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2021-048-E Social Svc-Art Therapy Institute Cardinal Managed Care agreement
DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 OUTSIDE AGENCY AND CARDINAL MANAGED CARE FUNDS PERFORMANCE AGREEMENT THIS AGREEMENT,made and entered into the first day of July 2020, ("Effective Date")by and between the County of Orange, a political subdivision of the State of North Carolina, Post Office Box 8181, Hillsborough,North Carolina,27278, ("County")and Institute of Art Therapy DBA Art Therapy Institute.,a not-for-profit corporation, located at 200 N. Greensboro St., Suite D-6, Carrboro, North Carolina 27510 ("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 uAgencys_Name» agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2020 to June 30,2021. 2. Scope of Services. a. Provider will provide services to the residents of Orange County, as outlined in the attached Cardinal Managed Funds Work Statement and any amendments or revisions thereto which is attached as Exhibit A,which is incorporated by reference. The Scope of Services and the Program Budgets 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. 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. Outside Agency Funding. i. Outside Agency Funding. The County agrees to appropriate funds for the provision of services described in Exhibit B, Scope of Services and may be more particularly described in the Revised Program Budget in Exhibit B, the maximum sum of $3,877.00 in Outside Agency Funds. ii. The Provider shall be paid Outside Agency Funds in four equal installments in the amount of$969.25. 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. b. Cardinal Managed Care Funding. i. Cardinal Managed Care Funding. The County agrees to appropriate funds for the provision of services described in Exhibit A, Work Statement and may be more («Agencys_Name)>) Orange County Outside Agency and Cardinal Managed Care Fund Performance Agreement Revised 112021 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 particularly described in the Revised Program Budget in Exhibit C,the maximum sum of$27,600.00 in Cardinal Managed Care Funds. ii. The Provider shall be paid Cardinal Managed Care Funds in twelve equal monthly installments in the amount of$2,300.00.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. c. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services and Work Statement, at the discretion of the County the Provider may be required to repay the funds to the County. d. The County's obligation to make the payments is contingent upon receipt of Progress Reports and/or request for reimbursement as provided in Section 4 below, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services and Work Statement. e. Once Provider has satisfied its obligations as provided in Sections 3 and/or 4 payment will be made 21 days after receipt of the Progress Report or Request for Reimbursement. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Outside Agency Funds Reporting. Provider will provide Orange County a Quarterly Progress Report for Outside Agency funds 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 10,April 10, and July 10 of the program fiscal year. b. Cardinal Managed Funds Reporting. Provider will provide Orange County a Monthly Progress Report for Cardinal Managed Care funds that includes a fiscal report and updates on performance measures as outlined in the Work Statement. Progress Reports are due by the 151 of the next month following the month being reported. c. 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 (((Agencys Name») Orange County Outside Agency Performance Agreement Page 3 Rev. 112021 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 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 shall pay Provider that portion of the fees and expenses that it has earned to the date of termination, less any costs or expenses incurred or anticipated to be incurred by the County due to errors or omissions of the Provider. 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. 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. e. Should this Agreement be terminated,the Provider shall deliver to the County within seven (7) days, at no additional cost, all deliverables including any electronic data or files relating to the Project. f. Waiver. The payment of any sums by the County under this Agreement or the failure of the County to require compliance by the Provider with any provisions of this Agreement or the waiver by the County of any breach of this Agreement shall not constitute a waiver of any claim for damages by the County for any breach of this Agreement or a waiver of any other required compliance with this Agreement. