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HomeMy WebLinkAboutCOM 0591.000 2010-2012 --,A VM M, ',. William P. Kenoi �.."": �,�d;�: Nancy E.Crawford ��. Director Mayor •*,n:,,t,.:"� •+': ��s!r Deanna S. Sako ♦l.;° qw:r.� Deputy Director County of Hawaii Finance Department ^' 25 Aupuni Street, Room 2103 • Hilo,Hawaii 96720 (808)961-8234 • Fax(808)961-8569 ry - G- ,-G February 15, 2012 Dominic Yagong Council Chair and .o Members of the Hawaii County Council o W Hawaii County Council 25 Aupuni Street Hilo, Hawaii 96720 Re: Nonprofit Grant Applications In compliance with Chapter 2, Article 25 of the Hawaii County Code, I am submitting the applications from eligible nonprofit organizations for your review and appropriation of funds for the FY2012-13 nonprofit grant program. Also enclosed is a list of these eligible organizations with the name of their program and the amount they are requesting from the County. Should you have any questions, please feel free to call Ted Schrey at 961-8489. V1161 1644 Nancy Crawford Director of Finance Enc. Applications for Nonprofit Grant Funds List of Nonprofit Grant Applicants Comm, No. Sg 1 Ref. To: f1 S S S L Ref. Dote, FEB 1 6 ni2 Hawaii County is an Equal Opportunity Provider and Employer NONPROFIT GRANT APPLICANTS FOR FY2012-13 ORGANIZATION NAME PROGRAM NAME REQUESTED Alahou Clean&Sober Clean and Sober Housing $30,000.00 Aloha Performing Arts Company A.R.T.S.Teach $45,000.00 American Cancer Society Hawaii Pacific,Inc Patient Services for Big Island Cancer Patients $15,000.00 American Red Cross,Hawai'i State Chapter Distaster Response&Preparedness for County of Hawaii $25,000.00 Arc of Hilo,The Advocacy $35,500.00 Arc of Kona,The Home and Community Based Services-Life Skills $15,000.00 Bay Clinic,Inc Medicaid/QUEST Enrollment $100,000.00 Big Brothers Big Sisters of Honolulu Hawai'i Island Big Brothers Big Sisters $20,000.00 Boys and Girls Club of the Big Island-Hilo Positive Youth Development Programs-Hamakua Club $40,000.00 Boys and Girls Club of the Big Island-Hilo Positive Youth Development Programs-Hilo Club $40,000.00 Boys and Girls Club of the Big Island-Hilo Positive Youth Development Programs-Kea'au Club $40,000.00 Boys and Girls Club of the Big Island-Hilo Positive Youth Development Programs-Ocean View/Na'alehu Club $40,000.00 Boys and Girls Club of the Big Island-Hilo Positive Youth Development Programs-Pahala Club $40,000.00 Boy's and Girls Club of the Big Island-Hilo Positive Youth Development Programs-Pahoa Club $40,000.00 Brantley Center Employment Rehabilitation $25,000.00 Child&Family Service Alternatives to Violence $40,000.00 Child&Family Service Domestic Abuse Shelters $60,000.00 Child&Family Service Hilo Transitional Housing $40,000.00 Child&Family Service Therapeutic Foster Homes $30,000.00 Eden Earthworks Eco-friendly Pork Production for Healthy Generations $13,082.00 Family Support Hawai'i Ka'u Family Center $75,000.00 Food Basket,The East Hawaii Programs $150,000.00 Food Basket,The West Hawai'i Programs $100,000.00 Friends of Big Island Drug Court Assistance to Drug Court Clients&Program $10,000.00 Friends of Kona Community Aquatic Center Warn Water for Kona Community Aquatic Center $70,000.00 Friends of the Children's Justice Center of East Hawai'i Special Needs&Enhancement,Center Support,Prevention/Education&Training $25,000.00 Friends of the Children's Justice Center of West Hawai'i Enhancement and Basic Needs $15,000.00 Goodwill Industries of Hawai'i Job Connections $30,000.00 Goodwill Industries of Hawaii Jr.Live Saving $45,000.00 Grassroots Community Development Group Kea'au Youth Business Center $45,000.00 Green Will Conservancy Inc.,The Hui Mana'o $35,000.00 Habitat for Humanity West Hawai'i Homebuilding for Hope $42,000.00 Hamakua Health Center The Amazing Tooth Brush School Outreach Program $15,000.00 Hamakua Youth Foundation Hamakua Youth Center $20,000.00 Hawai'i Centers for Independent Living Independent Living Services $15,000.00 Hawaii County Economic Opportunity Council Language Arts Multicultural&Stem $119,890.00 Hawai'i County Economic Opportunity Council Youth Mentoring&Drop Out Prevention $107,348.00 Hawaii Island Adult Care,Inc. Adult Day Care Centers $25,000.00 Hawaii Island Cardiovascular Services,Inc. Remote Cardiovascular Screening $145,000.00 Hawai'i Montessori,Inc Tuition/Financial Aid $40,000.00 Hawaii Island HIV/AIDS Foundation Multi-Disciplinary HIV Case Management, Hilo $15,000.00 Hawaii Island HIV/AIDS Foundation Transmission Prevention for HIV+Women in West Hawai'i $15,000.00 Ho'oulu Lahui Solar Dryer for Food Security $25,000.00 NONPROFIT GRANT APPLICANTS FOR FY2012-13 ORGANIZATION NAME PROGRAM NAME REQUESTED HOPE Services Hawaii Beyond Shelter Transitional Housing $15,000.00 HOPE Services Hawai'i Care-A-Van Homeless Outreach $20,000.00 HOPE Services Hawaii Hope Resource Center $20,000.00 HOPE Services Hawaii Kihei Pua Emergency Shelter $15,000.00 HOPE Services Hawai'i West Hawaii Emergency Housing Program $20,000.00 Hospice of Hilo Transitions Pre-Hospice $117,660.00 Hui Malama Ola Na'Oiwi Community Health Education Traditional Medicine $10,200.00 Hui Malama Ola Na'Oiwi Kokua Hali Health Transportation $20,000.00 Hui Malama Ola Na'Oiwi Mai Ka Mala'ai Diabetetes Management $28,855.00 Hui Malama Ola Na'Oiwi Outreach Case Management-Hele Mai Ai $7,344.00 Hui Pono Holoholona Subsidized Low Cost Spay/Neuter Clinics $20,000.00 Innovations Public Charter School Foundation Planting Wellness for our Keiki&Community $30,000.00 Island of Hawai'i YMCA,The IMPACT:Child&Youth Assets 2012-2013 $40,000.00 Ka Hale 0 Na Keiki Inc Families at Risk $10,000.00 Ka'Ohana 0 Honu'apo Honu'apo Park Programs 2012-2013 $22,740.00 Keaukaha One Youth Development Youth Development $10,000.00 Kohala Animal Relocation and Education Service(KARES) Canine Spay and Neuter $40,800.00 Kona Adult Day Center Adult Day Care $20,000.00 Kona Alano Club Road to Recovery $40,000.00 Kona Historical Society Living History Program Operations $15,000.00 Kona Literacy Council Kailua Learning Center $2,500.00 Kona Skatepark Assn Move on Wheels $15,000.00 Ku Aloha Ola Mau Hui Ho'ola 0 Na Nahulu 0 Hawaii $10,000.00 Ku'ikahi Mediation Center Community Conflict Resolution $15,000.00 Legal Aid Society of Hawai'i Removing Legal Barriers for Hawai'i County's Vulnerable Populations $40,000.00 Lyman Museum Education and Public Programs $40,000.00 Malama 0 Puna Jr.Live Saving $2,000.00 Malama 0 Punaj Puna Panthers $20,000.00 Malamalama Waldorf School Culture and Arts Specialty Program $25,000.00 Mental Health Kokua Residential Rehabilitation Service $5,000.00 Neighborhood Place of Puna Family and Community Strengthening $30,000.00 Neighborh000d Place of Puna Ready to Learn $5,000.00 O Ka'u Kakou Punalu'u Annual Fishing Tournament $7,000.00 Palakena Kai Ocean Safety,LLC Ocean Safety Program $30,000.00 Pantry,The Mama's Hale Clean&Sober Housing $32,000.00 Paradise Ponies,Inc. High-School Shop Cooperative $10,000.00 Parents and Children Together Economic Development Center $100,000.00 POlama is Kona Heritage Preservation Council Mamalahoa Kona Heritage Corridor $17,178.00 Puna Community Medical Center Uninsured/Underinsured Fund $120,000.00 Puna Men's Chorus $8,000.00 Recycle Hawaii Less Waste Means More Fun $19,400.00 Salvation Army Family Intervention Services,The Independent Living Skills $36,962.00 Salvation Army Family Intervention Services,The Prevention Programs-Kea'au $35,000.00 NONPROFIT GRANT APPLICANTS FOR FY2012-13 ORGANIZATION NAME PROGRAM NAME REQUESTED Salvation Army Family Intervention Services,The Prevention Programs-Pahoa $35,000.00 Special Olympics Hawaii Special Olympics Hawaii-East Hawai'i Area $25,000.00 Special Olympics West Hawaii SOWH General Funding $12,000.00 Sure Foundation Yeshua Outreach Center $70,000.00 Volcano Art Center HINA Project $25,000.00 West Hawaii Community Health Center Adult Emergency Dental Services $10,000.00 West Hawaii County Band Friends Volunteer Musician and Uniform Fund $23,000.00 West Hawaii Mediation Center Mediation Services $13,000.00 YWCA Hawaii Island Healthy Start Plus $75,000.00 YWCA Hawaii Island Sexual Assault Support Services $60,000.00 YWCA Hawaii Island YWCA Developmental Preschool $25,000.00 TOTAL $3,438,459.00 Note: The following non-qualifying organizations did not meet the application requirement(s). Aloha Independent Living Hawaii Independent Living Services $10,000.00 Hawaii Island Workforce&Economic Development Ohana HUIANA Student Internship $35,000.00 Hilo Community Players Shakespeare in the Park $5,500.00 HOlualoa Foundation for Arts&Culture Art Matters $66,225.00 Ka'u Community Radio $100,000.00 Kona Community School for Adults $338,000.00 Ocean View Community Assn $20,450.00 1 Alahou Clean & Sober Clean and Sober Housing Alahou Clean & Sober Clean and Sober Housing Program NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Copy Alahou Clean & Sober Clean and Sober Housing Program Agency Director: Sandra K. McCoy Phone No.: (808) 327-1694 Contact Person: Sandra K. McCoy Phone No.: (808) 327-1694 Mailing Address: 75-5708 Alahou Street Kailua-Kona, HI 96740 Facility/Site Address: 75-5708 Alahou Street Kailua-Kona, HI 96740 Fax No.: (808) 327-1654 Email Address: alahoucleanandsober @hawaii.rr.com Name of Accountant/CPA(include name of firm if applicable): Sharon Davis CPA PC Phone No.: (808) 883-2748 Mailing Address: P. 0. Box 383190 Waikoloa, HI 96738 Amount of Request for County Grant-in-Aid Funds: $30,000 Prior Year Award of County Grant-in-Aid Funds: 09-10 10-11 11-12 $0 $0 $0 Agency Mission Statement: Provide a clean, safe, low-cost and mutually supportive living environment for those in active recovery from alcohol or drugs who are committed to maintaining a clean and sober lifestyle. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 8 Alahou Clean & Sober Clean and Sober Housing Program Program Description: Life on the street in West Hawaii for an individual battling the dual adversaries of mental illness and addiction is a deadly, no-win game. Eating from garbage bins, at constant physical risk of violence and disease, and having no peer support or role models quickly erodes personal will and self-esteem —and the descent continues. The residents of Alahou Clean & Sober came from that world, and it is to that world they will return if we are unsuccessful in helping them keep their dream of recovery alive. Most of our participants came to Alahou either as homeless or from the judiciary system. For these 50 to 60 people, it's us or the street. Alahou Clean & Sober was formed for the specific purpose of providing up to 60 of these at-risk individuals with a clean, safe and affordable supported-living and recovery program in a peer-enforced drug- and alcohol-free environment. At Alahou, participants proactively care for and monitor each other as they continue to work on their individual recovery programs. The Alahou facility consists of 19 one- and two-bedroom furnished apartments in three separate but adjacent buildings. Apartments are segregated by gender, and bedrooms and living areas are shared. Common areas, including a large covered lanai and coin-operated laundry facility, are shared as well. Residents are responsible for maintaining all common areas, including landscaping, and for maintaining their individual apartments in a clean and habitable manner. Quarters are subject to entry and search without notice by the staff and members of the Residents' Council. On-site AA/Substance Abuse support group meetings are conducted several times a week and each resident must attend a minimum of two. Life-skills discussion groups are also conducted several times each week to assist participants in development of effective coping and interpersonal skills. These life- skills meetings are facilitated by professionals from other agencies whose missions include support of our population. Mandatory Community Meetings are held weekly during which topics of general interest are discussed and issues of concern are raised. The Alahou office is staffed during normal business hours by the Executive and Program Directors and during evening and weekend hours by resident volunteers who monitor the property, provide access to supplies, and respond to emergencies. At the time of occupancy, new residents are required to sign an agreement acknowledging a commitment to abide by Alahou house rules and restrictions, especially with regard to drug or alcohol possession or consumption. They further agree to immediate eviction if they are found to be in possession of drugs or alcohol on Alahou property, or fail to abide by Alahou's house rules regarding behavior. The Executive and Program Directors are the only employees of the corporation. All other administrative and operational functions are handled by volunteers from among our program participants. It is this voluntary acceptance of personal responsibility for one's individual success, the success of one's peers, and the success of the Alahou program that marks a significant step along the path to each participant's ongoing recovery. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 8 Alahou Clean & Sober Clean and Sober Housing Program Total Budget and Position Count: Total Program Budget $343,900 Total Program Position Count 2 Total Agency Budget $343,900 Total Agency Position Count 2 Program Objectives: 1) Provide accommodations for up to 60 at-risk individuals in need of a clean, safe and affordable supported-living and recovery program conducted in a peer-enforced drug- and alcohol-free environment. Through close coordination with partnering agencies, ensure that occupancy is maintained at or above 85% on a monthly basis. 2) Provide on-site AA/Substance Abuse support group meetings a minimum of four times per week and ensure that each participant attends a minimum of two meetings per week. Transportation is also provided to two off-site AA meetings each week to assist participants in finding sponsors from outside the Alahou community. 3) Provide on-site Relapse Prevention training/discussion group once each week and ensure that each participant attends a minimum of one session per month. 4) Conduct one on-site Community Meeting per week for discussion of topics of general interest and issues of concern. Ensure that each meeting is attended by a minimum of 80% of participants who are not working, in school, or volunteering. 5) Form and maintain a Residents' Council made up of volunteer participants which is responsible for overseeing property and apartment maintenance, monitoring property activities and providing access to supplies during non-business hours, and responding to emergencies. The Council is also responsible for monitoring individual participant behaviors, conducting UA and Breathalyzer testing as necessary, recommending consequences for infractions of house rules, and establishment of behavior contracts with incoming and relapsing participants. The Council will consist of a minimum of four members who will contribute a minimum of 40 hours each per month in performance of Council responsibilities. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 8 Alahou Clean & Sober Clean and Sober Housing Program Program Highlights (from Fiscal Year 2010-11): Background In 2006 Sandra McCoy became the Kona Residential Manager for Po'ailani, Inc., a Honolulu-based non-profit human services agency providing housing for individuals having a dual-diagnosis of chemical addiction coupled with mental illness. Until August of 2009, Po'ailani's Kona facility consisted of 19 apartments in a three-building complex located on Alahou Street in Kailua-Kona. The facility was leased from a local entrepreneur and is located on Alahou Street in Kona's "Hamburger Hill" neighborhood. Funded by a combination of rental income and state dollars, Po'ailani provided housing for up to 70 participants and employed 22 program staff. In August 2009, reductions in state funding forced Po'ailani to terminate the lease on two of the three buildings, retaining only seven apartments in the remaining building. In negotiations, the owner agreed to maintain a "clean-and-sober" requirement for tenants of the non-Po'ailani apartments, thereby helping to maintain a stable and less risky environment for program participants. In return for that agreement, Po'ailani agreed to act as Resident Manager for all three buildings at no cost to the owner. Po'ailani continued to operate with only nine program participants. The majority of the residents in the other buildings were previous Po'ailani consumers. These measures proved unsuccessful, however, and Po'ailani ultimately closed its Kona operation in April 2010. All program assets were returned to Oahu for use by Po'ailani's Honolulu program. At the time of the program closure, many of the property tenants were long-term Po'ailani program participants and had been clean and sober for two-to-three years. When the closure was announced, a group of the tenants approached Ms. McCoy asking for assistance in starting up a new non-profit agency called Alahou Clean & Sober. Their intent was to continue to maintain the facility as drug and alcohol-free housing where they could continue to work on their individual recoveries. Given their personal experience, not maintaining the environment in that state would result in many of them returning to life on the street and an addictive lifestyle. Fiscal Year 2010-11 was Alahou's first complete year of operation. During that time: 1) Residential services were provided to 151 unduplicated individuals. Borrowing the metric of "bed- night" from the Hospitality industry, meaning one occupied bed for one night, Alahou provided 16,331 bed-nights to program participants. 2) The average length of residency during the period was 108 days. Of the 110 individuals leaving the Alahou program during the period, 21 (19%) had obtained employment and were able to afford to move into private housing. 3) On May 12, 2011, Alahou was advised by the Internal Revenue Service that it had been certified as exempt from Federal income tax under Section 501(c)(3) of the Internal Revenue Code, effective as of July 22, 2010. 4) On June 1, 2011, Alahou was advised that it had been accepted as a United Way partner Agency by Hawaii Island United Way and was eligible to receive $25,000 in grant funding during FY2012 and again during FY2013. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 8 Alahou Clean & Sober Clean and Sober Housing Program Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Average Occupancy per month 81% 85% 85% Weekly On-Site AA/Substance Abuse 4 4 4 Meetings Average AA/Substance Abuse 3 2 2 Meetings attended per participant per week Monthly On-Site Relapse Prevention 1 2 4 Training/Discussion Groups Average Relapse Prevention Sessions n/a 1 1 attended per participant per month Weekly On-Site Community Meetings 1 1 1 Average percentage of participants n/a 80% 80% attending Community Meetings per week Average Number of Hours volunteered 80 40 40 by each Residents Council Member per month *If applicable NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 8 Alahou Clean & Sober Clean and Sober Housing Program Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages $0 $17,250 $103,500 Professional Fees $3,118 $6,700 $6,700 Operations $173,827 $206,700 $226,200 Equipment $5,627 $7,500 $7,500 Other# $0 $0 $0 Total $182,572 $245,650 $343,900 If applicable Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Rental Income $172,533 $218,000 $218,000 Other Income $6,637 $0 $0 County of Hawaii Grant-in-Aid $0 $30,000 State of Hawaii $0 $60,000 Big Island United Way $25,000 $25,000 Other Grants $10,900 Total $179,170 $243,000 $343,900 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 8 Alahou Clean & Sober Clean and Sober Housing Program Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The income stream generated by Alahou's rental revenues appears to be sufficient to cover its facility rental, utilities, insurance and other operating expenses. It is not sufficient, however, to also fund the salaries of our Executive and Program Directors. And, while much of the day-to-day facility oversight is handled by resident volunteers, staff leadership and experience are necessary to ensure adequate community outreach, inter-agency cooperation, and program coordination and integrity. Over the next two years, it is Alahou's intent to build a diversified funding base comprised of a combination of rental revenues, government and private sector grants, and community support. But, given the nature of our program and our participant base, it is unlikely that Alahou Clean & Sober will ever become self-sustaining based only on fees-for-service. Alahou Clean & Sober projects the provision of 17,065 bed-nights to some of Hawaii's most at-risk citizens—at a cost per bed-night of roughly $20.15. Of this cost, $12.77 is funded by program fees collected from our participants and $1.47 is funded by Big Island United Way. We ask the County of Hawaii to contribute another$1.75 per bed-night to help us bridge the gap. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawai'i: None. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 8 Alahou Clean & Sober Clean and Sober Housing Program I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. _ If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available to co.hawaii.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013 must be returned to the County of Hawai'i within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. t/Z 31 2m-2,-- -- Signature of Boar P sident/Chair or Date Agency Director — ( --i Signature of cutive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 8 2 Aloha Performing Arts Company A.R.T.S. Teach Aloha Performing Arts Company A.R.T.S. Teach Agency Director: Sam Valenti Phone No.: 808-322-9924 Contact Person: Sam Valenti Phone No.: 808-322-9924 Mailing Address: PO Box 794 Kealakekua, HI 96750 Facility/Site Address: Aloha Theatre 79-7384 Mamalahoa Hwy Kainaliu, HI 96750 Fax No.: 808-322-9924 Email Address: info @apachawaii.org Name of Accountant/CPA (include name of firm if applicable): Patricia K. Schumacher Phone No.: (480) 584-4344 Mailing Address: 530 E. Hunt Hwy Suite 103 PMB 488 San Tan Valley, AZ 85143 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $45,000 (However, any amount will help provide these services to area youth.) Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $0 $0 Agency Mission Statement: APAC's mission is to enrich the lives of Hawaii residents and visitors by presenting quality theatre and providing theatre education. APAC shall also maintain and operate a venue which provides opportunities for APAC and other organizations to present performing arts. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 6 Aloha Performing Arts Company A.R.T.S. Teach Program Description: A Theatre Education program designed to encourage and garnish enthusiasm and excitement in our younger generation of theatre participants through a combination of ongoing classes, one day workshops, and week long production workshops. Total Budget and Position Count Total Program Budget $45,000 Total Program Position Count 1 Total Agency Budget $380,000 Total Agency Position Count 5 Program Objectives: 1) To create a self sustaining theatre education and activity program through consistent class offerings for multiple age groups by the end of fiscal year 2013-14. 2) To build ongoing educational teams of students, additional instructors, an education committee, and volunteer aides. 3) Provide our youth with positive direction and productive time sharing opportunities by offering after school and school break programs. Program Highlights: (from Fiscal Year 2010-11) *Actually this is 2011-12 YTD because that is when the program started. 1) Education Program Showcase at Aloha Theatre (K-9 Inclusive) 2) Community Showcase (Arts of Kona) NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 6 Aloha Performing Arts Company A.R.T.S. Teach Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Maintain a minimum monthly 4 6 average of offered classes. Maintain a minimum monthly 6 10 student count. Write 4 grants per year 4 4 Collect Tuition $13,750 $15,000 Produce Public Showcases 2 3 Have Public Attendance of at least 100 120 Have Unique Participants of at least 50 75 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages $27,888 $30,000 Professional Fees $1,000 Operations $9,606 $10,000 Equipment $1,000 Other# $2,594 $3,000 Total $40,088 $45,000 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 6 Aloha Performing Arts Company A.R.T.S. Teach Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Donations $3,850 $4,000 Ticket Sales $200 Tuition $13,750 $15,000 Unspecified Grants $27,500 $25,000 Bill Healy Foundation $2,000 Concessions $220 $200 Total $45,320 $46,400 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? We have a development committee to help write grants for this program. The recently hired education director is also a grant writer. We would expect to have a solid tuition and donation base near the end of the 2013-14 fiscal year. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Dale Ross, our current Secretary, is the 1st Deputy Prosecuting Attorney for the County of Hawaii NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 6 Aloha Performing Arts Company A.R.T.S. Teach I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 6 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. G, ilzo Signature of Board President/Chair Date or Agency Director I/3D Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 6 • Aloha Performing Arts Company A.R.T.S. Teach Program Expenditures Other FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Costumes $220 $250 Production Food $550 $600 Makeup $55 $100 Printing & $110 $150 Reproduciton Props $165 $200 Set Construction $165 $250 Royalties $229 $250 Scholarships $1,100 $1,200 Total $2,594 $3,000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 7 3 American Cancer Society Hawaii Pacific, Inc Patient Services for Big Island Cancer Patients American Cancer Society Hawai'i Pacific, Inc. Patient Services for Big Island Cancer Patients Program Description: As the largest and most comprehensive cancer patient support organization, the American Cancer Society is determined to improve cancer patient quality-of-life by eliminating the gaps in services and information that are inherent in the current health care system. The American Cancer Society on the Big Island works tirelessly to enhance cancer patients quality-of-life through programs such as: transportation to complete their cancer treatment, informational support to patients and their families to better navigate their cancer journey, messaging about cancer prevention to all Big Island residents, and a venue for the the entire community to fight back against cancer. Total Budget and Position Count Total Program Budget $85,425 Total Program Position Count 0 Total Agency Budget $4,711,898 Total Agency Position Count 34 Program Objectives: 1) To support East and West Hawai'i residents of the Big Island who are newly diagnosed with cancer, in the completion of their medical treatment; 2) To improve the quality of life for East and West Hawai'i residents with a cancer diagnosis; 3) To provide Big Island patients with the most advanced medical information and help with navigating a diagnosis and managing their cancer experience. Program Highlights: (from Fiscal Year 2010-11) 1) Transportation to Treatment: Cancer patients can't be cured if they aren't able to complete their cancer treatment protocol. Many cancer patients are too frail, too weak, too poor or too emotionally drained to travel on their own. Transportation to their medical appointments is vital to their recovery and ACS provides financial assistance through taxicab reimbursements, Handi-van vouchers, gasoline debit cards for family members driving them, interisland airfare tickets, and partial transpacific airfare reimbursements when they must fly to the mainland for specialized treatment. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 8 In addition, ACS has created its own program, Road to Recovery, where specially trained volunteer drivers, many of whom are themselves cancer survivors, provide car rides to treatment in their own private cars, adding a special measure of empathy and compassion to the journeys. In FY2010/2011, 121 taxicab reimbursements, 210 $50 gasoline debit cards, 490 one-way interisland airline tickets and 18 partial reimbursements for transpacific airfare were distributed to Big Island residents. 2) ❑ Lodging Discount for Patients while on O'ahu for Treatment: Big Island cancer patients are provided discounted lodging while staying on Oahu for their cancer surgery or treatment, which helps to alleviate a major financial concern patients face when they cannot receive treatment on their home island. In FY2010/2011, 58 Big Island cancer patients utilized 429 nights of discounted lodging in Oahu partnering hotels. 3) ❑ Reach to Recovery: Visits are provided to newly diagnosed breast cancer patients, who receive kits containing a temporary bra and prosthesis. Reach to Recovery volunteers, each a breast cancer survivor themselves, are certified by ACS in the program. They help patients cope with body image issues, provide an information booklet, and explain options for prostheses and reconstruction. In FY2010/2011, 4 newly diagnosed Big Island breast cancer patients received this service. 4) ❑ Look Good...Feel Better and Wigs: Classes teach patients how to brighten complexions sallow from disease, create the illusion of eyebrows that have temporarily disappeared, care for nails affected by treatment, and more. For those patients feeling a loss of physical self-esteem, these small classes, shared with other patients, have a therapeutic value far beyond their cosmetic tips. Beautician volunteers are trained and certified to provide their expertise to this program. Wigs, hats, and/or scarves are also provided frre of charge to individuals coping with hair loss. 21 patients participated in Look Good...Feel Better sessions in FY2010/2011 and 46 wigs were distributed to Big Island patients. 5) ❑ Childhood Cancer programs for keiki with cancer and their families: Having a child with cancer can turn a family upside down. Adding to the heartbreak, there are time-consuming demands on parents, less time for the needs of siblings, and tremendous stress on the affected child. o Camp Anuenue is a weeklong summer camp for children with cancer, ages 7 to 17. This experience provides an opportunity to build friendships with other children who also are fighting cancer. It has helped many keiki find the hope and physical strength to survive. 3 Big Island children attended Camp Anuenue in FY2010/2011; o Ho'oulu Me Ka Ikaika ("Grow with Strength") is a retreat for teens and young adults, ages 14 to 21. This retreat empowers young people to face the combined stresses of cancer and the teen years. 0 Big Island teenagers attended the Teen Retreat in FY2010/2011; NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 8 o Families Can*Sur*Vive is a family conference for children with cancer, their parents and siblings that provides an opportunity for families to discover their individual and family strengths while encouraging trust and communication. 2 Big Island children with cancer, along with 4 parents and 3 siblings attended the Families Conference in FY2010/2011. 6) ❑ Personal Health Manager: The Personal Health Manager is an organizational portfolio for newly diagnosed patients that contains tailored information, relevant to the type of cancer, which will empower patients to make educated health decisions, and connect them to local resources and services. Additionally, the portfolio helps patients keep track of critical medical information provided by their healthcare team. In FY2010/2011, 201 Big Island cancer patients received their own Personal Health Manager portfolio. 7) ❑ Annual Survivor Celebration: Cancer survivors celebrate life and the victory over crisis. By design, these survivor celebrations are empowering to those who faced their health crisis head on and provide hope and inspiration to those still in treatment. During FY2010/2011, 697 cancer survivors participated in 7 Big Island annual survivor celebrations at Relay For Life events. 8) ❑ Client Services: Cancer patients and their families contact the American Cancer Society field offices and Patient Services Center to receive up-to-date cancer information on diagnoses, treatments and prognoses. In FY2010/2011, a grand total of 647 unique Big Island cancer patients were provided at least one type of direct service from ACS, which include any or a multiple of the above. 9) ❑ Trained Cancer Information Specialists: Hawaii residents are connected to the American Cancer Society's Patient Services Center based in Austin, Texas. The Patient Services Center keeps Hawaii time-zone business hours, and provides specialized agents who are trained and familiar with Hawaii's resources and facilities, plus are experts with dealing with the issues of cancer and its emotional, financial, physical and quality-of-life issues. Staff work with patients and families to provide support, navigate healthcare systems, refer to resources and even help patients who need to complete lengthy and often confusing applications. 10) ❑ The Society's National Cancer Information Center's 24-hour a day 1-800 telephone line, the national www.cancer.org website for cancer information, and the Hawai'i Pacific blog, www.acshawaiipacific.org, for local news, volunteer opportunities and event information. In FY2010/2011, over 66,000 web visits by Hawaii residents to the ACS website helped patients and families find out more information about cancer and the programs offered by the American Cancer Society. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 8 American Cancer Society Hawai'i Pacific, Inc. Patient Services for Big Island Cancer Patients Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget* Estimate Total Big Island Cancer Patients 635 626 647 Served Road to Recovery Rides to 201 160 175 Treatment Cancer Prevention/Early Detection 50,182 35,000 35,000 Information Provided in Face-to- Face Messaging (some people may have received multiple messages) Support Group Participants 41 50 50 Interisland Airline Transportation 456 400 500 Segments Provided Taxicab One-Way Reimbursements 116 90 120 Gasoline $50 Debit Cards Provided 201 140 210 Look Good...Feel Better Class 17 40 40 Participants Wigs Provided 36 30 45 Personal Health Manager Kits 180 96 225 Lodging Discounted Room Nights 341 400 425 Childhood Cancer Camp 5 8 6 Participants *From FY2011-12 grant submittal Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget * Estimate Salaries and Wages 0 0 0 Professional Fees 0 0 0 Operations 0 0 0 Equipment 0 0 0 Other# $72,185 $65,600 $85,425 Total $72,185 $65,600 $85,425 * From FY2011-12 grant submittal # See attached detail budget breakdown for FY2012-13 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 8 American Cancer Society Hawai'i Pacific, Inc. Patient Services for Big Island Cancer Patients Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget Estimate Adrienne Wong Toyozaki Fund 0 $7,000 $7,000 Theodore A. Vierra Fund $9,000 $9,000 $10,000 County of Hawaii $10,000 $10,000 $15,000 Hawaiian Airlines Charity Miles $3,900 $3,600 $4,000 (in-kind) Tai Up Yang Fund $1,700 $1,700 $1,700 Friends of Hawaii Charities $850 $850 $850 General Fundraising $46,735 $33,450 $46,875 Total $72,185 $65,600 $85,425 Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self- sustaining? Any shortfall in funding will be made up through the general operating funds from our community fundraising. Until major changes occur in health insurance coverage, physician and facility capacity, and cancer care protocols, we will continue to cobble together a safety net of volunteer programs, donated resources and grant funding to support cancer patients on the Big Island. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. • Nancy Crawford, County of Hawaii Director of Finance, has served in a leadership role for the American Cancer Society's Hawaii Island Advisory Council and for the Relay For Life of Hilo; • Lee Lord, County of Hawaii Division Manager, Department of Finance Vehicle Registration, has served in a leadership role for the American Cancer Society's Hawaii Island Advisory Council and for the Relay For Life of Hilo; • Phyllis Fujimoto, County of Hawaii Planning Department, has recently joined the American Cancer Society's Hawaii Island Advisory Council and has been an active volunteer at the Relay For Life of Hilo Survivor Activities. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 8 American Cancer Society Hawai'i Pacific, Inc. Patient Services for Big Island Cancer Patients I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai`i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 8 American Cancer Society Hawai'i Pacific, Inc. Patient Services for Big Island Cancer Patients Any funds unused by June 30, 2013 must be returned to the County of Hawai'i within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. /1/A1 L . i VZ 7/Z9/2 Signature of Board Pre-sent/Chair D to or Agency Director 41116 - i a-o/ a Signatu of Executive !'rector , D o NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 8 American Cancer Society Hawai'i Pacific, Inc. Quality of Life Services for Ca ncer Patients on the Big Island FY2012/2013: July 1, 2012 to June 30, 2013 MASTER Projected Budget County of Additional Total Budget Hawaii Funding Direct Patient Services FY12 Request 1 Resources Ground Transportation to Treatment(gas cards) for treatment travel on the Big Island and, if medically necessary, on O'ahu $10,5001 $3,000 $7,500 Taxicab Fare while on O'ahu for cancer surgery or treatment $3,000 $1,500' $1,500 Interisland Air Transportation to Treatment $40,000 $5,000 $35,000 Partial Transpacific Airfare Reimbursement $4,000 $0 $4,000 Reach to Recovery personal visits, support services and supplies for breast cancer patients, and volunteer training $5001 $0 $500 Road to Recovery development and volunteer training $500' $500 $0 Look Good...Feel Better and Wigs classes, wigs, volunteer training $2,300 $500 $1,800 Childhood Cancer Pro g rams (Anuenue, Ika ika, Family) 11,000 2,OO Oi $9_,000 1 Newly Enrolled Client Services including the most up to date information on cancer and local resources; a lending library; and monthly patients;s for atients; and educational materials and 3 displays. (Personal Health Managers) $3,375 $1,150 $2,225 Ongoing Client Services including supplies for cancer patients, volunteer training, general $0 $500 eneral services $500' Survivor Celebration and Fight Back at Relays (7 relays) $9,750 $1,350 $8,400 TOTAL Budgeted for Programs: $85,425 $15,000, $70,425 --- ------- Note: Based on an estimated 837 cancer patients on Big Island in FY2012, with 645 of them newly diagnosed. 4 American Red Cross, Hawaii State Chapter Distaster Response & Preparedness for County of Hawaii American Red Cross, Hawaii State Chapter Program Name: Disaster Response & Preparedness for County of Hawaii Agency Director: Coralie Chun Matayoshi, Chief Executive Officer Phone No.: 808-739-8101 Contact Person: Barney Sheffield, Disaster Coordinator, Hawaii County Phone No.: 808-935-8305 Mailing Address: American Red Cross Hawaii County 55 Ululani St., Hilo Hawaii 96720 Facility/Site Address: 55 Ululani St., Hilo Hawaii 96720 Fax No.: 808-969-3673 Email address: sheffieldb @hawaiiredcross.org Name of CPA: KPMG Phone No.: Mailing Address: 2001 M Street, NW Washington, DC 20036-3389 Amount of request for County Funds: $25,000 Prior Year(s) Funding: 2009-10 2010-11 2011-12 $20,000 $15,000 $15,000 Agency Mission Statement: The American Red Cross is a humanitarian organization led by volunteers and guided by its Congressional Charter and the Fundamental Principles of the International Red Cross Movement. Our mission is to prevent and alleviate human suffering by helping people prevent, prepare for, and respond to emergencies, and to provide disaster relief to the people of Hawaii 24 hours a day, 7 days a week, 365 days a year. Although established by Congressional Charter in 1905, the American Red Cross is NOT a government agency and must rely on the generosity of Hawaii's people to provide critical services to the community. All disaster training, services, and financial assistance to victims is free. Therefore, fundraising is critical to ensure that services can continue. The Hawaii State Chapter was founded in 1917 and has assisted victims of every major disaster in the islands' history, including the bombing of Pearl Harbor, Hilo tsunami, volcanic eruptions, Big Isle earthquake, Hurricanes Iwa and Iniki, New Years & Manoa floods, Kaloko Dam burst, Sacred Falls landslide, Xerox shooting, air transportation crashes, and hostage situations. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012—2013 Page 1 American Red Cross, Hawaii State Chapter Program Name: Disaster Response & Preparedness for County of Hawaii The American Red Cross is the only organization mandated by Congress to respond to disasters and provide emergency communication to military families, and the only local nonprofit organization that meets the needs of disaster victims any time of the day, 365 days a year. Because we are an island community and considering the time it takes for assistance from other neighbor islands and the mainland, having the response capacity on island immediately after a disaster is essential. Program Description: The Hawaii County Red Cross Disaster Response and Preparedness Program includes disaster relief assistance to help victims of single family and major disasters overcome the physical and emotional distress of a disaster and meet their immediate emergency needs as they begin to rebuild their lives after a tragedy. This assistance includes food, clothing, shelter, mental health counseling, and financial assistance to help families recover more quickly from a disaster. Our volunteers are ready to respond to disasters 24 hours a day, 7 days a week, 365 days a year. We have 626 active disaster volunteers statewide and leverage the resources of our volunteers to provide this critical service. We also have over a thousand more volunteers statewide who are trained to help in a major disaster. Recruiting, training and mobilizing all of these volunteers is an ongoing job. Because a disaster can strike at any time without notice, advance preparation makes a significant difference in the well-being of a family or the resiliency of a business. As an island community and considering the time it takes for assistance from other neighbor islands and the mainland, having the response capacity on island immediately after a disaster is essential. All disaster training and response are provided free of charge. The Hawaii State Chapter continually trains volunteers to become disaster responders to serve during time of disasters (all disaster training is free). In the last fiscal year, the Red Cross conducted courses for volunteers in different communities statewide to achieve our objective of providing a seamless response when disaster strikes. We train volunteers to be able to conduct disaster assessment in neighborhoods, serve as shelter managers, conduct crisis counseling and emergency first aid and provide financial assistance to those whose homes have been affected by disaster. Our volunteers actively exercise with state agencies in preparation for natural disasters, pandemics and acts of terrorism. Through trained and capable disaster responders, communities will be better prepared prior to, during and after disasters. In light of lessons learned from the recent flooding, Hurricane Katrina and in the past from Hurricane Iniki, it is critical to have trained and capable volunteers ready and prepared to respond if a large disaster struck our islands. In a larger disaster or tragic event, crisis counseling, mass care, family reunification, emergency first aid and other support services as appropriate are also provided to victims. These services are offered to anyone whose loved ones were directly affected by the event. Crisis counseling services may also be extended to the community for secondary victims. