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HomeMy WebLinkAbout2024-545-E-DEAPR-Dr. Charles van der Horst Water Safety Initiative-Outside Agency Performance AgreementOrange County Outside Agency Performance Agreement Revised 06/23—County Manager Version Page 1 of 10 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2024, (“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 Dr. Charles Van Der Horst Water Safety Initiative, a not-for-profit corporation, located at 1821 Hillandale Road, Suite aB #126, Durham, North Carolina 27705 (“Provider”). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners. NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Provider agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2024 to June 30, 2025. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit “A” and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of $9141. b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of $2285.25. 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. 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. Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 Orange County Outside Agency Performance Agreement Page 2 of 12 Rev.06/24 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 7, April 7 and July 7 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. Termination for Cause. 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. 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 Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 Orange County Outside Agency Performance Agreement Page 3 of 12 Rev.06/24 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. 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. Responsibilities of the County. Cooperation and Coordination. The County has designated (Ardra Webster) to act as the County's representative with respect to the Project who shall have the authority to render decisions within guidelines established by the County Manager or the County Board of Commissioners and who shall be available during working hours as often as may be reasonably required to render decisions and to furnish information. 7. 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. Cyber Liability. For protection from claims resulting from data breach, virus, and cyberattack; iii. 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; iv. Comprehensive Automobile Liability Insurance, including hired and non-owned vehicles, if any, covering personal injury or death, and property damage; and v. 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. vi. Sexual Misconduct. Sexual Abuse/Molestation Insurance is required when Provider works directly one-on-one with children, elderly or other at-risk populations. 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 ‐ Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 Orange County Outside Agency Performance Agreement Page 4 of 12 Rev.06/24 Statutory State NC, for each employee Limits for Coverage B ‐ Employers Liability of: $1 million Each Occurrence $1,000,000 BID limit  Cyber Liability $1,000,000 Each Occurrence; $2,000,000 Aggregate *Only required for agencies transmitting personal identifiable information that is disseminated electronically.  Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate  Automobile Liability $1,000,000 Each Occurrence *Only required for agencies doing travel as part of the agreement with the County.  Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate  Sexual Misconduct $1,000,000 Each Occurrence $2,000,000 Aggregate *Only required for agencies doing direct work with minors (under the age of 18). 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. For more information see the Orange County Risk Transfer Policy and Orange County Minimum Insurance Coverage Requirements, (each document is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php.) 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. 8. General Provisions. 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 identified, 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 Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 Orange County Outside Agency Performance Agreement Page 5 of 12 Rev.06/24 any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.81. b. 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, which is incorporated herein by reference and can be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php. The County may enforce this provision by an 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. c. 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. d. 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 Orange County Living Wage Policy, which is incorporated herein by reference, can be viewed at: http://www.orangecountync.gov/departments/purchasing_division/contracts.php. The County’s living wage is $17.65 per hour. To the extent possible, Orange County recommends that Provider provide a living wage to its employees. e. 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. There are no third party beneficiaries of this Agreement and nothing in this Agreement, express or implied, is intended to confer on any person other than the parties hereto (and their respective successors, heirs and permitted assigns), any rights, remedies, or obligations. f. 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. g. 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. Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 Orange County Outside Agency Performance Agreement Page 6 of 12 Rev.06/24 h. 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. i. 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. j. 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. k. 