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: («Agencys_Name)>) Orange County Outside Agency Performance Agreement Page 4 Rev. 112021 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 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. 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. S. 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. (aAgeneys_Name») Orange County Outside Agency Performance Agreement Page 5 Rev. 112021 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 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 parry without prior written consent from the County. 10. Limitation and Assignment. The County and the Provider each bind themselves,their successors, assigns and legal representatives to the terms of this Agreement. Neither the County nor the Provider shall assign or transfer its interest in this Agreement or the rights to payment to any other party without the written consent of the other. 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. Dispute Resolution.Any and all suits or actions to enforce,interpret or seek damages with respect to any provision of, or the performance or non-performance of,this Agreement shall be brought in the General Court of Justice of North Carolina sitting in Orange County, North Carolina. It is agreed by the parties that no other court shall have jurisdiction or venue with respect to such suits or actions. Binding arbitration may not be initiated by either Party,however,the Parties may agree to nonbinding mediation of any dispute prior to the bringing of such suit or action. 15. 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 $ 15 per hour. To the extent possible, Orange County recommends that Provider provide a living wage to its employees. 16. 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: County: Finance &Administrative Services Provider: Bridget Pemberton-Smith Orange County Institute of Art Therapy DBA Art Post Office Box 8181 Therapy Institute Hillsborough,NC 27278 200 N. Greensboro St., Suite D-6 Carrboro,NC (c(Agencys Name,,>) Orange County Outside Agency Performance Agreement Page 6 Rev. 112021 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 27510 17. 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. 18. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States,the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part,term or provision held to be invalid. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified,and has not utilized the services of any agent or subcontractor,on the list created by the State Treasurer pursuant to G.S. 147-86.58. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.81. 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 I IA and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WIIEREOF,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. al�q„Pehalf�of the Provider f?Vlj. rtYKbt,V'f6t&—SVK& 112712021 Bri get emberton-Smith,Institute of Art Therapy DBA Art Therapy Institute Date ,¢ � ,�tp,,iehalf of Orange County Government ))jbli,KA', �A�M►Mt,VS 1/29/2021 Bonnie ffarnin6rsley, County Manager Date (�tAgencys Name,0 Orange County Outside Agency Performance Agreement Page 7 Rev. 112021 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 ORANGE COUNTY—DEPARTMENT USE ONLY Party/Vendor Name: Institute of Art Therapy DBA Art Therapy Institute Party/Vendor Contact Person: Bridget Pemberton-Smith Contact Phone: 919-605-2081 Party/Vendor Address: 200 N. Greensboro St., Suite D-6 City Carrboro State: NC Zip: 27510 Department: Social Services Amount: $31,477 Purpose: outside agency funds + Behavioral Health MOE Budget Code(s): 10420020-710050/10495050-720109 Vendor#63288 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one)New ❑ Renewal ® Amendment ❑ Effective Date 7/l/2020 Approved by Board Yes®Non Agenda Date: 6/16/2020 This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this project has not been initiated prior to execution of the agreement: DocuSigned by: Department Director's Signature ;UA.G. cbS�bin. Date: 112712021 Agreements for emergency services or repair are not subject to the above affirmation. If services related to this agreement have already begun or been completed please briefly describe the nature of the emergency condition that was addressed: Information Technologies (Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer Date: Risk Management This agreement is approved for sufficienc i3�oystandards,specifications,and requirements: &A, cbvv�. N 112712021 Office of the Risk Management Officer ,,,F I,.