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012—2013 Page 2 American Red Cross, Hawaii State Chapter Program Name: Disaster Response & Preparedness for County of Hawaii Another component of this program is community education, which empowers families and individuals to prepare for and respond to disasters before they strike. This will result in more aware and prepared communities. Red Cross volunteers and staff continually go out into the community to speak to the public about the importance of being prepared before a disaster strikes: get a disaster supplies kit, make a plan for your family and workers, and be informed. Because a disaster can strike at any time without notice, it is essential for communities to be prepared. Advance preparation can make a significant difference in the well-being of a family or the resiliency of a business. With the threat of pandemic influenza, bio-terrorist attacks, and major natural disasters, the American Red Cross is more relevant and necessary than ever before. With global warming and changing weather patterns, it is not "if," but "when" a major disaster in Hawaii will occur. Hawaii is especially vulnerable to hurricanes, tsunami, earthquakes, and other natural disasters. When a disaster strikes, we will have to be able to survive longer on our own due to our isolation. It is critical for the Red Cross to be prepared for and respond to everyday disasters and major disasters. Who We Serve: The Big Island has had more than its share of disasters over the years, including devastating tsunami, lava flows, flooding, heavy rains, high surf, earthquakes, brush fires, air crashes, explosions and hazardous material incidents. Whatever the incident, the Red Cross has always been there, ready to help those in need. The Hawaii Red Cross provides compassionate aid to people in Hawaii who fall victim to natural and man-made disasters that occur every 3 to 4 days in Hawaii. Disaster victims served by the Hawaii Red Cross are the poorest of the poor. All disaster training and response are provided free of charge, due to the generosity of our donors. According to a U.S. Census Bureau Report, 13.1% of the Big Island population lives below the poverty level. This "poor and needy" population is particularly vulnerable to disasters and is dependent on Red Cross services when affected by a disaster. Based on family size and income levels, at least 69% of disaster families we served in FY11 on the Big Island were below the poverty level. In FY11, 68% of our Big Island client families made less than $25,000 a year. Of the disaster families, 35% owned their home and only 12% had structure insurance. Since over half of them do not own their homes and have no property insurance, they are truly destitute after a fire destroys everything they own or claims the life of a loved one. The Red Cross is truly a safety net for victims of "every day" disasters who have nowhere else to turn. The Red Cross not only offers food, clothing, and shelter to those who may have lost everything they own, but also volunteer caseworkers provide crisis counseling and emotional support to help these victims get back on their feet. Beyond the "every day" disasters, the Red Cross is preparing for and will respond to major disasters, which may affect the entire population of Hawaii, especially those with special needs like the elderly, frail, handicapped, and poor. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012—2013 Page 3 American Red Cross, Hawaii State Chapter Program Name: Disaster Response & Preparedness for County of Hawaii When disasters occur, the American Red Cross will be there to support the County of Hawaii by providing families with relief assistance in time of need. The Hawaii State Chapter is requesting $25,000 from the County of Hawaii to help provide immediate emergency assistance to Big Island disaster victims and support emergency responders during times of disasters, train volunteer disaster responders so that local communities on the Big Island are prepared, and to share important preparedness information to people on what to do before a disaster strikes. This amount does not even begin to cover the staff and volunteer training, equipment, and support needed to respond to every day disasters, as well as educate and prepare Big Island residents for the next major disaster that is sure to come. Hawaii County Funding is critical to build resiliency and capacity for the communities of Hawaii County. Total Budget and Position Count Total Program $224, 200 Total Program Position Count 1 Budget for FY 11-12 (Disaster Services) Total Agency Budget $600,000 Total Agency Position Count 1 for FY 12-13 1. Program Objectives: Overall Goal: To provide 24/7 emergency disaster response and relief to those in need on the Big Island after a disaster (man-made or natural), train volunteer responders and share critical preparedness information to the communities on the Big Island. Objectives: • Provide for the immediate emergency needs of Big Island disaster victims (food, clothing, shelter, crisis counseling). All disaster services are free. • Increase awareness of disaster preparedness to Big Island residents. Prepare families, businesses, and communities with essential preparedness material and information because a disaster can strike at any time without notice. • Train volunteer disaster responders to serve their local communities during times of disaster. We train volunteers to be able to conduct disaster assessment in neighborhoods, run shelters, conduct crisis counseling and emergency first aid, and provide financial assistance to those whose homes have been affected by disaster. Our volunteers actively exercise with federal, state, and county agencies to prepare for natural disasters, pandemics and acts of terrorism. All disaster volunteer training is free. 2. Program Highlights: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012—2013 Page 4 American Red Cross, Hawaii State Chapter Program Name: Disaster Response & Preparedness for County of Hawaii In the past fiscal year (July 1, 2010 through June 30, 2011), the American Red Cross in Hawaii County provided the following services to Big Island individuals and families: • Responded to 11 disasters on Big Island enabling 43 individuals to recover from their losses and begin rebuilding their lives (does not include earthquake response). More than 69% of families assisted were below the poverty level. Of those affected, 65% did not own their home and 88% did not have structure insurance. • Maintained a trained background checked base of 135 disaster volunteers with 22 signing up in FY11 • Reached 1520 persons with disaster preparedness information through community presentations. • Issued 318 certificates in free disaster training courses Examples of responses are as follows: • Kailua-Kona Fire: On 10/25/10, an apartment in Kailua-Kona was gutted by fire. The resident was not at home and when she returned 3 days later she had no place to go, no food, and only the clothes she was wearing. RC assisted her with a stay in a local hotel, assistance for food and clothing. The client was able to find another rental to move to with RC assistance with security deposit and 1St month's rent. She was also given referrals to local agencies to assist with her recovery process. The family who lived next door was impacted with heavy smoke/ash damage and required a 2-night hotel stay until the smoke and ash could be removed from their unit. • Tsunami Response Update: Following the March 11, 2011 Pacific tsunami that hit the State of Hawaii, West Hawaii did incur damage to residences. A total of 36 cases with 80 clients were opened to address these client's immediate emergency needs to include financial assistance for hotel stays, food, clothing, medication, tents, stoves, bedding and linens. The RC also made distributions of clean-up kits and provided 50 meals to community clean-up efforts in Kealakekua Bay. In the first half of this fiscal year (FY12) to date, the Red Cross has already responded to 8 house fires on the Big Island in Honaunau, Kapaau, Mountain View, Pahoa, and Ninole. Our efforts have enabled 23 individuals to recover from their losses and begin rebuilding their lives. We provided 67 community individuals with free disaster response training. • Honaunau Fire: On September 11th a fire occurred at an organic vegetable farm in South Kona located at the end of a 4-wheel drive road, 2 miles from the main highway. The resident lived in an old coffee days structure and was awakened at 2am by the smell of smoke and the sound of glass breaking. She realized the dwelling was partially engulfed with flames and the only way to escape was to jump out the window. She suffered a broken foot and numerous cuts & bruises as a result of her fall. The Fire Department was not notified due to the remoteness of the location. The Red Cross provided her with assistance for food, clothing, bedding, replacement glasses, a 3-night hotel stay, security deposit and first month rent on a new rental, and referrals for her medical needs related to her burns and broken foot. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012—2013 Page 5 American Red Cross, Hawaii State Chapter Program Name: Disaster Response & Preparedness for County of Hawaii • Kapaau Fire: There had not been any house fire incidents in the North Hawaii area of the Big Island in the last 8 years. On November 7, 2011, a fire destroyed a house in Kapaau displacing a family of 9. The Red Cross provided them emergency assistance of food, clothing, bedding, and the replacement of medications & eyeglasses. The family was able to move into another house temporarily until they decide on their long-term housing arrangements. Performance Measures: Disaster Response and Preparedness in Hawaii County - Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget Estimate Disaster Responses 11 14 15 Individuals Assisted After Disasters 43 35 40 Mass Shelters Opened/Indvls Sheltered 0 1/10 2/20 Numbers Reached through Disaster 1520 1500 1500 Presentations in Communities Trained Individuals in Disaster Response 318 180 200 Program Expenditures (Disaster Response and Preparedness): FY 2010-2011 FY2011-2012 FY2012-2013 Actual Budget Estimate Salaries and Wages 50,599 44,482 46,000 Operations (occupancy, communication, postage) 58,324 60,000 60,000 Equipment 1,137 1,100 1,200 Materials (Supplies) 4,574 4,500 4,500 Travel 5,162 5,000 5,000 Disaster Relief Assistance * 15,678 16,000 16,000 Administrative/Tech Support ** 69,709 70,000 72,000 Total 205,183 201,082 204,700 • Monies are budgeted for the entire state for disaster relief assistance as it is unknown where disasters will occur. As disasters occur on the Big Island, expenses will increase accordingly. **This refers to all administrative, technical and programmatic support provided to the Red Cross in Hawaii County from our Headquarters. Program Funding Source (Disaster Response & Preparedness)- Identify all funding sources (specific to this program only) Revenue Source for FY2010-2011 FY2011-2012 FY2012-2013 Disaster Services Program Actual Budget Estimate Hawaii County 15,000 _ 20,000 20,000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012—2013 Page 6 American Red Cross, Hawaii State Chapter Program Name: Disaster Response & Preparedness for County of Hawaii Hawaii Island United Way 19,250 20,000 20,000 Contributions (Direct Mail & Grants) * 24,908 25,000 25,000 Fundraising (Hats Off) * 10,276 10,000 10,000 Rent 5,927 4,500 4,500 TOTAL REVENUE 75,361 79,500 79,500 TOTAL EXPENSES 129,822 121,582 125,200 Amount Hawaii Chapter must 205,183 201,082 204,700 subsidize for both Hilo and Kona offices to meet expenses for this program (dis secs) NOTE: 1. HIUW. Total is amount pledged but actual received is dependent on success of their campaign. 2. Contributions and fundraising amounts subsidize both Disaster Services and our Health and Safety Services Program. 3. Grant funding not reflected above Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self- sustaining? We continue to work on increasing Red Cross visibility in the community in order to increase private individual and corporate donations from Big Island residents and businesses. We are looking at possible fundraising opportunities on the Big Island such as special events, along with major donor cultivation. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawai'i. Our staff person, Barney Sheffield, does not have any affiliation with the County of Hawaii. We have 141 volunteers on the Big Island and some are employed by County departments or have family members employed by the county. We have advisory councils on both East and West Hawaii. Members of the East Hawaii Advisory Council are: Ted Dixon (Publisher, Hawaii Tribune-Herald); Andrew Chun (KTA Superstores); Terrance Crowley (Wal-Mart Hilo); Chris Leonard (New West Broadcasting Corp); Alan Shiraishi (Bank of Hawaii - Kaikoo Branch); Darla De Ville (Hawaii Island United Way); Randy Hirokawa (University of Hawaii at Hilo); Gerald Kosaki (Hawaii County Fire Department); Major James O'Connor (Hawaii County Police Department); John Drummond (Hawaii County Civil Defense) Members of the West Hawaii Advisory Council are: Carol Kitaoka (Prosecuting Attorney's Office); Barbara Goldman Garcia (Kona-Kohala Chamber of Commerce); Judith Jennet (Nanea Kai, Inc. dba Ocean Sports); Tom Newhouse (Pacific Radio Group); John Yates, III (Wal-Mart Kailua-Kona). NONPROFIT GRANT APPLICATION FISCAL YEAR 2012—2013 Page 7 American Red Cross, Hawaii State Chapter Program Name: Disaster Response & Preparedness for County of Hawaii I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135—2-142.2, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that the applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your proqram's or agency's future funding requests. I (we) understand that there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013 must be returned to the County of Hawai'l within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. January 26, 2012 Scott Wo, C apter Chair Signature oard President/Chair Date January 26, 2012 Coralie Chun Matavoshi, CEO Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012—2013 Page 8 The Arc of Hilo- As enc Name Advocacy Program- Program Name Agency Director: Michael E. Gleason Phone No.: 935- 8534, ext. 201 Contact Person: Debbie Perkins Phone No.: 935- 8534, ext. 208 Mailing Address: 1099 Waianuenue Ave. , Hilo, HI 96720 Facility/Site Address: Aging and Disabilites Resource Center (ADRC) 1055 Kinoole St., Suite 104, Hilo, HI 96720 Fax No.: (808) 934-7714 Email Address: dperkins @hiloarc.org Name of Accountant/CPA (include name of firm if applicable): Ms. Ann Fukuhara, CPA,MBA, Accountancy Firm Phone No.: 961-5582 Mailing Address: 714 Kanoelehua Ave., Box 6691, Hilo, HI 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $35,500 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $20,000 $15,000 $15,000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 11 Agency Mission Statement: The Arc of Hilo's mission statement is to imporve the quality of life for people with developmental and other diabilities on Hawaii through educational, vocational, and skills training, as well as employment and residential opportunities. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 11 The Arc of Hilo - Agency Name Advocacy Program- Program Name j® Program Description: The Advocacy Program assists people with disabilities and their families to access the social services they need in East Hawaii. Services to people with disabilites include: information and referral, advocacy, counseling, outreach and education. This year The Arc of Hilo intends to initiate an individualized "Social Security Benefits Planning" service to Arc's eligible clients, and extend outreach to other people with disabilities in the East Hawai'i community. We plan to target South Hilo, Puna, Ka'u and the Hamakua Districts on a regular rotation basis. Total Budget and Position Count Total Program Budget 51,247 Total Program Position Count 1 Total Agency Budget 4.7 million Total Agency Position Count 124 Program Objectives: 1) The primary goal of this program is to advocate for the underserved individuals and families of East Hawai'i to access services such as general information, housing, wage, medical, dental, and insurance benefits, job placement, transportation, accomodation issues, vocational rehabilitation, and various other social services such as Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI). Medicare, Medquest, Food Stamps (SNAP Program), Ticket to Work, and PASS. 2) Continue program expansion and development by provding the very best services possible at the Office of Aging and Disability Resource Center (ADRC) through on-going evaluation of exsisting services offered and by analyzing the areas that are underserved and in need of services for people with disabilities in East Hawaii. 3) Make referrals to the Kokua Program when immediate direct care is needed for people with developmental disabilites. Work with elegible individuals and families to apply for various government funded programs for long-term supports and services. 4) Continue as a primary resource on disability issues at the ADRC one-stop shop. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 11 5) Gain visibility and credibility in the community by holding monthly benefits planning and informational sessions on a rotation basis in South Hilo and Hamakua for a full year, and quarterly sessions in Ka'u and Puna. 6) These benefits planning sessions would identify potential clients and provide an opportunity for assessment and intervention through counseling and guidance, so that once they do return to work, they can be equipped to make informed choices and keep their benefits. Without this service, many clients choose to remain on disability to avoid being penalized and losing their benefits. 7) Our primary advocate, enrolled in Cornell University's Social Security Disability Benefits Planning Certification Program, held at UH Manoa. He is trained to assist and empower disabled individuals in making informed decisions on their private and public disability benefits, thus establishing The Arc of Hilo and the ADRC as a primary source of information and assistance. Program Highlights: (from Fiscal Year 2010-11) The Arc of Hilo's Disabilities Services Advocate provided or engaged in the following activities at the County's Aging and Disabilities Resource Center (ADRC), and in other areas in East Hawaii during this past fiscal year: 1) Advocated for people with a variety of disabilities in the community (including individuals and families from other island communities and cultures) to help them access services they need, including referrals for legal assistance, subsidized housing, General Assistance, MedQuest and Food Stamps applications, Social Security benefits, wage payments, assistance with Medicaid Waiver applications and Department of Vocational Rehabilitation intakes, transportation, and medical care; 2) Provided advocacy for benefit denials and successfully obtained benefits in the Department of Human Services General Assistance, Food Stamps, and MedQuest; Social Security, Medicaid Waiver Program's Developmental Disability Services, medical and dental services. 3) Assisted individuals with disabilities living in subsidized housing to maintain their housing by advocating for client with property manager to provide Fair Housing and ADA (American's with Disabilities Act) reasonable accommodations; referring clients to an agency that teaches and reinforces independent living skills such as housekeeping and timely rental payments; and monitoring clients who are high risk for landlord/tenant problems; 4) Participated in community health and disability awareness events throughout the East Hawaii area; NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 11 5) Serves as Vice-Chair on the Mayor's Committee on People with Disabilities that addresses County issues that affect people with disabilities and engaged in community activities to create public awareness of this committee; 6) Completed the Stanford University's Chronic Disease Self Management Program (CDSMP) and conducted classes in Naalehu and Waimea. The CDSMP program teaches life skills for people with chronic diseases to make the changes in their lives that can increase their level of wellness and postpone disability and debilitation. 7) Serves on the Workforce Development's Workforce Solutions committee to increase public and employer awareness of incentives of employing people with disabilities and ADA reasonable accommodation. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 11 THE ARC OF HILO ADVOCACY PROGRAM FY 2012-13 Operational Expenses Included: Internet&Telephone 2256.00 Notes from Page 3, "Other #" Mileage Reimbursement 300.00 Advertising 2000.00 Postage 60.00 Promotional Items, print materials, CD, book 2100.00 Office supplies 140.00 Insurance 400.00 Total $5000 In the coming fiscal year, the Advocacy program will be expanding its' scope of work to include the following: 1) As more and more clients are dealing with self management of chronic diseases, we feel it is imperative to address these issues. A six week class will be held 4 times a year for 40 students, based on the Stanford University's Chronic Disease Self Management Program. This program utilizes a manual, book, and CD. The CD is for relaxation techniques, and the text contains essential supplemental reading for the manual. The cost of the text is $15 and the CD is $13, plus shipping and handling. 2) Because Federal and State programs are constantly changing and frequent updates are imperative to effective Social Security benefits guidance, this information needs to be relayed to the consumer in a timely fashion, in order to allow them continued access to their health care needs. By access, we mean that the client has the ability to obtain medical treatment, and pay for the services. Beginning in July 2012, a rotation schedule would begin with monthly trips to Hamakua and South Hilo, quarterly trips to Puna and Ka'u, totaling 32 sessions. Brochures would be available to all participants explaining services and future meeting dates. The sessions would identify potential clients and provide an opportunity for assessment and intervention, through counseling and guidance so that once they do return to work, they can be equipped to make informed choices and keep their benefits. Without this information, many clients choose to remain on disability to avoid being penalized and losing their benefits. In order to reach a higher volume of clients, The Arc of Hilo will be initiating a radio and news- print advertising campaign to make people aware of our services, classes and counseling opportunities. The Arc of Hilo - Agency Name Advocacy Program - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Information: number of contacts ** ** 240 Referrals: number of referrals 295 200 200 Outreach: number of contacts 507 300 300 Advocacy: number of contacts ** ** 250 Education: number of contacts _ 22 60 40 Benefits Planning: number of contacts _ ** ** 60 _ Chronic Diseases Self-Management classes: number of contacts ** ** 180 Number of clients served 24 40 70 **items previously reported as units of services *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages 44,403 47,100 49,500 Professional Fees _ 61 56 110 Operations 6598 11,466 2256 Equipment Other# 1486 2,750 *5000 Total $52,548 $61,372 $56,866 * If applicable Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 11 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 11 The Arc of Hilo m Agency Name Advocacy Program e Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* _ Estimate HMSA Foundation Grant $6,530 HEI Foundation Grant 10,000 Friends of Hawaii Charities $5,000 * The above grants are pending funding. Total $21,530 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Currently, we are in our third year of service to ADRC and our outreach has expanded. As the economy continues to suffer and unemployment continues to rise, the Advocacy Program is actively providing educational services to public and private service organizations and community groups. Additionally, we are persuing foundation grants, private support and donations. By offering consumers the opportunity to increase their knowledge of Social Security's work incentives, they become more self-sustaining; and by successfully returning to work, The Arc of Hilo will receive compensation over a period of time (anywhere from 5 to 10 years) from the Ticket to Work Program and PASS, thus subsidizing our program in the future. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 11 Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Mr. Wesley Tanigawa, Arc of Hilo's Disability Advocate serves as Vice-Chair on the Mayor's Committee on People with Disabilities. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 11 The Arc of Hilo - Agency Name Advocacy Program - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of11 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. -- /7 ,,�� nature of Board President/Chair Date or Agency Director thy/f 2- Sign.ture of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 11 6 Arc of Kona, The Home and Community Based Services - Life Skills co) (- y Arc of Kona County Grant Application 2012-2013 Arc of Kona HOME AND COMMUNITY BASED SERVICES LIFE SKILLS PROGRAM Agency Director: Gretchen Lawson Phone No.: 808-323-2626 Contact Person: Jeani Navarro Phone No.: 808-775-1090 Mailing Address: PO Box 127 Kealakekua, HI 96750 Facility/Site Address: 81-1065 Konawaena School Road Kealakekua, HI 96750 Fax No.: 808-323-9444 Email Address: jeani@arcofkona.org Name of Accountant/CPA: Ann N. Fukuhara, CPA, MBA An Accountancy Corporation Phone No.: 808-961-5532 Fax: 808-934-8589 Mailing Address: PO Box 6691, Hilo, HI 96720 Amount of Request for County Grant-in-aid funds: $15,000.00 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $15,000 10,000 $10,000 Agency Mission Statement: The Arc of Kona is committed to helping people with disabilities achieve the fullest possible independence and participation in society consistent with their wishes. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 1 of 9 Arc of Kona County Grant Application 2012-2013 Arc of Kona HOME AND COMMUNITY BASED SERVICES LIFE SKILLS PROGRAM Program Description: For over forty years, the Arc of Kona has successfully operated an Adult Day Health (ADH) standard classroom program that currently serves 23 participants and a Personal Assistant/Habilitation program island-wide that serves 70 plus participants on a daily basis in their community setting. This year the Department of Health added a new service titled Employment Services which includes pre vocational skills training, assessment and job placement services. These three programs are combined as Home and Community Based Services for individuals with an intellectual or developmental disability. The Arc of Kona is committed to serving this population especially those residing in the most rural areas (Puna/ Hamakua/Kohala) that lack adequate access to services. All of the participants in the Home and Community Based Services programs have been identified as having a diagnosis of a disability (DD/ID Developmentally Disabled/Intellectual Disability) by the State of Hawaii and have cognitive limitations that prevent them from living as independently as possible without extensive life skills training and other needed supports. The population is a mix of Native Hawaiian, Asian/Pacific Islander, Filipino and Caucasian youth and adults ranging from 8 to 60 years of age with a core group of young adults in their late teens and mid 20's. All of these individuals are unable to make good judgments due to cognitive delays; therefore needing various supports that insure their safety and help with activities of daily living. The individuals need to be in a caregiver's line of vision at all times and require assistance gaining access to community services and activities that will allow them to begin integration into the communities where they reside. The DD/ID population has several risk and protective factors that we consider when designing individual life skills training. First, this population is at risk of abuse, both sexual and physical, and need to be taught the skills for saying "NO" and reporting abuse. They are known to be at risk for chronic disease and have a high incidence of diabetes and heart problems related to weight and diet. Finally, they are all at risk for homelessness and/or being unprepared to live independently both with daily living skills and finances. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 2 of 9 Arc of Kona County Grant Application 2012-2013 Arc of Kona HOME AND COMMUNITY BASED SERVICES LIFE SKILLS PROGRAM Protective factors we consider include: a) training in social development, b) appropriate sexual behaviors, c) protection from abuse including family members, employers and strangers, d) proper nutrition, e) preparing individuals to find their own housing accommodations and live as independently as possible, with or without assistance and other agency supports, and f) preparing for work either supported or unsupported at the work site, non-traditional employment and entrepreneurial start ups. The "community as a classroom" where participants can practice these skill sets becomes essential to strengthening the protective factors around this vulnerable population. When provided with community access services for their life skills component, our participants not only learn but have the opportunity to share many of their own skills and gifts that benefit the larger community. The Arc of Kona's $15,000.00 request will enhance service delivery by providing for life skills training supplies and access to and from home and the classroom, and into community as well as portion of the staffing and payroll taxes attached to the salaries. Total Budget and Position Count Total Program Budget $360,133 Total Program Position Count 6 Total Agency Budget $3,194,582 Total Agency Position Count 104 Program Objectives: 1) Provide a safe, healthy, and supportive environment for daily living skills in the community setting for 365 days per year from July 1, 2012 to June 30, 2013 for the participants receiving Home and Community Based Services island-wide with focus on the rural underserved areas of the island thus relieving families of the stress of daily care giving and allowing them the opportunity to work if they desire and make a living and/or care for other children. 2) Provide individualized life skills training programs, with measurable goals and objectives that allow each participant to develop at his or her own pace in order to live as independently as possible. 3) Insure access to community events and resources that will be a learning laboratory for independent living and reinforce skills taught throughout the program year, including those for supported employment. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 3 of 9 Arc of Kona County Grant Application 2012-2013 Arc of Kona HOME AND COMMUNITY BASED SERVICES LIFE SKILLS PROGRAM 4) Provide needed materials to assess, instruct and support life skills specific training in health and safety areas relating to abuse and appropriate sexual behavior as well as hygiene, money management, household safety issues and nutrition. 5) Provide needed supports for interacting appropriately with each other and the public within the community setting throughout the program year that supports the independent living skills/and or work setting required to function on a daily basis. 6) Provide supports for seeking and receiving employment. Program Highlights (from Fiscal Year 2010-2011): The Arc of Kona's programs grew last year increasing our ADH classroom and Personal Assistant/Habilitation with additional participants. This continued growth success has been in part because the Life Skills Program is results driven and families have been pleased and excited with our innovations, especially those in the area of employment preparation. 1) 85 participants received daily lessons on health and safety as they pertain to daily living and toward independent living (including information on hygiene, appropriate sexual behavior, yoga for stretching and balance, fire safety, and classes on nutrition and weight maintenance). Training positively resulted in a reduced number of behavior outbursts and incident reports. 2) 85 participants have been able to access the community (as required by law)for practicum in independent living skills in real life community settings. This resulted positively in 100% of the participants meeting two or more of their individual objectives toward their personal goals and 85% of participants actually attaining one of their personalized goals. 3) 25 participants were able to participate in yoga classes, walking and stretching training that has resulted in better balance and body awareness and therefore less falling/tripping and more self esteem. 4) 85 participants received training in the nutritional value of foods and were trained to assist in the preparation of healthier meals. The goal this year was to make healthy food choices unsupervised. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 4 of 9 Arc of Kona County Grant Application 2012-2013 Arc of Kona HOME AND COMMUNITY BASED SERVICES LIFE SKILLS PROGRAM Performance Measures: Home and Community Based FY 2010-11 FY 2011-12 FY 2012-2013 Services Life Skills Program Actual* Budget* Estimate 1. a. Provide a safe, secure classroom 260 days of 260 days of ADH 260 days of environment with sufficient staff ADH standard standard ADH standard supervision, 5 days a week, 52 weeks a classroom classroom classroom year, for current 25 DD/ID participants. activities with a activities with a activities with a b. Deliver ongoing life skills training in one staff to four one staff to four one staff to four the classroom and the rural areas as per participant ratio participant ratio ratio for 25-30 each individual's plan which is developed for 25 partici- for 25 partici- participants by the Department of Health, the family pants and 365 pants and 365 and 365 days and the Arc of Kona. days of one on days of one on of one on one one services for one services for services for 90 participants. 90 participants. 90+ partici- pants. 2. Provide access to the community for 144 ADH 144 ADH 144 ADH hands-on life skills training experiences classroom group classroom group classroom including food and clothing shopping, fire transports for 25 transports for 25 transports safety, ordering and eating in public, people into the people into the proposed and handling money, making appointments, community and community and 365+ individual nutrition and exercise, and appropriate 365+ individual 365+ individual transports behaviors in public (including sexual transports to transports for proposed to behavior). achieve Life activities that achieve Life Skills plan in the promote Skills plan in community. individual life the community. skills goals. 3. Provide on-going Life Skills 260 days of 365 days of 365 days of assessments and data collection for each classroom completed instruction individual. This includes areas such as instruction and instruction for Life proposed with recognizing and reporting abuse, health, 365 days of Skills and daily assessment, hygiene, safety, socialization, basic community living activities base line, and cooking skills, behaviors, consumerism, instruction for with pre and post data collection basic literacy and job skills training. Life Skills and testing for for results daily living assessment of reporting. activities with base line skills, pre and post data collection testing for and quarterly and assessment of year end base line skills, reporting on data collection achieved results. and quarterly and year end reporting on achieved results. *If applicable: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 5 of 9 Arc of Kona County Grant Application 2012-2013 Arc of Kona HOME AND COMMUNITY BASED SERVICES LIFE SKILLS PROGRAM Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages $266,741 $289,829 $298,524 Professional Fees Operations $56,202 $63,890 $64,529 Equipment Other# Total $322,943 $353,719 $363,053 * If applicable Please explain in detail on separate sheet Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate County of Hawaii $10,000 $10,000 $15,000 Hawaii Island United Way $26,667 $30,000 $26,666 State Medicaid Waiver $297,843 $320,133 $321,472 Client Fees (Third Party) $10,569 Total $345,079 $360,133 $363,138 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Each year, the week before Thanksgiving, we hold a bazaar and craft sale that is our signature event. In June of each year, we hold a musical concert in conjunction with Hawaii Performing Arts Festival. We also have an upcoming Blue Grass benefit concert with Grammy award winning artists Laurie Lewis and Tom Rozum scheduled at the Aloha Theater January of 2012. We have been actively and successful working with our island wide donors for additional program support. In addition, the Arc of Kona has applied to be an Employment Network (EN) which if granted, will provide a new employment related funding stream for participants that are Social Security Administration Ticket To Work ticket holders. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 6 of 9 Arc of Kona County Grant Application 2012-2013 Arc of Kona HOME AND COMMUNITY BASED SERVICES LIFE SKILLS PROGRAM Our overall goal for the valuable Life Skills Program is to be self sustaining and we see this as attainable in the near future if our plans and projections come to fruition. Like all non-profits, the rising costs for services and budget reductions that have dramatically affected our families and participants' programs. However, we have taken a proactive stance and made internal organizational changes so that our programs can maintain their integrity. With the benefit of a recent grant through the Walmart Foundation, we are able to work with local high schools to transition students with a diagnosis of a disability into off campus work sites and at graduation into competitive employment. This step is one of the proactive measures we are taking to not only help our participants enjoy their community and receive wages for real work, but also not be as dependent on government funds in the future. We are also working with Social Security Benefits Educators to assist families with understanding how benefits work and take the fear out of employment creating a loss of medical and other needed benefits. The Arc of Kona is celebrating its 46th anniversary this year. We have been working diligently to find new and creative ways to raise unrestricted funds to support our numerous programs and actively working with our Board of Directors and the community to offer events all through the year which will also educate the public about the needs of our population and generate a stronger donor list both local and through our website. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Jeani Navarro, Vice President for Program Services, is on the Mayor's Committee on Persons with Disabilities. She is also chairperson of the Employment Subcommittee. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 7 of 9 Arc of Kona County Grant Application 2012-2013 Arc of Kona HOME AND COMMUNITY BASED SERVICES LIFE SKILLS PROGRAM I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copies documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 8 of 9 Arc of Kona County Grant Application 2012-2013 Arc of Kona HOME AND COMMUNITY BASED SERVICES LIFE SKILLS PROGRAM By signing below, you are acknowledging that you have read and understand these requirements. Signature of Board Pre ide t/Chair Date or Agency Director Sig : ure of Executi a Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 9 of 9 7 Bay Clinic, Inc Medicaid/QUEST Enrollment Bay Clinic, Inc. Medicaid/QUEST Enrollment Program Agency Director: Paul Strauss Phone No.: (808) 961-4083 Contact Person: Youlsau Bells Phone No.: (808) 961-4078 Mailing Address: 224 Haili Street, Building B Hilo, HI 96720 Facility/Site Address: 224 Haili Street, Building B Hilo, HI 96720 Fax No.: (808) 961-5678 Email Address: ybells@bayclinic.org Name of Accountant/CPA: Ann Fukuhara, CPA MBA An Accountancy Corporation Phone No.: (808) 961-5532 Mailing Address: 714 Kanoelehua Avenue P.O. Box 6691 Hilo, HI 96720 Amount of Request for County Grant-in-aid funds: $100,000 Prior Year Award of County Nonprofit Gran-in-Aid funds: 09-10 10-11 11-12 $0 $35,000 $0 Agency Mission Statement: To provide high quality, patient-centered, comprehensive health care that is accessible, affordable, coordinated, culturally competent, and community directed for all. Program Description: Program Need We respectfully request that the County of Hawaii Grant-in-Aid consider awarding the Bay Clinic Eligibility Program a grant of$100,000 that will go towards helping the current and newly uninsured people in our community enroll in Med-QUEST, the state sponsored health care insurance program for low-income people. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 8 Bay Clinic, Inc. Medicaid/QUEST Enrollment Program Target Population Bay Clinic, Inc. is a 501(c)3 non-profit community health center with 8 locations serving 18,000 patients, of which 88% are uninsured or on Medicaid/Medicare and live in poverty. Bay Clinic serves the districts of Hilo, Puna, and Ka'u with a combined population of 106,745; 43% of which live 200% below the federal poverty line; 1 in 3 receive food stamps; 2 of 5 are on temporary assistance for needy families; and the unemployment rate is 12% with some areas reaching 16%. There is a direct link between access to health care and poverty. The majority of people facing financial hardship generally have little to no health insurance coverage and tend not to access health care services when needed for fear of the associated costs, which can be a substantial portion of their total household income. In addition, access to care for children who live in poverty Brenda age 52 was is critical as studies have shown that children who have a diagnosed with breast good start in life have much less risk of being poor as cancer. When she first adults and of initiating another cycle of poverty with their noticed a lump, she own children. Poor nutrition and limited access to health was in the three-month care are known to cause mental and other developmental waiting period for the health insurance offered delays that affects a child's ability to learn and develop through the job she had recently good social skills and untreated medical and dental taken. Within days of qualifying for diseases are major factors in excessive absences from this coverage, she was laid off school. We work to improve the health of our Uninsured and facing this diagnosis, community's children and adults. Brenda was eligible to enroll in her state's Medicaid Breast and Cervical Bay Clinic offers comprehensive medical, dental, and Cancer Prevention and Treatment mental health care to all regardless of a person's ability to Program. pay. We care for the uninsured, underinsured, privately insured, and those who participate in Med-QUEST. This Medicaid program has covered nearly all of Brenda's cancer care, including a hospital stay and Medicaid/Med-QUEST mastectomy, chemotherapy, Medicaid is the nation's public health program for low- prescription medicines, imaging and income residents, particularly children, pregnant women, lab services, and specialist care. parents of eligible children, people with disabilities and Brenda pays a small amount for her elderly needing nursing home care. The Medicaid prescriptions, but with her very low program is jointly financed and operated by the state and income, and costs for her cancer care federal governments. Each state administers its own totaling close to$100,000,she would Medicaid program, called Med-QUEST in Hawaii, while the be devastated by medical debt if she federal Centers for Medicare and Medicaid Services did not have Medicaid benefits. monitors the state-run programs. Medicaid is the largest Kaiser Family Foundation,Medicaid Story source of funding for medical and health-related services for people with limited income. Medicaid provides access to affordable and comprehensive health care and accounts for roughly one sixth of the nation's health care spending and almost half of all spending on long NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 8 Bay Clinic, Inc. Medicaid/QUEST Enrollment Program term care. Medicaid's guarantee of federal financing that matches state spending helps states respond to losses of private health insurance due to unemployment and rising health insurance premiums, increases in health care costs, emergencies and disasters, and an aging society. Hawaii's Med-QUEST program helps to improve and maintain health coverage for low-income disabled and elderly populations, families, and children who are left out of our country's fragmented, employer-based health care system. Bay Clinic's Eligibility Program The declining job market has resulted in more people and families facing economic hardship through loss of income and employer-based health insurance coverage. The shrinking economy is leading to more people who are newly uninsured needing affordable health care. For example in 2010, our Med-QUEST patients increased by 626 from 2009; but the number of uninsured patients only decreased by 3 during the same period. These statistics show that although we are increasing the number of people covered by Med-QUEST, there is a growing number who are newly uninsured and needing guidance and help on what support services are available and how to access these services. In an effort to meet the growing need for affordable care, over the past two years Bay Clinic added two more facilities and expanded services to increase access to the growing number of people requiring affordable health care. To help with our efforts to reach those newly uninsured, in 2010 the Hawaii Primary Care Association (HPCA) provided support to our pilot Med-QUEST Eligibility Program. HPCA contributed $44,424 to support one eligibility staff position. The program proved to be effective and has increased the number of our Med-QUEST insured patients by 12%. But we still need to do more to help reach the growing number of those who are at-risk in our community. Bay Clinic's Eligibility Program for which we are seeking support will provide for three Eligibility staff to rotate between our 8 health center's working with uninsured patients to: 1) determine a person or family's Med-QUEST eligibility, 2) assist eligible Med-QUEST patients through the enrollment process, including advocating on the patients behalf once the paperwork is submitted. The Eligibility staff will also link high needs community members with other social service support they may require such as transportation assistance, medical referrals, housing assistance, food stamps, food pantries, legal aid, mental health, and substance abuse services. In addition to the growing number of recently uninsured people, a surge in new patients is expected as health center's such as Bay Clinic are expected to be the conduit for the uninsured to gain access to care through the Affordable Care Act's expansion of Medicaid. Currently, Medicaid provides health coverage for about 1 in every 5 Americans. During down economies, Medicaid places pressure on state and federal budgets as the number of people who qualify for the program grows. Without Medicaid, most of its beneficiaries would be uninsured or lack coverage for essential care. Although Medicaid reaches many poor Americans, it does not NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 8 Bay Clinic, Inc. Medicaid/QUEST Enrollment Program reach all of them. Under the new health reform law, beginning in 2014, millions of uninsured, low-income Americans will gain health coverage through a major expansion of Medicaid. But help in accessing and navigating this coverage is essential. The shrinking economy and the expansion of Medicaid requires that we work harder to ensure those community members who are in need get the care they need. Our goal for this project is to reduce the number of medically uninsured residents in our community by 15% by the year 2014. We will accomplish this by working harder to: 1) Outreach and educate residents on Med-QUEST, including one-on-one assistance; 2) Enroll eligible residents and families in Med- QUEST and advocate for them throughout the enrollment process; and 3) Follow-up with patients and families to remind and help more Med-QUEST qualifying residents retain their insurance status annually from within our low income community. Total Budget and Position Count Total Program Budget $170,545 Total Program Position Count 3 Total Agency Budget $12,074,362 Total Agency Position Count 155 Program Objectives: 1) To reduce the number of uninsured residents in our community by 15% by assisting eligible people and families enroll in Med-QUEST insurance and advocating for them throughout the process. Program Highlights: (from Fiscal Year 2010-11) 1) Bay Clinic is successfully carrying out its mission through expanding access to health care services by increasing the number of care sites and growing the diversity of our programs provided within a culturally sensitive patient-centered setting. 