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. l. Entire Agreement. This Agreement represents the entire and integrated agreement between the County and the Provider and supersedes all prior negotiations, representations or agreements, either written or oral. This Agreement may be amended only by written instrument signed by both parties. Modifications may be evidenced by facsimile signatures. m. Notices. Any notice required by this Agreement shall be in writing and delivered by certified or registered mail, return receipt requested to the following: Orange County Provider’s Name Dr. Charles van der Horst Water Safety Initiative Attention: Ardra Webster Attention: Dr. Jonathan E. Klein P.O. Box 8181 Address: 1821 Hillandale Road, Suite 1B #126 Hillsborough, NC 27278 Durham, NC 27705 Email:awebster@orangecountync.gov Email: jonathan.klein@swimforcharlie.org n. 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 and on behalf of the Provider _____________________________ _______________________ Dr. Jonathan Klein, Executive Director Date Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 8/27/2024 Orange County Outside Agency Performance Agreement Page 7 of 12 Rev.06/24 For and on behalf of Orange County Government _______________________________ ________________________ Travis Myren, County Manager Date Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 9/12/2024 Orange County Outside Agency Performance Agreement Page 8 of 12 Rev.06/24 ORANGE COUNTY—INTERNAL USE ONLY ______________________________________________________________________________ Finance Information Vendor Name: Dr. Charles van der Horst Water Safety Initiative Vendor Contact Person: Dr. Jonathan Klein Phone: 919-260-0089 Address: 1821 Hillandale Road, Suite 1B #126 City Durham State: NC Zip: 27705 Department: DEAPR Amount: $9141 Purpose: Outside Agency Performance Agreement Budget Code(s): 10290050 719105 Vendor # 68113 Vendor Status with NCSOS: Vendor is a BOCC consultant: Yes No Contract Details Contract Type: New Amendment (Original Contract: ) (Most Recent Amendment ) Effective Date July 1, 2024 End Date June 30, 2025 Notice Date (Notice Purpose ) Award Approved by Board (Agenda Date: June 18, 2024); Made or Administered by Signature Authority - BOCC Express Delegation (Agenda Date: ) -Policy 9.4:Under $5,000; Service Under $90,000; Construction Under $250,000 - Budget Policy Section XV (Capital Improvement Project: ) Bidding Informal Bidding ($30k-$90k); Formal RFP ($90k+); Other (<$30k); Exception(# ) Department Affirmation 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. This agreement is approved as to technical form and content. Services related to this agreement have already begun or been completed. Description of the nature of the emergency condition that was addressed: Department Director’s Signature ________________________________________ Date: ________ Information Technologies This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer___________________________________ Date: ________ Inapplicable because no hardware/software purchases or related services Risk Management This agreement is approved for sufficiency of insurance standards, specifications, and requirements: Office of the Risk Management Officer___________________________________ Date: _________ Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: Office of the Chief Financial Officer ____________________________________ Date: _________ Legal Services This agreement is approved as to legal form and sufficiency: Office of the County Attorney __________________________________________Date: ________ Clerk to the Board All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov The following signature block is for hard copies only and is not required for Docusign contracts: Received for record retention: Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 8/27/2024 9/12/2024 9/12/2024 9/12/2024 Orange County Outside Agency Performance Agreement Page 9 of 12 Rev.06/24 Office of the Clerk to the Board __________________________________________Date:_________ Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 1/16/24, 2:02 PM HSOA-24-49 https://chapelhillnc.workflow.opengov.com/#/explore/records/62830/297526 1/14 Town of Chapel Hill, NC 1/16/2024 HSOA-24-49 Human Services/Outside Agencies Funding Application Fiscal Year 2025 Status: Active Submitted On: 1/12/2024 Applicant Lynn Garrett 612-327-0883 lynn.garrett@swimforcharlie.org 714 Lorentello Circle Hillsborough, NC 27278 Agency Information Agency's Legal Name Dr. Charles van der Horst Water Safety Initiative Agency's Mailing Address (Street, City, State & Zip Code) 1821 Hillandale Road, Suite 1B #126, Durham, NC 27705 Agency's Physical Address (Street, City, State & Zip Code) 6730 Creek Wood Drive, Chapel Hill, NC 27514 Agency’s Web Address https://swimforcharlie.org Tax ID: **-***7052 Date of Incorporation (Month/Year) August 2019 Executive Director Name Dr. Jonathan E. Klein E-Mail Address jonathan.klein@swimforcharlie.org Telephone Number 919-260-0089 Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 1/16/24, 2:02 PM HSOA-24-49 https://chapelhillnc.workflow.opengov.com/#/explore/records/62830/297526 2/14 Agency's Purpose/Mission Statement brief description of your organization’s past achievements Wages and Positions Does the agency pay permanent employees a living wage? Yes Is the agency an Orange County Living Wage Certified Employer? Yes Award Programs Check one or more of the following application types. Human Services Awards (Chapel Hill, Carrboro, and Orange County) Small Awards (Chapel Hill & Carrboro Applicants Only) Community Impact Awards (Chapel Hill Applicants Only) To equip children with life-saving water safety skills by providing a