- 198 Date: Financial Services This instrument has been pre-audited ' D"g2&4 equired by the Local Government Budget and Fiscal Control Act: ('b� 1/29/2021 Office of the Chief Financial Officer t-E=s-rar�e Date: Legal Services This agreement is approved as t t 2eYfd sufficiency: Office of the County Attorney ` Date; 1/29/2021 Clerk to the Board Received for record retention: All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountyne.gov The following signature block is for hard copies only and is not required for Docusign contracts: Office of the Clerk to the Board Date: &4gencys Name») Orange County Outside Agency Performance Agreement Page 8 Rev. 112021 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 Exhibit A Cardinal Managed Care Funds Work Statement (uAgencys Namev) Orange County Outside Agency Performance Agreement Page 9 Rev. 112021 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 I COVER PAGE Applicant Contact Information Applicant Organization's Legal Name_ Institu R of Art Therapy Inc_(DBA Art Therapy In .l Applicant Organization's Physical Address: 200 N. Greensboro St, D-6,S.arrboro, NC, 27510 Applicant Organization's Mailing Address: 200 N -Gre,enshoro St, D-6, Carrboro, NC, 27510 Applicant Organization's Web Address: www ncati org Executive Director: Hiller R i_�besin Telephone Number: 610-348-7215113 i I : E-Mail: hrubesin�ncati.ora ,i Tax ID Number: 26-14_47-S Eunding Req!e-st Please list all Fiscal Year 2021 Human Services (HS)funding requested for alI programs and the proposed use of funds (please list program name only) , Orange j Program Carrboro HS Chapel Hill HS Total County HS Newcomers Art Therapy Program $10,000 $10,000 $20,000 Arts and Peer Support Group $10,000 $10,000 i Totals $10,000 $10,000 $10,000 $30,000 Briefly explain your pmpo_sed use of funds: Requested funds will be used to staff the Newcomers Art Therapy Program which provides art therapy to newly arrived immigrants and refugees in CHCCS schools and local community centers. The funds will also be used to staff the Arts and Peer Support Group which provides weekly therapy to adults living with chronic and persistent mental illness in Orange County. Beyond using funds to pay our clinicians, the funds will be used to purchase art supplies for the programs, and to conduct and analyze culturally-congruent, ethical research on the program outcomes. Cover Page Page 6 of 22 I DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 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: 01/13n020 Executive Director Date v f Signature: 01t13i2020 Board Chairpers n Date __.._.__.... ....._. ----................._............._....._......__.............._.._.........._._..........._............._......__....................._ _,....__ ........ _..................._........ ............._.......-........--._......_........._..._._....._.... Cover Page P a g e 7 of 22 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 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: Y_E_S. NQ 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? i d) Paid providers of goods or services to the program or having other financial interest in the program? 3 If you have answered YES to any question, please provide a full explanation below. i 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. I 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 conflia may-reG l ink -rmination of any -gran awarded. 0111 3/2 0 2 0 Signature: Executive Director Date Signature: 0111 3/2 0 2 0 --- Board Chairper n Date I Cover Page P a g e a 0 f 2 2 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 AGENCY INFORMATION Please provide the following information about your agency: 1. Date of Incorporation (Month/Year): Se. mber 2009 2. Agency's Purpose/Mission (no more than a few sentences): To advance the well-being and mental health of diverse North Carolinians through accessible, strengths-based, culturally responsive art therapy; to further support our communities through local events and professional development opportunities; to contribute to and uphold research, theory, and practice of the creative arts therapies. 3. Please provide a brief description of your organization's past achievements in carrying out similar projects and evidence of successful record of meeting proposed budgets and timetables (no more than 100 words). The Arts & Peer Support Group has successfully met all proposed budgets and timetables since its inception in 2011. We have secured and successfully implemented grants from various foundations, including the Mary Duke Biddle Foundation, the Strowd Roses Foundation, Duke's Doing Good Fund, and the American Endowment Foundation, among others, to help support this arts- and community-based program for adults living with severe and persistent mental illness. Our careful stewardship of funds over the past nine years has enabled us to run one of the only free, weekly, non- insurance-based arts groups for adults living with mental illness in Orange County, 4. Living Wage Does this agency pay permanent employees a minimum living wage-? (Yes/No) Yes If yes, is this agency an (Jrarlae County Living Wage Certified Employer?Yes If no, please briefly explain. Schedule of Positions: # of FTE — Full-Time Paid Positons: A # of FTE—Part-Time Paid Positions: 7 PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. 