2) We cared for 18,000 patients with 60,000 total encounters. 3) For the second year in a row, patients reported receiving "Good to Excellent Care" in our annual patient satisfaction survey. 4) Opened the Bay Clinic Hilo Women's Center in 2010. 5) Expanded our women's health program to include OB/GYN supervised prenatal care, including labor and delivery services in 2010. 6) November 2011, conducted a groundbreaking ceremony for the construction of the new 5,286 square feet Ka'u Family Health and Dental Center in Na'alehu town, expected to be completed in 2013. 7) December 2011, opened the new Hilo Family Dental Center in the Hilo Shopping Center. 8) Employed 155 people, including 28 providers, contributing significantly to the economy and workforce of Hawai'i Island. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 8 Bay Clinic, Inc. Medicaid/QUEST Enrollment Program Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual* Budget* Estimate An increase in the number of Med-QUEST 10,295 10,810 12,432 insured patients by 15%. *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual* Budget* Estimate Salaries and Wages 37,524 63,589 116,988 Professional Fees 0 0 0 Operations 7,644 11,844 14,577 Equipment 2,700 2,400 2,600 Other# 9,381 15,897 36,380 Total 57,249 93,730 170,545 *If applicable #please explain in detail on separate sheet Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual* Budget* Estimate Hawaii Primary Care Association $44,424 $0 $0 Hawai'i County— pending $0 $0 $100,000 Bay Clinic, Inc. In-Kind $12,825 $93,730 $70,545 Total $57,249 $93,730 $170,545 *If applicable To meet the demand for affordable care, we have added two additional facilities and staff, which has enabled us to expand access to the increasing number of people requiring affordable health care. In the 2012, we plan to have a total of three Eligibility staff members who will provide outreach and work directly with eligible individuals and families to enroll them in Med- QUEST. Our goal will be to reduce the number of our uninsured patient population. We only seek support for the first year expansion as we expect the program to be sustainable through increased insurance billing by 2014. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 8 Bay Clinic, Inc. Medicaid/QUEST Enrollment Program Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Our past Grant-in-Aid requests show that we do not ask for consecutive year program support. Our request history demonstrates that we ask for assistance only when needed and only for those programs that we expect to be self-sustaining. To this end, we are asking for one-time support of our Med-QUEST program as we anticipate that through improved Med-QUEST enrollment numbers the program will be sustainable via increased billing and insurance revenue. We expect to increase the number of people enrolled in Med-QUEST by 15%, thereby enabling us to bill for health care services of these newly enrolled patients. On average, we receive $135 per visit including write-offs, uninsured patients, and other insurance reimbursements. Even at one visit per year for each newly enrolled Med-QUEST covered patient, the increase in billing of $218,970 (15% increase @ 1,622 people x$135). By 2014, we anticipate a balanced budget, relying only on the federal support that helps us provide care to uninsured individuals in our service area. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 8 Bay Clinic, Inc. Medicaid/QUEST Enrollment Program Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawai'i. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 0 2-142.2, Hawai'i County Code, relating to Application of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013 must be returned to the County of Hawai'i within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 8 Bay Clinic, Inc. Medicaid/QUEST Enrollment Program By signing below, you are acknowledging that you have read and understand these requirements. iqz /i Sig ature of Board President/Chair /Date or Agency Director — 2_0 _ 2� Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 8 8 Big Brothers Big Sisters of Honolulu Hawaii Island Big Brothers Big Sisters Big Brothers Big Sisters of Honolulu Hawaii Island Big Brothers Big Sisters Agency Director: Dennis Brown Phone No.: 808-695-4570 Contact Person: Jill Matro Phone No.: 808-695-4564 Mailing Address: 418 Kuwili Street,Suite 106 Honolulu,HI 96817 Facility/Site Address: 418 Kuwili Street, Suite 106 Honolulu,HI 96817 Fax No.: 808-356-3536 Email Address: jmatro @bigshonolulu.org Name of Accountant/CPA: Rebekah Remchuk Phone No.: 808-695-4561 Mailing Address: 418 Kuwili Street, Suite 106 Honolulu,HI 96817 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $20,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $0 $0 Agency Mission Statement: Big Brothers Big Sisters of Honolulu (BBBSH) is a preventative non-profit agency whose vision is to create successful one-to-one mentoring relationships for all children who need and want them, contributing to better schools,brighter futures and stronger communities for all. We develop positive relationships that have a direct and measurable impact on the lives of young people, helping them to become responsible adults. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 6 Big Brothers Big Sisters of Honolulu Hawai'i Island Big Brothers Big Sisters Program Description: Big Brothers Big Sisters of America was founded over 100 years ago and was first established in Hawaii in 1963. Big Brothers Big Sisters of Honolulu offers one-to-one mentoring to at-risk children between the ages of six and 18 with the goal of having these youth reach their fullest potential as responsible adults. There are two primary programs; Community Based and School Based. In the Community Based Program a "Big" (mentor) and "Little" (child) commit to be matched for a minimum of one year, and hopefully longer. Many matches continue for several years. Matches spend time together doing activities they enjoy in the community,typically twice per month for two to four hours at a time. The School Based Program also pairs mentors and children in a one-to-one friendship, but provides a structured environment where `Gigs" and "Littles" interact weekly in one to two hour sessions in a classroom setting under the supervision of agency staff. Curriculum includes educational and recreational activities. This program now has more than twenty sites on Oahu and Kauai. `Gigs" in the School Based Program can be high school students as well as adults, while `Gigs" in the Community Based Program must be 18 or older. A national study conducted by a private research group examined the impact of mentoring on youth and found that when compared to their peers, "Little Brothers" and "Little Sisters" who met with their`Gigs" regularly were 46%less likely to start using drugs,27%less likely to start drinking,52%less likely to skip a day of school and 33%less likely to hit someone. Big Brothers Big Sisters takes the safety of our`Gigs" and"Littles"very seriously and so has an extensive and thorough screening,matching and supporting process for every match in both Programs. This requires having qualified and trained staff in each position as Enrollment, Match Support and Case Managers. Match Support for the Community Based Program entails contacting each match party;"Big","Little" and parent on a set time schedule in order to ensure that"Littles"are safe and benefiting from the program,that the parents are involved in the match and that the`Gigs"have the support they need to continue as long as possible. Big Brothers Big Sisters of Honolulu is currently expanding its services to the island of Hawai'i in order to provide the keiki of this island with mentors and thus extend the success of the program to more children. We are seeking funding for this new Hawai'i Island program which began in 2012. The model will be based upon the description above, and the program will begin with one full-time staff member on-island. By July 2012, the beginning of the next fiscal year, we hope to have one full-time case manager on staff, seven Community Based matches and one school partnership with a School Based Program serving six to eight matches. As there will soon be branches on Oahu, Kauai, Maui and Hawai'i, there are plans to change the name of the agency to Big Brothers Big Sisters Hawai'i to better represent the work of the agency. Total Budget and Position Count Total Program Budget $69,600 Total Program Position Count 1 Total Agency Budget $1.85 mil Total Agency Position Count 18 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 6 Big Brothers Big Sisters of Honolulu Hawai'i Island Big Brothers Big Sisters Program Objectives: 1 I Hire one full-time staff member to maintain and grow current programs. 2 Build upon successes of the School Based Program in 2011-2012 school year and reopen same site with more matches expected during the course of the year. 3 j Create 17 matches between`Gigs"and"Littles"in the Community Based Program. 4 Establish two School Based sites with five to ten matches in each. 115 'Support all matches in the Community Based and School Based Programs by maintaining a"Match I Support Contacts Done"rate of 91%or above. 6 Support all matches in the Community Based Program by maintaining a"Match Support Contacts Done On-Time"rate of 68%or above. 7 Support all matches in the School Based Program by maintaining a"Match Support Contacts Done j On-Time"rate of 73%or above. 8 Maintain a 6 month retention rate of 75%or above for the Community Based Program,as studies show that"Littles"benefit more from longer matches. 9 Plan and orchestrate two match activities in the community to keep`Gigs"and"Littles"invested and help them feel connected to the agency. 10 Strive for measurable impact for the children served in both Programs,to be measured with the 'Youth Outcomes Survey(YOS),which is a pre/post test measuring the categories of Parental Trust, Sense of Social Acceptance by Peers,Confidence in School Abilities,Educational Expectations, Grades and Disapproval of Unhealthy Behaviors. The goal is that 75%of the children served will improve in at least two of the six categories after having been matched a full school year for School 1 Based or a full year for Community Based. 11 :Ensure that at least 80%of the"Littles"in the Community Based program and 90%of the"Littles" in the School Based program fall into the category of"at-risk". 12 j Forge two new community partnerships. Program Highlights: (from Fiscal Year 2010-11) As Hawai'i Island Big Brothers Big Sisters was not officially started until 2012,any Program Highlights from Fiscal Year 2010-2011 were in preparation for the Program's official opening. No matches were served,but much was accomplished. 1. An advisory committee comprised of 15 prominent citizens from the community was created; meetings commenced. 2. Initial funding for the Program was secured from Kamehameha Schools/Bishop Estate. 3. Working relationships with other Hawai'i Island agencies,such as the YMCA,YWCA,Boys and Girls Club and Queen Lili'uokalani Children's Center were established. 4. The first potential Big Brother and Big Sister mentor applicants were interviewed and the screening process begun. 5. Several meetings with Kamehameha School and Kea'au Elementary Public School administration and counselors took place,in order to initiate a School Based Mentoring Program in Puna. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 6 Big Brothers Big Sisters of Honolulu Hawai'i Island Big Brothers Big Sisters Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual* Budget* Estimate Children served in the Community Based N/A 7** 23 Program Children served in the School Based Program N/A 8** 21 Community Based"Match Support Contacts N/A 91% 91% Done" Community Based"Match Support Contacts N/A 68% 68% Done On-Time" School Based"Match Support Contacts Done" N/A 91% 91% School Based"Match Support Contacts Done N/A 73% 73% On-Time" Percentage of children in the Community Based N/A N/A 75% Program who after being matched a full year, according to the Youth Outcomes Survey, improved in at least two categories given; Parental Trust, Sense of Social Acceptance by Peers,Confidence in School Abilities, Educational Expectations,Grades and Disapproval of Unhealthy Behaviors. Percentage of children in the School Based N/A N/A 75% Program who after being matched a full school year,according to the Youth Outcomes Survey, improved in at least two categories given; Parental Trust, Sense of Social Acceptance by Peers,Confidence in School Abilities, Educational Expectations,Grades and Tlicannrnval of T Tnhnalth ,R•havinrc *If applicable **Keep in mind that Hawai'i Island Big Brothers Big Sisters was not officially underway until January of 2012,meaning that the numbers above for FY 2011-2012 reflect only half of a fiscal year. Program Expenditures: FY 2010-11 Actual* FY 2011-12 Budget* FY 2012-13 Estimate Salaries and Wages N/A $22,000 $43,700 Professional Fees N/A $3,000 $8,000 Operations N/A $5,000 $14,900 Equipment N/A N/A $3,000 Total N/A $30,000 $69,600 *If applicable s Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 6 Big Brothers Big Sisters of Honolulu Hawai'i Island Big Brothers Big Sisters Program Funding Sources: Identify all funding sources(specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual* Budget* Estimate Federal Office of Juvenile Justice and N/A $3,000 $17,500 Delinquency Prevention(OJJDP) Kamehameha Schools N/A $25,000 $25,100 Hawaii Community Foundation N/A $2,000 $7,000 Hawaii County N/A N/A $20,000 Total N/A $30,000 $69,600 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The board of Big Brothers Big Sisters of Honolulu(BBBSH)has passed a resolution to expand the agency state-wide. With the expansion to the island of Hawai'i and an upcoming merger with Maui,BBBSH will serve all four counties of Hawaii. BBBSH will bring to the table the resources of current funding streams, training,experience and fund development. The funding resources available to the soon-to-be state-wide agency has increased to include a grant from the federal government through Big Brothers Big Sisters of America. The national office has awarded BBBSH an Office of Juvenile Justice and Delinquency Prevention (OJJDP) grant worth $131,000. The OJJDP grant period began on January 1, 2012 and will end June 30, 2013. In the grant application, BBBSH allocated the equivalent of one part-time position to Hawai'i Island Big Brothers Big Sisters,which will allow us to hire a full time Case Manager, rather than the part-time Case Manager previously planned for. In addition to this support, Hawai'i Island Big Brothers Big Sisters will work to find solid partnerships, fundraising ideas and grant opportunities that will ensure that they can reach the same self-sustainability that both the Oahu and Maui branches have been able to achieve for the past 40 years. In particular, our national Big Brothers Big Sisters signature fundraiser, Bowl for Kids' Sake, has been highly successful on Oahu for the past 25 years and on Kauai for the past two years of their four-year existence. This national model of fundraising has generated over$300,000 combined for Oahu and Kauai over the past two years. Please disclose(list here)any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. To the best of our knowledge,no one affiliated with our organization currently has any personal or professional affiliations with the County of Hawai'i. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 6 Big Brothers Big Sisters of Honolulu Hawai'i Island Big Brothers Big Sisters I(we)have read and understood all of the eligibility requirements;grant conditions;award procedures;and records,reporting and fiscal accountability requirements as mandated in Article 25,Sections 2-135—2- 142.2,Hawai`i County Code,relating to Appropriation of Funds to Nonprofit Organizations. I(we)hereby certify that information supplied herein including all supporting documents is correct and that I(we)have the authority and ability to fully administer the program(s)pursuant to law. I(we)understand that information supplied herein shall be made public according to Chapter 92F,Hawai`i Revised Statutes. I(we)understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I(we)understand that all documents requiring a signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai`i,I(we)understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant,a complete accounting of all expenditures supported by County of Hawai`i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely,complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I(we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30,2013 must be returned to the County of Hawaii within 30 days(July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understand these requirements. l/ q�'�t/i %[�t6(/� //3v/i 2. Signature of Board President/Chair // Date or Agency Director t2 7 2A/L. Sig e of Ex ive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 6 9 Boys and Girls Club of the Big Island - Hilo Positive Youth Development Programs - Hamakua Club Boys & Girls Club of the Big Island Positive Youth Development Programs: Hamakua Club Agency Director: Zavi Brees-Saunders Phone No.: 961-5536 Contact Person: Zavi Brees-Saunders Phone No.: 961-5536 Mailing Address: 100 Kamakahonu Street, Hilo, Hawaii 96720 Facility/Site Address: 43-1477 Hauola Road, Pa'auilo, Hawaii 96776 Fax No.: 961-5534 Email Address: zavi @becbi.com Name of Accountant/CPA(include name of firm if applicable): Ann Fukuhara, CPA, MBA; An Accounting Corporation Phone No.: (808) 968-1002 Mailing Address: 714 Kanoelehua Avenue, P.O. Box 6692, Hilo, HI 96720 Amount of Request for County Funds: $40,000 • Prior Year(s) Funding: 09-10 10-11 11-12 $20,000 $15,000 $15,000 Agency Mission Statement: Our vision is to provide a world-class club experience that assures success is within reach of every young person who walks through our doors, with all members on track to graduate from high school with a plan for the future, demonstrating good character and citizenship, and living a healthy lifestyle. Our mission "to inspire and enable all Big Island youth, to become productive and responsible citizens by offering quality programs in a safe and caring environment"defines our passion to ensure that our Island community's youth have greater access to quality programs and services that will enhance their lives and shape their futures. Program Description: When opportunities are available in a community for positive participation, children are less likely to engage in substance use and other problem behaviors. The Boys and Girls Club of the Big Island (BGCBI) — Hamakua Club, provides those opportunities on a daily basis to the young people of the Paauilo community. Through fun and engaging activities, BGCBI provides a positive atmosphere for youth ages 6 to 18 to explore their interests so that they can reach their full potential and contribute to their communities as productive, responsible citizens. The Club offers programs and services during non-school hours aimed at instilling a positive sense of self, increase self-esteem, self-confidence, and teach the skills necessary to make good, sound decisions. For over 50 years, Boys and Girls Club of the Big Island (BGCBI), has been in the forefront of youth development, working with young people ages 6-18 years old, from all backgrounds, including NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 1 Boys & Girls Club of the Big Island Positive Youth Development Programs: Hamakua Club disadvantaged economic, social and family circumstances. Serving nearly 400 members per day in its afterschool programs in 2011, and serving well over 50,000 members since its inception in 1952. The Hamakua Club conducts daily after-school, half-day intercession, and occasional weekend and evening, weekend programs which include Boys & Girls Club of America's five core programs areas: Sports, Fitness and Recreation Development: develops fitness, positive use of leisure time, skills for stress management, appreciation for the environment and social skills. The Arts: enables youth to develop their creativity and cultural awareness through knowledge and an appreciation of the visual arts, crafts, performing arts and creative writing. Education and Career Development: enables youth to become proficient in basic educational disciplines, apply learning to everyday situations and embrace technology to achieve success in a career. Character & Leadership Development: empowers youth to support and influence their Club and community, sustain meaningful relationships with others, develop a positive self-image, participate in the democratic process and respect their own and others' cultural identities. Health & Life Skills Development: develops youth's capacity to engage in positive behaviors that nurture their own well-being, set personal goals and live successfully as self-sufficient adults. Every day at the Hamakua Club, youth are greeted by caring, trained youth development staff. These professionals have joined the Boys and Girls Clubs of America "Movement-wide effort to help assure that the members of the Club succeed in school, lead healthy lifestyles, and become the kinds of citizens and leaders their community needs. BGCBI vision is that every young person who walks through the doors of the Club progresses from each grade to the next on time and graduates from high school with a solid plan for the future." By offering a wide variety of programs and activities that focus on academic success, healthy living, and leadership and service, the youth of the Hamakua Club are better prepared for a positive, bright future. Total Budget and Position Count— FY 2011-2012 Total Program Budget $82,305 Total Program Position Count 4 Total Agency Budget $1 ,238,760 Total Agency Position Count 35 Program Outcome Measures and Objectives: 1) Increase participants' knowledge and awareness of the consequences and harmful effects of tobacco, alcohol, and other drugs on their health and well-being and make healthy choices and lifestyles. 2) Increase participants' involvement in positive civic and community events. 3) Increase participants' positive attitude toward school/education and academic success. 2010-2011 Program Highlights: We have been doing the following programs: Power Hour, Triple Play, TGFDV, Life Skills, Arts and Crafts, Educational/College Prep skills (through discussion and in Power Hour), Conflict Resolution, social skill building, life-long skills (teach members various clerical skills, have members take turns doing "jobs" to build confidence and esteem and feel a reward from doing something productive and helpful for others. Some members help clean club, help with simple clerical tasks, tutor other kids with homework, etc. Other activities consisted of Recycling and Reusing, theatrical performance (performing arts)—singing, dancing, musical instruments. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 2 Boys & Girls Club of the Big Island Positive Youth Development Programs: Hamakua Club The club finished off the year nicely with Christmas party for its members, an appreciation power hour recognition celebration for those members who completed required sessions, and held open hours for members' holiday break. We were pleased to have so many members come to our holiday party to decorate ginger bread houses, play games and have food paid for by the Boys and Girls Club program funds. Our members are fortunate to have us to help them with their home work every day for an hour upon reaching the club, as well as the addition of the X-Box home entertainment system to play games and enjoy a reward after completing their required assignments. We have been determined to teach our members the importance of integrity, honesty, respect, and the necessity for cleaning up after their own mess. It has been a long haul, but with some effort and consistent enforcement of club rules and values, our members are now able to enjoy a more peaceful, cleaner and just place because of it. Agencies BGCBI continued to maintain relationships included: Paauilo Hongwonji, Tobacco-Free Big Island Coalition, American Lung Association, American Cancer Society, REAL, The Salvation Army Family Intervention Services, Lanikila Learning Center, Alu Like, Department of Defense Summer Youth Employment Program, United States Tennis Association—Hawaii Pacific Section, Bay Clinic, State of Hawaii Department of Education, PATCH, Kick-the-Nic, Prosecuting Attorney's Office, MADD, and the Hawaii County Department of Parks & Recreation. Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget Estimate Youth will participate in The Arts Programs. 25 75 50 Youth will participate in Character and Leadership programs. 15 30 25 Youth will participate in Education and Career Development Programs. 25 100 50 Youth will participate in Health and Life Skills Programs. 25 75 50 Youth will participate in Sports, Fitness and Recreation Programs. 25 100 50 Parents/families will participate in Family Strengthening activities. 2 events 4 events 4 events Program Expenditure FY 2010-11 FY 2011-12 Budget FY 2012-13 Estimate Actual Salaries and Wages $64,000 $55,800 $81,800 Professional Fees $6,000 $6,000 $6,500 Operations $20,000 $15,000 $15,200 Equipment/Supplies $9,900 $5,505 $15,200 Total $99,900 $82,305 $119,000 Program Funding Sources: Identify all funding sources NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 3 Boys & Girls Club of the Big Island Positive Youth Development Programs: Hamakua Club Revenue Source FY 2010-11 FY 2011-12 Budget FY 2012-13 Actual Estimate County of Hawaii — $15,000 $20,000 $40,000 Nonprofit Grant Hawaii Community Foundation: Tobacco $12,500 $12,500 $12,500 Settlement Trust Fund Rural Youth Crime Prevention $27,200 $10,300 $0 Program (BGCH/OJP)— Hawaii Island United Way $2,500 $2,500 $5,000 BGCA - COX Grant $10,000 $ 0 DOH-ADAD 0 0 $35,000 BGCA/Walmart Foundation $5,000 5,000 0 COH SPF SIG initiative $7,700 4,630 0 Department of Human Services/Office of Youth $10,000 0 0 Services BGCA/OJP 2010 Mentoring 0 $12,375 $16,500 Club Fundraising $10,000 $10,000 $10,000 Total $99,900 $82,305 $119,000 Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? BGCBI Board of Directors and leadership professionals have the following components in place for increased sustainability of programs: a) established annual agency fundraisers; b) an increase in special event fund raising efforts; c) an annual planned giving program in alignment with the Boys and Girls Clubs of America's standards of effective operations— It Just Takes One Campaign to include corporation and individual donors; d) in 2009, BGCBI created a Resource Development Department with a full-time Development Director with increase in grant writing; e) increased marketing initiatives via website design and functionality for resource development purposes; f) Board of Director strategic planning to establish an endowment fund. With BGCBI's mission of serving all youth regardless of ability to pay, BGCBI will always be looking for resources to sustain programs, including a combination of unrestricted fundraising and an array of grants and contracts. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 4 Boys & Girls Club of the Big Island Positive Youth Development Programs: Hamakua Club If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the Legislative auditor within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. -7() //?D7,2___ Signature of Board esident/Chair Dat / ��o ,�d �i natur of_Execut+virec t r D to (Signature of Resource Development Director in the absence of Executive Director) UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 5 10 Boys and Girls Club of the Big Island - Hilo Positive Youth Development Programs - Hilo Club Boys & Girls Club of the Big Island Positive Youth Development Programs: Hilo Club Agency Director: Zavi Brees-Saunders Phone No.: 961-5536 Contact Person: Zavi Brees-Saunders Phone No.: 961-5536 Mailing Address: 100 Kamakahonu Street, Hilo, Hawaii 96720 Facility/Site Address: 100 Kamakahonu Street, Hilo, Hawaii 96720 Fax No.: 961-5534 Email Address: zavi@bgcbi.com Name of Accountant/CPA(include name of firm if applicable): Ann Fukuhara, CPA, MBA; An Accounting Corporation Phone No.: (808) 968-1002 Mailing Address: 714 Kanoelehua Avenue, P.O. Box 6692, Hilo, HI 96720 Amount of Request for County Funds: $40,000 Prior Year(s) Funding: 09-10 10-11 11-12 $30,000 $20,000 $20,000 Agency Mission Statement: Our vision is to provide a world-class club experience that assures success is within reach of every young person who walks through our doors, with all members on track to graduate from high school with a plan for the future, demonstrating good character and citizenship, and living a healthy lifestyle. Our mission "to inspire and enable all Big Island youth, to become productive and responsible citizens by offering quality programs in a safe and caring environment"defines our passion to ensure that our Island community's youth have greater access to quality programs and services that will enhance their lives and shape their futures. Program Description: When opportunities are available in a community for positive participation, children are less likely to engage in substance use and other problem behaviors. The Boys and Girls Club of the Big Island (BGCBI) — Hilo Club, provides those opportunities on a daily basis to the young people of the Hilo community. Through fun and engaging activities, BGCBI provides a positive atmosphere for youth ages 6 to 18 to explore their interests so that they can reach their full potential and contribute to their communities as productive, responsible citizens. The Hilo Club offers programs and services during non-school hours aimed at instilling a positive sense of self, increase self-esteem, self-confidence, and teach the skills necessary to make good, sound decisions. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 1 Boys & Girls Club of the Big Island Positive Youth Development Programs: Hilo Club For over 50 years, Boys and Girls Club of the Big Island (BGCBI), has been in the forefront of youth development, working with young people ages 6-18 years old, from all backgrounds, including disadvantaged economic, social and family circumstances. Serving nearly 400 members per day in its afterschool programs in 2011, and serving well over 50,000 members since its inception in 1952. The Hilo Club is located in downtown Hilo and sits on a 14 acre property of the Hilo Boarding School. This beautiful site includes 2 baseball fields, a small t-ball/soccer field, and a full size gymnasium. The renovated Clubhouse includes a Club reception area, administrative offices, recreation/game room, art room, teen area, computer lab, patio for leisure and eating, ADA compliant restrooms, ADA compliant entry ways and Hilo Clubhouse façade that can be used as a gathering/program area. The Hilo Club conducts daily after-school, evening, weekend and full-day intercession programs which include Boys & Girls Club of America's five core programs areas: Sports, Fitness and Recreation Development: develops fitness, positive use of leisure time, skills for stress management, appreciation for the environment and social skills. The Arts: enables youth to develop their creativity and cultural awareness through knowledge and an appreciation of the visual arts, crafts, performing arts and creative writing. Education and Career Development: enables youth to become proficient in basic educational disciplines, apply learning to everyday situations and embrace technology to achieve success in a career. Character & Leadership Development: empowers youth to support and influence their Club and community, sustain meaningful relationships with others, develop a positive self-image, participate in the democratic process and respect their own and others' cultural identities. Health & Life Skills Development: develops youth's capacity to engage in positive behaviors that nurture their own well-being, set personal goals and live successfully as self-sufficient adults. Every day at the Hilo Club, youth are greeted by caring, trained youth development staff. These professionals have joined the Boys and Girls Clubs of America "Movement-wide effort to help assure that the members of the Club succeed in school, lead healthy lifestyles, and become the kinds of citizens and leaders their community needs. BGCBI vision is that every young person who walks through the doors of the Club progresses from each grade to the next on time and graduates from high school with a solid plan for the future." By offering a wide variety of programs and activities that focus on academic success, healthy living, and leadership and service, the youth of the Hilo Club are better prepared for a positive, bright future. Total Budget and Position Count— FY 2011-2012 Total Program Budget $335,165 Total Program Position Count 8 Total Agency Budget $1,238,760 Total Agency Position Count 35 Program Outcome Measures and Objectives: 1) Increase participants' knowledge and awareness of the consequences and harmful effects of tobacco, alcohol, and other drugs on their health and well-being and make healthy choices and lifestyles. 2) Increase participants' involvement in positive civic and community events. 3) Increase participants' positive attitude toward school/education and academic success. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 2 Boys & Girls Club of the Big Island Positive Youth Development Programs: Hilo Club 2010-2011 Program Highlights: During Club hours, youth are involved with the Power Hour program, in which they are completing homework assignments, receiving peer mentoring and tutoring, and striving to achieve good grades to receive quarterly incentives. The Hilo Key Club assisted with the Power Hour as tutors every Monday and Wednesday from 2pm to 4pm. In September, we celebrated our 2010 Day for Kids. We had 4 physical activities that our members had to challenge against each other. They all worked together, cheered for their team, and encouraged the other teams as they participated in the activities. This event was filled with positive actions by participants, and it was especially FUN. In collaboration with University of Hawaii Nursing Baccalaureate Program, we participated in 2010 National Kick Butts Day with a lunchtime rally at Hilo High School and after-school program celebration of a tobacco-free lifestyle with tobacco education games and activities. We collaborated with the Big Island Table Tennis Association, BITTA, in which they hosted the state championship Table Tennis tournament at the Hilo Club. This collaboration opened the doors for our youth to participate in their practices and tournaments throughout the year. The adults and older youth participating in the BITTA became the teachers of table tennis, and mentored youth that were interested in playing table tennis. Youth are able to participate in their practices every Tuesdays and Thursdays. The Torch Club participated in the 2011 American Heart Association Start! Heart Walk in Hilo. The walk was 2.13 miles, and youth managed to raise $95 for the American Heart Association. Youth also participated in the health fair and collected helpful information and participated in the activities at each booth. We also participated with the 2011 E Ola Youth Health & Future Fair at the Hawaii Community College. We provided an informational booth and face painting for youth and their families. We passed out brochures, registration forms, and BE GREAT buttons to families. In June, the teens held the first annual Boys and Girls Club Family Fun Day. This day was the culmination of much of their efforts to prevent underage drinking. It was a free community event where teens could share their message with their target audiences regarding limiting access of alcohol to minors. There was live music, dancing, carnival games, inflatables, petting zoo, horseback rides, a community resource fair, and much more. There were an estimated 500-600 people that attended. Over 400 additional youth are served in the organized athletic program at the Hilo Boys and Girls Club. The baseball fields are used year-round and the Hilo Athletic Director serves as the Commissioner of all leagues played at the Boys and Girls Club. He works closely with all teams and creates an environment that promotes the philosophy of the Positive Coaching Alliance - to teach youth sports organization leaders how to create an organizational culture in which Honoring the Game is the norm. Agencies BGCBI continued to maintain relationships with included: Tobacco-Free Big Island Coalition, American Lung Association, American Cancer Society, REAL, The Salvation Army Family Intervention Services, Lanikila Learning Center, Alu Like, Department of Defense Summer Youth Employment Program, Pahoa Weed and Seed Project, United States Tennis Association — Hawaii Pacific Section, Bay Clinic, State of Hawaii Department of Education, PATCH, Kick-the-Nic, Junior Achievement program, Prosecuting Attorney's Office, and Hawaii County Department of Parks & Recreation. Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget Estimate Youth will participate in The Arts Programs. 150 150 150 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 3 Boys & Girls Club of the Big Island Positive Youth Development Programs: Hilo Club Youth will participate in Character and Leadership programs. 115 50 50 Youth will participate in Education and Career Development Programs. 193 100 100 Youth will participate in Health and Life Skills Programs. 186 100 100 Youth will participate in Sports, Fitness and Recreation Programs. 416 400 400 Parents/families will participate in Family Strengthening activities. 4 events 4 events 4 events Program Expenditure FY 2010-11 FY 2011-12 Budget FY 2012-13 Estimate Actual Salaries and Wages $174,000 $211,000 $195,000 Professional Fees $6,500 $6,500 $6,500 Operations $75,000 $76,100 $71,200 Equipment/Supplies $16,356 $41,565 $13,500 Total $271,856 $335,165 $286,200 Program Funding Sources: Revenue Source FY 2010-11 FY 2011-12 Budget FY 2012-13 Actual Estimate County of Hawaii - Nonprofit Grant $20,000 $20,000 $40,000 Hawaii Community Foundation: Tobacco $12,500 $12,500 $12,500 Settlement Trust Fund Rural Youth Crime Prevention $20,300 $20,300 Program (BGCH/OJP)- Hawaii Island United Way $5,000 $5,000 $5,000 Walmart Foundation State Giving Grant $5,000 $5,000 0 Boys and Girls Club of America/Walmart Foundation $6,000 0 0 County of Hawaii SPF SIG $69,400 $41,640 0 initiative Boys and Girls Clubs of America - COX Super $21,700 $0 $21,700 Resource Grant DOH-ADAD $15,000 $95,600 $87,000 BGCA/OJP Mentoring $11,666 $90,125 $100,000 Department of Human Services/Office of Youth $65,290 $25,000 0 Services Club Fundraising $20,000 $20,000 $20,000 Total $271,856 $335,165 $286,200 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 4 Boys & Girls Club of the Big Island Positive Youth Development Programs: Hilo Club Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? BGCBI Board of Directors and leadership professionals have the following components in place for increased sustainability of programs: a) established annual agency fundraisers; b) an increase in special event fund raising efforts; c) an annual planned giving program in alignment with the Boys and Girls Clubs of America's standards of effective operations— It Just Takes One Campaign to include corporation and individual donors; d) in 2009, BGCBI created a Resource Development Department with a full-time Development Director with increase in grant writing; e) increased marketing initiatives via website design and functionality for resource development purposes; f) Board of Director strategic planning to establish an endowment fund. With BGCBI's mission of serving all youth regardless of ability to pay, BGCBI will always be looking for resources to sustain programs, including a combination of unrestricted fundraising and an array of grants and contracts. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the Legislative auditor within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. ` #4. / d Signature of Board "resident/Chair Date c�llb ( 1d / Z ature of Executive Director D to (Signature of Resource Development Director in the absence of Executive Director) UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 5 11 Boys and Girls Club of the Big Island - Hilo Positive Youth Development Programs - Kea'au Club Boys & Girls Club of the Big Island Positive Youth Development Programs: Keaau Club Agency Director: Zavi Brees-Saunders Phone No.: 961-5536 Contact Person: Zavi Brees-Saunders Phone No.: 961-5536 Mailing Address: 100 Kamakahonu Street, Hilo, Hawaii 96720 Facility/Site Address: Holy Rosary Church Shipman Gym Road, A 25 Keaau, HI 96749 Fax No.: 961-5534 Email Address: zavi@bgcbi.com Name of Accountant/CPA(include name of firm if applicable): Ann Fukuhara, CPA, MBA; An Accounting Corporation Phone No.: (808) 968-1002 Mailing Address: 714 Kanoelehua Avenue, P.O. Box 6692, Hilo, HI 96720 Amount of Request for County Funds: $40,000 Prior Year(s) Funding: 09-10 10-11 11-12 $20,000 $15,000 $15,000 Agency Mission Statement: Our vision is to provide a world-class club experience that assures success is within reach of every young person who walks through our doors, with all members on track to graduate from high school with a plan for the future, demonstrating good character and citizenship, and living a healthy lifestyle. Our mission "to inspire and enable all Big Island youth, to become productive and responsible citizens by offering quality programs in a safe and caring environment"defines our passion to ensure that our Island community's youth have greater access to quality programs and services that will enhance their lives and shape their futures. Program Description: When opportunities are available in a community for positive participation, children are less likely to engage in substance use and other problem behaviors. The Boys and Girls Club of the Big Island (BGCBI) — Keaau Club, provides those opportunities on a daily basis to the young people of the Keaau community. Through fun and engaging activities, BGCBI provides a positive atmosphere for youth ages 6 to 18 to explore their interests so that they can reach their full potential and contribute to their communities as productive, responsible citizens. The Keaau Club offers programs and services during non-school hours aimed at instilling a positive sense of self, increase self-esteem, self-confidence, and teach the skills necessary to make good, sound decisions. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 1 Boys & Girls Club of the Big Island Positive Youth Development Programs: Keaau Club For over 50 years, Boys and Girls Club of the Big Island (BGCBI), has been in the forefront of youth development, working with young people ages 6-18 years old, from all backgrounds, including disadvantaged economic, social and family circumstances. Serving nearly 400 members per day in its afterschool programs in 2011, and serving well over 50,000 members since its inception in 1952. The Keaau Club is located at the Holy Rosary Church and uses two portable classrooms along with outdoor spaces covered with pop-up tenting. A partnership exists with P&R at Shipman Gymnasium for use of the gymnasium when available. The Church location is within walking distance for middle and high school members and elementary school youth are transported daily via the Club van. BGCBI is actively searching for a permanent home for the Keaau Club. The Keaau Club conducts daily after-school, evening, weekend and full-day intercession programs which include Boys & Girls Club of America's five core programs areas: Sports, Fitness and Recreation Development: develops fitness, positive use of leisure time, skills for stress management, appreciation for the environment and social skills. The Arts: enables youth to develop their creativity and cultural awareness through knowledge and an appreciation of the visual arts, crafts, performing arts and creative writing. Education and Career Development: enables youth to become proficient in basic educational disciplines, apply learning to everyday situations and embrace technology to achieve success in a career. Character & Leadership Development: empowers youth to support and influence their Club and community, sustain meaningful relationships with others, develop a positive self-image, participate in the democratic process and respect their own and others' cultural identities. Health & Life Skills Development: develops youth's capacity to engage in positive behaviors that nurture their own well-being, set personal goals and live successfully as self-sufficient adults. Every day at the Keaau Club, youth are greeted by caring, trained youth development staff. These professionals have joined the Boys and Girls Clubs of America "Movement-wide effort to help assure that the members of the Club succeed in school, lead healthy lifestyles, and become the kinds of citizens and leaders their community needs. BGCBI vision is that every young person who walks through the doors of the Club progresses from each grade to the next on time and graduates from high school with a solid plan for the future." By offering a wide variety of programs and activities that focus on academic success, healthy living, and leadership and service, the youth are better prepared for a positive, bright future. Total Budget and Position Count— FY 2011-2012 Total Program Budget $328,040 Total Program Position Count 7 Total Agency Budget $1,238,760 Total Agency Position Count 35 Program Outcome Measures and Objectives: 1) Increase participants' knowledge and awareness of the consequences and harmful effects of tobacco, alcohol, and other drugs on their health and well-being and make healthy choices and lifestyles. 2) Increase participants' involvement in positive civic and community events. 3) Increase participants' positive attitude toward school/education and academic success. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 2 Boys & Girls Club of the Big Island Positive Youth Development Programs: Keaau Club 2010-2011 Program Highlights: Throughout the year, our Power Hour(homework assistance) program proved to be effective during the after school program. Although at times the older youth did not take full advantage of the service, they became the peer tutors and assisted helping the younger youth complete their homework. The implementation of the curriculum-Too Good For Drugs and Violence has been successful. The youth at first are skeptical of the sessions, but with interactive activities, role playing, and hands on learning, youth were interested in the information and the learning of the sessions. Topics included: Communication skills, Decision Making, Drug Awareness, Bullying, and Violence Prevention. In the month of November, the Keaau Club had its first family game night. The focus of the family night was for families to spend quality time with their children and with other parents. During the night, we shared program information and future events. Activities were fun, exciting, and friendly. We also participated in the annual Keaau Christmas Parade. We decorated the club van with lights and Christmas decorations. There were 15 youth that participated in the parade singing Christmas songs and passing out candy and program flyers. Parents were happy to see their youth participating in the parade, and their cheers and clapping were felt by the youth with a sense of pride and support. Many of the field trips have been educational for the kids. The botanical garden was awesome. They were surprised to hear that there are over 165 different types of orchids in the garden. They really got a kick out of the parrots that could say aloha and good bye and it was a good workout! The excursion to the Volcano National Park was a fun learning experience. We went all the way down to the cliffs where we saw the amazing Sea Arch and also hiked to see the ancient Hawaiian petroglyphs. We have also been utilizing the Keaau Middle School's library a lot. We probably visit at least 3 times a week. The kids enjoy reading books, borrowing movies and just getting away from the club. Agencies BGCBI continued to maintain relationships with included: Keaau Holy Rosary Catholic Church, Tobacco-Free Big Island Coalition, American Lung Association, American Cancer Society, REAL, The Salvation Army Family Intervention Services, Lanikila Learning Center, Alu Like, Department of Defense Summer Youth Employment Program, Pahoa Weed and Seed Project, United States Tennis Association — Hawaii Pacific Section, Bay Clinic, State of Hawaii Department of Education, PATCH, Kick-the-Nic, Prosecuting Attorney's Office, MADD, and the Hawaii County Department of Parks & Recreation. Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget Estimate Youth will participate in The Arts Programs. 104 75 75 Youth will participate in Character and Leadership programs. 55 50 50 Youth will participate in Education and Career Development Programs. 112 100 100 Youth will participate in Health and Life Skills Programs. 89 75 75 Youth will participate in Sports, Fitness and Recreation Programs. 127 120 120 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 3 Boys & Girls Club of the Big Island Positive Youth Development Programs: Keaau Club Parents/families will participate in Family Strengthening activities. 4 events 4 events 4 events Program Expenditure FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget Estimate Salaries and Wages $170,000 $200,800 $178,900 Professional Fees $6,000 $6,500 $6,500 Operations $75,000 $74,100 $71,200 Equipment/Supplies $16,356 $46,640 $17,600 Total $220,000 $328,040 $274,200 Program Funding Sources: Identify all funding sources Revenue Source FY 2010-11 FY 2011-12 Budget FY 2012-13 Actual Estimate County of Hawaii - $15,000 $15,000 $40,000 Nonprofit Grant Hawaii Community Foundation: Tobacco $12,500 $12,500 $12,500 Settlement Trust Fund Rural Youth Crime Prevention Program $23,300 $20,300 $0 (BGCH/OJP)- Hawaii Island United Way $2,500 $3,000 $3,000 Walmart Foundation State $5,000 $5,000 0 Giving Grant Boys and Girls Club of America/Walmart $6,000 0 0 Foundation County of Hawaii SPF SIG $69,400 $41,640 0 initiative Boys and Girls Clubs of America - COX Super $21,700 $0 $11,700 Resource Grant DOH-ADAD $15,000 $95,600 $87,000 BGCA/OJP Mentoring $11,666 $90,000 $100,000 Department of Human Services/Office of Youth $65,290 $25,000 0 Services Club Fundraising $20,000 $20,000 $20,000 Total $267,356 $328,040 $274,200 Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? BGCBI Board of Directors and leadership professionals have the following components in place for increased sustainability of programs: a) established annual agency fundraisers; b) an increase in NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 4 Boys & Girls Club of the Big Island Positive Youth Development Programs: Keaau Club special event fund raising efforts; c)an annual planned giving program in alignment with the Boys and Girls Clubs of America's standards of effective operations — It Just Takes One Campaign to include corporation and individual donors; d) in 2009, BGCBI created a Resource Development Department with a full-time Development Director with increase in grant writing; e) increased marketing initiatives via website design and functionality for resource development purposes; f) Board of Director strategic planning to establish an endowment fund. With BGCBI's mission of serving all youth regardless of ability to pay, BGCBI will always be looking for resources to sustain programs, including a combination of unrestricted fundraising and an array of grants and contracts. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the Legislative auditor within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. wr Signature of Board President/Chair Da e Sic, n ure of Executive t■irectcr I qbte (Signature of Resource Development Director in the absence of Executive Director) UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 5 12 Boys and Girls Club of the Big Island - Hilo Positive Youth Development Programs - Ocean View/Na`alehu Club Boys & Girls Club of the Big Island Positive Youth Development Programs: Ocean View/Naalehu Club Agency Director: Zavi Brees-Saunders Phone No.: 961-5536 Contact Person: Zavi Brees-Saunders Phone No.: 961-5536 Mailing Address: 100 Kamakahonu Street, Hilo, Hawaii 96720 Facility/Site Address: County P & R— Na'alehu Community Center 95-5635 Mamalahoa Highway Na'alehu, HI 96772 Fax No.: 961-5534 Email Address: zavi @becbi.com Name of Accountant/CPA (include name of firm if applicable): Ann Fukuhara, CPA, MBA; An Accounting Corporation Phone No.: (808) 968-1002 Mailing Address: 714 Kanoelehua Avenue, P.O. Box 6692, Hilo, HI 96720 Amount of Request for County Funds: $40,000 Prior Year(s) Funding: 09-10 10-11 11-12 $20,000 $15,000 $25,000 Agency Mission Statement: Our vision is to provide a world-class club experience that assures success is within reach of every young person who walks through our doors, with all members on track to graduate from high school with a plan for the future, demonstrating good character and citizenship, and living a healthy lifestyle. Our mission "to inspire and enable all Big Island youth, to become productive and responsible citizens by offering quality programs in a safe and caring environment"defines our passion to ensure that our Island community's youth have greater access to quality programs and services that will enhance their lives and shape their futures. Program Description: When opportunities are available in a community for positive participation, children are less likely to engage in substance use and other problem behaviors. The Boys and Girls Club of the Big Island (BGCBI) — Ocean View/Naalehu Club, provides those opportunities on a daily basis to the young people of the Ocean View/Naalehu community. Through fun and engaging activities, BGCBI provides a positive atmosphere for youth ages 6 to 18 to explore their interests so that they can reach their full potential and contribute to their communities as productive, responsible citizens. The Club offers NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 1 Boys & Girls Club of the Big Island Positive Youth Development Programs: Ocean View/Naalehu Club programs and services during non-school hours aimed at instilling a positive sense of self, increase self-esteem, self-confidence, and teach the skills necessary to make good, sound decisions. For over 50 years, Boys and Girls Club of the Big Island (BGCBI), has been in the forefront of youth development, working with young people ages 6-18 years old, from all backgrounds, including disadvantaged economic, social and family circumstances. Serving nearly 400 members per day in its afterschool programs in 2011, and serving well over 50,000 members since its inception in 1952. The Ocean View Club opened its doors to the youth of the Ka'u District in February 2007 while based at the Ocean View Community Center. Transportation for this Club was a daily challenge and in May 2008, BGCBI chose to relocate the operation to Na'alehu Elementary and Intermediate School where we are able to serve both communities with ease. The Club operated out of the school gymnasium and uses all outdoor facilities for sports and fitness activities. Through partnership with Hawaii County Parks & Recreation, the Na'alehu Community Center is now the Club home to conduct game room/social recreation, computer technology, fitness, and health and nutrition programs. In the summer of 2009, the Ocean View Club made a decision to serve two communities in partnership with Hawaii County Parks & Recreation. They wanted to assure that the youth had supervised activities to engage in on a full-time basis. The Ocean View staff spent their mornings in Na'alehu and afternoons in Ocean View at Kahuku Park. In 2010, BGCBI and the County of Hawaii Department of Park & Recreation agreed to locate the Ocean View Club operation at the Na'alehu Community Center. In 2011 the Ocean View site was closed and to date Ocean View members are served at the Na'alehu site and driven to Ocean View for pick up by their parents at the end of the day. The Ocean View Club conducts daily after-school, half-day intercession, and occasional weekend and evening, weekend programs which include Boys & Girls Club of America's five core programs areas: Sports, Fitness and Recreation Development: develops fitness, positive use of leisure time, skills for stress management, appreciation for the environment and social skills. The Arts: enables youth to develop their creativity and cultural awareness through knowledge and an appreciation of the visual arts, crafts, performing arts and creative writing. Education and Career Development: enables youth to become proficient in basic educational disciplines, apply learning to everyday situations and embrace technology to achieve success in a career. Character & Leadership Development: empowers youth to support and influence their Club and community, sustain meaningful relationships with others, develop a positive self-image, participate in the democratic process and respect their own and others' cultural identities. Health & Life Skills Development: develops youth's capacity to engage in positive behaviors that nurture their own well-being, set personal goals and live successfully as self-sufficient adults. Every day at the Club, youth are greeted by caring, trained youth development staff. These professionals have joined the Boys and Girls Clubs of America "Movement-wide effort to help assure that the members of the Club succeed in school, lead healthy lifestyles, and become the kinds of citizens and leaders their community needs. BGCBI vision is that every young person who walks through the doors of the Club progresses from each grade to the next on time and graduates from high school with a solid plan for the future." By offering a wide variety of programs and activities that focus on academic success, healthy living, and leadership and service, the youth in the Club are better prepared for a positive, bright future. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 2 Boys & Girls Club of the Big Island Positive Youth Development Programs: Ocean View/Naalehu Club Total Budget and Position Count— FY 2011-2012 Total Program Budget $82,305 Total Program Position Count 4 Total Agency Budget $1,238,760 Total Agency Position Count 35 Program Outcome Measures and Objectives: 1) Increase participants' knowledge and awareness of the consequences and harmful effects of tobacco, alcohol, and other drugs on their health and well-being and make healthy choices and lifestyles. 2) Increase participants' involvement in positive civic and community events. 3) Increase participants' positive attitude toward school/education and academic success. 2010-2011 Program Highlights: All Clubs organized a Teen Leadership Development Conference. There were 22 attendees from Hilo, Keaau, Pahoa, and Ka'u. We collaborated with a non-profit agency-Team Building Hawaii in which they provided activities focused on Team-building, Leadership, and Action Planning. There were 3 guest speakers; Barbara Hastings, Debbie Allen, and Darron Cambra. Barbara Hastings facilitated skills to formulate a message of underage drinking prevention, and present it in a thoughtful way to the community. Debbie Allen is a parent of a youth Shelby that lost her life to acute alcohol poisoning. Debbie and her husband is traveling the country for presentations about the dangers of drinking, and how to identify the signs of alcohol poisoning, and how to get help for their friends. The third speaker was Darron Cambra from Youth Speaks Hawaii. Darron is a spoken word poet, teacher, and mentor. He taught the teens to write down their feelings and ideas in a creative and impactful way. BGCBI participated in the Ho'olaule'a Festival on Labor Day Weekend. We shuttled people from the parking lot to the festival area from 10am until 5pm. Lehua Lopez who was in charge of the festival, appreciated the hard work and dedication on the day of the festival. They had many wonderful comments made about the clubs participation. She said that they would love to partner with us in any way that they may help us out some time. We implemented the Money Matters program and made it age appropriate to each youth. We teach the youth about saving money. We have a clean-up program where each day they have a different job to do which is again age appropriate. They get 2 BGC dollars for every task they complete so they can get 10 BGC dollars a week, if they misbehave we take out"taxes". We made rice krispies treats and li hing mui lollipops so they can use their monies to buy those. They have also been asked to buy little toys from Oriental Trading so they have more varieties to choose from. Agencies BGCBI continued to maintain relationships with in FY 2010-2011 included: Tobacco-Free Big Island Coalition, American Lung Association, American Cancer Society, REAL, The Salvation Army Family Intervention Services, Lanikila Learning Center, Alu Like, Department of Defense Summer Youth Employment Program, Pahoa Weed and Seed Project, United States Tennis Association — Hawaii Pacific Section, Bay Clinic, State of Hawaii Department of Education, PATCH, Kick-the-Nic, Prosecuting Attorney's Office, MADD, and the Hawaii County Department of Parks & Recreation. Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget Estimate Youth will participate in The Arts Programs. 59 50 50 Youth will participate in Character and NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 3 Boys & Girls Club of the Big Island Positive Youth Development Programs: Ocean View/Naalehu Club Leadership programs. 25 35 25 Youth will participate in Education and Career Development Programs. 62 75 60 Youth will participate in Health and Life Skills Programs. 45 75 50 Youth will participate in Sports, Fitness and Recreation Programs. 62 100 60 Parents/families will participate in Family Strengthening activities. 4 events 4 events 4 events Program Expenditure FY 2010-11 FY 2011-12 Budget FY 2012-13 Estimate Actual Salaries and Wages $64,000 $55,800 $81,800 Professional Fees $6,000 $6,500 $6,500 Operations $20,000 $15,500 $15,200 Equipment/Supplies $59,900 $5,505 $15,500 Total $99,900 $82,305 $119,000 Program Funding Sources: Identify all funding sources Revenue Source FY 2010-11 FY 2011-12 Budget FY 2012-13 Actual Estimate County of Hawaii - $20,000 $25,000 $40,000 Nonprofit Grant Hawaii Community Foundation: Tobacco $12,500 $12,500 $12,500 Settlement Trust Fund Rural Youth Crime Prevention $27,200 $10,300 $0 Program (BGCH/OJP)- Hawaii Island United Way $2,500 $2,500 $5,000 BGCA- COX Grant $10,000 0 $0 DOH-ADAD 0 0 $35,000 BGCA/Walmart Foundation $5,000 5,000 0 COH SPF SIG initiative $7,700 4,630 0 Department of Human Services/Office of Youth $10,000 0 0 Services BGCA/OJP Mentoring 0 $12,375 $16,500 Club Fundraising $10,000 $10,000 $10,000 Total $99,900 $82,305 $119,000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 4 Boys & Girls Club of the Big Island Positive Youth Development Programs: Ocean View/Naalehu Club Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? BGCBI Board of Directors and leadership professionals have the following components in place for increased sustainability of programs: a) established annual agency fundraisers; b) an increase in special event fund raising efforts; c) an annual planned giving program in alignment with the Boys and Girls Clubs of America's standards of effective operations — It Just Takes One Campaign to include corporation and individual donors; d) in 2009, BGCBI created a Resource Development Department with a full-time Development Director with increase in grant writing; e) increased marketing initiatives via website design and functionality for resource development purposes; f) Board of Director strategic planning to establish an endowment fund. With BGCBI's mission of serving all youth regardless of ability to pay, BGCBI will always be looking for resources to sustain programs, including a combination of unrestricted fundraising and an array of grants and contracts. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the Legislative auditor within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. Or /' D /Z Signature of Board President/Chair Dat i nature of Executive Director Da - (Signature of Resource Development Director in the absence of Executive Director) UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 5 13 Boys and Girls Club of the Big Island - Hilo Positive Youth Development Programs - Pahala Club Boys & Girls Club of the Big Island Positive Youth Development Programs: Pahala Club Agency Director: Zavi Brees-Saunders Phone No.: 961-5536 Contact Person: Zavi Brees-Saunders Phone No.: 961-5536 Mailing Address: 100 Kamakahonu Street, Hilo, Hawaii 96720 Facility/Site Address: County of Hawaii Department of Parks & Recreation Pahala Community Center 96-1149 Kamani Street Pahala, HI 96777 Fax No.: 961-5534 Email Address: zavi @becbi.com Name of Accountant/CPA(include name of firm if applicable): Ann Fukuhara, CPA, MBA; An Accounting Corporation Phone No.: (808) 968-1002 Mailing Address: 714 Kanoelehua Avenue, P.O. Box 6692, Hilo, HI 96720 Amount of Request for County Funds: $40,000 Prior Year(s) Funding: 09-10 10-11 11-12 $20,000 $15,000 $20,000 Agency Mission Statement: Our vision is to provide a world-class club experience that assures success is within reach of every young person who walks through our doors, with all members on track to graduate from high school with a plan for the future, demonstrating good character and citizenship, and living a healthy lifestyle. Our mission "to inspire and enable all Big Island youth, to become productive and responsible citizens by offering quality programs in a safe and caring environment"defines our passion to ensure that our Island community's youth have greater access to quality programs and services that will enhance their lives and shape their futures. Program Description: When opportunities are available in a community for positive participation, children are less likely to engage in substance use and other problem behaviors. The Boys and Girls Club of the Big Island (BGCBI)— Pahala Club, provides those opportunities on a daily basis to the young people of the Pahala community. Through fun and engaging activities, BGCBI provides a positive atmosphere for youth ages 6 to 18 to explore their interests so that they can reach their full potential and contribute to their communities as productive, responsible citizens. The Club offers programs and services during non- NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 1 Boys & Girls Club of the Big Island Positive Youth Development Programs: Pahala Club school hours aimed at instilling a positive sense of self, increase self-esteem, self-confidence, and teach the skills necessary to make good, sound decisions. For over 50 years, Boys and Girls Club of the Big Island (BGCBI), has been in the forefront of youth development, working with young people ages 6-18 years old, from all backgrounds, including disadvantaged economic, social and family circumstances. Serving nearly 400 members per day in its afterschool programs in 2011, and serving well over 50,000 members since its inception in 1952. In collaboration with the Hawaii County Parks and Recreation Division facility at the Pahala Community Center, the Pahala Club conducts daily after-school, half-day intercession, and occasional weekend and evening, weekend programs which include Boys & Girls Club of America's five core programs areas: Sports, Fitness and Recreation Development: develops fitness, positive use of leisure time, skills for stress management, appreciation for the environment and social skills. The Arts: enables youth to develop their creativity and cultural awareness through knowledge and an appreciation of the visual arts, crafts, performing arts and creative writing. Education and Career Development: enables youth to become proficient in basic educational disciplines, apply learning to everyday situations and embrace technology to achieve success in a career. Character & Leadership Development: empowers youth to support and influence their Club and community, sustain meaningful relationships with others, develop a positive self-image, participate in the democratic process and respect their own and others' cultural identities. Health & Life Skills Development: develops youth's capacity to engage in positive behaviors that nurture their own well-being, set personal goals and live successfully as self-sufficient adults. Every day at the Pahala Club, youth are greeted by caring, trained youth development staff. These professionals have joined the Boys and Girls Clubs of America "Movement-wide effort to help assure that the members of the Club succeed in school, lead healthy lifestyles, and become the kinds of citizens and leaders their community needs. BGCBI vision is that every young person who walks through the doors of the Club progresses from each grade to the next on time and graduates from high school with a solid plan for the future." By offering a wide variety of programs and activities that focus on academic success, healthy living, and leadership and service, the youth of the Pahala Club are better prepared for a positive, bright future. Total Budget and Position Count— FY 2011-2012 Total Program Budget $82,305 Total Program Position Count 4 Total Agency Budget $1,238,760 Total Agency Position Count 35 Program Outcome Measures and Objectives: 1) Increase participants' knowledge and awareness of the consequences and harmful effects of tobacco, alcohol, and other drugs on their health and well-being and make healthy choices and lifestyles. 2) Increase participants' involvement in positive civic and community events. 3) Increase participants' positive attitude toward school/education and academic success. 2010-2011 Program Highlights: Fitness is a big thing for us at the Pahala Club because we do believe that staying active and constantly moving is a better way to live a healthy life. We also planted flowers to put into our little garden we've NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 2 Boys & Girls Club of the Big Island Positive Youth Development Programs: Pahala Club started to teach the kids on how to go green. The kids really liked this project because we're trying to see who can make the most beautiful flower and the winner gets a prize in the end. We mostly love to dance, we do Zumba in our own way. It is more kid friendly, we make games like freeze dance when the song stops you have to freeze. And the kids love the one where they have to follow the moves I'm doing and we just have so much fun with it. There's no way you can fail at dancing because there's no certain way to dance and that's what we teach our kids is that dancing is a form of art a way of expressing yourself. We do many different sports because our kids love to stay active so we play lots of kickball, dodge ball, and tennis. We attended the dedication for Neil Abercrombie in Pahala and the children sang Christmas carols and Mr. Abercrombie joined them. The children enjoyed themselves and it was meaningful that they had the opportunity to meet the Governor of Hawaii. The food line followed the dedication and of course the children had their fill of many different tasteful dishes. Following the dedication was the Pahala Parade in which we were in. The parade was quite long and our children made it half way through, it was very hot and tiring for most of them. We provided the"Too Good For Drugs and Violence"program with our keystone club. Youth participated in skits and puppet shows to show the kids what drugs can do to you and the way your life is going to be if you choose the wrong path. For Power Hour we are trying a different approach on the youth during homework because those that don't have any homework will be put at one of four centers, there's a puzzle center, reading center, coloring or drawing center and Playdough center. Power Hour points that youth earned were rewarded with a Water Slide. Agencies BGCBI continued to maintain relationships with in FY 2010-2011 included: Tobacco-Free Big Island Coalition, American Lung Association, American Cancer Society, REAL, The Salvation Army Family Intervention Services, Lanikila Learning Center, Alu Like, Department of Defense Summer Youth Employment Program, Pahoa Weed and Seed Project, United States Tennis Association—Hawaii Pacific Section, Bay Clinic, State of Hawaii Department of Education, PATCH, Kick-the-Nic, Prosecuting Attorney's Office, MADD, and the Hawaii County Department of Parks & Recreation. Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget Estimate Youth will participate in The Arts Programs. 35 50 50 Youth will participate in Character and Leadership programs. 26 25 25 Youth will participate in Education and Career Development Programs. 53 75 60 Youth will participate in Health and Life Skills Programs. 39 50 50 Youth will participate in Sports, Fitness and Recreation Programs. 53 75 60 Parents/families will participate in Family Strengthening activities. 4 events 4 events 4 events NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 3 Boys & Girls Club of the Big Island Positive Youth Development Programs: Pahala Club Program Expenditure FY 2010-11 FY 2011-12 Budget FY 2012-13 Estimate Actual Salaries and Wages $64,000 $55,800 $81,800 Professional Fees $6,000 $6,000 $6,500 Operations $20,000 $15,000 $15,200 Equipment/Supplies $9,900 $5,505 $15,200 Total $99,900 $82,305 $119,000 Program Funding Sources: Identify all funding sources Revenue Source FY 2010-11 FY 2011-12 Budget FY 2012-13 Actual Estimate County of Hawaii - $15,000 $20,000 $40,000 Nonprofit Grant Hawaii Community Foundation: Tobacco $12,500 $12,500 $12,500 Settlement Trust Fund Rural Youth Crime Prevention $27,200 $10,300 $0 Program (BGCH/OJP)- Hawaii Island United Way $2,500 $2,500 $5,000 BGCA- COX Grant $10,000 $5,000 0 DOH-ADAD 0 0 $35,000 BGCA/Walmart Foundation $5,000 5,000 0 COH SPF SIG initiative $7,700 4,630 0 Department of Human Services/Office of Youth $10,000 0 0 Services BGCA/OJP 2010 Mentoring 0 $12,375 $16,500 Club Fundraising $10,000 $10,000 $10,000 Total $99,900 $82,305 $119,000 Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? BGCBI Board of Directors and leadership professionals have the following components in place for increased sustainability of programs: a) established annual agency fundraisers; b) an increase in special event fund raising efforts; c) an annual planned giving program in alignment with the Boys and Girls Clubs of America's standards of effective operations - It Just Takes One Campaign to include corporation and individual donors; d) in 2009, BGCBI created a Resource Development Department with a full-time Development Director with increase in grant writing; e) increased marketing initiatives via website design and functionality for resource development purposes; f) Board of Director strategic planning to establish an endowment fund. With BGCBI's mission of serving all youth regardless of ability to pay, BGCBI will always be looking for resources to sustain programs, including a combination of unrestricted fundraising and an array of grants and contracts. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 4 Boys & Girls Club of the Big Island Positive Youth Development Programs: Pahala Club I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the Legislative auditor within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. '77)g7 i �D / Z Signature of Board President/Chair Dat ,A,) /if Signa ure of Executive Director C date (Signature of Resource Development Director in the absence of Executive Director) UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 5 14 Boy's and Girls Club of the Big Island - Hilo Positive Youth Development Programs - Pahoa Club Boys & Girls Club of the Big Island Positive Youth Development Programs: Pahoa Club Agency Director: Zavi Brees-Saunders Phone No.: 961-5536 Contact Person: Zavi Brees-Saunders Phone No.: 961-5536 Mailing Address: 100 Kamakahonu Street, Hilo, Hawaii 96720 Facility/Site Address: Pahoa Intermediate & High School 15-3038 Puna Road, Pahoa, Hawaii 96778 Fax No.: 961-5534 Email Address: zavi@bgcbi.com Name of Accountant/CPA(include name of firm if applicable): Ann Fukuhara, CPA, MBA; An Accounting Corporation Phone No.: (808) 968-1002 Mailing Address: 714 Kanoelehua Avenue, P.O. Box 6692, Hilo, HI 96720 Amount of Request for County Funds: $40,000 Prior Year(s) Funding: 09-10 10-11 11-12 $20,000 $15,000 $15,000 Agency Mission Statement: Our vision is to provide a world-class club experience that assures success is within reach of every young person who walks through our doors, with all members on track to graduate from high school with a plan for the future, demonstrating good character and citizenship, and living a healthy lifestyle. Our mission "to inspire and enable all Big Island youth, to become productive and responsible citizens by offering quality programs in a safe and caring environment"defines our passion to ensure that our Island community's youth have greater access to quality programs and services that will enhance their lives and shape their futures. Program Description: When opportunities are available in a community for positive participation, children are less likely to engage in substance use and other problem behaviors. The Boys and Girls Club of the Big Island (BGCBI) — Pahoa Club, provides those opportunities on a daily basis to the young people of the Pahoa community. Through fun and engaging activities, BGCBI provides a positive atmosphere for youth ages 6 to 18 to explore their interests so that they can reach their full potential and contribute to their communities as productive, responsible citizens. The Pahoa Club offers programs and services during non-school hours aimed at instilling a positive sense of self, increase self-esteem, self-confidence, and teach the skills necessary to make good, sound decisions. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 1 Boys & Girls Club of the Big Island Positive Youth Development Programs: Pahoa Club For over 50 years, Boys and Girls Club of the Big Island (BGCBI), has been in the forefront of youth development, working with young people ages 6-18 years old, from all backgrounds, including disadvantaged economic, social and family circumstances. Serving nearly 400 members per day in its afterschool programs in 2011, and serving well over 50,000 members since its inception in 1952. The Pahoa Club has been making a difference in the Puna District since October 2003, initially providing services part-time 2-3 days a week at the Nanawale Subdivision's Community Center. In August 2004, the program expanded to five days a week and in June 2006 moved to their present location at Pahoa Intermediate and High School, operating Monday through Friday from 2:00 pm to 6:00 pm. On school days off and intercessions, the Club is open full-day providing care to those youth whose parents are employed. The Pahoa Club has formed a strong relationship with the Pahoa DOE School Complex who supports their efforts by providing the BGCBI two large portable classrooms used for implementing BGCA core programs. The Pahoa Club also has use of the school complex fields and outdoor facilities available for sports fitness and athletic activities. The Pahoa Club conducts daily after-school, evening, weekend and full-day intercession programs which include Boys & Girls Club of America's five core programs areas: Sports, Fitness and Recreation Development: develops fitness, positive use of leisure time, skills for stress management, appreciation for the environment and social skills. The Arts: enables youth to develop their creativity and cultural awareness through knowledge and an appreciation of the visual arts, crafts, performing arts and creative writing. Education and Career Development: enables youth to become proficient in basic educational disciplines, apply learning to everyday situations and embrace technology to achieve success in a career. Character & Leadership Development: empowers youth to support and influence their Club and community, sustain meaningful relationships with others, develop a positive self-image, participate in the democratic process and respect their own and others' cultural identities. Health & Life Skills Development: develops youth's capacity to engage in positive behaviors that nurture their own well-being, set personal goals and live successfully as self-sufficient adults. Every day at the Pahoa Club, youth are greeted by caring, trained youth development staff. These professionals have joined the Boys and Girls Clubs of America "Movement-wide effort to help assure that the members of the Club succeed in school, lead healthy lifestyles, and become the kinds of citizens and leaders their community needs. BGCBI vision is that every young person who walks through the doors of the Club progresses from each grade to the next on time and graduates from high school with a solid plan for the future." By offering a wide variety of programs and activities that focus on academic success, healthy living, and leadership and service, the youth of the Pahoa Club are better prepared for a positive, bright future. Total Budget and Position Count— FY 2011-2012 Total Program Budget $327,540 Total Program Position Count 7 Total Agency Budget $1,238,760 Total Agency Position Count 35 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 2 Boys & Girls Club of the Big Island Positive Youth Development Programs: Pahoa Club Program Outcome Measures and Objectives: 1) Increase participants' knowledge and awareness of the consequences and harmful effects of tobacco, alcohol, and other drugs on their health and well-being and make healthy choices and lifestyles. 2) Increase participants' involvement in positive civic and community events. 3) Increase participants' positive attitude toward school/education and academic success. 2010-2011 Program Highlights: The Boys and Girls Club of America has a year-long project called "Year of Service". Participation in this program requires clubs all over the country to complete at least four community service projects. Youth were involved with a coastline clean-up for the nation-wide Dr. Martin Luther King Jr. Day of Service in January. In February, our teen members raised awareness of child soldiers all over the world by hosting a "Red Hand Day" event during recess at Pahoa High and Intermediate School. Students wrote messages of protest to world leaders. In September, our club participated in the BGCA's Worldwide Day of Play by hosting the Ohana Kickball Game. Over 100 children, teens, and adults had fun in a healthy, active way. In November, the Pahoa Club members and families honored our country's soldiers by making over 100 orchid leis and placed them on the burials at Haili Veterans Cemetery on Veterans Day. Other positive activities around the community consisted of Holiday Sign-waving "No Drunk Driving" in collaboration with PHIS Student Body Government, and Hawaii Police Department. We also participated in the Pahoa Holiday Parade and various Community Clean-ups. Due to the huge interest in skate boarding, we developed a youth group called the SK8 Club. Youth members and teen volunteers are teaching and mentoring each other and other youth that don't know much about skateboarding. We have developed a culture of respect and drug-free expectations that all who attend abide by. Another activity our youth participated in was the Black and White Night High School Dance. Our youth assisted with decorations and advertisement of the event. We also provided an informational booth with BISAC displaying anti-drug and anti-smoking facts. We also participated with the Kick Butts Day event on O'ahu. Youth participated in workshops about youth advocacy and how "Big Tobacco" targets youth. Youth all walked over to the State Capital for lunch and our youth dropped off packets to legislature members, where youth got the opportunity to speak to Puna's representative Faye Hanohano about tightening anti-tobacco laws and not spending the Master Settlement Fund on anything but tobacco-related issues. Agencies BGCBI continued to maintain relationships included: Tobacco-Free Big Island Coalition, American Lung Association, American Cancer Society, REAL, The Salvation Army Family Intervention Services, Lanikila Learning Center, Alu Like, Department of Defense Summer Youth Employment Program, Pahoa Weed and Seed Project, United States Tennis Association — Hawaii Pacific Section, Bay Clinic, State of Hawaii Department of Education, PATCH, Kick-the-Nic, Prosecuting Attorney's Office, MADD, and the Hawaii County Department of Parks & Recreation. Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget Estimate NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 3 Boys & Girls Club of the Big Island Positive Youth Development Programs: Pahoa Club Youth will participate in The Arts Programs. 75 75 75 Youth will participate in Character and Leadership programs. 45 40 40 Youth will participate in Education and Career Development Programs. 158 100 100 Youth will participate in Health and Life Skills Programs. 88 80 80 Youth will participate in Sports, Fitness and Recreation Programs. 148 120 120 Parents/families will participate in Family Strengthening activities. 4 events 4 events 4 events Program Expenditure FY 2010-11 FY 2011-12 Budget FY 2012-13 Estimate Actual Salaries and Wages $170,000 $202,800 $178,900 Professional Fees $6,000 $6,500 $6,500 Operations $72,000 $71,100 $69,200 Equipment/Supplies $16,356 $46,640 $16,600 Total $264,356 $327,040 $271,200 Program Funding Sources: Identify all funding sources Revenue Source FY 2010-11 FY 2011-12 Budget FY 2012-13 Actual Estimate County of Hawaii - Nonprofit Grant $15,000 $15,000 $40,000 Hawaii Community Foundation: Tobacco $12,500 $12,500 $12,500 Settlement Trust Fund Rural Youth Crime Prevention $20,300 $20,300 0 Program (BGCH/OJP)- Hawaii Island United Way $2,500 $2,500 0 Walmart Foundation State $5,000 $5,000 0 Giving Grant Boys and Girls Club of $6,000 0 0 America/Walmart Foundation County of Hawaii SPF SIG initiative $69,400 $41,640 0 Boys and Girls Clubs of America - COX Super $21,700 $0 $11,700 Resource Grant DOH-ADAD $15,000 $95,600 $87,000 BGCA/OJP Mentoring $11,666 $90,000 $100,000 Department of Human Services/Office of Youth $65,290 $25,000 0 Services NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 4 Boys & Girls Club of the Big Island Positive Youth Development Programs: Pahoa Club Club Fundraising $20,000 $20,000 $20,000 Total $264,356 $327,540 $271,200 Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? BGCBI Board of Directors and leadership professionals have the following components in place for increased sustainability of programs: a) established annual agency fundraisers; b) an increase in special event fund raising efforts; c) an annual planned giving program in alignment with the Boys and Girls Clubs of America's standards of effective operations— It Just Takes One Campaign to include corporation and individual donors; d) in 2009, BGCBI created a Resource Development Department with a full-time Development Director with increase in grant writing; e) increased marketing initiatives via website design and functionality for resource development purposes; f) Board of Director strategic planning to establish an endowment fund. With BGCBI's mission of serving all youth regardless of ability to pay, BGCBI will always be looking for resources to sustain programs, including a combination of unrestricted fundraising and an array of grants and contracts. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. If awarded a grant from the County of Hawai`i, I (we) understand and will comply with the requirement to submit a year-end report to the Legislative auditor within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. . ----?