high-quality water safety program to second grade North Carolina students. Spring 2020 the program taught 194 2 graders at 3 Title I OCS elementary schools. In FY 2022-2023 the program taught 393 OCS students in 6 Title I schools and 326 students in 8 Durham Title I schools. FY 2023-2024 is off to a strong beginning with participation from 582 students in 7 Title I schools in the two districts and 4 more Title I schools enrolled in each of the two districts for Spring 2024. nd Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 1/16/24, 2:02 PM HSOA-24-49 https://chapelhillnc.workflow.opengov.com/#/explore/records/62830/297526 3/14 Agency Demographics Please ensure that each subsection listed below adds up to the total number of staff and board members listed here. Number of Part-Time Paid Positions 4 Number of Full-Time Paid Positions 0 Staff Members Total Number of Staff 4 Staff Members - Sex Number of Male Staff 0 Number of Female Staff 4 Number of Nonbinary Staff 0 Number of Staff who prefer not to answer 0 Staff Members - Race and Ethnicity Number of American Indian or Alaska Native Staff 0 Number of Asian Staff 0 Number of Black or African American Staff 1 Number of Native Hawaiian or Other Pacific Islander Staff 0 Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 1/16/24, 2:02 PM HSOA-24-49 https://chapelhillnc.workflow.opengov.com/#/explore/records/62830/297526 4/14 Number of White Staff 3 Number of Staff of more than one race 0 Number of staff who prefer not to answer 0 Number of Staff who identify as a race/ethnicity not listed 0 Total Number of Staff who identify as Hispanic or Latino 0 Total Number of Staff who do not identify as Hispanic or Latino 4 Board Members Total Number of Board of Members 7 Board Members - Sex Number of Male Board Members 4 Number of Female Board Members 3 Number of Nonbinary Board Members 0 Number of Board Members who prefer not to answer 0 Board Members - Race and Ethnicity Number of American Indian or Alaska Native Board Members 0 Number of Asian Board Members 0 Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 1/16/24, 2:02 PM HSOA-24-49 https://chapelhillnc.workflow.opengov.com/#/explore/records/62830/297526 5/14 Number of Black or African American Board Members 1 Number of Native Hawaiian or Other Pacific Islander Board Members 0 Number of White Board Members 6 Number of Board Members of more than one race 0 Number of Board Members who prefer not to answer 0 Number of Board Members who identify as a race/ethnicity not listed 0 Total Number of Board Members who identify as Hispanic or Latino 0 Total Number of Board Members who do not identify as Hispanic or Latino 7 Race & Equity Consistent with our commitment to equity and inclusion, the Towns of Chapel Hill and Carrboro and Orange County Government are taking steps together to center racial equity in the Human Services Funding Program. We are requesting basic information about your organization’s racial equity work. Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 1/16/24, 2:02 PM HSOA-24-49 https://chapelhillnc.workflow.opengov.com/#/explore/records/62830/297526 6/14 Describe how the agency incorporates racial equity into its goals. (150 word limit) Describe how the intended beneficiaries of the proposed project(s) were involved in the planning and design process. (150 word limit) Percent (%) of Staff who attended racial equity trainings. 100 Percent (%) of Board Members who attended racial equity trainings. 71 Describe other racial equity related activities. Water safety statistics show: Past discriminatory actions denied many families of color access to swimming facilities and swim lessons. As a result, children grew up in households where adults were unable to learn and pass on water safety and basic swimming skills. SFC began in 2019 with the goal of breaking that cycle by targeting higher need children (those of lower income and of color). Currently SFC is working with 15 Title I schools -- 6 in OCS and 9 in Durham Public Schools. 75% of the population are students of color. 10 people drown each day in the US. • 80-100 near drownings occur daily in the US. • 79% of children in households with incomes less than $50,000 have little-to-no swimming ability. • 64% of black, 45% of Hispanic/Latino, and 40% of white children have little to no swimming ability. • 88% of childhood drownings can be prevented with formal swimming lessons.• We work closely with our partners at the schools and the pools on the development of timelines, logistics, and a participation permission form. We have joint communication sessions with pool staff, school teachers and administrators, and parents. All partners have access to all SFC teaching handbooks. Our first partnership in Durham was with DPS and NC Central University (NCCU), a historically black college/university (HBCU). This partnership has NCCU students, most of whom are people of color, teaching the 2nd grade students in the surrounding elementary schools. Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 1/16/24, 2:02 PM HSOA-24-49 https://chapelhillnc.workflow.opengov.com/#/explore/records/62830/297526 7/14 Program Funding Request Please list all of the current Fiscal Year Human Services (HS) funding requested for all programs and the proposed use of funds. Program Name Swim for Charlie Town of Carrboro 0 Town of Chapel Hill 0 Orange County 21000 Total Short description of proposed use of funds. 