5. Program Name: Arts and Peer Support Group Program Primary Contact and Title: Hillary Rubesin, Executive Director Telephone Number: 610-348-7253 E-Mail: hrubesi ncati.ora _..._. ....................._.__..... ......................._........-...................... .... ........._.... Program information P a g e 9 o f 2 2 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 G 6. Please briefly describe the proposed program, including an explanation of how it aligns with the Town of Chapel Hill and Carrboro's-Results_Eram.e-W-Qrk, and Oran nty E30CC Goals and Priorities, and the target population to benefit from the program. (100 words or less) The Arts and Peer Support Group (APS) is a collaboration between ATI, UNG School of Social Work, and various local artists and galleries focused on building a community- based network that provides basic mental healthcare and wellness support to Orange County residents. The majority of participating adults live below the poverty line; are socially isolated; suffer from physical and mental health concerns; and are unable to afford integral mental health services like group therapy. Understanding these realities, APS has been free to participants since inception. Orange County funding would help pay program therapists, purchase art supplies, and support research efforts. 7. Target Population: Please complete the table below with numbers (not percentages) of individuals served and projected to be served. Program Target Population Demographics Projected Actual Projected Projected 2018-19 2018-19 2019-20 2020-21 Gender Men 5 7 8 10 Women 20 18 24 25 Nonbinary/Genderqueer 7 7 8 10 Self-Describe Total 32 32 40 45 Race and Ethnicity Black or African-American 4 8 5 10 American Indian or Alaska Native i Asian 1 = Caucasian 25 21 30 30 Native Hawaiian or other Pacific Islander Two or more races 1 Some other race 3 2 5 5 Total 32 32 40 45 Of the above, how many Hispanic/Latino 1 1 5 5 Of the above, how many non-Hispanic/Latino 31 31 35 40 Total 32 32 40 45 1 l ......._.. ........ -..........--- --..._.._......_.......... ... ........__._.. - ......._....._........... ---- ----- Progran7 in ontiat-ion P a g e 10 of 22 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 Age 0-5 years 6-18 years 2 2 4 5 19-50 years 19 28 30 35 51+ years 11 2 6 5 Total 32 32 40 45 Geographic Location Town of Chapel Hill 12 10 15 10 Town of Carrboro 10 12 15 15 Orange County (outside of Chapel.Hill/Carrboro) 5 6 5 10 Outside of Orange County 5 4 5 10 Total 32 32 40 45 Income Low-income (80% of the Area Median Income and 27 27 32 35 Below) Please see income table in the attachments Total 27 27 32 35 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 2018-19 Projected 2019-20 Projected 2020-21 Total Cost of Program $10,580.00 $12,500.00 $13,080.00 Total # of Individuals 32 40 45 Cost Per Individual $330.63 $312.50 $290.67 9. Performance Indicators For Chapel Hill and Carrboro applicants: Please complete the following chart with information about the Strategic Objective, Intermediate Result, and the Agency Performance Indicator for each program for which you are applying for funding. Please see the Results Framework in the Attachments section as a reference. Program Name: NIA ❑ Children improve their educational outcomes Strategic Objective (please choose ❑ Residents Increase their livelihood security one from the Results Framework) ❑ Residents improve their health outcomes . � ° _......... ..........._._............._..__.............._....................................... . ... ..... .................--........_........--._..._.................................................................._.._,..__............__...._....._............................ Program information Page 11 of 22 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 3 1 Intermediate Result (please choose one from the Results Framework) RESULTS Actual Projected Projected 2018-19 2019-20 2020.21 Performance Indicators ❑ Children improve their educational outcomes Strategic Objective (please choose ❑ Residents Increase their livelihood security one from the Results Framework) ❑ Residents improve their health outcomes -211-10 Intermediate E Result (please choose one from the Results Framework) ' coal Projected 1 }� [ 5 _ � x Performance Indicators 3 7 1 i i i .............._...