() / - Z Signature of Board a resident/Chair Date eip0 (73d4 S gn t� ure of Executive Director ' "Date (Signature of Resource Development Director in the absence of Executive Director) NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page,5 15 Brantley Center Employment Rehabilitation Brantley Center, Inc. Employment Rehabilitation Agency Director: Steven Pavao Phone No.: 775-7245 Contact Person: Steven Pavao Phone No.: 775-7245 Mailing Address: P.O. Box 1407 Honoka'a, HI 96727 Facility/Site Address: 45-370 Ohelo Street Honoka'a, HI 96727 Fax No.: 775-0211 Email Address: bcenter2 @hawaiiantel.net Name of Accountant/CPA (include name of firm if applicable): Jennifer Gossert, CPA Phone No.: 969-3115 Mailing Address: 688 Kinoole Street Suite 201 Hilo, HI 96720 Amount of Request for County Funds: $25,000 Prior Year(s) Funding: 09-10 10-11 11-12 $20,000 $20,000 $15,000 Agency Mission Statement: To provide quality rehabilitative services to people with disabilities that empower them to participate independently in their community. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 1 Brantley Center, Inc. Employment Rehabilitation Program Description: The Employment Rehabilitation Program provides participants with a variety of services that develop and support the accomplishment of goals leading to meaningful employment . These services include; job-readiness classes, competitive employment placement services, and on-the-job follow-up services. Participants receive quality vocational training and at the same time are paid for the work performed. Program staff work closely with the community to provide community-based vocational training, and at the same time provide the public with an additional workforce. Also included in this program are the work transition services for high school students with disabilities. Total Budget and Position Count Total Program Budget 195,107 Total Program Position Count 4 Total Agency Budget 345,180 Total Agency Position Count 8 Program Objectives: 1) Provide vocational evaluations to 35 clients 2) Provide individualized employment planning services to 25 clients 3) Provide work adjustment training to 25 clients 4) Provide occupational skills to 25 clients 5) Provide job-readiness classes to 20 clients 6) Provide competitive job placement and follow-up services to 15 clients 7) Provide work transition services to 15 high school students with disabilities Program Highlights: (from Fiscal Year 2010-11) 1) Provided vocational evalautions to 12 clients 2) Provided individualized employment planning services to 14 clients 3) Provided work adjustment training to 10 clients 4) Provided vocational training skills to 18 cleints 5) Provided specialized job-readiness classes for 9 cleints 6) Provided job placement services for 8 clients 7) Provided work transition services to 6 high school students NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 2 Emplyment Rehabilitation Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Number of clients who received 22 24 24 employment rehabilitation services. Number of consumers with 10 12 12 improved scores on the vocational Evaluation Training Report Number of consumers with 14 14 14 imporved productivity percentages Number of consumers who 10 10 11 successfully completed the job- readiness class Number of consumers placed in 10 10 10 competitive employment for a minimum of 90 days Number of students who received 12 12 8 work transition services and were placed in competitive employment *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 126,470 136,788 136,788 Professional Fees 15,415 16,000 12,000 Operations 76.592 79,677 82,765 Equipment 0 0 0 Other# 0 0 Total 218,477 232,465 231,553 *If applicable°Please explain in detail on separate sheet Brantley Center, Inc. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 3 Employment Rehabilitation Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate County of Hawaii 20,000 15,000 25,000 State of Hawaii 30,000 30,000 30,000 Hawaii Island United Way 20,000 10,000 10,000 County of Hawaii-Mass Transit 21,000 21,000 21,000 Program Sales & Services 121,753 125,000 130,000 Fundraising 4,188 2,477 6,465 Total 216,741 218,477 232,465 *If applicable Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The Brantley Center, Inc. has made a concerted effort to expand its fund development capabilities. In 2010 it initiated it first "Annual Campaign" to raise individual donations for operating capital. The Center is currently working on plans for additional fundraising in 2012. The current financial climate however makes fundraising challenging. The goal for this program is to become self- sustaining, but the current reality of the economic climate makes that impossible. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 4 Brantley Center, Inc. Employment Rehabilitation I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135—2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. --itkA– ( -0--0, ( i — 3 i — k.7--- Si ature of Board President/ hair Date ( -- i 12, Signature o xecutive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 5 16 Child & Family Service Alternatives to Violence Child & Family Service - Agency Name Alternatives_to Violence - Program Name Agency Director: Howard Garval, President and CEO Phone No.: (808) 681-3500 Contact Person: Heidi Koop, Director of Hawaii Island Programs Phone No.: (808) 935-8229 Mailing Address: 91-1841 Fort Weaver Road Ewa Beach, HI 96706 Facility/Site Address: 1266 Kamehameha Avenue, Suite A Hilo, HI 96720 81-6587 Mamaloha Highway, Bldg. C Kealakekua, HI 96750 Fax No.: (808) 961-2073 East Hawaii (808) 323-2999 West Hawaii Email Address: hkoop @cfs-hawaii.org Name of Accountant/CPA (include name of firm if applicable): N&K CPAs, Inc. Phone No.: (808) 524-2255 Mailing Address: American Savings Bank Tower 1001 Bishop Street, Suite 1700 Honolulu, HI 96813-3696 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $40,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $15,000 $20,000 $17,000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 7 Child & Family Service - Agency Name Alternatives to Violence - Program Name Agency Mission Statement: "Strengthening families and fostering the healthy development of children" Since 1899, Child & Family Service (CFS) has dedicated its efforts to its mission of "Strengthening families and fostering the healthy development of children." CFS has 37 programs statewide that offer an array of effective and culturally relevant services to Hawaii's residents in need. The broad spectrum of services provided by CFS include: domestic violence intervention, case management, residential group homes, alternative education for alienated youth, prevention and treatment of child abuse, and family, school, and community-based counseling services for children and their families. Infants, children, adolescents, young adults, older adults, individuals, and families in need benefit from these services. CFS's programs are responsive, flexible, and focused on positive outcomes. Services are provided in homes, schools and in the community as well as CFS's offices. CFS provides services through 35 sites throughout the State, on the islands of Hawaii, Kauai, Maui, Molokai, and Oahu. CFS's strengths lie not only in its size and ability to share expertise and resources statewide, but also in its ability to adapt services so that they are unique and appropriate to the island and communities it serves. Despite significant changes in funding, CFS successfully continued Domestic Violence services on the island of Hawaii by consolidating operations and optimizing resources. As the community continues to face a multitude of difficult problems during continuing challenging economic times, CFS will demonstrate our commitment to the community of the Big Island by supporting populations that present with increasingly complex problems and situations. CFS continues to be at the forefront of developing the skills, knowledge, and service models to address these needs. Program Description: Funds are requested to support the operation of the Alternatives to Violence (ATV) Program in the County of Hawaii, more specifically the victim support component of our program. The victim support component consists of Temporary Restraining Order Assistance, Survivor Court Advocacy and Women Support and Pattern Changing groups. The Domestic Violence Specialist works with the survivors of domestic violence with the goal of ensuring future safety for every member of the family. Safety Plans are developed with each survivor at intake time that is tailored to their family's unique situation. The ATV Program utilizes an evidence-based curriculum that incorporates cultural and value based components. The ATV Program provides an array of Domestic Violence Intervention (DVI) services to men, women and youth. The services to male and female batterers include psycho-educational groups that teach skills of non-violence and NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 7 Child & Family Service - Agency Name Alternatives to Violence - Program Name accountability for their behavior. The services to victims include assistance to complete and file temporary restraining orders, court advocacy, individualized safety planning, psycho-educational and pattern changing groups, victim support groups and case management. This proposal seeks funding to support victim services and support the full-time position of two Domestic Violence Specialists, one in West Hawaii and one in East Hawaii. Adult victims of both genders, including same sex partners, are offered support services, group and/or brief individual services. Victim support groups provide education and support to those individuals who are in, or have been in, abusive intimate relationships. The purpose of the group is to provide information about how to be safe, developing a safety plan and understanding what has happened. Our primary goal is to educate about the dynamics of domestic violence; assist participants to understand their anger, improve problem solving and social support; and identify and remove barriers to safety and decrease isolation. Most importantly, we help them regain their identity in order to build a firm cultural and mental foundation which is essential to the success of developing a healthy sense of self-worth. This opens up pathways to empower individuals and to teach the necessary tools of self sustainment. The goal is for clients to understand how violence is used as power in intimate relationships and causes disrespect and harm that is inconsistent with the values, beliefs and conduct of every culture. Total Budget and Position Count Total Program Budget $843,634 Total Program Position Count 13 Total Agency Budget $4,114,018 Total Agency Position Count 127 Program Objectives: 1. Establish an Individualized Safety Plan with 90% of TRO petitioners at the time of the TRO assistance services. 2. Ensure that 80% of victims participating in Victim Support Services are able to identify at least 3 personal safety skills. 3. Increase the weekly group attendance by 50% 4. Provide victim group services for 12 to 15 participants a month. Program Highlights: (from Fiscal Year 2010-11) ATV Program clients who have been affected by domestic violence (offenders, victims, child witnesses) were offered classes that taught them how to overcome the trauma of domestic violence and to live violence free. The objective is to NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 7 Child & Family Service - Agency Name Alternatives to Violence - Program Name remind the men and women of the value of respect that can be found in every culture. In Fiscal Year 2010-2011, the program achieved the following: 1) 1,717 unduplicated individuals were served. 2) 1,583 individuals received Temporary Restraining Order Services. 3) 2,018 Court Advocacy services were provided. 4) 102 classes were held for victims of domestic violence. 5) 10 women graduated from the women's support & pattern changing group. 6) 91% of victims participating in Support Services identified at least 3 personal safety skills. 7) 99 men completing batterer intervention services demonstrated the knowledge, skill and attitudes necessary for maintenance of non-abuisve behavior which includes learning non-violent conflict resolution and non- aggressive communication. Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Number of individuals served 1,717 1,700 1,700 (unduplicated) Number of individuals served through 1,583 1,500 1,500 TRO assistance Number of provided Court Advocacy 2,192 2,000 2,000 Number of Victim Support and Pattern 102 110 120 Changing Classes held Number of women's offenders classes 126 140 160 held *If applicable Program Expenditures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages 396,453 578,055 589,616 Professional Fees Operations 209,040 265,579 270,891 Equipment Other# Total 605,493 843,634 860,507 * If applicable # Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 7 Child & Family Service - Agency Name Alternatives to Violence - Program Name Rainy Day funds were extended to CFS throughout FY 2012. No Rainy Day funds are expected for FY 2013. To continue providing high quality services to victims and their families that ensures safety at home and in the community, additional funds are requested from the County of Hawaii to cover the expected gaps of support by the Judiciary. Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Judiciary 487,564 723,434 505,499 County of Hawaii 20,000 17,000 40,000 Program Fees 59,626 55,700 55,000 HIUW 6,667 7,500 7,500 Federal VAWA 31,283 \ 40,000 0 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? CFS was a recipient of Rainy Day Funds which support this program. This funding will end June 30, 2012, reflected in the revenues above. CFS is actively working with legislators and the Judicidiary to strategize on how to address this gap in funding. CFS has actively increased its fundraising pursuits and has achieved some successful milestones which benefit all CFS programs. CFS also actively pursues other sources of funding from the Hawaii Island United Way, the Visitor Industry Charity Walk and private foundations with a focus on Hawaii County. CFS also explores national funding sources. For the Domestic Violence Intrvention groups, CFS collects a $18 fee per group session. Fees can be waived and replaced by work exchange. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. N/A NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 7 Child & Family Service - Agency Name Alternatives to Violence - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 7 Child & Family Service - Agency Name Alternatives to Violence - Program Name Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Kathy Inouye, Board Chair: I.2�-12. Signature o :oard 'resident/Chair Date or Agency airector Howard S. Garval, President and CEO: Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 7 17 Child & Family Service Domestic Abuse Shelters Child & Family Service - Agency Name Domestic Abuse Shelters - Program Name Agency Director: Howard Garval, President and CEO Phone No.: (808) 681-3500 Contact Person: Heidi Koop, Director of Hawaii Island Programs Phone No.: (808) 935-8229 Mailing Address: 91-1841 Fort Weaver Road Ewa Beach, HI 96706 Facility/Site Address: 1266 Kamehameha Avenue, Suite A Hilo, HI 96720 81-6587 Mamaloha Highway, Bldg. C Kealakekua, HI 96750 Fax No.: (808) 961-2073 East Hawaii (808) 323-2999 West Hawaii Email Address: hkoop @cfs-hawaii.org Name of Accountant/CPA (include name of firm if applicable): N&K CPAS, Inc. Phone No.: (808) 524-2255 Mailing Address: American Savings Bank Tower 1001 Bishop Street, Suite 1700 Honolulu, HI 96813-3696 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$60,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $15,000 $20,000 $17,000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 10 Child & Family Service - Agency Name Domestic Abuse Shelters - Program Name Agency Mission Statement: "Strengthening families and fostering the healthy development of children." Since 1899, Child & Family Service (CFS) has dedicated its efforts to its mission of "Strengthening families and fostering the healthy development of children." CFS has 32 programs statewide that offer an array of effective and culturally relevant services to Hawaii's residents in need. The broad spectrum of services provided by CFS include: domestic violence intervention, case management, residential group homes, alternative education for alienated youth, prevention and treatment of child abuse, and family, school, and community- based counseling services for children and their families. Infants, children, adolescents, young adults, older adults, individuals, and families in need benefit from these services. CFS's programs are responsive, flexible, and focused on positive outcomes. Services are provided in homes, schools and in the community as well as CFS's offices. CFS provides services throughout the State on the islands of Hawaii, Kauai, Maui, Molokai, and Oahu. CFS's strengths lie not only in its size and ability to share expertise and resources statewide, but also in its ability to adapt services so that they are unique and appropriate to the island and communities it serves. Despite a 40% reduction of funds, CFS successfully continued Domestic Violence services on the island of Hawaii by consolidating operations, optimizing resources and seeking other funding. As the community continues to face a multitude of difficult problems during challenging economic times, CFS will demonstrate our commitment to the community of the Big Island by supporting populations that present with increasingly complex problems and situations. CFS continues to be at the forefront of developing the skills, knowledge, and service models to address these needs. Program Description: CFS has been providing emergency shelter for domestic violence victims in the Big Island community for 24 years. The West Hawaii Domestic Abuse Shelter opened in 1988 followed by the East Hawaii Domestic Abuse Shelter in 1995. These two shelters are the only shelters on the Big Island to serve the immediate needs of residents seeking safety due to domestic violence. Funds are requested to provide partial funding for two full-time Shelter Worker positions, one in the Kona Domestic Abuse Shelter and one in the Hilo Domestic Abuse Shelter. Shelter Workers are critical to answer the hot line calls, provide referrals and information, and support the participants in their daily challenges when it comes to their traumatic experience as domestic violence survivors, including finding safe housing and employment. Shelter Workers also help the participants to understand the behaviors of their children and to parent wisely. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 10 Child & Family Service - Agency Name Domestic Abuse Shelters - Program Name The Domestic Abuse Shelters (DAS) provide emergency shelter to single women/men and women/men with children who are victims of domestic violence (for a maximum of 90 days). The victims flee from the geographic areas of Ka'u all the way to Kohala, from Volcano to Puna, from Puna to Hamakua. Victims from East Hawaii often access the DAS in West Hawaii and victims from West Hawaii will also access the DAS in East Hawaii for safety reasons. Please note that most victims of domestic violence are women. CFS does provide services for men who are victims of domestic violence but generally finds alternate housing for them rather than co-locating them with women in the shelter. There are no restrictions to enter the shelter as long as the circumstances of need are identified within 48 hours as a domestic violence issue. The shelter operates 24 hours a day/365 days a year including holidays. Staff members monitor and oversee the safety and needs of the residents. The victims are from all walks of life and all socioeconomic backgrounds. The main goal of the program is to provide a safe environment. Experienced advocates help families identify their needs and develop a plan to meet these needs. The Shelters offer emergency food, transportation, referrals as needed, case management, individual counseling, advocacy, outreach services, safety planning, Temporary Restraining Orders assistance, support groups, and personal planning to all residents. The Shelter staff works with the mothers/fathers and children to build healthy relationships and to strengthen their role as effective parents without using physical and/or verbal violence towards their children. We are committed to raising the consciousness of our society by: educating our families on a violence free lifestyle; promoting family coping and stability; and, providing a place of refuge. Each Shelter operates a 24-hour domestic violence hotline which provides crisis intervention, information, and referral services. During the last 18 months, the hotline utilization by victims of domestic violence has increased due to the added economic stressors in the communities of the Big Island. The hotline worker, also an on-shift Shelter Worker, provides a safety assessment, makes recommendations and provides referral and resource information for the callers. It is expected that the hotline will continue to see an increase of calls due to the rising violence resulting from increased poverty and homelessness. The Shelter in West Hawaii provides three bedrooms with a total of 21 beds for families who enter into the program. In addition to the three bedrooms each room has a full bathroom to accommodate the residents who share the bedroom space. One bedroom is specifically geared towards housing single women and women with disabilities. This room is ADA compliant. The facility also has an NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 10 Child & Family Service - Agency Name Domestic Abuse Shelters - Program Name ADA ramp for easy access in/out of the Shelter. In addition to the client areas, the shelter has two offices, a playground and a children's room. These offices are used for intake and exit interviews to provide client confidentiality, case management, and individual counseling. The Shelter also provides our residents with a laundry facility, full kitchen, a large living room and a dining area. A large Matson container on the Shelter site holds furniture items, clothing and household miscellaneous items. These items are donated throughout the year from the West Hawaii community who supports the Shelter. The East Hawaii Domestic Abuse Shelter is located in a two-story home on approximately three acres in an agricultural/residential area of East Hawaii and is set off from the roadway. It has three full bathrooms, four bedrooms and has a 20-person capacity. The downstairs of the Shelter facility has a laundry room that is accessed through the covered double car garage entrance. A comfortable-sized living room with an adjoining bathroom is accessible via the laundry room and a short walkway connects into the spacious kitchen area. There is an adjoining dining room and pantry which is also accessible via an entrance off the side of the kitchen that exits into the side yard of the property. The Shelter facility is ADA compliant by having an ADA ramp which leads to the lower floor where an ADA bedroom is located. Total Budget and Position Count Total Program Budget $768,298 Total Program Position Count 17.50 Total Agency Budget $4,114,018 Total Agency Position Count 127 Program Objectives: The CFS Domestic Abuse Shelters' objectives are: 1. Increase client knowledge of community resources by 85%. 2. Complete Safety Plan with 90% of shelter clients for themselves and their children. 3. Moving from the shelter to a non-abusive home environment will occur among 60% of clients (victims). Program Highlights: (from Fiscal Year 2010-11) 1) During the fiscal year of 2010 to 2011, the West Hawaii Domestic Abuse Shelter (WHDAS) served 100 children and 112 adults. The WHDAS provided 5,373 bed days. The WHDAS received 216 hotline calls that involved a crisis due to domestic violence. The WHDAS handled 149 requests for information and referral. In FY 11, WHDAS experienced an increase of victims and their children served compared to fiscal year 2009- NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4of10 Child & Family Service - Agency Name Domestic Abuse Shelters - Program Name 2010. In East Hawaii, there has been no significant increase since 2009- 2010; it was already high. However, from 2008-2009 to 2009-2010, bed days increased by 37%. In West Hawaii, there has been no significant increase since 2009-2010. However, from 2008-2009 to 2009-2010, bed days increased by 75%. 2) During the fiscal year of 2010-2011, East Hawaii Domestic Abuse Shelter (Hale 'Ohana) served 99 children and 132 adults. Hale 'Ohana provided 5,300 bed days. Hale 'Ohana received 1,116 hotline calls that involved a crisis due to domestic violence. Hale 'Ohana handled 543 requests for information and referral. Hale 'Ohana continues to experience high occupancy in fiscal year 2010-2011 as in the prior fiscal year 2009-2010. 3) As anticipated, an increase of domestic violence occurred during the last fiscal year due to economic stressful times which historically effects domestic violence between domestic partners. CFS continues to be committed to support the community to ensure that families are protected. 4) Both Domestic Abuse Shelters achieved 100% of their outcomes during the fiscal year of 2010-2011 except for West Hawaii in the area of adults and families moving into a non-abusive environment. Due to the increasing challenges obtaining affordable housing in West Hawaii under the current economic situation, the expected outcome for WHDAS was at 47%. The staff of WHDAS will continue to support the adults and families to establish a transition to safe housing. 5) Other services include: assisting the residents with personalized safety planning, increasing awareness among parents and caregivers of the effects on children who witness domestic violence, increasing awareness of community resources, and providing education on healthy relationships. 6) During the past year, CFS staff has been trained in a new, evidence- based methodology called Trauma Informed Care. This approach greatly assists the staff in helping clients through understanding the complex ways that exposure to trauma can affect their behavior. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 10 Child & Family Service - Agency Name Domestic Abuse Shelters - Program Name Performance Measures in West Hawaii: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate** # of Bed Days 5,373 5,500 5,500 # of Hotline Calls 216 225 225 # of Single Women 60 70 70 # of Women w/children 54 60 60 # of Children Served 100 100 100 # of requests for information and 449 500 500 referral only # of group session 208 200 200 # of individual session hours 1,270 600 600 provided # of meals provided 13,433 13,500 13,500 # of transportation hours provided 178 200 200 *If applicable ** Estimates are based on historical data. Performance Measures in East Hawaii: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate** # of Bed Days 5,300 5,300 5,300 # of Hotline Calls 1,116 1,200 1,200 # of Single Women 71 70 70 # of Women w/children 56 60 60 # of Children Served 99 100 100 # of requests for information and 554 600 600 referral only # of group session 203 200 200 # of individual session hours 3,485 3,500 3,500 provided # of meals provided 13,287 13,500 13,500 # of transportation hours provided 508 500 500 "If applicable ** Estimates are based on historical data. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 10 Child & Family Service - Agency Name Domestic Abuse Shelters - Program Name Program Expenditures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages 419,662 518,268 528,633 Professional Fees 1,302 Operations 280,584 278,444 284,013 Equipment Other# Total 701,548 796,712 812,646 * If applicable "Please explain in detail on separate sheet Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Department of Human Services 590,278 672,447 466,018 County of Hawaii 20,000 17,000 60,000 Hawaii Island United Way 13,333 25,000 25,000 DHS Emergency Shelter Grant 28,000 28,344 28,344 Prosecutors VOCA 6,932 7,207 7,000 EBT Food Stamps 12,509 10,000 10,000 Private Foundation 25,851 5,500 5,000 Program Fees 2,605 2,800 2,800 Total 699,508 768,298 604,162 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? CFS was a recipient of Rainy Day Funds which support this program. This funding will end June 30, 2012, reflected in the revenues above. CFS is actively working with legislators and the Department of Human Services to strategize on how to address this gap in funding. CFS is committed to supporting critical services in the community despite tight budgetary limitations. Recent funding reductions, including unexpected reductions instituted late in the year, have had a tremendous impact on the program. CFS has increased its staff through the addition of Grants Officer and new avenues for funding are being explored. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 10 Child & Family Service - Agency Name Domestic Abuse Shelters - Program Name CFS relies on other funding sources to fund its Domestic Abuse Shelters, such as Hawaii Island United Way (HIUW), Emergency Shelter Grant (ESG) and Victims of Crime Act from the Prosecutor's Office. The shelter charges a modest fee to those clients with an ability to pay. CFS has utilized Community Development Block Grants for much needed repairs and improvement projects in West and East Hawaii that are now completed. We are asking for additional funding from the County of Hawaii to help offset the cutbacks. A well run domestic abuse shelter is essential to the integrity of a community. A community must be able to provide for those who need help the most when they need it. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawai`i. N/A NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 10 Child & Family Service - Agency Name Domestic Abuse Shelters - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 10 Child & Family Service - Agency Name Domestic Abuse Shelters - Program Name Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Kathy Inouye, Board Chair: w 1- 2G-12 Signature of :•ard 'resident/Chair Date or Agency D' ecto Howard S. Garval, President and CEO: Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 10 18 Child & Family Service Hilo Transitional Housing Child & Family Service - Agency Name Hilo Transitional Housing - Program Name Agency Director: Howard Garval, President and CEO Phone No.: (808) 681-3500 Contact Person: Heidi Koop, Director of Hawaii Island Programs Phone No.: (808) 935-8229 Mailing Address: 91-1841 Fort Weaver Road Ewa Beach, HI 96706 Facility/Site Address: 1266 Kamehameha Avenue, Suite A Hilo, HI 96720 Fax No.: (808) 961-2073 Email Address: hkoop @cfs-hawaii.org Name of Accountant/CPA (include name of firm if applicable): N&K CPAs, Inc. Phone No.: (808) 524-2255 Mailing Address: American Savings Bank Tower 1001 Bishop Street, Suite 1700 Honolulu, HI 96813-3696 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $40,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $15,000 $10,000 $17,000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 8 Child & Family Service - Agency Name Hilo Transitional Housing - Program Name Agency Mission Statement: "Strengthening families and fostering the healthy development of children" Since 1899, Child & Family Service (CFS) has dedicated its efforts to its mission of "Strengthening families and fostering the healthy development of children." CFS has 37 programs statewide that offer an array of effective and culturally relevant services to Hawaii's residents in need. The broad spectrum of services provided by CFS include: domestic violence intervention, case management, residential group homes, alternative education for alienated youth, prevention and treatment of child abuse, and family, school, and community-based counseling services for children and their families. Infants, children, adolescents, young adults, older adults, individuals, and families in need benefit from these services. CFS' programs are responsive, flexible, and focused on positive outcomes. Services are provided in homes, schools and in the community as well as CFS' offices. CFS provides services through 35 sites throughout the State, on the islands of Hawaii, Kauai, Maui, Molokai, and Oahu. CFS' strengths lie not only in its size and ability to share expertise and resources statewide, but also in its ability to adapt services so that they are unique and appropriate to the island and communities it serves. Despite a 40% reduction of funds, CFS successfully continued Domestic Violence services on the island of Hawaii by consolidating operations and optimizing resources. As the community continues to face a multitude of difficult problems during challenging economic times, CFS will demonstrate our commitment to the community of the Big Island by supporting populations that present with increasingly complex problems and situations. CFS continues to be at the forefront of developing the skills, knowledge, and service models to address these needs. Program Description: Funds are requested to support the operation of the East Hawaii Transitional Housing Program. The County of Hawaii funding will be used to support a portion of the position of a Domestic Violence Specialist. Victims of Domestic Violence are faced with many challenges when making the courageous decision to finally leave their batterers. Both women and men are provided services in our Domestic Abuse programs, but it is mostly women who are confronted with financial challenges. When leaving the batterer, the victim embarks upon a path that is as fearful for her and her children as it is to stay with an abusive partner. Many of these women leave with just the clothes that they are wearing, seeking shelter, safety and, most of all, assurances that they made the right choice. Many lack the skills, tools and resources needed to sustain themselves and their children away from their batterer. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 8 Child & Family Service - Agency Name Hilo Transitional Housing - Program Name Many women are faced with the reality of no financial resources, and inability to access resources due to marital assets retained by the abusers which disqualifies them from eligibility for public assistance or subsidized housing. Many victims turn to the East or West Hawaii Domestic Abuse Shelters initially where they can recover and start planning a new life. The Domestic Abuse Shelters provide safety, basic needs, counseling and support for up to 90 days. Securing a safe home for themselves and their children is one of the serious challenges that the victims are facing in the County of Hawaii due to an expensive rental market and the current economic situation. At the end of the 90 days in a Domestic Abuse Shelter, the victim must make a decision not only for herself but for her children as well. Unfortunately that decision is often to return to the abuser she sought refuge from or to become homeless since resources of financial and housing support are limited. The Hilo Transitional Housing Program is a 24 month program that assists victims of domestic violence and their children to rebuild their lives. The program goal is to assist victims and their children to gain stability and independence while transitioning into a violence-free lifestyle. Victims who qualify for services transition from the Domestic Abuse Shelters located in West and East Hawaii and can be placed in one of six apartments/houses. During their 24 month stay, victims and their families receive intensive support services that guide the victims and their families towards independence: to move to a regular home in the community, to secure income and to be able to care for the children. By providing weekly home visits, case management, individual family service plans, and information and referrals to community resources, the program allows both the victims and their children the time to heal, and to live safely. The program is in need of a full-time Domestic Violence Specialist to provide case management, counseling, and support to victims. The Specialist also works with the participants on developing employment and education opportunities. The County of Hawaii funding, matched by other funding, will allow for a full-time Domestic Violence Specialist to be hired. Without a full-time Domestic Violence Specialist, positive outcomes for clients are greatly impacted since the time spent with victims to provide support and resources is reduced. The Domestic Violence Specialist gives the victims weekly opportunities to learn about and to enhance their life skills, including budgeting, money management and job training, nutrition, increasing self esteem, emotional and physical health. Support groups are also provided by the Domestic Violence Specialist to educate participants on the effects violence can have on victims as well as their children. Groups are beneficial in building a much needed support system for those in the NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 8 Child & Family Service - Agency Name Hilo Transitional Housing - Program Name program. In doing so, the Domestic Violence Specialist addresses many of the barriers to establishing income, housing and independence. Total Budget and Position Count Total Program Budget $143,145 Total Program Position Count 1.05 Total Agency Budget $4,114,018 Total Agency Position Count 127 Program Objectives: 1. Increase the knowledge of community resources, including housing, employment and finances, among 80% of participants in program. 2. Maintain a safe and violence free lifestyle during participation in the program among 80% of clients in the program. 3. Support safety by having 90% of the clients maintain a Safety Plan for themselves and their children at intake and for the duration of their participation in program. 4. Secure independent housing after 24 months of safe transitional housing among 80% of the clients seeking permanent safe living quarters. Program Highlights: (from Fiscal Year 2011-12) 1. The program is fulfilling a high need for providing the only transitional housing for victims of domestic abuse and their families in Hawaii County. 2. Nine families were provided with transitional housing from July 2010 to June 2011 . 3. The staff has developed a strong program that focuses on reintegrating victims of domestic abuse into the community and gaining their independence and self-sufficiency. 4. Three families successfully transitioned into permanent housing between July 2010 and June 2011. 5. Two participants obtained part-time employment. 6. Two participants decided to further their education, one enrolled at the University of Hawaii, working on a degree in marine biology, the other did an online course and received a Veterinarian assistant certificate. 7. Of the 28 participants who have transitioned out of program since its beginning in 2006, 79% of participants have made the decision not to re- involve themselves with their abusers and have established a violent free home for themselves and their children. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 8 Child & Family Service - Agency Name Hilo Transitional Housing - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate # of families provided housing 9 6 7 # of service plans developed 9 6 7 # provided case management 11 7 7 # of safety plans developed 11 7 7 # provided aftercare services 6 2 3 # w/secured income 9 6 7 # enrolled in education program 2 2 3 # w/secure employment 2 2 3 # obtained permanent housing 3 2 3 *If applicable Program Expenditures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages 37,703 47,136 42,638 Professional Fees Operations 128,533 117,372 120,893 Equipment Other# Total 166,236 164,508 163,531 * If applicable #Please explain in detail on separate sheet Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate U.S. Department of Justice 146,010 117,145 92,571 County of Hawaii 10,000 17,000 40,000 Program Fees 8,354 9,000 8,500 Office of Prosecuting Attorney 21,363 VOCA Total 164,364 164,508 141,071 *If applicable NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 8 Child & Family Service - Agency Name Hilo Transitional Housing - Program Name Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The Hilo Transitional Housing Program has been primarily funded by the Department of Justice, Office of Violence Against Women (OVW). Additional funding options have been explored including charging program fees, however, CFS would prefer not to do that. Clients are not turned away if they cannot pay. CFS has a strong history of fundraising and is committed to growing our private donations and grants. We continue to apply for alternative funding sources for our programs and have expanded our efforts to receive funding from private foundation sources dedicated to the belief that everyone deserves a violence free life.. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. N/A NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 8 Child & Family Service - Agency Name Hilo Transitional Housing - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 8 Child & Family Service - Agency Name Hilo Transitional Housing - Program Name Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Kathy Inouye, Board Chair: ,, 1- 2(-12 Signature of B.:rd "resident/Chair Date or Agency Director Howard S. Garval, President and CEO: Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 8 19 Child & Family Service Therapeutic Foster Homes Child & Family Service - Agency Name Therapeutic Foster Homes - Program Name Agency Director: Howard Garval, President and CEO Phone No.: (808) 681-3500 Contact Person: Heidi Koop, Director of Hawaii Island Programs Phone No.: (808) 323-2664 Mailing Address: 91-1841 Fort Weaver Road Ewa Beach, HI 96706 Facility/Site Address: East Hawaii: 1266 Kamehameha Avenue, Suite A, Hilo, HI 96720 West Hawaii: 81-6587 Mamaloha Highway, Bldg. C Kealakekua, HI 96750 Fax No.: East Hawaii: (808) 961-2073 West Hawaii: (808) 323-2999 Email Address: hkoop @cfs-hawaii.org Name of Accountant/CPA (include name of firm if applicable): N&K CPAs, Inc. Phone No.: (808) 524-2255 Mailing Address: American Savings Bank Tower 1001 Bishop Street, Suite 1700 Honolulu, HI 96813-3696 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$30r,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $20,000 $18,000 $17,000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 9 Child & Family Service - Agency Name Therapeutic Foster Homes - Program Name Agency Mission Statement: "Strengthening families and fostering the healthy development of children" Since 1899, Child & Family Service (CFS) has dedicated its efforts to its mission of "Strengthening families and fostering the healthy development of children." CFS has 32 programs statewide that offer an array of effective and culturally relevant services to Hawaii's residents in need. The broad spectrum of services provided by CFS include: domestic violence intervention, case management, residential group homes, alternative education for alienated youth, prevention and treatment of child abuse, and family, school, and community- based counseling services for children and their families. Infants, children, adolescents, young adults, older adults, individuals, and families in need benefit from these services. CFS' programs are responsive, flexible, and focused on positive outcomes. Services are provided in homes, schools and in the community as well as CFS' offices. CFS provides services throughout the State on the islands of Hawaii, Kauai, Maui, Molokai, and Oahu. CFS' strengths lie not only in its size and ability to share expertise and resources statewide, but also in its ability to adapt services so that they are unique and appropriate to the island and communities it serves. As the community continues to face a multitude of difficult problems during challenging economic times, CFS will demonstrate our commitment to the community of the Big Island by supporting populations that present with increasingly complex problems and situations. CFS continues to be at the forefront of developing the skills, knowledge, and service models to address these needs. Program Description: Funds are requested to support the Therapeutic Foster Homes (TFH) Program in its work with children who present with severe behavioral challenges including self-injuries, property damage, physical assaults, truancy, substance abuse and stealing. These children are in high need of professional Support Coordinators and highly trained therapeutic foster parents who are able to give them one-on- one attention. CFS is requesting funding for a full-time Support Coordinator and monies to continue supporting therapeutic activities in the homes and the community. The TFH Program provides foster placement and clinical services for youth who have been identified as needing out-of-home placement. Additional resources are provided to accommodate their emotional, behavioral, and mental health issues. The TFH Program offers a system of support, counseling and skill building to youth as well as training and support to the caregivers/family and NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 9 Child & Family Service - Agency Name Therapeutic Foster Homes - Program Name foster parents. The TFH Program provides services countywide on the island of Hawaii. The goal of the program is to teach the youth and his/her family how to build trusting relationships that support the youth in achieving his or her highest potential. The behavioral health and residential programs at CFS continue to see an increase in the number of youth who are in need of "line of sight" supervision and therapeutic activities throughout the day, including weekends. Often, these children are neurologically challenged due to exposure to substances in utero and/or to child abuse and neglect. Most of these children have experienced multiple traumas, unsuccessful placements and/or the 'ohana are unable to support that youth in their homes due to the severity of the behavior and/or other family and work commitments. Many of these youths are so desperate that their behaviors place them in acute units of hospitals. It is well known that the Big Island has been seriously affected by the use of methamphetamine ("ice"). It is anticipated that over time, the number of youth referred for behavioral health services, including therapeutic foster homes, will increase as Hawaii's "ice babies" grow up. During the screening project of a 1,000 pregnant women in 2008-2009 conducted by the Children's Research Triangle on the Big Island, 49.4 % pregnant women reported that they used substances in the month prior to knowledge of pregnancy. The rate of substance use was the highest among Caucasian and Hawaiian women. In addition, it was reported that 42.2% of the women who were drinking in early pregnancy continued drinking after learning of their pregnancy which can put their children at risk for significant neurological impairments. Youth with neurological impairments may have learning impairments, behavioral deficits, increased motor activity, and enhanced conditioned avoidance responses. Parents and foster parents become frustrated and cannot cope with the demands, resulting in many placements for these youth. Often times, multiple placements reinforce problem behaviors and erode the self-esteem of these youth. It is cost-beneficial to provide interventions as early as possible to prevent further problems from developing. The current staffing on the Big Island consists of a Director of Hawaii Island Programs and Clinical Supervisor who provide programmatic oversight of the Therapeutic Foster Homes. A Master's level Mental Health Specialist provides intensive clinical and case management services for the child, the therapeutic foster parents and biological family members. The proposed Support Coordinator will provide daily practical support to the therapeutic foster parents for transportation and appointments. Other duties include the licensing of foster NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 9 Child & Family Service - Agency Name Therapeutic Foster Homes - Program Name homes and preparing new intakes, providing groups to teach life skills, providing one-on-one staffing to allow the youth to adjust to his/her new therapeutic foster home, learn independent living skills and get along in the community within the school and with peers, and providing intensive services at the beginning of the placement, during crisis situations and during the transition to reunification with the family or another permanent placement. CFS has been innovative in exploring new modalities to achieve better outcomes for the youths and the families. Having staff trained on neurological impairments, Trauma Informed Care, Cognitive Behavioral Therapy modalities and family engagements, the TFH staff focuses on how the TFH placement addresses the trauma that families experience, and rebuilds connections between the youth and the family with the goal for reunification and higher level of functioning of youth and family members. When these youths are placed into our TFH Program, there is a high need for providing one-on-one staffing to allow the youth to adjust to his/her new therapeutic foster home, learn independent living skills and get along in the community within the school and with peers. The youth is often adjusting to a new school environment and making connections with peers in the community which is a challenge for these youths. CFS staff have received extensive training including Trauma Informed Care that focuses on working with youths between the ages 5 and 18 years old with these difficulties. To further support this project, an experienced and well trained Support Coordinator is needed to provide the described intensive services at the beginning of the placement, during crisis situations and during the transition to reunification with the family or another permanent placement. The Support Coordinator would be working under the direct supervision of a Clinical Supervisor in coordination with the Mental Health Specialist. The Support Coordinator would provide groups to teach life skills that allow the children to learn managing their neurological challenges in a healthy way. Total Budget and Position Count Total Program Budget $302,713 Total Program Position Count 3 Total Agency Budget $4,114,018 Total Agency Position Count 127 Program Objectives: The intermediate goal of the TFH Program is to provide a safe and stable living environment to youth who experience emotional and/or behavioral problems. This stable environment is needed while the youths engage in therapy to address their individualized mental health and behavioral issues. The long-term goal of the program is to provide the support and skill building necessary to empower youth to engage in socially appropriate and manageable behaviors, thereby NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 9 Child & Family Service - Agency Name Therapeutic Foster Homes - Program Name facilitating the re-unification (if appropriate) of children with their biological families or at the very least to be able to move to a less restrictive environment Measurable objectives for the TFH Program include: 1 . Demonstrate the development of interpersonal relations and life skills 90% of the time as measured by the youth's participation in extracurricular, community or otherwise pro-social activities. 2. Demonstrate being a positive and productive member of a family 90% of the times as measured by the youth's ability to follow daily scheduling and completion of household duties. 3. Achieve quarterly goals of identified permanency plan by 100% of youth. Program Highlights: (from Fiscal Year 2011-12) The TFH Program has been very successful in working with the youths and families. Focus has been on developing the program's ability to provide innovative and valuable therapeutic interventions to each youth. CFS continues to be a pioneer in offering services that are trauma informed and that cater to the unique needs of these special children. One method currently being implemented is through CFS's Risking Connection trainings for our foster parents which will enable them to recognize and effectively address the child's trauma history. This approach has helped to prevent referring children to acute services in Honolulu. This evidence-based approach helps to assure that youth are provided supportive services on the Big Island for optimal success. Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate # of clients served 5 12 20 # of bed days utilized 1,446 2,400 4,000** # of licensed foster homes 5 9 15 # of individual therapy, therapeutic 206 350 600 activities and/or skill building #family therapy sessions 98 170 550 # of discharges to a lateral or lower 2 10 12 level of care *If applicable **An increase of TFH placements is expected due to reduction of residential care programs in Hawaii. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 9 Child & Family Service - Agency Name Therapeutic Foster Homes - Program Name Program Expenditures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages 94,222 128,820 142,364 Professional Fees 232 Operations 154,722 166,728 170,866 Equipment Other# Total 249,176 295,548 313,230 * If applicable #Please explain in detail on separate sheet Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Department of Health (Child and 273,341 285,713 260,025 Adolescent Mental Health) County of Hawaii 18,000 17,000 , 30,000 Private Foundation 1,000 Total 292,341 302,713 290,025 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? CFS is committed to providing critical services for the Big Island community and pursues new treatment modalities such as Trauma Informed Care (Risking Connection), despite budgetary limitations. CFS is actively writing grants for supplemental funding to keep its critical programs operating. CFS was able to hire a Hawaii trained staff that is very familiar with the local needs and their families. As the program continues to grow and shows strong outcomes, CFS will continue to collaborate with the State Child and Adolescent Mental Health Division and other funding sources to continue the Trauma Informed Care TFH project to reunify youths and families in their homes with skills that allow the whole family to be successful in their respective community. CFS is confident that the evidence-based methods of working with this challenging population will continue to strengthen the Program. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 9 Child & Family Service - Agency Name Therapeutic Foster Homes - Program Name Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. N/A NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 9 Child & Family Service - Agency Name Therapeutic Foster Homes - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 9 Child & Family Service - Agency Name Therapeutic Foster Homes - Program Name Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Kathy Inouye, Board Chair: I' 1 .2� 12 Signature of B .r. President/Chair Date or Agency D' ecto Howard S. Garval, President and CEO: Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 9 20 Eden Earthworks Eco-friendly Pork Production for Healthy Generations Eden Earthworks - Agency Name Eco-friendly Pork Production for Healthy Generations- Program Name Agency Director: Neena Roumell Ph.D. Phone No.: 808 333 7444 Contact Person: Neena Roumell, Ph.D. Phone No.: 808 333 7444 Mailing Address: PO Box 711458 Facility/Site Address: 18-3840 S. Lauko Road Mountain View, HI 96771 Fax No.: Email Address: Edenearthwork @gmail.com Name of Accountant/CPA (include name of firm if applicable): Phone No.: Mailing Address: You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $13,082 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $8,000 $00 $00 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 10 Agency Mission Statement: The organization is committed to planting, maintaining and harvesting organic produce to benefit 'Lighthouse food' programs through local churches. The organization through its volunteers and volunteer non paid staff, produce and distribute organic food stuff to donate to the needs through a "food bank" program. The operations will be conducted on the organizations' field farm and greenhouse located in Mountain View, HI. The farm land is donated by the director Neena Roumell. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 10 Eden Earthworks - Agency Name Eco-friendly pork production for Healthy Generations- Program Name Program Description: Small-family swine farming is crucial for food security by providing needed protein.There is a major challenge on Hawaii Island due to the attrition of pig farms in Hawaii. Pig farmers have endured hardship due to urbanization pressure i.e., complaints from neighbors due to odor pollution. There is a strong surge of interest in revitalizing pig farming (returning to or starting) a small scale or backyard piggery. In order to encourage a network of eco-friendly piggeries, Eden Earthworks will provide monthly workshops at our demonstration and educational center (a 34x 54ft' 'greenhouse') to teach the Korean Natural Farming method of waste (pig run off) management technology. In this system indigenous microorganisms (IMOs) native to every farm are used for dry bed construction and aerobic odor minimization. The IMO/Inoculated deep litter system (IDLS) microbic action digests the manure, eliminates waste run off and pen washing; unmanaged effluence finds its way to local surface water systems and coastal waters. The IDLS technology also provides compliancy with new laws regarding waste management (pig waste), food safety and conservation concerns of improving water, soil and air and protecting the environment. An added advantage is that the IDLS system destroys pathogens resulting in healthy nonstressed pigs. Through monthly workshops this project will increase eco-friendly pork production, eco-friendly swine farmers and high quality protein security. This project will also decrease soil, water and air degredation and decrease negative perceptions of pig farmers as producing odor pollution. With this system pigs become good neighbors. This project will promote overall community food self-reliance, enhance econommic security and will benefit Hawaii Island's environment, the farmer, his farm profits and the pigs. Total Budget and Position Count Total Program Budget 28,083 Total Program Position Count 12 Total Agency Budget 40,080 Total Agency Position Count 14 Program Objectives: 1) 1) increase the number of eco-friendly swine farmers and eco-friendly healthy high quality local pork production (85% of pork, a primary protein NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 10 source), is presently imported. 2)Recruit prospective swine farmers, current swine farmers,backyard gardeners/farmers to participate in Inoculated Deep Litter System (IDLS) training for one-stall backyard) or small scale swine farming.3)Provide practical hands on mentoring on how to create and direct observation in basic 5-step layering method for dry bed construction (piggery) and odor minimization employoing Korean Natural Farming technology and indigenous microorganisms (IMOs). 4)Provide information and training necessary for compliancy with the new laws which address waste management (pig waste run-off), food safety and conservation concerns of improving water, soil and air and protecting the environment. 5)Pig care and feeding with sustainable homegrown foods. In light light of the strong interest in the revitalization of pig farming, our expectation is a notable achievement of goals over the next year. Program Highlights: (from Fiscal Year 2010-11) 1) This is a new program. Therefore there is no data collection available from prior instructional-based workshops. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 10 Eden Earthworks - Agency Name Eco-friendly Pork Production for Healthy Generations - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Evaluation to determine program NA NA 80% or effectiveness will be a pre and post greater questionnaire presented at each workshop. The questionnaire will address 1) participants' understanding of the (inoculated deep litter system pig pen 2)Basic steps in the construction of effective aerobic odor minimization for pig pen. 3)Basic information needed to reach compliancy with new laws concerning air, soil and water, associated with piggery 4)Basic information concerning food safety as it relates to pig farming 5)Pig care and feeding with homegrown foods. Evaluation will be used as a determinant for improvement in these areas.Analysis of participants responses will determine if we are meeting the goals; to determine where changes need to be made to better meet these goals and to form new teaching strategies. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5of10 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages NA NA 0 Professional Fees NA NA 0 Operations NA NA 0 Equipment NA NA 1,109 Other# NA NA 11,974 Total NA NA 13,083 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 10 01 0 0 0 0 0 0 0 0 0 0 0 0 01 to to L/1 M N 0 0 0 0 CO 0 N 00 In 01 N 03 Ln to N N U1 .0' I. M. I. co m 0 N N to N. r-I d' to M 01 .t m N e. N .-4 eh N M e-1 .-1 In N L? 00 I- N .-1 a1 a-i ei an- ...i.1/! in in in in lI 1A 1/1 1/1•to 1.4 in. 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Co of Eden Earthworks - Agency Name Eco-friendly Pork Production for Healthy Generations - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate County of Hawaii Non-Profit Grant NA NA 13,083 Sustainable Ag/Res/Ed WSARE NA NA 15,000 In-Kind Contribution NA NA 11,997 Total 40,080 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Due to the efficacy of the inoculated deep litter system (IDLS) and the aerobic odor minimization mechanism, there is virtually no maintenance of the pens. It is anticipated that the self-sustainability should be accomplished within the second year of this program through the sale of piglets. Subsequent demonstration/workshops fror the Ecofriendly Pork Production Project will continue on a monthly basis and be open to community outreach classes, UH Ag outreach, interested prospective pig farmers, backyard gardeners and farmers and 4-H youth groups. Due to the strong surge of interest in the revitalizatioin of pig farming, it is anticipated that the Eden Earthworks IDLS will be an educational hub for the development of ecofriendly pork production and continue support to community members. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 10 Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. NA NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 10 Eden Earthworks - Agency Name Eco-friendly Pork Production for Healthy Generations - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 10 Any funds unused by June 30, 2013 must be returned to the County of Hawai`i within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Signature of Board President/Chair Date or Agency Director Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 10 21 Family Support Hawaii Ka'u Family Center Family Support Hawaii Ka`u Family Center Agency Director: Patrick "Paki" Story Phone No.: (808) 334-4115 Contact Person: Pam Naumann Phone No.: (808) 334-4121 Mailing Address: 75-127 Lunapule Rd., Suite 11 Kailua-Kona, HI 96740 Facility/Site Address: 95-5649 B Mamalahoa Highway Na'alehu, HI 96227 Fax No.: (808) 326-4063 Email Address: pstory@fsswh.org Name of Accountant/CPA (include name of firm if applicable): Rozanne Connell, Manager Carbonaro CPA & Associate, Inc. Phone No.: (808) 968-1002 Mailing Address: P.O. Box 4372 Hilo, HI 96720 Amount of Request for County Grant-in-Aid funds: $75,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $40,000 $20,000 $55,000 Agency Mission Statement: Family Support Hawaii (FSH) was founded in 1979 as a grassroots organization providing family support in communities throughout West Hawaii. FSH incorporated in 1981 as a private, non-profit organization whose mission is "to NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 13 Support Families and Communities in Providing Love and Care for our Children." As are all mission statements, this one is carefully chosen. It embodies two key elements: support for families and support for communities. The first guides us in the direct work of supporting families, which we do through our counseling, home visiting, school based and parent education and support programs. The second is assisting communities to develop the capacity to provide a supportive environment for families. These are achieved through our community development activities, economic development projects, collaboration building and advocacy work for a better quality of life for families in Hawaii. Program Description: Since its inception, FSH has been a leader in the field of providing quality intervention and prevention services in the State of Hawaii. The agency opened its first Family Resource Center in 1990. Family Resource Centers offer all individuals and parents what informal neighborhood networks once supplied. Family support programs offer a whole new philosophy of community service -- one that builds on strengths, focuses on the entire family within the culture and community, and one that gives the family the central role in the planning, design and delivery of implemented services. Family supports are designed to empower parents, build communities and help prevent such problems as child abuse and neglect, low birth weight, teen pregnancy and youth dropping out of school. FSH is seeking funding from the County of Hawaii to continue the work of the Ka`u Family Center. This family center lives in the heart of rural Na'alehu. It is a welcoming place open daily for families to access emergency food, clothing and household items. Along with meeting the critical needs within the community, the family center provides linkages for health care, mental health needs, career opportunities, and educational and financial assistance. Families within the community are given the opportunity to access computers, fax machines and copiers, all at no charge, enabling them to make connections to improve their individual and family circumstances. The family center also offers a space for community meetings, support groups and family enrichment projects along with many other programs, activities and services. Community members find the family center a comfortable place to bring their children to play while they sit and "talk story". This is all made possible by the financial support of the County of Hawaii and through the generous donations of community members and organizations. The family center opens its doors to other non-profit organizations and community groups to use the facilities, providing office and meeting space. The Malama Perinatal, Early Head Start, and Ka`u Child Development (Early Interventions Services) have staff stationed in the center. Families are, thus, able to access these services without having to travel long distances. This NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 13 alleviates some of the transportation and financial concerns many community residents face. Being community based is a fundamental principle for FSH. What this means is that our staff work in the communities in which they live. The Ka`u Family Center Coordinator, Teresa Alderdyce, is a lifelong resident in the community and has provided services at the center for nineteen years. Teresa has the true understanding and heart to help those in need. She is involved in many local groups and organizations. She facilitates the Ka`u Community Partnership which meets monthly to address community needs. This meeting affords the opportunities of partnership groups such as Queen Lili`uokalani Children's Center (QLCC), Tutu and Me, The Boys and Girls Club, Friends of Kahuku Park, Ocean View Community Association, Once Upon a Story, Na'alehu Elementary School, Ka`u Chamber of Commerce, Public Health as well as other community individuals and service providers allowing them to voice their opinions and celebrate successes. Teresa is also a member of the Ka`u Action Team (KAT) which meets monthly to address substance abuse prevention by providing drug free events and initiatives in the community. The members of KAT represent Adult Mental Health, Lokahi Treatment Center, Ka'u High School, Na'alehu Elementary School, Ocean View Community Association, QLCC and partners with Ka'u Ho`olaulea and provide events in the community. As a project community liaison for the K`au Community Development Plan, she stays well informed on not only the immediate needs within the community, but also the direction in which it is headed. Teresa is a trusted and respected person in the community; one that individuals and families know they can go to in order to receive the help they need--be it referrals, linkages or direct services. The family center hopes to introduce two new programs to its scope of services. With the continued support by the County of Hawaii, FSH will be able to fully implement both. The first program would be to bring FSH's Na Makuakane Maika`i 0 Hawaii, Fatherhood Initiative, to Na'alehu. Due to previous funding challenges, this successful program has been unable to reach out to the outlying rural areas of West Hawaii. The partnership with the Ka`u Family Center would provide a venue, staff support and referrals for this program. Group meetings utilizing the curriculum Nurturing Fathers: Developing Attitude and Skills for Male Nurturance enhanced with culturally sensitive activities will be provided on a weekly basis at the family center. Meals and child care would also be provided during this engagement. The second program to be introduced has evolved as a growing need has been assessed. More and more individuals have been using the family center's technology area to write resumes, job search, and take advantage of the computer classes available. A series of classes would be offered on a quarterly basis in which individuals would be directed in all aspects of job searching from pre-employment through new employment. Modules on how to write a resume, find a job, learn interview skills, how to dress for an interview and a newly acquired job, and what to expect while transitioning to a new job would be included. A partnership with Grandma's Closet, a re-sale store NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 13 in Na'alehu, would afford graduates of this initiative the opportunity to "shop" for interview clothes and work clothes at no charge. Families in this remote district of Ka`u face many challenges. Accessing child care, health care, employment, housing, substance abuse counseling, financial assistance, educational resources, and transportation are only some of these challenges. In the last few years, with the sharp decline in the nation's economic condition, Ka`u has taken a particularly hard strike. Families are feeling the financial burdens of simply keeping a roof over their family's heads and food in their children's stomachs. Dealing with this type of stress can lead to substance abuse, crime, and family violence. The family center is essential in the community providing the families in need with linkages and referrals and, thus, preventing detrimental issues. A report from The Hawai'i State Department of Labor and Industrial Relations in November 2011 showed a 9.6% unemployment rate on the Big Island. This percentage is significantly higher than both the state and national averages. Na'alehu School reports that 91.4% of students attending in the 2010-2011 school year qualified for free or reduced meals. The demand for emergency food from the Family Center's pantry has increased significantly in the last year with over five times the amount of individuals receiving food. These disheartening statistics and the lack of services in the southern regions of Hawaii Island support the continued need for services in the Ka'u District. If the funding requested is awarded in full, the center would be staffed at one full time and one quarter time position benefitting the community with additional services to include, but not limited to, facilitating classes in parenting education/family planning, computer literacy education with on-site technical support, career development, financial counseling and cultural exploration. We have recently been awarded funding that will enable the provision of a teleconference link housed at the Ka`u Family Center. There will be additional teleconference hubs located in Kona, Waimea, and Hilo. This will afford community partners an opportunity to schedule and utilize the equipment. Eventually this valuable resource would be made available for the community at large. The center would continue to be a base for other FSH programs, and other service providers and organizations that would also benefit the community. The Ka`u Family Center has proven its worth and established its value to the community by being a consistent point of reference to those who reside there as well as those simply passing through. Our hope for the future is that the center will be available for the community for as long as the need exists. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 13 Family Support Hawaii Ka`u Family Center Total Budget and Position Count Total Program Budget $75,000.00 Total Program Position Count 1.25 FTE Total Agency Budget $3,477,644.00 Total Agency Position Count 77 Program Objectives: 1) Mobilize public and private community resources to help children and families in need. 2) Assist families in achieving economic independence and self-sufficiency. 3) Decrease social isolation in rural communities. 4) Enhance children's development and ability to attain academic and social success. 5) Promote successful transitions throughout a family's major milestones. Program Highlights: (from Fiscal Year 2010-11) 1) Information and referral services were provided to 182 new and 782 returning individuals during the 2010-2011 fiscal year. There were a total of 1196 requests for assistance with items such as emergency food, clothing, shoes and household items---all of which have been provided through donations from community members and groups. 2) Provided technological support to 448 individuals in Ka`u over the year for job search, resume preparation, service coordination, and communication. 3) Received in-kind donations including 74 volunteer hours from community members and numerous donations of goods and funds for distribution to families. 4) Other community helping organizations were able to utilize the Ka`u Family Center to provide 303 hours of outside service to 198 individuals in the community. These organizations included Ohana Conference, Neighborhood Place of Kona, Department of Parks and Recreation, Hawaii Intake Services, Mental Health Kokua Project, ALULIKE, YWCA Sexual Assault Treatment, Substance Assessment and Counseling, and PATCH. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 13 5) The family center housed programs designed to support families at many different stages of development. These include Healthy Start Home Visiting, Enhanced Healthy Start servicing 15 children in the past year; Early Head Start Programs also providing services to 15 children in the past year; Malama Perinatal Program; the Ka`u Child Development Program for infants and toddlers with disabilities and their families; and Early Intervention providing services to 16 Ka`u infants and toddlers with disabilities and their families. These services include physical, occupational, speech and developmental therapies. 6) There were several community-wide family events and activities in which 2711 people participated, including Ka `Ghana 0 Honu'apo Ho`oloaulea where over 500 attended. The FSH booth distributed program information and materials encouraging a drug free community and family activities. 7) Two fundraisers were facilitated by the Family Center Coordinator. The first raised over $600 from the sale of orchids donated by Newman's Orchids of Puna during the Ka`u Family Fun Fest. An annual food drive was also organized and brought in a surplus of rice which was shared with the Ocean View Pantry and a local senior center. The drive raised $1078 in monetary donations. All proceeds benefited the family center's emergency food pantry. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 13 The Ka`u Family Center provides assistance with a comprehensive array of family support programs, services, activities, and referrals. CHILDREN'S HEALTH CHILDREN'S ISSUES • Health and developmental • Play and Learn groups screenings for infants and toddlers • Health, medical and nutritional • Medical Home Support services through Early Head • Evaluations for developmental Start and Malama Perinatal delays programs • Therapeutic services for infants ADULT HEALTH CARE and toddlers with disabilities • Child safety in and out of the • Access to prenatal care home • Access to general medical care • Info on diet, nutrition and health SOCIAL SERVICES DRUG AWARENESS & COUNSELING • Employment opportunities and job seeking support • General information • Information and referral to other • Resource and referral services government and community • Access to mental health services resources • Support Groups • Emergency food, clothing and household items DOMESTIC ISSUES • Ka`u Partnership (Advisory • Parenting education Council) • Financial counseling, planning and management • Housing EDUCATION • After school tutorial programs • Access to GED programs • Reading is FUNdamental early literacy program NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 13 Family Support Hawaii Ka`u Family Center Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Education 34 75 85 Employment 233 75 250 Financial 52 25 60 Health 142 25 150 Parenting Information 39 75 50 Office Equipment/Computer Use 448 _ 450 500 Food 1196 425 1200 Substance Abuse Support/Info 9 75 30 *If applicable Program Expenditures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages $ 9,688.00 $ 30,489.00 $ 45,770.00 Professional Fees $ 0.00 $ 250.00 $ 250.00 Operations $ 95.00 $ 0.00 $ 200.00 Equipment $ 508.00 $ 2,000.00 $ 1,000.00 Other# $ 9,654.00 $ 22,260.00 $ 27,780.00 Total $ 19,945.00 $ 54,999.00 $ 75,000.00 * If applicable #Please explain in detail on separate sheet(see attached) NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 13 Family Support Hawaii Ka`u Family Center Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate County of Hawaii $20,000.00 $55,000.00 $75,000.00 Private Donations/Fundraising $ 1,573.00 $ 3,000.00 $ 3,500.00 Total $21,573.00 $58,000.00 $78,500.00 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The Ka`u Family Center concept is central to the work of providing supportive services to low-income and immigrant families in rural areas. It is expected that FSH will continue to expand its services to better cover the area of Ocean View Estates--a Ka`u community in which many FSH program participants currently live. This includes families from the Marshall Islands who are having severe challenges with finances, health, social service and educational systems. Family support is about investing in the promotion of the positive assets that parents want for their children. In the long term, family support is a societal investment in the creation of happy, healthy, productive citizens. This investment has an impact on the families who participate in services, and on society as a whole. Research shows that by investing in positive outcomes for children and families, family support programs also, over the long term can lead to: • fewer teen pregnancies • less juvenile delinquency • improved behavior and performance of children at school • fewer incidents of child abuse and neglect • more families moving from welfare to work • increased self-confidence, knowledge of child development and parenting skills among parents • greater educational attainment among parents Through these positive outcomes, family support allows our society to invest in the positive development of citizens rather than investing into more prisons, foster homes, and public welfare. This investment has a tremendous effect on NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 13 overall productivity as a society and on the community and, on a greater scale, of the nation. Collaboration has been a key to the success of the family center programs and is recognized as top priority in the continued growth and service of the center. Alliance among numerous agencies, student organizations, local governments, school systems, departments of health and social services, civic and religious organizations provides on-site programs, services, and activities. Representation on local advisory boards, scholarships and financial assistance, volunteers, and in-kind donations such as educational materials, transportation, and center space are also contributions that will continue to support the programs. The continued support from the County of Hawaii, along with the powerful support and donations given by community members, is vital to our continuation of the much needed services provided at the Ka`u Family Center. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Family Support Hawaii is unaware of any affiliations that any of our employees or volunteers may have with the County of Hawaii. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 13 Family Support Hawaii Ka`u Family Center I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 13 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. /Signature Board President/Chair Dat/, or Agency Director // ,) G /( . Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 12 of 13 Family Support Hawaii Ka`u Family Center *Attachment: Other Program Expenditures: FY 2010-11 FY 2011-12 FY 2011-12 Actual * Budget * Estimate Employee Benefits $ 1,777.00 $ 6,475.00 $ 9,612.00 Payroll Taxes $ 1,375.00 $ 4,009.00 $ 5,950.00 Occupancy $ 5,651.00 $ 6,500.00 $ 7,800.00 Supplies $ 828.00 $ 2,500.00 $ 2,168.00 Travel--Mileage $ 23.00 $ 2,526.00 $ 2,000.00 Insurance $ 0.00 $ 250.00 $ 250.00 Total $ 9,654.00 $ 22,260.00 $ 27,780.00 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 13 of 13 22 Food Basket, The East Hawaii Programs The Food Basket,Hawaii Island's Food Bank Agency Director: Nani Lee, Ph.D. Phone No.: (808) 933-6030 Contact Person: Nani Lee,Ph.D. Phone No.: (808) 933-6030 Mailing Address: 140-B Holomua Street, Hilo, HI 96720 Facility/Site Address: 140-B Holomua Street,Hilo, HI 96720 Fax No.: (808) 934-0701 Email Address: nanilee.foodbasketHI@gmail.com Name of Accountant/CPA(include name of firm if applicable): Ann Fukuhara,CPA MBA,An Accountancy Corporation Phone No.: (808) 961-5532 Mailing Address: P. 0.Box 6691,Hilo, HI 96720 You are responsible to keep the above information current. Amount of Request for County Grant-in-aid funds: $ 150,000 East Hawai'i Programs Prior Year Award of County Nonprofit Grants in Aid Funds: 09-10 10-11 11-12 -0- -0- -0- Agency Mission Statement: To feed the hungry on the Island of Hawai'i while attending to the root cause of the social problem. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 -2013 Page 1of11 The Food Basket, Hawaii Island's Food Bank Program Description: The Food Basket's primary program is the acquisition and distribution of food on the Island of Hawai'i. This requires us to secure monetary and food donations and to pick up and deliver food,inspect,warehouse (store non perishable and perishable food [refrigerate/chill &freeze],serve as advocates for the hungry on the Island of Hawai'i, meet all governmental (Federal-USDA&TEFAP) (State-Department of Health) and Feeding America compliance issues, and administer the gathering,distribution and storing of the food product. As our partner agencies involved in our soup kitchen programs do not have the capacity to store frozen and refrigerated foods,The Food Basket must maintain large freezers and a bank of refrigerators for this purpose,incurring not only the cost of electricity but we are constantly seeking freezer space to accommodate frozen food from the USDA/TEFAP programs as well as local donations. Mission and Purpose:The mission of The Food Basket, Inc.is to feed the hungry in Hawai'i County while attending to the root causes of this critical social problem.The Food Basket will accomplish its mission by; (1) preventing the waste of all edible food in Hawai'i County; (2) feeding the hungry with this food; (3) educating the community about local hunger and what can be done to solve this social problem; and (4) collaborating with organizations of partnering missions to eradicate the root of hunger and other social ills: poverty. The Food Basket is an island wide,supplemental food network that collects and distributes nutritious,high quality food to low income households, the working poor,the disabled,the ill, senior citizens,children's programs and other charitable organizations that serve this population. Supplemental food is provided regardless of religious beliefs,gender or ethnicity. The Food Basket is a clearinghouse for food and non-food items that retailers,wholesalers,and farmers would normally discard (reasons for discarding food include surplus product,discontinued product,near pull date product,ripped labeling,off-grade produce),and for food donated by the community through food drives. On a daily basis,Food Basket staff members drive to donor sites to receive these items.All goods are delivered to the warehouses,one in East Hawai'i and one in West Hawai'i,where staff and volunteers weigh the incoming poundage and salvage usable products. Once items are salvaged,they are stocked for distribution to non-profit member agencies.Member agencies then distribute goods directly to the public either by serving meals,providing food boxes, or providing snacks to adults and children in various programs.Agencies include child and adult programs,programs that serve the chronically ill,programs that serve the homeless,abuse shelters, senior living facilities,and substance abuse recovery programs. The Food Basket also receives food NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 -2013 Page 2 of 11 The Food Basket,Hawaii Island's Food Bank from the Hawaii Foodbank on Oahu for a small fee and shipping costs. USDA foods are now being shipped directly to The Food Basket for distribution as well. In July, 2007, Hawaii Island Food Bank operations became a separate 501(c)(3) named The Food Basket,Inc.by island school children. Led by a core founding board of Hawaii Island business leaders,the agency continues its work.The agency as a 501©3 launched as the economy began its decline.This organization faced increasing number of individuals accessing Food Basket programs as unemployment increased and government subsidies decreased. This past year,almost 1.25 million pounds of food were distributed via this network of approved nonprofit member agencies. 70 non-profits are involved in The Food Basket member agency network. The numbers served by program type are as follows: • Partner food pantries served,on the average, 7,960 individuals per month. Taking into account multiple pantry visits per month,it is as if 129,709 individuals were assisted in total over the fiscal year. • Partner soup kitchens served,on the average,6,274 individuals per month (men, women,and children) and served 322,019 meals over the entire fiscal year. • Partner shelters and residential facilities served,on the average,924 individuals per month and served a total of 392,694 meals and snacks over the fiscal year. • *Senior Farmer's Market Nutrition Program -For 15 weeks,from June, 2011 through September 2011,the Food Basket administered the Senior Farmer's Market Nutrition Program (partially funded by the U.S.D.A.) that distributed fresh,locally grown produce weekly to over 1,770 low-income senior citizens. This accounts for approximately 140,000 pounds of fresh,locally grown produce distributed. Distribution sites were located in North and South Kona, Ka'u, North and South Kohala,Hamakua,Puna,and Hilo. • *Senior Brown Bags from October 2010 through May 2011,the Food Basket served 554 low income seniors and from October 2011 through December 2011,the Food Basket increased the number of seniors served to 683. These bags are delivered to rural sites and include: Pahoa,Volcano,Pahala,Na'alehu, Miloli'i,Honaunau, Waimea,Honoka'a,Papa'aloa and Pepe'ekeo. • *"We Got Your Back"(Keiki Backpack Pilot Program at Keaukaha Elementary) seves 252 children who qualify for free and reduced lunch. Member agencies distribute goods directly to the public either by serving meals,providing food boxes,or providing snacks to adults and children in various programs.The largest segment of these agencies provides emergency food pantries to the hungry in their respective communities.Agencies also include those that serve hot meals,child and adult programs,programs that serve the chronically ill,homeless and abuse shelters and substance abuse recovery programs. *These are programs operated directly by The Food Basket with assistance from volunteers in the community, who assist with packing the food at the warehouse and they assist with distribution at the sites once they are delivered by The Food Basket. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 - 2013 Page 3 of 11 The Food Basket,Hawaii Island's Food Bank Equally important to The Food Basket is its educational component.Throughout the years,The Food Basket participates in community forums and presentations to civic groups,schools, businesses and other interested parties about hunger on the island and steps we all can take to help make a difference in the life of someone hungry. A special emphasis is our work with school children empowering them to plan and participate in projects which promote community security. Brochures,poverty data,and other statistical information are distributed at the forums and presentations.Forging partnerships through collaborations and building on community strengths, we believe,will move us closer to eliminating hunger on the Big Island. The Food Basket holds a unique position amongst the Food Banks in the State of Hawaii. We are the only food bank that has two (2)warehouses. This is attributed to the shear size of the Island of Hawaii and the fact that the majority of our island is rural with limited public transportation. Our Hilo warehouse currently has a full-time staff of 3. Our Kona warehouse is staffed with 2 full time staff and 1 part time members. The configuration include two warehouse/drivers in Kona,two warehouse/drivers in Hilo, a dispatcher/office staff and one part-time warehouse helper Kona. Three full time staff serve both warehouses in an administrative capacity: Executive Director, Operations Manager and HR/Compliance/Grants. Three part time employees serve Island wide: accountant,account clerk and office/data clerk. The Director of Agency Relations serves Island wide as a part-time contractor Total Budget and Position Count - Hilo Food Distribution Total Program Budget 485.402 Total Program 3 FT.,3FT-shared Position Count Total Agency Budget 809,003 Total Agency 10 FTE Position Count Program Objectives: 1. Expand food supply and distribution • Increase core food distribution by 10%from 1.2525 million pounds in 2011 to 1.3 million pounds of food in 2012. • Decrease the number of pounds of waste from food collected. • Apply for a$285,000 grant for the Senior Farmers'Market Nutrition Program that would run for approximately 15 weeks,providing a minimum of 1770 low-income seniors Island wide with weekly locally grown,fresh fruits and vegetables. • Apply for a supplemental grant of$10,000 to extend the Senior Farmers' Market Nutrition Program beyond 15 weeks • To evaluate the current"We Got Your Back"supplemental food program (Keaukaha Elementary School serving 216 children on free and reduced lunch) and expand this program by 1 school NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 - 2013 Page 4 of 11 The Food Basket, Hawaii Island's Food Bank 2. Support pp t partner agency development by assisting in building capacity where needed (including equipment,logistics,fund development and management) • Increase the support of partner agencies by increasing site visits and consultations; • Continue the Island wide training for partner agencies with the goal of having partner agencies optimize their resources and meet the Basic Agreement standards for: a. Optimal use of Food Bank's product offerings,etc. b. Food safety,storage,and handling of food c. Quality of service to consumers and accountability and d. Meeting Civil Rights Training 3. Strengthen and manage food bank's community resources by increasing the community's capacity to support the Food Basket through forming coalitions of: a. Corporations b. Civic Organization c. Youth Groups To develop a pool of volunteers to assist in all volunteer opportunities (i.e.training,presentation delivery,warehousing,office/clerical work). NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 -2013 Page 5 of 11 The Food Basket,Hawaii Island's Food Bank Program Highlights: (from Fiscal Year 2010-2011) 1) The Food Basket received 1.5 million pounds of food from 40 corporate and community donors as well as the U.S.D.A.in 2010. 