR E LTR POLICY NUMBER MM DD YYYY MM DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY ASNNCF112308664 02/2712017 02/27/2018 DA ATORENTED PREMI ESES Ea occurrence $ 50,000 CLAIMS-MADE 7�r7 OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY 7 PRO 7 LOC $EC� AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCL D?UDE F—] N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Youth Community Program CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orange County ACCORDANCE WITH THE POLICY PROVISIONS. 200 South Cameron Street Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. 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