-..._._._._......__.... - --........... ..---......._._._......----•..•_.........-.._.._....-.-. ............ ......._._.._._......._........._.__._........ Prograrn information P a g e 12 o f 2 2 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 Outside Agencies/Human Services Please use the drop down menu below to select which function area best aligns with your agency and program(s) in which you are requesting funding. Please.Gel _ only one from the d mp_down mE nu be_lovv_ Behavior Health If you selected other, please tell us what function area best aligns with your organization: N/A Please indicate three program goals/performance measures below, A few notes: ® If you use percentages, please put the actual number equivalence. ® Please ensure your performance measures are outcome based and not outputs. Ensure a community network of basic human services Program Goal # 1 and infrastructure that maintains, protects, and promotes the well-being of all county residents Performance Measure Residents access basic health care services (primary, (How will you accomplish behavioral, dental), as evidenced by the number of your goal?) group participants. 100% (32 people) of APS participants in 2019-20 will report having access to free, behavioral group Actual Results healthcare through ATI. (Outcome) Ending FY18-19 (This program was not funded through Orange County in 2018-2019; however we still recorded demographics.) Projected Results 100% (40 people) of APS participants in 2019-20 will (Outcome) report having access to free, behavioral group Ending FY2020 healthcare through ATI. Projected Results 100% (45 people) of APS participants in 2020-21 will (Outcome) report having access to free, behavioral group Ending FY2021 healthcare through ATI, ...._.._......--...............---...............-.-.................. ...... _..._. ........._................_---...-................................_.....- ...- __..........._...-................-..._._._....-.........._................-... _...-..._.._._.. Program information Page 13 of 22 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 Outside Agencies/Human Services Ensure a community network of basic human services Program Goal#2 and infrastructure that maintains, protects, and promotes the well-being of all county residents Performance Measure Residents demonstrate new healthy lifestyle behaviors (How will you accomplish as evidenced by responses on a self-report survey. your goal?) Actual Results N/A (Program was not funded through Orange County (Outcome) , in 2018-2019, so this goal was not measured.) Ending FY18 19 - Projected Results 75% (30/40 people) will report healthier functionality (Outcome) and lifestyle behaviors on APS participant survey, as Ending FY2020 well as report learning and implementing at least one new wellness goal 75% (34/45 people) will report healthier functionality Projected Results and lifestyle behaviors on APS participant survey, as (Outcome) well as report learning and implementing at least one Ending FY2021 new wellness goal Ensure a community network of basic human services Program Goal # 3 and infrastructure that maintains, protects, and promotes the well-being of all county residents Performance Measure Residents will learn about and know how to connect (How will you accomplish with community-based resources (housing, food, legal your goal?) services, etc.) that help ensure asocial safety net, as evidenced by responses on a self-report survey. Actual Results N/A (Program was not funded through Orange County (Outcome) in 2018-2019, so this goal was not measured.) Ending FY18-19 75% (30/40 people) will report feeling connected to and Projected Results knowledgeable about outside resources (housing, food, (Outcome) legal services, etc.)that help ensure a social safety for EndingFY2020 some of our county's most marginalized and under- resourced communities. 75% (34/45 people) will report feeling connected to and Projected Results knowledgeable about outside resources (housing, food, (Outcome) legal services, etc.) that help ensure a social safety for 7 Ending FY2021 some of our county's most marginalized and under- resourced communities. .._..._........___ __.__ __ _ _._..__........_.__ ...... _._.._._...