2) The Food Basket stored and distributed 1.25 million pounds of food to 75 partner agencies in 2010. 3) Through its Senior Brown Bag program and emergency food boxes,the Food Basket directly distributed brown bags to approximately 320 low-income seniors per month.In 2010,The Food Basket expanded its delivery sites to include the communities of Volcano and Ocean View. 4) The Food Basket,working with partner food pantries served,on the average, 7,960 individuals per month.Taking into account multiple pantry visits per month,it is as if 129,709 individuals were assisted in total over the fiscal year. 5) Partner soup kitchens served,on the average,6,274 individuals per month (men, women,and children) and served 322,019 meals over the entire fiscal year. 6) Partner shelters and residential facilities served,on the average,924 individuals per month and served a total of 392,694 meals and snacks over the fiscal year. 7) For 15 weeks,from June, 2011 through September 2011,the Food Basket administered the Senior Farmer's Market Nutrition Program (funded by the U.S.D.A.) that distributed fresh,locally grown produce weekly to over 1,770 low-income senior citizens. This accounts for approximately 140,000 pounds of fresh,locally grown produce distributed. Distribution sites were located in North and South Kona,Ka'u, North and South Kohala, Hamakua,Puna,and Hilo. 8) Senior Brown Bags from October 2010 through May 2011,the Food Basket served 554 low income seniors and from October 2011 through December 2011,the Food Basket increased the number of seniors served to 683. These bags are delivered to rural sites and include: Pahoa,Volcano,Pahala,Na'alehu,Miloli i,Honaunau,Waimea,Honoka'a,Papa'aloa and Pepe'ekeo. 9) "We Got Your Back" (Keiki Backpack Pilot Program at Keaukaha Elementary) seves 252 children who qualify for free and reduced lunch. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 6 of 11 The Food Basket, Hawaii Island's Food Bank Performance Measures: 2010 2011 2012 Actual Budget Estimate Increase core food distribution to the hungry and food insecure individuals and families in the county by 10% 1.2 lbs of 1.25 lbs of 1.3 lbs of food food food Increase the number of weeks that low-income seniors receive fresh produce through the USDA fresh produce 1,670 1,770 1,790 program (extend from 15 weeks to at least 17 weeks) Reduce the number of children at-risk of hunger with nutritious, easy-to-prepare food through a backpack 252 350 program Decrease"pig waste" 8.35% 7.97% 6% Increase the number of agency partners participating in 77% 95% 98% training Increase the community's capacity to support the Food Basket through the formation of coalitions in the area of: 2% 15% corporations,civic,member organizations and youth groups Program Expenditures: 2010 2011 2012 Actual Budget Estimate Salaries, Wages, 365,369 234,591 282,256 Benefits&Taxes Professional Fees 15,159 19,139 18,000 Operations 189,652 241,538 169,157 Equipment 18,308 13,101 15,989 Other Total 528,757 508,369 485,402 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012- 2013 Page 7 of 11 The Food Basket,Hawaii Island's Food Bank Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source 2010 2011 2012 (Actual) (Budget) (Estimate) Contributed Income 399,231 443,772 469,200 Donations,government contracts Trusts&Foundations Program Services Revenue 106,149 60,478 41,765 Interest Income 6,991 2,804 3,358 Other 16,831 1,158 Cost of Goods Sold 900 Total Income 507,574 524,784 515,481 Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The Food Basket conducts various fund-raising campaigns and food drives throughout the year and supports food drives/fundraisers conducted by various businesses and community groups. The Food Basket also continuously submits grant proposals to public and private funding sources for assistance. The Food Basket continues to work to increase the capacity of the community to support THE ONLY Food Bank on the Island of Hawai'i. To this end,the Board of Directors and staff will continue to work toward building coalitions amongst the businesses and corporations on the Island to support the Food Basket. The Food Basket fund-raising activities include or will include the following: 1. Mail solicitation-The Food Basket has used,and will continue to use, direct mail solicitations to raise funds.The Corporation plans to distribute five direct mail solicitations during the annual campaign year,the first will be mailed in the summer and the second will be mailed in the fall.The goals of the direct mail program is to (i) increase community awareness of the Corporation's name,mission and services; (ii) increase awareness and educate the community regarding hunger problems on the Island of Hawaii;and (iii)attract new donors,volunteers and other supporters of the Corporation. 2. Personal solicitations-The Food Basket utilizes personal solicitations for donations in excess of$1,000,000,which are classified as major gifts.Volunteers are trained to conduct face-to-face meetings to solicit mature donors and special prospects to the organization. Personal solicitations are not utilized as a means to contact the general public. 3. Foundation grant solicitations-The Food Basket currently applies for grants from private foundations that are located in the State of Hawaii. 4. Donations via website-The Food Basket's website is designed to receive contributions from donors. Contributions made through the website are processed as credit card transactions. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 - 2013 Page 8 of 11 The Food Basket, Hawaii Island's Food Bank 5. Government grant solicitations-The Food Basket currently applies for county,state,and federal grants on an annual basis and will continue to apply for government grants in the future. 6. Other • Fundraising events-in the past,The Food Basket has conducted food drives where both monetary and food donations were received.In addition,the Corporation has organized golf tournament fundraising dinners,and donation events at supermarkets. • Gifts-The Food Basket receives unsolicited monetary donations from individuals, corporations and other organizations in the community on a regular basis. • Annual development plan-The Board of Directors is working on an Annual Development Plan for fundraising purposes.This is a comprehensive plan for developing the Corporation's major gift program,developing an in-kind giving program,establishing gift acceptance and donor recognition policies,recruiting staff for fund development and public relations functions,creating a gift tracking system and other fundraising plans. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawai'i. Not applicable. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 - 2013 Page 9 of 11 The Food Basket,Hawaii Island's Food Bank I (we)have read and understood all of the eligibility requirements;grant conditions; award procedures; and records,reporting and fiscal accountability requirements as mandated in Article 25,Sections 2-135 = 2-142.2,Hawai'i County Code,relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we)understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not b e reviewed by County personnel accepting our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the county of Hawai'I.I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after lune 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant,a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely. complete and accurate year-end report will impact the evaluation ofyour program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 - 2013 Page 10 of 11 The Food Basket,Hawaii Island's Food Bank Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understand these requirements. Signature of Board President/hair or Date Agency Director dee- 4,.h.! 013o-1.2.S' nature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 11 of 11 23 Food Basket, The West Hawaii Programs The Food Basket Inc.,Hawaii Island's Food Bank Agency Director: Nani Lee,Ph.D. Phone No.: (808) 322-1418 Contact Person: Nani Lee,Ph.D. Phone No.: (808) 322-1418 Mailing Address: 79-1016A East Honalo Road,Kailua-Kona,HI 96740 Facility/Site Address: 79-1016A East Honalo Road,Kailua-Kona, HI 96740 Fax No.: (808) 322-7373 Email Address: nanilee.foodbasketHI@gmail.com Name of Accountant/CPA(include name of firm if applicable): Ann Fukuhara,CPA MBA,An Accountancy Corporation Phone No.: (808) 961-5532 Mailing Address: P. 0. Box 6691,Hilo,HI 96720 You are responsible to keep the above information current. Amount of Request for County Grant-in-aid funds: $ 100,00 'West Hawaii Program Prior Year Award of County Nonprofit Grants in Aid Funds: 09-10 10-11 11-12 -0- -0- -0- Agency Mission Statement: To feed the hungry on the Island of Hawaii while attending to the root cause of the social problem. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 1of11 The Food Basket Inc.,Hawaii Island's Food Bank Program Description: The Food Basket's primary program is the acquisition and distribution of food on the Island of Hawai'i. This requires us to secure monetary and food donations and to pick up and deliver food,inspect,warehouse (store non perishable and perishable food [refrigerate/chill &freeze],serve as advocates for the hungry on the Island of Hawai'i,meet all governmental (Federal-USDA&TEFAP) (State-Department of Health) and Feeding America compliance issues, and administer the gathering,distribution and storing of the food product. As our partner agencies involved in our soup kitchen programs do not have the capacity to store frozen and refrigerated foods,The Food Basket must maintain large freezers and a bank of refrigerators for this purpose,incurring not only the cost of electricity but we are constantly seeking freezer space to accommodate frozen food from the USDA/TEFAP programs as well as local donations. Mission and Purpose:The mission of The Food Basket is to feed the hungry in Hawai'i County while attending to the root causes of this critical social problem.The Food Basket will accomplish its mission by; (1) preventing the waste of all edible food in Hawai'i County; (2) feeding the hungry with this food; (3) educating the community about local hunger and what can be done to solve this social problem; and (4) collaborating with organizations of partnering missions to eradicate the root of hunger and other social ills:poverty. The Food Basket is an island wide,supplemental food network that collects and distributes nutritious,high quality food to low income households, the working poor,the disabled,the ill, senior citizens,children's programs and other charitable organizations that serve this population. Supplemental food is provided regardless of religious beliefs,gender or ethnicity. The Food Basket is a clearinghouse for food and non-food items that retailers,wholesalers,and farmers would normally discard (reasons for discarding food include surplus product,discontinued product,near pull date product,ripped labeling,off-grade produce), and for food donated by the community through food drives.On a daily basis,Food Basket staff members drive to donor sites to receive these items.All goods are delivered to the warehouses,one in East Hawai'i and one in West Hawai'i,where staff and volunteers weigh the incoming poundage and salvage usable products. Once items are salvaged,they are stocked for distribution to non-profit member agencies.Member agencies then distribute goods directly to the public either by serving meals,providing food boxes, or providing snacks to adults and children in various programs.Agencies include child and adult programs,programs that serve the chronically ill,programs that serve the homeless,abuse shelters, senior living facilities,and substance abuse recovery programs. The Food Basket,Inc.also receives NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 - 2013 Page 2 of 11 The Food Basket Inc.,Hawaii Island's Food Bank food from the Hawaii Foodbank on Oahu for a small fee and shipping costs. USDA foods are now being shipped directly to The Food Basket for distribution as well. In July, 2007,Hawaii Island Food Bank operations became a separate 501(c)(3) named The Food Basket,Inc.by island school children.Led by a core founding board of Hawaii Island business leaders,the agency continues its work.The agency as a 501©3 launched as the economy began its decline.This organization faced increasing number of individuals accessing Food Basket programs as unemployment increased and government subsidies decreased. This past year,almost 1.25 million pounds of food were distributed via this network of approved nonprofit member agencies. 70 non-profits are involved in The Food Basket member agency network. The numbers served by program type are as follows: • Partner food pantries served,on the average, 7,960 individuals per month. Taking into account multiple pantry visits per month,it is as if 129,709 individuals were assisted in total over the fiscal year. • Partner soup kitchens served,on the average,6,274 individuals per month (men, women,and children) and served 322,019 meals over the entire fiscal year. • Partner shelters and residential facilities served,on the average,924 individuals per month and served a total of 392,694 meals and snacks over the fiscal year. • *Senior Farmer's Market Nutrition Program-For 15 weeks,from June,2011 through September 2011,the Food Basket administered the Senior Farmer's Market Nutrition Program jvartially funded by the U.S.D.A.) that distributed fresh,locally grown produce weekly to over 1,770 low-income senior citizens. This accounts for approximately 140,000 pounds of fresh,locally grown produce distributed. Distribution sites were located in North and South Kona, Ka'u, North and South Kohala,Hamakua,Puna,and Hilo. • *Senior Brown Bags from October 2010 through May 2011,the Food Basket served 554 low income seniors and from October 2011 through December 2011,the Food Basket increased the number of seniors served to 683. These bags are delivered to rural sites and include: Pahoa,Volcano,Pahala,Na'alehu, Miloli i,Honaunau, Waimea, Honoka'a,Papa'aloa and Pepe'ekeo. • *"We Got Your Back"(Keiki Backpack Pilot Program at Keaukaha Elementary) seves 252 children who qualify for free and reduced lunch. Member agencies distribute goods directly to the public either by serving meals,providing food boxes,or providing snacks to adults and children in various programs.The largest segment of these agencies provides emergency food pantries to the hungry in their respective communities.Agencies also include those that serve hot meals,child and adult programs,programs that serve the chronically ill,homeless and abuse shelters and substance abuse recovery programs. *These are programs operated directly by The Food Basket with assistance from volunteers in the community,who assist with packing the food at the warehouse and they assist with distribution at the sites once they are delivered by The Food Basket. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 - 2013 Page 3 of 11 The Food Basket Inc.,Hawaii Island's Food Bank Equally important to The Food Basket is its educational component.Throughout the years,The Food Basket participates in community forums and presentations to civic groups,schools, businesses and other interested parties about hunger on the island and steps we all can take to help make a difference in the life of someone hungry. A special emphasis is our work with school children empowering them to plan and participate in projects which promote community security. Brochures,poverty data,and other statistical information are distributed at the forums and presentations.Forging partnerships through collaborations and building on community strengths, we believe,will move us closer to eliminating hunger on the Big Island. The Food Basket holds a unique position amongst the Food Banks in the State of Hawai'i. We are the only food bank that has two (2)warehouses. This is attributed to the shear size of the Island of Hawai'i and the fact that the majority of our island is rural with limited public transportation. Our Hilo warehouse currently has a full-time staff of 3. Our Kona warehouse is staffed with 2 full time staff and 1 part time members. The configuration include two warehouse/drivers in Kona,two warehouse/drivers in Hilo, a dispatcher/office staff and one part-time warehouse helper Kona. Three full time staff serve both warehouses in an administrative capacity: Executive Director, Operations Manager and HR/Compliance/Grants. Three part time employees serve Island wide: accountant,account clerk and office/data clerk. The Director of Agency Relations serves Island wide as a part-time contractor Total Budget and Position Count - West Hawai'i Food Distribution Total Program Budget 323,601 Total Program 2.5 FTE.,3FTE- Position Count shared with East Hawai Total Agency Budget 809,003 Total Agency 10 FTE Position Count Program Objectives: 1. Expand food supply and distribution • Increase core food distribution by 10%from 1.2525 million pounds in 2011 to 1.3 million pounds of food in 2012. • Decrease the number of pounds of waste from food collected. • Apply for a$285,000 grant for the Senior Farmers'Market Nutrition Program that would run for approximately 15 weeks,providing a minimum of 1770 low-income seniors Island wide with weekly locally grown,fresh fruits and vegetables. • Apply for a supplemental grant of$10,000 to extend the Senior Farmers'Market Nutrition Program beyond 15 weeks • To evaluate the current"We Got Your Back"supplemental food program (Keaukaha Elementary School serving 216 children on free and reduced lunch) and expand this program by 1 school NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 -2013 Page 4 of 11 The Food Basket Inc.,Hawaii Island's Food Bank 2. Support partner agency development by assisting in building capacity where needed (including equipment,logistics,fund development and management) • Increase the support of partner agencies by increasing site visits and consultations; • Continue the Island wide training for partner agencies with the goal of having partner agencies optimize their resources and meet the Basic Agreement standards for: a. Optimal use of Food Bank's product offerings,etc. b. Food safety,storage,and handling of food c. Quality of service to consumers and accountability and d. Meeting Civil Rights Training 3. Strengthen and manage food bank's community resources by increasing the community's capacity to support the Food Basket through forming coalitions of: a. Corporations b. Civic Organization c. Youth Groups To develop a pool of volunteers to assist in all volunteer opportunities (i.e.training,presentation delivery,warehousing,office/clerical work). NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 -2013 Page 5 of 11 The Food Basket Inc.,Hawaii Island's Food Bank Program Highlights: (from Fiscal Year 2010-2011) 1) The Food Basket received 1.5 million pounds of food from 40 corporate and community donors as well as the U.S.D.A.in 2010. 2) The Food Basket stored and distributed 1.25 million pounds of food to 75 partner agencies in 2010. 3) Through its Senior Brown Bag program and emergency food boxes,the Food Basket directly distributed brown bags to approximately 320 low-income seniors per month.In 2010,The Food Basket expanded its delivery sites to include the communities of Volcano and Ocean View. 4) The Food Basket,working with partner food pantries served,on the average, 7,960 individuals per month.Taking into account multiple pantry visits per month,it is as if 129,709 individuals were assisted in total over the fiscal year. 5) Partner soup kitchens served,on the average, 6,274 individuals per month (men, women,and children) and served 322,019 meals over the entire fiscal year. 6) Partner shelters and residential facilities served,on the average,924 individuals per month and served a total of 392,694 meals and snacks over the fiscal year. 7) For 15 weeks,from June,2011 through September 2011,the Food Basket administered the Senior Farmer's Market Nutrition Program (funded by the U.S.D.A.) that distributed fresh,locally grown produce weekly to over 1,770 low-income senior citizens. This accounts for approximately 140,000 pounds of fresh,locally grown produce distributed. Distribution sites were located in North and South Kona,Ka'u,North and South Kohala, Hamakua, Puna,and Hilo. 8) Senior Brown Bags from October 2010 through May 2011,the Food Basket served 554 low income seniors and from October 2011 through December 2011,the Food Basket increased the number of seniors served to 683. These bags are delivered to rural sites and include: Pahoa,Volcano,Pahala,Na'alehu,Miloli'i,Honaunau,Waimea, Honoka'a,Papa'aloa and Pepe'ekeo. 9) "We Got Your Back" (Keiki Backpack Pilot Program at Keaukaha Elementary)seves 252 children who qualify for free and reduced lunch. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 -2013 Page 6 of 11 The Food Basket Inc., Hawaii Island's Food Bank Performance Measures: 2010 2011 2012 Actual Budget Estimate Increase core food distribution to the hungry and food insecure individuals and families in the county by 10% 1.2 lbs of 1.25 lbs of 1.3 lbs of food food food Increase the number of weeks that low-income seniors receive fresh produce through the USDA fresh produce 1,670 1,770 1,790 program (extend from 15 weeks to at least 17 weeks) Reduce the number of children at-risk of hunger with nutritious,easy-to-prepare food through a backpack 252 350 program Decrease"pig waste" 8.35% 7.97% 6% Increase the number of agency partners participating in 77% 95% 98% training Increase the community's capacity to support the Food Basket through the formation of coalitions in the area of: 2% 15% corporations,civic,member organizations and youth groups Program Expenditures: 2010 2011 2012 Actual Budget Estimate Salaries, Wages, 203,759 156,394 188,170 Benefits&Taxes Professional Fees 10,106 12,760 12,000 Operations 126,434 161,025 112,772 Equipment 12,205 8,734 10,569 Other Total 352,505 338,913 323,601 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 - 2013 Page 7 of 11 The Food Basket Inc.,Hawaii Island's Food Bank Program Funding Sources: Identify all funding sources(specific to this program only) Revenue Source 2010 2011 2012 (Actual) (Budget) (Estimate) Contributed Income 264,820 295,848 296,461 Donations,Government Contracts& Support,Trusts&Foundations Interest Income 2,796 1,869 2,238 Program Service Fees 70,766 40,319 27,834 Special Events 12,000 Other Income 11,221 4,339 Cost of Goods Sold 600 772 Total 338,383 349,856 343,664 Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The Food Basket conducts various fund-raising campaigns and food drives throughout the year and supports food drives/fundraisers conducted by various businesses and community groups. The Food Basket also continuously submits grant proposals to public and private funding sources for assistance. The Food Basket continues to work to increase the capacity of the community to support THE ONLY Food Bank on the Island of Hawai'i. To this end,the Board of Directors and staff will continue to work toward building coalitions amongst the businesses and corporations on the Island to support the Food Basket. The Food Basket fund-raising activities include or will include the following: 1. Mail solicitation-The Food Basket has used,and will continue to use,direct mail • solicitations to raise funds.The Corporation plans to distribute five direct mail solicitations during the annual campaign year,the first will be mailed in the summer and the second will be mailed in the fall.The goals of the direct mail program is to (i) increase community awareness of the Corporation's name,mission and services; (ii) increase awareness and educate the community regarding hunger problems on the Island of Hawaii;and (iii) attract new donors,volunteers and other supporters of the Corporation. 2. Personal solicitations-The Food Basket utilizes personal solicitations for donations in excess of$1,000,000,which are classified as major gifts.Volunteers are trained to conduct face-to-face meetings to solicit mature donors and special prospects to the organization. Personal solicitations are not utilized as a means to contact the general public. 3. Foundation grant solicitations-The Food Basket currently applies for grants from private foundations that are located in the State of Hawaii. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 -2013 Page 8 of 11 The Food Basket Inc.,Hawaii Island's Food Bank 4. Donations via website-The Food Basket's website is designed to receive contributions from donors. Contributions made through the website are processed as credit card transactions. 5. Government grant solicitations-The Food Basket currently applies for county,state,and federal grants on an annual basis and will continue to apply for government grants in the future. 6. Other • Fundraising events-in the past,The Food Basket has conducted food drives where both monetary and food donations were received.In addition,the Corporation has organized golf tournament fundraising dinners,and donation events at supermarkets. • Gifts-The Food Basket receives unsolicited monetary donations from individuals, corporations and other organizations in the community on a regular basis. • Annual development plan-The Board of Directors is working on an Annual Development Plan for fundraising purposes.This is a comprehensive plan for developing the Corporation's major gift program, developing an in-kind giving program,establishing gift acceptance and donor recognition policies,recruiting staff for fund development and public relations functions, creating a gift tracking system and other fundraising plans. Please disclose (list here)any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Not applicable. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 -2013 Page 9 of 11 The Food Basket Inc.,Hawaii Island's Food Bank I (we)have read and understood all of the eligibility requirements; grant conditions;award procedures;and records,reporting and fiscal accountability requirements as mandated in Article 25,Sections 2-135 = 2-142.2, Hawai'i County Code,relating to Appropriation of Funds to Nonprofit Organizations. I (we)hereby certify that information supplied herein including all supporting documents is correct and that I (we)have the authority and ability to fully administer the program(s)pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we)understand that applications will not b e reviewed by County personnel accepting our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the county of Hawai I.I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant,a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely,complete and accurate year-end report will impact the evaluation ofyour program's or agency's future funding requests. I (we)understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 -2013 Page 10 of 11 The Food Basket Inc.,Hawaii Island's Food Bank Any funds unused by June 30, 2013 must be returned to the County of Hawai'i within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below,you are acknowledging that you have read and understand these requirements. January 30. 2012 Signature of Board President/Chair or Date Agency Director ,�. 1L4.444/ Gteu Sign ure of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012 -2013 Page 11 of 11 24 Friends of Big Island Drug Court Assistance to Drug Court Clients & Program Friends of Big Island Drug Court- Agency Name Assistance to Drug Court Clients & Program- Program Name Agency Director: None Phone No.: N/A Contact Person: Carol VanCamp, President Phone No.: (808) 938-0828 Mailing Address: PO Box 6100, Hilo, HI 96720 Facility/Site Address: None Fax No.: 969-1499 Email Address: cvancamp3 @hawaii.rr.com Name of Accountant/CPA (include name of firm if applicable): Brian Iwata, CPA, Taketa, Iwata, Hara & Assoc., LLC Phone No.: (808) 935-5404 Mailing Address: 101 Aupuni St., Suite 139, Hilo, HI 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $10,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $10,000 $10,000 $8,000 Agency Mission Statement: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 8 The Mission of the Big Island Drug Court is to help address societal problems related to substance abuse in order to minimize their societal and economic costs, and to protect the Big Island community by providing timely and effective treatment for drug offenders with appropriate sanctions and incentives. Simply stated, the "Friends of Big Island Drug Court" is a 501©3 organizations created to provide financial and other support for Drug Court clients and the overall program. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 8 Friends of Big Island Drug Court - Agency Name Assistance to Drug Court Clients & Program- Program Name Program Description: The Friends of Big Island Drug Court provides funding and other support for the clients and programs of Big Island Drug Court. This includes rewards and incentives to clients during their drug-free journey (such as gift certificates, movie tickets, etc.), loans or awards for tuition to further their education, and loans or awards for housing, travel or other such needs. The Friends also sponsors graduation supplies for Drug Court clients, and responds to individual requests for support. They also support alumni and support group activities to help ensure long-term success for clients. All programs and activities are conducted by volunteers, as there are no paid employees. The organization is governed by a volunteer board of directors, representing a cross-section of individuals from the community. Total Budget and Position Count Total Program Budget $11,500 Total Program Position Count 0 Total Agency Budget $14,000 Total Agency Position Count 0 Program Objectives: 1) The Friends is designed to integrate community/private support into governmental efforts directed at the rehabilitation of adult men and women and juveniles, who are charged with or convicted of non-violent felonies and assessed as chemically dependent on alcohol and/or other drugs, by securing financial support for governmental efforts to operate Big Island Drug Court in the Third Circuit. Program Highlights: (from Fiscal Year 2010-11) 1) Through private donations and fundraising and county non-profit grant assistance, we have been able to provide financial rewards and incentives to motivate Drug Court clients and also to provide awards and loans for tuition, housing, or various other needs of Drug Court clients. The specific NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 8 goal is to assist in ways that government cannot to help clients successfully complete the Drug Court program and return to society as contributing citizens The cost and benefits to society to rehabilitate these individuals is far less than incarceration, and it also helps to rebuild entire families when a loved one is returned to them as a functional law-abiding citizen.. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 8 Friends of Big Island Drug Court - Agency Name Assistance to Drug Court Clients & Program - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Fund Balance as of 12-31-10 $17,828,64 $14,000 $14,000 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 0 0 0 Professional Fees 0 0 0 Operations 2,723 2,275 2.725 Equipment Other# 7,277 7,275 7,275 Total $10,000 $10,000 $10,000 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 8 AGENCY/ORGANIZATION: FRIENDS OF THE BIG ISLAND DRUG COURT PROJECT NAME: FRIENDS OF THE BIG ISLAND DRUG COURT Page 5, Program Expenditures Details FY 2010-11 FY 2011-12 FY 2012-13 Operations Expenditures: Actual Budget Budnet Occupancy- Rent; Utilities; PO Box rental $ 176.00 $ 180.00 $ 180.00 Insurance-General Liability; NDOA Board Insurance 1,815.10 1,815.00 1,815.00 Office, printing, postage, etc. 732.20 730.00 730.00 TOTAL - Operations Expenditures $ 2,723.30 $ 2,725.00 $ 2,725.00 Other Program Expenditures: Loans to Clients $ 2,037.50 $ 2,200.00 $ 2,200.00 Drug Court Incentives 2,257.73 2,200.00 2,200.00 Drug Court Graduation Expenses 802.38 700.00 700.00 Drug Court Graduation Gifts to Grads 275.00 250.00 250.00 Grants to Drug Court Participants 1,492.99 1,500.00 1,500.00 Drug Court Month Expenses 411.10 425.00 425.00 TOTAL - Other Program Expenditures s $ 7,276.70 $ 7,275.00 $ 7,275.00 County of Hawaii- NONPROFIT GRANT APPLICATION-FY 2012-13 Friends of Big Island Drug Court - Agency Name Assistance to Drug Court Clients & Program - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate County of Hawaii $10,000 $8,000 $10,000 Total $10,000 $8,000 $10,000 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? We plan to solicit donations from the general public, and those associated with the Drug Court program - i.e., attorneys, medical care professionals, etc. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. None NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 8 Friends of Big Island Drug Court - Agency Name Assistance to Drug Court Clients & Program - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 8 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. &k,a., - ( P7 6 y /-30 -/a--- Signature of Board President/Chair Date or Agency Director Signature of - - - : - - : Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 8 25 Friends of Kona Community Aquatic Center Wam Water for Kona Community Aquatic Center Friends of Kona Community Aquatic Center- Agency Name Warm water for Kona Community Aquatic Center- Program Name Agency Director: Janice Beeson Phone No.: 808- 325-7865 Contact Person: Janice Beeson Phone No.: 808- 325-7865 Mailing Address: P.O. Box 1693 Kailua Kona HI 96745 Facility/Site Address: None Fax No.: None Email Address: jdbeeson @hawaii.rr.com Name of Accountant/CPA (include name of firm if applicable): Ann Finney-Treasurer Phone No.: 808-322-1460 Mailing Address: 77-158 Koa Koa Street You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$70,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $00000 $00000 $00000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 9 Agency Mission Statement: The mission of Friends of Kona Community Aquatic Center is to bring solar hot water to Kona Community Aquatic Center. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 9 Friends of Kona Community Aquatic Center - Agency Name Warm water for Kona Community,Aquatic Center- Program Name Program Description: Friends of Kona Community Aquatic Center is requesting funding for installation of solar panels to provide hot water for showers year round. Solar is a clean renewable energy that would replace the currant system now in use. We Have researched sources located on Hawaii Island and have had two courtesy bids to establish an estimate for our program. When funds would be made available our organization would hire a contractor to install 22 solar panels on the south facing roof of the mechanical building. The 22 solar panels will provide 1962 gallons of hot water per day based on an average of 600 users or 392 showers using a base of 5 gallons of hot water per user. The existing propane heater would be used as a backup if more hot water is needed. Our program is a much needed upgrade that would benefit the swimming pool, gymnasium, tennis courts, basketball courts and sports fields that all use the shower facilities. Total Budget and Position Count Total Program Budget $1528 Total Program Position Count 0 Total Agency Budget 0 Total Agency Position Count 0 Program Objectives: 1) Determine final project budget by 16 July 2012. 2) Develop final project plan and solar hot water system size by 20 July 2012. 3) Secure final quote for system installation by 10 August 20. 4) Hire contractor for installation by 17 August 2012. 5) Install the solar hot water system by 04 May 2013. 6) Attend a final inspection of the solar installation by Hawaii County by 18 May 2013. 7) Conduct a ribbon-cutting ceremony and secure press coverage for project at Kona Community Aquatic Center 25 May 2013. 8) Maintain a accurate accounting of grant funds expended and return unspent funds by 14 June 2013. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 9 Program Highlights: (from Fiscal Year 2010-11) 1) Determined the lack of hot water for showers at Kona Community Aquatic Center in March 2011. 2) Classified as a business on 01 April 2011 through the State of Hawaii Department of Taxation for Friends of Kona Community Aquatic Center. 3) Recognized as a Friend of the Park with the Department of Parks & Recreation of Hawaii County on 08 April 2011. 4) Established Friends of Kona Community Aquatic Center as a nonprofit corporation on 26 May 2011. 5) Created bylaws for Friends of Kona Community Aquatic Center, 08 July 2011. 6) Applied for Friends of Kona Community Aquatic Center nonprofit charity 501(c)(3) status with the IRS on 22 July 2011. 7) Approved by the IRS as a nonprofit charity 501(c)(3) for Friends of Kona Community Aquatic Center on 27 September 2011. 8) Accepted donations for solar hot water for Kona Community Aquatic Center on 01 October 2011. 9) Selected for exemption from general excise tax from State of Hawaii Department of Taxation for donations and grants on 07 November 2011. 10) Interviewed by West Hawaii Today about our solar project for Kona Community Aquatic Center on 21 November 2011. 11) NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 9 Friends of Kona Community Aquatic Center - Agency Name Warm water for Kona Community Aquatic Center - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Cost savings on propane per month $1660.00 Cost savings on propane per year $19,920.00 Return on Investment 3.5 years • *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 0 Professional Fees $300.00 Operations $100.00 Equipment $70,000.00 Other' Total $70,400.00 *If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 9 Friends of Kona Community Aquatic Center - Agency Name Warm water for Kona Community Aquatic Center - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Public Donations $1528 $5000 Business Donations $2500 Hawaii County Grant $70,000 Hawaii State Grant $25,000 Federal Grant $25,000 HEI Grant $25,000 Bill Healy Foundation $25,000 Change Happens $18,000 Total $1528 $195,500 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Once completed the solar hot water system will become a part of Kona Community Aquatic Center which is under the management of Hawaii County Parks & Recreation Department. All warranty certificates will be issued to Hawaii County by the contractor and manufacturer. When warranty expires it will be the responsibility of the Hawaii County Parks & Recreation to provide any future maintaince to the hot water solar system. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 9 None NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 9 Friends of Kona Community Aquatic Center - Agency Name Warm water for Kona CommunityAquatic Center - Program Name (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii. I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 9 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within.30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Ali/IA /few. /- 0V- /A Sig ature of Board President/Chair Date or A gency Director att- _ALA& - - 2- Signature of Executive Direc or Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 9 26 Friends of the Children's Justice Center of East Hawaii Special Needs & Enhancement, Center Support, Prevention/Education & Training © Qpy Friends fo the Childrens Justice Center of East Hawaii - Agency Name Special Needs & Enhancement, Center Support, Prevention/Education & Training Programs- Program Name Agency Director: Stan Golembeski , Board President Phone No.: 935-8755 Contact Person: Robin Benedict , Program Coordinator Phone No.: 935-8755 Mailing Address: P.O. Box 6908 Hilo, HI 96720 Facility/Site Address: 1290 Kinoole Street Hilo, HI 96720 Fax No.: (808) 933-0968 Email Address: fcjceh @hawaii.rr.com Name of Accountant/CPA (include name of firm if applicable): Jennifer L. Gossert/ (Jennifer Gossert, CPA) Phone No.: (808) 969-3115 Mailing Address: 688 Kinoole Street, Suite 201, Hilo, Hawaii 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $25,000.00 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $10,000.00 $10,000.00 $15,000.00 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1of11 Agency Mission Statement: The mission of the Friends of the Children's Justice Center of East Hawaii is to help sexually, physically, emotionally abused and neglected children, and children who are witnesses to crime, in partnership with the Children's Justice Center of East Hawaii. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 11 Friends of the Children's Justice Center of East Hawaii - Agency Name Special Needs & Enhancement, Center Support, Prevention/Education & Training Programs- Program Name Program Description: Founded in 1990, the Friends of the Children's Justice Center, also known as the "Friends", is a private nonprofit organization, with the primary goal of enhancing and protecting the physical and psychological well being of abused and neglected children. The Friends work in partnership with the Children's Justice Center (CJC), a State of Hawaii Judiciary Program. The CJC provides a safe, neutral homelike atmosphere, where children can be interviewed regarding allegations of abuse, particularly sexual abuse. This Children's Justice Center facilitates and coordinates the system's response to victims of child abuse, to reduce their trauma, through a multi-disciplinary team approach, which involves police, social workers, prosecutors, guardians ad litem, medical professionals, advocates, and others. The Friends support the CJC primarily by helping to provide resources for direct services and programs, for child victims and their families, which are not available through any other public or private source. The Friends accept requests for funding from State and private agencies working with child abuse victims, such as Child Protective Services, Child and Family Services, Hawaii Behavioral Health, Catholic Charities, Parents Inc., and other agencies. The Friends serve children between the ages of 0-18, who are victims of abuse (sexual, physical, emotional, mental abuse or neglect, or are witnesses to crime) residing in East Hawaii. This includes North Hilo, South Hilo, Hamakua, Puna and parts of Ka'u. We serve children with active or documented cases of abuse and neglect. The Special Needs and Enhancement Program is designed to help child victims develop positive self-worth. The Friends provide resources for needs that are not covered by any other public or private source. Funds are used to provide basic essentials (i.e. clothing, diapers, toiletries), special needs (i.e. air/ground transportation, school supplies, correspondence courses) and enhancement support (i.e. sports, music lessons, and tutoring). The Friends also have a holiday gift program for children not covered by other programs. The Friends of the Children's Justice Center of East Hawaii utilize an Outcome Measurement tool to evaluate the impact of the program and to solicit feedback from our fund recipients, their foster parents/families and referring professionals, NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 11 to find out how funding impacted the children. Some category choices on our Evaluation Tool include: Improving Family/Guardian Relationships; Improving Peer Relations; Relieving Family Stress; Impacting Social Behavior; Impacting School Behavior; School/Academic Performance; Enhancing Self Esteem and Self Confidence; Impacting Physical or Mental Health; or Helping to Cope with a Crisis. In FY 2010-11 , 720 SNR requests were processed by the FCJCEH, 426 Evaluation Forms were completed and returned (approximately 59% overall return rate). The most widely selected categories included: Improving the Child's Self Esteem and Self Confidence (this category was the number one choice in 10 of twelve months); and Reducing Family Stress (this category was the number one choice in two of twelve months, and the second most selected in 5 of twelve months). Center Support: The Friends provide resources to help reduce trauma and ensure the safety and comfort of the children that come to the Children's Justice Center for interviews. The Friends maintain the Center's safe, child-friendly and homelike atmosphere with toys, games and snacks. The community supports our efforts with donations of clothing, for our clothes closet, and stuffed animals. The Friends also help maintain the Center's appearance with repairs and refurbishing when needed. The Prevention and Education Program is designed to educate the community regarding child abuse issues. This program plans events for the public, promoting awareness and prevention of child abuse. The Training Program helps to sponsor the attendance of various professionals (i.e. social workers, police & therapists) at seminars and conferences to learn state-of-the-art interviewing techniques and refine their overall skills. These professionals work with child victims and their families. Training opportunities enhance the quality of services and prevents victims from being re-traumatized by possible difficiencies in the system's response to the allegations of abuse. Total Budget and Position Count Total Program Budget 201275 Total Program Position Count 1 Total Agency Budget 179275 Total Agency Position Count 1 Program Objectives: 1) Provide funds for clothing, toiletries, bed/mattress and other necessities for children in emergency or relative foster placement. 