21000 The funds will pay to continue the 2 grade Water Safety/Swimming Skills program at all 7 Orange County Public Schools. (Central, Efland-Cheeks, New Hope, Grady Brown, Hillsborough, River Park and Pathways). The funds will be used to pay the swim instructor and lifeguard/training and salaries, swimming supplies for students including swimsuits/towels for those who cannot afford them, mesh bag for all students to carry their swimsuit and towel, student certificates, skill evaluation and student progress reports to parents, and a plaque for each school in the program. Funds will also be used to pay the staff who coordinate the program between the schools and the Sportsplex; arrange for instructors and instructor training; offer informational sessions to the PTO; evaluate all aspects of the water safety curriculum, and to obtain swimsuits/towels for students needing them,. nd Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 1/16/24, 2:02 PM HSOA-24-49 https://chapelhillnc.workflow.opengov.com/#/explore/records/62830/297526 8/14 Funding Totals Carrboro Chapel Hill Orange County Total Program Information Program Name Swim for Charlie Primay Contact's Name Jonathan Klein Primary Contact's Phone Number 919-260-0089 Primary Contact's Email Address jonathan.klein@swimforcharlie.org Describe the proposed program and the target population to benefit from the program. Please also explain how the program aligns with the Town of Chapel Hill and Carrboro's Human Services Program Results Framework and/or Orange County's BOCC Goals and Priorities (250 words or less). 0 0 21000 21000 We target schools and school districts with higher need, which Swim for Charlie interprets as a greater percentage of children eligible for Free and Reduced lunches who are proportionately people of color. In our expansion, we chose to add Durham Public Schools before Chapel Hill-Carrboro County Schools. Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 1/16/24, 2:02 PM HSOA-24-49 https://chapelhillnc.workflow.opengov.com/#/explore/records/62830/297526 9/14 Target Population The program target population demographics table is included as an attachement on the application cover page. Please download the excel spreadsheet and fill out the demographic data in the table and then upload it with your application. Provide one copy per program that you are requesting funding for. Program Cost This cost per individual must reflect the total program budget divided by the total number of program individuals in this application. Actual Cost 2022-2023 Total Program Cost (Actual 2022-2023) 30402 Total Number of Individuals (Actual 2022-2023) 462 Cost Per Individual (Actual 2022-2023) 66 Projected Cost 2023-2024 Total Program Cost (2023-2024) 38414 Total Number of Individuals (Projected 2023- 2024) 300 Cost Per Individual (Projected 2023-2024) 128 Projected Cost 2024-2025 Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 1/16/24, 2:02 PM HSOA-24-49 https://chapelhillnc.workflow.opengov.com/#/explore/records/62830/297526 10/14 Total Program Cost (Projected 2024-2025) 44515 Total Number of Individuals (Projected 2024- 2025) 510 Cost Per Individual (Projected 2024-2025) 87 Performance Indicators/Program Goals Strategic Objective* 3. Residents improve their health outcomes Intermediate Result* 3.2 Residents demonstrate new healthy lifestyles behaviors If applying to Orange County, please select the funding area that best aligns with your program. Public Health & Health Education Based on the strategic objective, intermediate result, and/or funding area selected above, what are the performance indicators/program goals related to this program? Actual Outcomes 2022-2023 Goal 1. The program will have a high participation rate among second graders who are offered the program. Goal 2. Children who enter at a level indicating no water skills and/or fear of the water will become water safe by advancing at least 2 skill levels. Goal 3. Children who enter with some water safety skills will advance at least 1 skill level. 1. 93% participation rate. 2. 61% of students who entered at a level indicating they had no water skills and/or a fear of the water advanced at least 2 skill levels and became water safe. 3. 87% of students who entered with some water safety skills advanced at least 1 skill level. Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 1/16/24, 2:02 PM HSOA-24-49 https://chapelhillnc.workflow.opengov.com/#/explore/records/62830/297526 11/14 Projected Outcomes 2023-2024 Projected Outcomes 2024-2025 Community Impact Award Please describe the impact the proposed programs will have on the target population. Please include specific quantitative and qualitative data in your response. What methods/tools will your organization use to evaluate the proposed program’s effectiveness? Please include specific examples, such as a logic model. Please briefly describe how your proposed programs aligns with evidence-based approaches to addressing human service need(s). Please describe one to three key partnerships/collaborations that add the most value to the success of the proposed programs. Goal 1: 93% participation rate. Goal 2: 75% of students who enter at a level indicating no water skills and/or fear of the water will become water safe by advancing at least 2 skill levels. Goal 3: 80% of students who enter at a water safe level will advance at least one level. Goal 1: Retain a 93% participation rate. Goar 2: Continue to push toward a 75% rate. In 2022-2023, we reached 61% achievement and expect to grow toward the 75% goal in 2023-2024, but not yet reach it. Goal 3: Retain the 80% goal of at least one level of advancement. We need more data before we can determine if the 87% outcome in 2022-2023 was an anomaly. Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 1/16/24, 2:02 PM HSOA-24-49 https://chapelhillnc.workflow.opengov.com/#/explore/records/62830/297526 12/14 If you are not awarded a Community Impact Award, what would your agency’s funding request be? Applicant Statement Disclosure of Conflicts of Interest Are any board members or agency employees, including their immediate relatives and business associates, current beneficiaries of the proposed program for which funds are being requested? No Are any board members or agency employees, including their immediate relatives and business associates, members of or related to members of the governing bodies of Chapel Hill, Carrboro, or Orange County? No Are any board members or agency employees, including their immediate relatives and business associates, paid providers of goods or services to or have other financial interest in the proposed program? No Are any board members or employees, including their immediate relatives and business associates, related to employees of that Town of Chapel Hill, Town of Carrboro, or Orange County? No If the answer to any of the above is yes, please provide an explanation. Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 1/16/24, 2:02 PM HSOA-24-49 https://chapelhillnc.workflow.opengov.com/#/explore/records/62830/297526 13/14 Non-discrimination Clause 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. Applicant Statement 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. Name of Person Submitting the Application Jonathan E. Klein Agency Role of Person Submitting the Application President and Board Chair Agency Representative Signature Jonathan E. Klein Jan 10, 2024 By submitting this application, the agency representative noted above affirms they are either the Executive Director, or, if someone other than the Executive Director is submitting this application, they affirm the Executive Director has reviewed the application for accuracy and approved it for submittal. Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 1/16/24, 2:02 PM HSOA-24-49 https://chapelhillnc.workflow.opengov.com/#/explore/records/62830/297526 14/14 Approval Details Approved Amount – Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 Certified by: _______________________ Title: __________________________ Date: ____________ (Provider’s Signature) EXHIBIT “B” Scope of Services – FY 2024-25 Outside Agency Performance Agreement Agency Name: Swim for Charlie Program Name: Dr. Charles van der Horst Water Safety Initiative Funding Award: $9,141 Outline how the agency will spend Orange County’s funding award. Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2025. • Generate positive word-of-mouth from principals, teachers, and parents who have gone through the program. Ensure a well-run program where students are learning water safety skills. Outreach and program monitoring will allow for a continued high participation rate. • Continue instructor recruitment so as to maintain an ongoing low student to teacher ratio. • Ensure the program has a group of trained, motiviated and effective instructors. This, in combination with the previous bullet, will help us attain a high advancement rate for our students. 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 93% Participation rate. 510 is the projected number of students who will be offered the program in the 7 schools. 474 student participants 75% advancement rate for early learners (students who start the program afraid of being in the water or those who may not be fearful but have no water safety swimming skills). Our projected number of early learners is 382, and the goal is to have 286 advance to being able to independently get from a front to a back float and pull themselves out of the water. 286 advancing Expense Description Amount Operations (supplies, instructor/lifeguard fees, student certificates, skill and evaluation reports to parents) $12,000 Personnel salaries $26,076 Travel and Training $1,200 Other Expenses $5,239 Administrative Assistant 08/12/2025 Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 Orange County Outside Agency Performance Agreement Page 12 of 12 Rev.06/24 ATTACHMENT “A” Orange County Certifications – FY 2024-2025 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. Certified by: _______________________ Title: __________________________ Date: ___________ (Provider’s Signature) Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 8/27/2024President/Executive Director Orange County Outside Agency Performance Agreement Page 13 of 12 Rev.06/24 FOR INFORMATION ONLY ATTACHMENT “B” As mentioned in Sections 3- Funding and Section 4- Agency Reporting of the performance agreement, the following two forms will be required before quarterly reimbursements can be made. They are included below for informational purposes. Forms are available online at https://www.orangecountync.gov/736/Contracts-Reporting Quarterly Expense Report Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 Orange County Outside Agency Performance Agreement Page 14 of 12 Rev.06/24 Quarterly Outcomes Form Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY Email:Fax: 07/16/2024 Viola Insurance Services, Inc. PO Box 25027 Winston Salem NC 27114 Steven H. Viola (336)893-0483 (336)893-0282 steve@violainsurance.com Dr Charles van der Horst Water Safety Initiative 1821 Hillandale Rd Ste 1B 126 Durham NC 27705 Alliance Of Nonprofits For Ins Rr 10023 Guard Ins Co 42390 QBE Ins Corp 39217 A Y 2024-63026 01/21/2024 01/21/2025 1000000 500000 20000 1000000 2000000 2000000 A 2024-63026 01/21/2024 01/21/2025 1000000 B R2WC491584 03/11/2024 03/11/2025 100,000 100,000 500,000 C Group Accident MHH010307 01/21/2024 01/21/2025 Excess Acccident 250,000 Medical Orange County Sportsplex is included as additional insured on the General Liability policy. Orange County Sportsplex 101 Meadowlands Dr Hillsborough NC 27278 Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32 Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32