__._.._ Program information P a g"e 14 o f 22 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 1 L ,J_.... M_-____.LJ_ Agency Budget -� ���� •�� -, � _�_ � _ ---- Operating Budget for Program PROGRAM NAME: -- Institute of Art Therapy Annual Budget - ��-- Actual Estimated Projected Percent PROGRAM REVENUE _ 2018-19 2019-20 2020.21 Chan e Private Donations $ 35,402 $ 40,000 $ 40,000 0% Program Generated Revenue _ $ 196,448 $ 225,000 $ 250,000 11% _ nt Grants:Local Government- Human Services-Town of Carrboro $ 6,000 $ 5,400 $ 10,000 85% _ Other-Town ofCarrboro $ - $ $ 0 m Human Services-Town of Chapel Hill _ $ 3,000 $ 5,000 $ 1moo 100% _ Other-Town of Chapel Hill $ $ - $ 0- Human Services-Oran a ountX $ 3,300 $ 3,877 $ 10,000 158%M -v Other-Orange Count 27,600 $ 27 600 $ 27 600 0% Other-Town of Hillsborou h $ - $ - $ - 0 Other Government Grants Triangle United Way $ $ $ 0 State Government $ $ $ 0 Federal Government(CDBG/HOMFJetc.) -- $ $ $ 0 Private Foundation Grants1$ 59,800.00 $ 60,000.00 $ 60,000.00 $ - Other Revenue $ $ Is 0 Total Program Revenue $ -330,550, $ 366,877 $: 407,600 11% l PROGRAM EXPENSES Corn ensation - _ $ 232,589 $ 330,000 $ 340,000 3% -----___ _ Rent&Utilities $ 15,475 $ 16,800 $ 18,000 7% Su lies&Equipment _-__ _ $ 5,206 $ 6 000 $ 6,000 0% �- Travel&Trainin_ _ _ $ 598 $ 1,000 $ 1,000 0% Other Expenses., -� _ $ 33,386 $ 30,000 $ 35,000 17% _ Total Program Expettaes $ °287,254' $ 383,800 $ 400,000 45o �^ I SURPLUS/(DEFICIT)FOR PERIOD' $ 43,296 $ 16,923 $ 7,600 145% _ { Please explain Other Grants:Every year,we have received small grants from various local and national foundations,Including the _ American Endowment Foundation,the Longleaf Foundation,the NOVO foundation, the Triangle Community Foundation,and i various private family foundations, Does your program budget show a surplus or deficit? Please provide a brief explanation for the surplus or deficit:We should run on a small surplus for the upcoming year if all of our program revenue comes in as expected.We operated on a small deficit last year because we were finally compensating our staff with more competitive wages and health stipends.We raised more move during the previous year 2018-2019 seeclficallyio implement this plan, 1. , i F E 1 1 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 Exhibit B Provider's Outside Agency Funds Revised Scope of Services and Program Budget ((eAgeneys_Vame») Orange County Outside Agency Performance Agreement Page 10 Rev. 112021 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 EXHIFBIT`B" Scope of Services—FY 2020-21 Outside Agency Performance Agreement Agency Name: The Art Therapy Institute(MOE Funds) Program Name: Newcomers Art Therapy Program (NATP) Funding Award: $27,600 Outline how the agency will spend Orange County's funding award. Expense Description Amount Therapy Servicas(payment for clinical services of uninsured child clients,adult clinic clients and refugee women's group;cultural training of clinicians;clinical supervision of NATP clinicians) $16,600 Interpreter costs(payment of interpreter services for all NATP needs) $10,000 Additional program cost:research and evaluation $1000 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2021. Provide individual art therapy services to uninsured newcomer children in CHCCS and Orange County schools;Provide individual therapy sessions to newcomer adults referred by • Piedmont Health services;Provide group art therapy services to to refugee women from Burma in the community;Provide appropriate Interpreter services as needed for therapy sessions • Provide ongoing training and supervision to NATP clinicians in cultural competency,cultural humillty and cultural safety. • Conduct culturally-congruent research and evaluation of NATPto assess and improve program outcomes. 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 von 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 AT]will reach at least 35 newcomers in Orange County through both individual and group therapy 35 services (Served weekly or monthly throughout the year)as evidenced by agency records of attendance. Newcomers ATI will hire interpreters to serve at least 75 newcomer clients during the 75 20-21 fiscal year, as evidenced by agency records of number of Newcomers newcomer clients served by interpreters. ,,¢¢ Title:DocuSigned by: Certified by: I/t t ��wt(4t,VfblA.—Swtl Executive Director Date: 1/27/2021 (Provider's Electronic Signature) "You will sign this document electronically with your performance agreement. DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 EXHIBIT`B" Scope of Services—FY 2020-21 Outside Agency Performance Agreement Agency Name: The Art Therapy Institute Program Name: Arts and Peer Support Group Funding Award: $3877 Outline how the agency will spend Orange County's funding award. Expense Description Amount Clinical compensation for licensed art therapists $3000 Supplies and Equipment(art supplies) $377 Research and evaluation of project $500 Program Services Outline the critical set-vices(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2021. Provide free,community-based group art therapy services to local adults living with severe and persistent mental illness,providing appropriate • and high quality art supplies for program activities. • Provide one 1-hour group per week, with at least two licensed clinicians present. • Conduct ethical, participatory research and evaluation to assess and improve program outcomes. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Oran e County,only(all Towns and municipalities). If you use percentages you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results 100% of participants (45 residents) will have access to free weekly behavioral 45 health services residents/y ear 75% of participants (34/45 people) will report healthier functionality and lifestyle 34 behaviors on APS participant survey as well as report learning and people/year implementing at least one new wellness goal 75% (34/45 people) will report feeling connected to and knowledgeable about outside 34 resources (housing, food, legal services, etc) that help ensure a social safety net for people/year some of our county's most marginalized and under-resourced communities DocuSigned by: Certified by: �jVld PVMbt,V'�"bla—S►�t{✓t Title: Executive Director Date: 112712021 E$��EE�a+s (Provider's Electronic Signature) "You will sign this document electronically with your performance agreement. DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 ATTACHMENT "A" Orange County Certifications—FY 2021 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. , .D''ocuSigned by: ''II f ` pt,�M V'bvu—sw�lTu Executive Di rector 1/27/2021 Certified by: Title: Date: (Provider's Signature) trAgencys Name»)' Orange County Outside Agency Performance Agreement Page 12 Rev. 112021 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 DATE(MM/DD/YYYY) ACCV?" CERTIFICATE OF LIABILITY INSURANCE 03/31/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: _ Affinity Insurance Services Inc HONK Ext: 8 -3214 FAX c No): 847-953-2700 1100 Virginia Drive, Suite 250 ADDRIESS: Fort Washington,PA 19034 _ INSURER(S)AFFORDING COVERAGE NAIC# INSURER A; CM 20427 INSURED INSURER B; Institute of Art Therapy, Inc. dba The Art Therapy Institute INSURER C: 200 N Greensboro St, Ste D6 INSURER D: Carrboro, NC 27510 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 I ADDL SUER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE p POLICYNUMBER MM/DD/YYYY MMIDO COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 DAMAGE A X OCCUR IRERENTED SES B CLAIMS-MADE a ocou ante $ General Liability X MED EXP(Any one person) $ 411940881 04/01/2020 04/01/2021 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 3,000,000 PRO POLICY❑JECT FI LOC PRODUCTS-COMP/OP AGG $ OTHER; AUTOMOBILE LIABILITY E.COMBINED c 6en'SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB _C__LAIMS-MADE AGGREGATE $ DED RETENTION$ PER $ WORKERS COMPENSATION S_T_ATUTE �R _ AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICEPJMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L,DISEASE-POLICY LIMIT $ A Per Claim $1,000,000 Professional Liability 411940881 4/01/2020 04/01/2021 $3,000,000 Aggregate DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Sexual Misconduct Limits: $1,000,000 per claim/2,000,000 aggregate Additional Insured: County of Orange State of NC, 200 S Cameron St., Hillsborough, NC 27278 CERTIFICATE HOLDER CANCELLATION County of Orange State of NC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 200 S Cameron St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hillsborough, NC 27278 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 Institute of Art Therapy ERIE INSURANCE COMMERCIAL GENERAL LIABILITY CG 20 12(Ed.4/13)OF-9669 POLICY NUMBER:Q41 0451038 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: Orange County, its officers, official agents and employees Information required to complete this Schedule,if not shown above,will be shown in the Declarations. A. Section H—Who Is An Insured is amended to include as 2. This insurance does not apply to: an additional insured any state or governmental agency or subdivision or political subdivision shown in the Schedule, a. "Bodily injury", "property damage" or "personal subject to the following provisions: and advertising injury" arising out of operations performed for the federal government, state or 1. This insurance applies only with respect to operations municipality;or performed by you or on your behalf for which the state b. "Bodily injury" or "property damage" included or governmental agency or subdivision or political within the"products-completed operations hazard". subdivision has issued a permit or authorization. However: B. With respect to the insurance afforded to these additional insureds,the following is added to Section III—Limits Of a. The insurance afforded to such additional insured Insurance: only applies to the extent permitted by law;and If coverage provided to the additional insured is required b. If coverage provided to the additional insured is by a contract or agreement,the most we will pay on behalf required by a contract or agreement, the insurance of the additional insured is the amount of insurance: afforded to such additional insured will not be broader than that which you are required by the 1, Required by the contract or agreement;or contract or agreement to provide for such 2. Available under the applicable Limits of Insurance additional insured. shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. ©Insurance Services Office,Inc.,2012 1 DocuSign Envelope ID:8C3AC364-2OA8-477A-92A7-8FBD4923E2DO Erie CERTIFICATE OF INSURANCE DATE ISSUED(MM/DD/YY) 1 nsurance® —THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY— v19/21 Home Office - 100 Erie Insurance Place • Erie,Pennsylvania 16530 • 814.870,2000 Toll free 1.800.458.0811 • Fax 814.870.3126 • wwv✓.erleinsurance.com NAME AND ADDRESS OF AGENCY AFFINITY INSURANCE GROUP AGENT'S NO. 800 W WILLIAMS ST STE 231H C ERE NS A C 0 PANY JJ3788 Co.:D ER E INS RAN E PROPERTY&CASUALTY COMPANY APEX,NC 27502-5204 Co.:E ErjIE INSURANCE EXCHANGE Not Applicable r e Indemnl Co, ttorne -in-Fact in NY INSURANCE COMPANY OF NEWYORK (919)296-3787 Co,v G FLAGSHIP CITY INSURANCE COMPANY This certificate is issued for information purposes only and confers NAME AND ADDRESS OF NAMED INSURED no rights on the certificate holder. It does not affirmatively or negatively amend,extend,or otherwise alter the terms,exclusions INSTITUTE OF ART THERAPY and conditions of insurance coverage contained in the polfcy(ies) 200 N GREENSBORO ST,Unit#D-6 indicated below.The terms and conditions of the policy(ies)govern the insurance coverage as applied to any given situation.Limits CARRBORO,NC 27510-1838 shown may have been reduced by claims paid.This certificate of insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer and the certificate holder. This is to certify that policies,as Indicated by the Policy Number below,are in force for the Named Insured at the time that the Certificate is being issued. LTR GO Add I TYPE OF INSURANCE POLICY NUMBER LIMITS E FX-]GENERAL LIABILITY 5/4/20 5/4/21 EACH OCCURRENCE 1,0001000 FM COMMERCIAL GENERAL LIABILITY Q41 0451038 FIRE DAMAGE(Any One Fire) 1,000,000 ❑CLAIMS MADE © OCCUR MED EXP(Any One Person) 5,000 ❑ PERSONAL&ADV.INJURY 1,000,000 ❑ GENERAL AGGREGATE 2,000,000 GENTAGGREGATE LIMITAPPLIES PER: PRODUCTS-COMP/OPAGG 2,000,000 ❑POLICY X❑PROJECT ❑LOG ❑ AUTOMOBILE LIABILITY BODILYINJURY ❑ "ANYAUTO"(NON D HIRE , (EACH PERSON) $ ❑ A OWNED E HLACCIDENT) $ ❑ HIRED PROPERTYDAMAGE $ ❑ NON-OWNED BODILYINJURYAND ❑ GARAGE PRO COMBINED AGE $ ❑EXCESS LIABILITY EACH OCCURRENCE $ ❑ OCCURRENCE AGGREGATE $ ❑ RETENTION $ $ E WORKERS COMPENSATION& STATUTORY g9 5400347 5/4/20 5/4/21 EMPLOYERS LIABILITY Q BODILY ACCIDENT $ 100,000 EACH ACCIDENT INJURY DISEASE $ 500,000 POLICY LIMIT BY DISEASE $ 100,000 EACH EMPLOYEE OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Orange County,its officers,official agents and employees as an additional insured on the General Liability Policy,form CG2012.Included is a Workers'Compensation Waiver of Subrogation. County shall be notified at least 30 days in advance of cancellation or material change in coverage. CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIV- ERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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). NAME AND ADDRESS OF CERTIFICATE HOLDER Orange County AUTHORIZED REPRESENTATNE Attn:Risk Management 7 200 South Cameron Street Hillsborough,NC 27278 EIG6230 8/11 Page 1 of 2 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 LONG NAME INSURED: INSTITUTE OF ART THERAPY ART THERAPY INSTITUTE OF NC DB/A 200 N GREENSBORO ST,Unit#D-6 CARRBORO,NC 27510 COMPLETE NAME AND ADDRESS OF CERTIFICATE HOLDER OR ADDITIONAL INSURED: Orange County Attn:Risk Management 200 South Cameron Street PO Box 8181,Hillsborough,NC 27278 EIG6230 8/11 Page 2 of 2 DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 ERIE INSURANCE WORKERS COMPENSATION AND EMPLOYERS LIABILITY WC 00 03 13(Ed. 1/86)OF-8641 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule.This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us. This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. Schedule "Organizations for which the Named Insured has agreed to by written contract executed prior to the loss to furnish waiver" 01984 National Council on Compensation Insurance,Inc. 1