2) Provide funds for tutoring, correspondence courses or summer school to allow a child to graduate or progress to the next grade level. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 11 3) Provide funds for ground or air transportation for children to participate in family vacations/reunions, attend school or team events, or to see medical specialists. 4) Provide funds for children to participate in supervised Spring and Winter Intersession activities, or summer camps. 5) Pay for fees, equipment and supplies needed for extracuricular activities ie: sports, music, art, drama, dancing lessons, etc. 6) Provide funds for holiday or birthday gifts when a child would otherwise not receive a gift. 7) Provide funds (or gift cards) for gas, to families on a limited budget so children may be able to attend treatment programs. 8) Provide funds for diapers, car seats and other baby supplies for infants who are victims of abuse and neglect. 9) Pay for event fees, prom dresses, senior pictures, yearbooks, etc., to give a student a chance to participate in school functions. 10) Assist police, social workers, and other professionals in keeping up to date with the latest investigative techniques, sensitivity training, forensics and knowledge of resources by helping to sponsor their attendance at training workshops and seminars. 11) Provide privacy, comfort and safety for children and family members who come to the Center, by maintaining its warm environment. 12) Participate with the East Hawaii Coalition for Child Abuse Prevention in community education activities to increase public awareness. Program Highlights: (from Fiscal Year 2010-11) 1) Filled 856 Special Needs Requests for abused and neglected children to provide for their emergency or enhancement needs that would otherwise have gone unmet. 2) Continued to partner with Children's Justice Center of East Hawaii to provide requested funds for professionals to attend trainings, including Social Workers, police and other professionals who interface with alleged child victims of abuse. 3) Increased community awareness of Abuse Prevention by participating in educational activities including: ongoing work with the East Hawaii Coalition to Prevent Child Abuse and Neglect, especially for April - Child Abuse Prevention Month; participated in Celebrate Your Family Day at Sangha Hall; participated in the Boy Scouts annual Makahiki Festival; attended community education fairs at UH Hilo's Family Affair event, the Puna Informational Fair at the Pahoa Community Center; and to local churches and organizations. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 11 4) Provided 136, $30 Holiday Gift Cards to Walmart, to teens 12 to 17 years old. Coordinated a group of volunteers from the local school Resource Team to assist with wrapping gift cards. 5) Held our signature fundraiser (The Phantom) by distributing over 300 invitations and raised nearly $18,000. 6) Sponsored a 6th Annual Prevent Child Abuse Golf Tournament for FCJCEH, at the Mauna Lani South Golf Course 7) Held a Legislative Open House, December '10, inviting State Legislators to visit our agency and meet our Board and volunteers. 8) Continued effort to investigate other grant opportunities. 9) Assisted at Aid Station for runners participating in the 2010 Ironman Triathlon in Kona, as our service to the community. 10) Participated in the 2010 Annual Visitor Industry Charity Walk, a statewide event coordinated by the Hawaii Hotel & Lodging Association. 11) Recruited two new Board Members to our Board of Directors. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 11 Friends of the Children's Justice Center of East Hawaii - Agency Name Special Needs & Enhancement, Center Support, Prevention/Education & Training Programs - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Fill Emergency and Enhancement 720 950 1 ,100 requests through the (SNR Program) Maintain Holiday Gift Program 136 148 160 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 30,106 38,932 39,000 Professional Fees 9,340 14,141 10,200 Operations 13,767 9,889 9,940 Equipment 4,498 2,004 0 Other" 83,178 113,409 120,135 Total 140,889 178,375 179,275 * If applicable "Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 11 Friends fo the Childrens Justice Center of East Hawaii - Agency Name Special Needs & Enhancement, Center Support, Prevention/Education & Training Programs - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate County of Hawaii 10,000 15,000 25,000 Hawaii Island United Way, Inc. 2,817 5,000 5,000 Charity Walk 3,000 3,000 3,000 T. Hughes Foundation 35,000 35,000 40,000 Geist Foundation 43,217 40,000 45,000 Other Corporate & Foundations 4,250 7,000 20,000 Fundraising 9,000 0 15,000 Special Event (Phantom Mail out) 17,763 17,200 18,000 Donations 3,027 1 ,500 1,500 Admin fees from Custodial accounts 620 450 500 Interest income 673 600 300 Refunds 323 600 0 Carryover Reserve funds 11 ,199 50,025 5.975 Total 140,889 178,375 179,275 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The Friends do not collect fees for any of our services. We are continuously researching for additional grant funding, striving to increase donations for our Phantom non-event fundraiser, and expanding participation in our golf tournament fundraiser. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 11 Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. To the best of our knowledge, there is no employee or volunteer who has any affiliations with the County of Hawaii. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 11 Friends fo the Childrens Justice Center of East Hawaii - Agency Name Special Needs & Enhancement, Center Support, Prevention/Education & Training Programs - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 11 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. • N - -Z'1 - 12.. Signature of Board President/Chair Date or Agency Director 1/ 7 / ao I Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 11 27 Friends of the Children's Justice Center of West Hawaii Enhancement and Basic Needs FRIENDS of the Children's Justice Center of West Hawai'i—Agency Name Enhancement and Basic Needs—Program Name Agency Director: Michelle Ono Phone Number: 808.331.2425 Contact Person: Michelle Ono Phone Number: 808.331.2425 Mailing and Facility Address: 77-6403 Nalani Street Kailua-Kona, HI 96740 Fax Number: 808.327.4988 Email Address: fcjcwh@hawaii.rr.com Name of Accountant/CPA: Steve Fassbender Phone Number: 808.331.2425 Mailing Address: 77-6403 Nalani Street Kailua-Kona, HI 96740 Amount of Request for County Funds: $15,000.00 Prior Years Funding: 09-10 10-11 11-12 $15,000.00 $10,000.00 $15,000.00 Agency Mission Statement: FCJC-WH mission is to provide assistance to the children of West Hawai'i who have been traumatized by sexual assault, physical abuse and/or neglect,or who have been witnesses to violent crime;to support the Children's Justice Center of West Hawai'i;and to promote the awareness and prevention of child abuse. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 1 FRIENDS of the Children's Justice Center of West Hawai'i—Agency Name Enhancement and Basic Needs—Program Name Program Description: The FRIENDS of the Children's Justice Center of West Hawai'i(FGC-WH)was established in 1989 as a 501 (c) 3 non-profit organization to work in partnership with the Children's Justice Center of West Hawai'i, a part of the State of Hawai'i Judiciary,to provide a safe and child-friendly setting where children can be interviewed by trained professionals about allegations of sexual abuse, physical abuse, and/or as witnesses to violent crime. Our goal is"to help a victim become a child again". The FGC-WH developed an "Enhancement and Basic Needs" program to provide financial assistance to help support and nurture the healing process for children who have been traumatized by child abuse and neglect.Through our Enhancement and Basic needs program,we are able to increase the opportunities for child and teen victims of abuse to participate and benefit from activities,services,and programs that help to build self-esteem and strengthen self-image and self-worth,all crucial elements of a successful healing process. A few examples of supported activities and programs are:after-school tutoring, ukulele lessons, martial arts, Horseplay therapeutic horse camp/lessons, Donkey Mill Art Center Youth Summer Camp, Winners' Camp, Pop-Warner Football,therapy, and many other local programs that support the healing process for our keiki. Another aspect of our program is assistance with basic needs such as emergency clothing, emergency personal hygiene products, blankets,age and school specific school supplies,food for children traveling to and from court during a child abuse trial,snacks and games to play while at the Children's Justice Center for forensic interviews,and other needs critical to a child's health,dignity,and well-being. The FGC-WH also collaborates with local social service agencies,such as the YWCA Sexual Support Services,to contribute and participates in events and public presentations that focus on the awareness and prevention of child abuse in our communities.We recognize we are a small organization and presently believe we are able to best serve and contribute to the cause by combining efforts to maximize the resources available. The FGC-WH Executive Director regularly attends professional and public trainings that strive to improve the quality and effectiveness of the multi-disciplinary response to allegations of child abuse, ensuring that the professionals working with potential child victims of abuse and their protective families are aware of the resources and support the FCJC-WH can provide. The FCJC-WH requires that a "needs request"form be submitted through a professional working directly with a child/teen such as a social worker, private therapist,guardian ad litem,or school counselor.All of the children we serve have been victimized by child abuse and/or neglect or a witness to violent crime. By collaborating with a vast array of professionals,we continue to increase our ability to effectively identify and fulfill needs of child and teen victims of abuse that have not and/or cannot be adequately be met by governmental and/or other private agencies in West Hawai'i. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 2 FRIENDS of the Children's Justice Center of West Hawaii—Agency Name Enhancement and Basic Needs—Program Name Total Budget and Position Count Total Program Budget 101,400.00 Total Program Position Count 1 Total Agency Budget 136,102.50 Total Agency Position Count 1 Program Objectives: 1) Assess and process 1000 enhancement and needs requests benefiting 400 children by 6/2013. 2) Provide school and grade level specific school supplies with a high quality backpack that will last throughout the school year to at least 125 child victims of abuse and DV by August 15,2012. 3) Provide school clothes in July and August 2012 for an estimated 12 -20 keiki residing at the Domestic Violence Shelter in West Hawai'i. 4) Work with 15 different social service agencies to ensure providers are familiar with and able to utilize Enhancement and Basic Needs assistance on behalf of the child victims they are working with. 5) Give 50'You've Got a FRIEND Bag"to children entering the foster care system and/or Domestic Violence Shelters by June 30, 2013. 6) Provide tuition scholarships for 5 at risk teens to attend Winners'Camp during July 2012,to help decrease the risk of re-victimization by helping build leadership skills and enhance self-esteem. 7) Facilitate 4 Winners'Camp Reunion and Project Visitation activities to support positive peer relationships and enhance the opportunities to siblings separated by foster care to visit with each other. 8) Collaborate with partner agencies in 2 or more prevention and awareness community campaigns in West Hawai'i and/or on the Hawai'i Island. 9) Present 3 or more informative talks to social service agencies provide opportunities to reflect and analyze the needs of child victims of abuse, neglect,and domestic violence. 10) Distribute 125 Holiday gift bags to child victims in West Hawai'i by December 31,2012. 11) Create and maintain a working website by June 30,2013. 12) Provide support to 100 children who may be interviewed at the Children's Justice Center of Hawai'i regarding allegations of child abuse. Program Expenditures: 1) In 2011,the FCJC-WH processed 1237 Enhancement and Basic Needs Requests, benefiting 351 individual children. 2) Provided school clothes in July and August 2012 for 25 keiki residing at the DV Safe House in West Hawai'i. 3) Work with 15 different social service agencies to ensure providers are familiar with and able to utilize Enhancement and Basic Needs assistance on behalf of the child victims they are working with by June 30, 2013. 4) Give 50'You've Got a FRIEND Bag"to children entering the foster care system and/or Domestic Violence Shelters by June 30, 2013. 5) Provided tuition scholarships for 14 at risk teens to attend Winners' Camp during 3/11 and 7/11 6) Facilitated 4 Winners' Camp Reunion and Project Visitation activities NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 3 FRIENDS of the Children's Justice Center of West Hawai'i—Agency Name Enhancement and Basic Needs—Program Name 7) Collaborated with partner agencies in 2 or more prevention and awareness community campaigns in West Hawai'i and/or on the Hawai'i Island. 8) Presented 3 or more informative talks to social service agencies. 9) Distributed 125 Holiday gift bags to child victims in West Hawai'i. 10) Provided support to 100 children were interviewed at the Children's Justice Center of Hawai'i regarding allegations of child abuse. Performance Measures: FY 2010-2011 FY 2011-2012 FY 2012-2013 Actual Budget Estimate Children brought CJC-WH for forensic interviews 101 120 130 Approved Needs Requests 950 800 1000 Individual Children Served 401 400 400 "You've Got a FRIEND Bag"distributed 25 50 50 Holiday Gift bags 84 150 150 Winners'Camp Attendees 14 15 5 Winners'Camp/Project Visitation Activities 4 5 4 Grade and School Specific School Supplies 25 50 125 Program Expenditures: FY 2010-2011 FY 2011-2012 FY 2012-2013 Actual Budget Estimate Salaries and Wages 0 26,400.00 26,400.00 Professional Fees 22553.80 0 0 Operations 0 0 0 Equipment 0 0 0 Other# 70,937.16 74,900.00 75,000.00 Total: 93,490.95 101,300.00 101,400.00 Program Funding Sources(Specific to this program only): Revenue Source FY 2010-2011 Actual FY 2011-2012 Budget FY 2012-2013 Estimate County of Hawai'i 10,000.00 15,000.00 15,000.00 Private Foundations 54,650.00 80,501.00 75,501.00 Donations 39,284.57 18,704.00 9,500.00 Total 103,934.57 114,205.00 100,001.00 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 4 Other Expenditures: FRIENDS of the Children's Children Center of West Hawa'i ITEM 2010-2011 2011-2012 2012-2013 Actual Budget Budget Athletic Supplies and Lessons $ 6,458.93 $ 5,500.00 $ 5,000.00 Center Support $ 12,225.29 $ 3,000.00 $ 3,000.00 Christmas Bags $ 3,537.00 $ 1,500.00 $ 1,500.00 Christmas,Other $ 2,750.00 $ 1,000.00 $ 3,500.00 Clothing $ 6,950.00 $ 4,000.00 $ 4,000.00 Dental $ - $ 1,000.00 $ 1,000.00 Education $ 9,909.17 $ 5,000.00 $ 5,000.00 Emergency/Basic Needs $ 1,595.00 $ 2,000.00 $ 3,500.00 Enhancement,Miscellaneous $ 6,624.96 $ 4,000.00 $ 5,000.00 Food $ 670.00 $ 500.00 $ 500.00 Food Coupons $ 1,150.00 $ 1,000.00 $ 1,000.00 FRIEND Boxes $ 2,792.28 $ 1,000.00 $ 2,000.00 Furniture $ 2,881.86 $ 500.00 $ 500.00 Gas Coupons $ 800.00 $ 100.00 $ - Graduation $ - $ 250.00 $ 250.00 Medical $ - $ 500.00 $ 500.00 Music Lessons/Instruments $ 1,164.78 $ 500.00 $ 1,000.00 Art/ Performing Arts $ 276.03 $ 1,000.00 $ 1,000.00 School Break Programs $ 100.00 $ 3,000.00 $ 2,000.00 School Pictures/Yearbook $ 2,039.40 $ 300.00 $ 250.00 School Supplies/fees $ 1,406.40 $ 1,000.00 $ 5,500.00 Summer Camp/Fun $ 6,671.51 $ 5,000.00 $ 5,000.00 Summer School $ 2,440.74 $ 2,000.00 $ 2,000.00 Therapy $ 100.00 $ 300.00 $ 500.00 Travel $ 1,943.80 $ 5,000.00 $ 1,500.00 Winners'Camp $ 16,469.66 $ 15,000.00 $ 15,000.00 Winners'Camp reunions $ 1,808.16 $ 5,000.00 $ 5,000.00 TOTALS: $ 92,764.97 $ 68,950.00 $ 75,000.00 FRIENDS of the Children's Justice Center of West Hawai'i—Agency Name Enhancement and Basic Needs—Program Name Explain what plans.If any,your agency and/or program have to increase revenues to support this program.When do you anticipate your program to become self-sustaining? It is our vision that these supportive activities can "help a victim become a child again",decrease the potential for re-victimization,and ultimately help to break the cycle of child abuse in West Hawai'i. Essentially,our Enhancement and Basic Needs program is self-sustaining.We are aware of the current increase in needs and the possibility of less grant funds received.This is being discussed at every Board meeting along with ways to increase fundraising revenues in the most cost effective ways. We are also applying for new grants; in hopes that new resources will become available to the children we are privileged to serve. We have also seen an increase in volunteers and people who as individuals and small local business want to support our efforts and recognize the value in helping our keiki heal. By collaborating with a vast array of professionals,we continue to increase our ability to effectively identify and fulfill needs of child and teen victims of abuse that have not and/or cannot be adequately be met by governmental and/or other private agencies in West Hawaii. Please disclose any affiliations any employee or volunteer of your organization may have with the County of Hawai'i. We have a RSVP volunteer, Ms. Eileen Matsumoto,who has been a tremendous asset to both the Children's Justice Center Program as well as the FRIENDS of the Children's Justice Center.She has a wonderful and caring presence and has helped with us with tasks such as answering foods,food preparation,wrapping Christmas and birthday presents,and provided reception coverage during meetings and CJC child interviews. She does not participate in grant writing,financial aspects of the organization and/or fundraising efforts. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 5 R.t>✓■ts of- -rh“, csc- w N- - Agency Name - Program Name Nerds I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. 'AA / I31112, Signature of4 oard Pres 7-- ' air Date or Agency Director jaid_II / ems a, Si J nat. e of Exe utive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 28 Goodwill Industries of Hawaii Job Connections Goodwill Industries of Hawaii, Inc. - Agency Name Job Connections - Program Name Agency Director: Laura Smith Phone No.: 808-836-0313 Contact Person: Bettye Williams Phone No.: 808-934-8118 Mailing Address: 500 Kalanianaole Ave., Hilo 96720 Facility/Site Address: 200 Kanoelehua Ave., Suite 101, Hilo 96720 Fax No.: 808-969-3861 Email Address: bwilliams @higoodwill.org Name of Accountant/CPA (include name of firm if applicable): Catha Combs, Wikoff Combs and Co., LLC Phone No.: 808-791-1420 Mailing Address: 1001 Bishop Street, Suite 2760, Honolulu, HI 96813 Amount of Request for County Funds: $30,000 Prior Year(s) Funding: 08-09 09-10 10-11 $14,000 $10,000 $7,500 Agency Mission Statement: Our mission statement is: Goodwill Industries of Hawaii, Inc. helps people with employment barriers to reach their full potential and become self- sufficient. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 1 Goodwill Industries of Hawaii, Inc. - Agency Name Job Connections - Program Name Goodwill Industries of Hawaii (GIH) has been in business in the State of Hawaii since 1959 providing vocational training and employment services to persons with barriers to employment, including: • Individuals with disabilities; • Youth who have disabilities or are economically disadvantaged; • Disabled veterans; • Asian and Pacific Islander immigrants; • Older individuals and dislocated workers; and • Adults who are economically disadvantaged, including First-to-Work and Food Stamp recipients. With over 53 years of experience operating vocational training programs as well as teaching life skills, GIH has developed an expertise in bringing about success to the people we serve. The Hawaii Island Branch has been serving our community since 1998. The GIH team envisions a world where all individuals with disabilities and other barriers will have the opportunity to participate in a full range of life's experiences, including employment. We provide services to empower individuals to be productive and independent, based on their abilities and interests. It is our belief that work is a basic right that will assist people to attain other life goals. Moreover, we believe in each individual's right to self-determination, to make their own decisions regarding life choices as a means of promoting independence and self-sufficiency. From July 2010 to June 2011, GIH successfully provided services to 15,551 people statewide, and placed 1,502 people into gainful employment. The Hawaii Island Branch provided services to 3,780 individuals and placed 428 people into employment in 2010-2011. Over the past five years, GIH has provided training and employment services to 58,567 people statewide with barriers to employment, and placed 8,557 people into employment. Over the past five years, the Hawaii Island Branch served 12,706 people and placed into employment 2,344 people. Successful past outcome data confirm that GIH has the necessary skills and experience to perform the proposed services. In previous years, GIH has provided a menu of services to train, place and support individuals with barriers into gainful employment and assist them to overcome their barriers to both employment and job retention. Additionally, GIH is committed to providing services to help individuals after they have obtained employment to acquire skills and resources to advance, and improve their economic self-sufficiency through training in basic literacy, computer literacy, GED, ESL, and Earned Income Tax Credit filing. Participants in our Human Service programs also receive follow-up supports and transitional services once they are employed. GIH will coordinate these services with the appropriate NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 2 Goodwill Industries of Hawaii, Inc. - Agency Name Job Connections - Program Name agencies and identified networks of support, to better serve the participant on a long-term basis. Examples of agencies and partners with whom we coordinate services include the Department of Health, Division of Vocational Rehabilitation, Workforce Development Department, Department of Human Services, Office of Community Services, the Hawaii Island Going Home Consortium, YWCA, Hawaii Literacy, Department of Education, Legal Aid Society, East Hawaii Coalition for the Homeless, Chamber of Commerce, Goodwill Industries International, employers in identified industries with job opportunities corresponding to participants' career goals, and others. When possible, natural supports will be developed to enhance the individual's experience in the workplace. Collaboration between employer, family, friends, and the program staff will be emphasized to increase the probability of success. Program Description: Funding is requested to provide support services to low-income individuals (at or below 150% of the Federal Poverty Guidelines), and particularly to those who have been incarcerated and are being released from Hawaii Correctional Centers. The funding requested will target support services to local ex-offenders for the purpose of creating a safer community and reunifying families by reducing recidivism. GIH's Job Connections Program will provide job development and support services to employers and program participants. Upon placement into employment, the Job Connections Program will continue to provide case management and support for a period of one year. These supportive services ensure that we achieve the goal of helping ex-offenders become stable, gainfully employed individuals capable of providing financial support for themselves and their families. The funding requested will provide services for fifty-three (53) individuals that include the following three components: (1) Intake and Assessment including Individual Program Plan Development (2) Job Readiness Training (3) Job Development and Job Placement Assistance GIH's Job Connections Program has become a leader in providing motivational and inspirational training by using a hands-on approach. First, in the process of assessment, participants learn about themselves by identifying skills acquired, both inside and outside of correctional institutions. As part of assessment, participants are given work skills, soft-skills, interests and personality assessments and corresponding choice of careers. The assessments help give participants language to describe themselves and their skills on a resume and talk about themselves to potential employers. The assessments also assist in NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 3 Goodwill Industries of Hawaii, Inc. - Agency Name Job Connections - Program Name career exploration and identifying personal career goals. Participants create their Individual Program Plan that serves as a guide to achieve their desired goals and outcomes. A simple soft-skills assessment assists in identifying areas of weakness such as poor time management and poor money management. GIH's Employment Counselors work closely with program participants to improve these skills through formal training and follow-up. Second, a 20 hour Job Readiness Training course is scheduled within one week of intake to educate and support participants in becoming job ready. In the hands-on class, participants learn how to correctly fill out applications, write their resumes, create cover letters, learn interviewing skills, and learn innovative ways to job search. Graduation is a culmination of all the skills they have learned. They are expected to present themselves properly in appearance, body language, written material, and verbally in mock interviews. GIH Employment Counselors and/or former graduates (that participants are not familiar with) conduct the mock interviews to simulate elements of a real interview. Third, the participant is assigned a GIH Employment Counselor who helps the participant identify barriers to employment and solutions for removal of the barriers. The participant sets goals for him/herself while the Employment Counselor provides support for them to achieve those goals. Job Development is an important part of the process of job placement. The GIH team contacts employers, post job openings on a daily basis, and uncover hidden job markets. Participants are invited to use the Job Connections Program office for their job search after graduation. The GIH team will meet regularly with former participants to assist with job searching. All participants have access to computers, internet for job searches, researching companies, and completing applications, daily newspaper, telephone and telephone books, fax machine, and their Employment Counselor's guidance. The result is job placement, self- sufficiency and a stronger local economy. In FY 2010-2011 the demographics of all participants in the program were: • 45% identified themselves as Hawaiian or part Hawaiian. • 80% identified themselves as having a criminal background. • 11% identified themselves as having less than a high school education. Total Budget and Position Count Total Program Budget $30,000 Total Program Position Count 3 Total Agency Budget $3,000,000 Total Agency Position Count 88 *Total Agency Budget denotes Hawaii Island Branch only NONPROFIT GRANT APPLICATION FISCAL YEAR 2012_-2013 Page 4 Goodwill Industries of Hawaii, Inc. - Agency Name Job Connections - Program Name Program Objectives: (1) Enroll 53 participants in the Job Connections Program. (2) Conduct Intake and Assessment including assessment of skills, soft-skills, personality, career goals, work history and barriers to employment. (3) Develop an Individual Program Plan (IPP) with each participant that includes creating their goals and the steps needed to achieve them. (4) Conduct Job Readiness Training consisting of 20 hours of hands on classroom training. This may also incorporate topics related to Hawaiian Culture and Values as well as Post Incarceration Syndrome as applicable. (5) Place participants into employment. (6) Conduct job developing activities with employers, pre-screening, job placement and follow up to ensure a smooth transition into employment. The Job Connections Program will continue to support the participants and employers for one year from date of placement with a focus on successful job retention and advancement. The emphasis of our program is giving the participants the confidence and tools to maximize their abilities. Our philosophy is to provide an environment for people to believe they can succeed, achieve goals, develop skills and change the barriers they face every day. At GIH we believe in the power of work. We create hope, jobs and futures. Program Highlights: (1) In FY 2010-11, the Job Connections Program served 172 participants identified as low-income. Of those participants, 99 were new participants and all completed job readiness training; and 68 were successful in finding employment, leading to a 69% placement rate. (2) Below are some recent success stories that illustrate the work being done: A recent parolee was referred to the program by his parole officer. Before going to prison, he accrued many driving violations and had his driver's license suspended. The participant attended the Job Readiness Training and with the assistance of his Employment Counselor was able to obtain a laborer job. His employer wanted to expand his duties by having him make deliveries for the company but he was unable to obtain a license due to having outstanding fines. GIH's Employment Counselor assisted the participant with writing a letter to the judge requesting a restricted driver's license so he could accept the additional responsibilities assigned by his employer. The judge granted the request, but required that the NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 5 Goodwill Industries of Hawaii, Inc. - Agency Name Job Connections - Program Name fines be paid off before the participant would be allowed to receive an unrestricted license. GIH's Employment Counselor assisted him with creating a budget to save money. By following the budget, the participant was able to pay his outstanding fines and now has his unrestricted driver's license. A Hawaii Community Correctional Center work furlough referral came to the Job Connections Program. After completing Job Readiness Training, he began his job search. With the assistance of the GIH Employment Counselor, this participant was able to get a job as a laborer. His true passion and overall goal was to work with cars but the client did not have the training and certification to obtain a position in the automotive industry. The GIH Employment Counselor assisted him with registering at Hawaii Community College in the Automotive Mechanics Technology program and there he has started working on cars to fulfill his passion and obtain employment. (3) Through participation in the Job Connections Program ex-offenders experience a positive transition into the community. For Hawaii Community Correctional Center work furlough inmates, the Job Connections Program staff are the first people the inmates come into contact with when released to attend Job Readiness Training classes. Participants progress from fear of failure to becoming confident men and women in one week's time. The Hawaii Paroling Authority refers parolees who have been unsuccessful in obtaining employment. GIH's Employment Counselors work closely with parole officers to assist parolees in barrier removal and job placement. As a result, participants gain: • Empowerment • Initiative • Communication skills • Recognizing triggers for re-offending • Work Ethics • Honesty Performance Measures: FY 2011-12 FY 2011 FY 2012-13 Actual * Budget * Estimate Job Connections Program $10,000 $7,500 $30,000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 6 Goodwill Industries of Hawaii, Inc. - Agency Name Job Connections - Program Name Goodwill's Outcome Management System evaluates program services by asking persons served, employers, and referring agencies to complete a follow-up survey used to evaluate the satisfaction and effectiveness of services. Upon program exit, each participant, employer and referring agency will be asked to complete a satisfaction survey. Parties are asked to respond to questions in several areas including the quality of services received, the service outcomes, level of satisfaction regarding the program, and suggestions for changes. Satisfaction surveys are compiled and analyzed on an annual basis. The results are shared with funding sources and Goodwill's Board of Directors. Recommendations for needed changes are analyzed. Plans for improvements are then developed and implemented as a result of this feedback. For the most recent year 2010-11, 100% of the participants were satisfied with their experience in the Job Connections Program. Participant comments included: • "Gave me encouragement and the will to succeed." • "I liked best about the program was the support that they (the staff) gave. The mock interview was really good. It helped me understand what to do and what not to." Program Expenditures FY 2011-12 FY 2012-13 FY 2012-13 Actual * Budget * Estimate Salaries and Wages $10,000_ $7,500 $30,000 Professional Fees Operations Equipment Other (Payroll Processing Charges)# Total $10,000 $7,500 $30,000 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 7 Goodwill Industries of Hawaii, Inc. - Agency Name Job Connections - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2011-12 FY 2012-13 FY 2012-13 Actual * Budget * Estimate County of Hawaii Non-Profit Grant $10,000 $7,500 $30,000 State of Hawaii $75,000 $70,000 $70,000 Total $85,000 $77,500 $100,000 *If applicable Explain what plans, if any, your agency acid/or program has to increase revenues to support this program. When do you anticipate your program to become self- sustaining? The funds requested in this application are for a component of an existing performance based program funded by the State of Hawaii, Office of Community Services. The funding provided by the County allows us to conduct intake and assessments; conduct Job Readiness Training; and place participants into employment. The remaining State of Hawaii funding will cover the case management and job retention support for the participant and employer until employment for one year is achieved. GIH will continue to support participants to reach job retention goals of 90 days, 180 days and 360 days on the job. GIH is actively working with our funders as well as the Goodwill Industries International to seek out opportunities to apply for additional funding. As mentioned earlier, this is the second of two separate applications GIH submitted this year. Our top priority is the Work Experience Program. Funding for the Job Connections Program should only be considered if the Work Experience Program is accepted by the County. We do not want to jeopardize the Work Experience Program as the County grant serves as funding of last resort for our trainees who are people with disabilities, who have no other options. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 8 Goodwill Industries of Hawaii, Inc. - Agency Name Job Connections - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant Submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013 must be returned to the County of Hawai`I within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 9 Goodwill Industries of Hawaii, Inc. - Agency Name Job Connections - Program Name By signing below, you are acknowledging that you have read and understand these requirements. Signature of Board President/Chair Da e Or Agency Director Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 10 29 Goodwill Industries of Hawaii Jr. Live Saving Goodwill Industries of Hawaii, Inc. — Agency Name Work Experience Program — Program Name Agency Director: Laura Smith Phone No.: 808-836-0313 Contact Person: Mary Roblee Phone No.: 808-961-0307 Mailing Address: 500 Kalanianaole Ave, Hilo, HI 96720 Facility/Site Address: 500 Kalanianaole Ave, Hilo, HI 96720 Fax No.: 808-969-3861 Email Address: mroblee @higoodwill.org Name of Accountant/CPA (include name of firm if applicable): Catha Combs, Wikoff Combs and Co., LLC Phone No.: 808-791-1420 Mailing Address: 1001 Bishop Street, Suite 2760, Honolulu, Hi 96813 Amount of Request for County Funds: $45,000 Prior Year(s) Funding: 09-10 10-11 11-12 $28,000 $25,000 $10,000 Agency Mission Statement: Our mission statement is: Goodwill Industries of Hawaii, Inc. helps people with employment barriers to reach their full potential and become self- sufficient. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 1 Goodwill Industries of Hawaii, Inc. — Agency Name Work Experience Program — Program Name Goodwill Industries of Hawaii (GIH) has been in business in the State of Hawaii since 1959 providing vocational training and employment services to persons with barriers to employment, including: • Individuals with disabilities; • Youth who have disabilities or are economically disadvantaged; • Disabled veterans; • Asian and Pacific Islander immigrants; • Older individuals and dislocated workers; and • Adults who are economically disadvantaged, including First-to-Work and Food Stamp recipients. With over 53 years of experience operating vocational training programs as well as teaching life skills, GIH has developed an expertise in bringing about success to the people we serve. The Hawaii Island Branch has been serving our community since 1998. The GIH team envisions a world where all individuals with disabilities and other barriers will have the opportunity to participate in a full range of life's experiences, including employment. We provide services to empower individuals to be productive and independent, based on their abilities and interests. It is our belief that work is a basic right that will assist people to attain other life goals. Moreover, we believe in each individual's right to self-determination, to make their own decisions regarding life choices as a means of promoting independence and self-sufficiency. From July 2010 to June 2011, GIH successfully provided services to 15,551 people statewide, and placed 1,502 people into gainful employment. The Hawaii Island Branch provided services to 3,780 individuals and placed 428 people into employment in 2010-2011. Over the past five years, GIH has provided training and employment services to 58,567 people statewide with barriers to employment, and placed 8,557 people into employment. Over the past five years, the Hawaii Island Branch served 12,706 people and placed into employment 2,344 people. Successful past outcome data confirm that GIH has the necessary skills and experience to perform the proposed services. In previous years, GIH has provided a menu of services to train, place and support individuals with barriers into gainful employment and assist them to overcome their barriers to both employment and job retention. Additionally, GIH is committed to providing services to help individuals after they have obtained employment to acquire skills and resources to advance, and improve their economic self-sufficiency through training in basic literacy, computer literacy, GED, ESL, and Earned Income Tax Credit filing. Participants in our Human Service programs also receive follow-up supports and transitional services once NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 2 Goodwill Industries of Hawaii, Inc. — Agency Name Work Experience Program — Program Name they are employed. GIH will coordinate these services with the appropriate agencies and identified networks of support, to better serve the participant on a long-term basis. Examples of agencies and partners with whom we coordinate services include the Department of Health, Division of Vocational Rehabilitation, Workforce Development Department, Department of Human Services, Office of Community Services, the Hawaii Island Going Home Consortium, YWCA, Hawaii Literacy, Department of Education, Legal Aid Society, East Hawaii Coalition for the Homeless, Chamber of Commerce, Goodwill Industries International, employers in identified industries with job opportunities corresponding to participants' career goals, and others. When possible, natural supports will be developed to enhance the individual's experience in the workplace. Collaboration between employer, family, friends, and the program staff will be emphasized to increase the probability of success. Program Description: Funding in the amount of $45,000 is requested for a Work Experience Program and a Hawaii Design and Art Program. The Work Experience Program provides wage subsidy for individuals with disabilities and other barriers to employment. The program format will allow work training opportunities for individuals that do not have work experience or who need additional supports or training to succeed in their employment goals. The current training program available is for Janitorial positions. The GIH Work Experience Program will follow guidelines as set forth by the Department of Labor. GIH has a subminimum wage certificate that requires the following: • A standard be set for each work station, • Community wage survey be conducted annually, and • Each participant's productivity be measured every six months. Each participant will become familiar with and decide if the Janitorial program is right for them. When the work experience path has been chosen, the participant will be trained on how to perform the essential job functions needed for the position. The benefits of developing these work skills extend beyond the work environment. Through this program participants learn what it is like to earn a paycheck, while being provided valuable work experience and enhancing skills in a real work setting. The GIH team recognizes the intrinsic value of work and understand the profound effects that meaningful, tangible employment brings to our trainees' lives. More than bringing financial self-sufficiency, work taps the spirit of the NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 3 Goodwill Industries of Hawaii, Inc. — Agency Name Work Experience Program — Program Name individual, provides equal opportunity, and demands commitment and dedication, values that provide the foundation for the community. In 2010-2011, the Work Experience Program served seventeen (17) participants that were enrolled in a GIH training program. The format allowed work-training opportunities for individuals to choose a position in our Janitorial program or Textile/Wares Processing program. The Work Experience Program followed guidelines as set forth by the Department of Labor. A standard was set for each workstation, a community wage survey was conducted, and each participant's productivity was measured every six months. Participants developed problem solving skills, motivational skills, an attitude for success, and increased their self- confidence in the workplace. This year we would like to develop a Hawaii Design and Art program to allow participants at every level of disability the opportunity to learn skills and provide tools which encourage entrepreneurship, greater independence and self- sufficiency in a highly competitive job market. Funding will pay for assistive technology devices such as an electronic embroidery machine, electronic sewing machines, ergonomically designed rolling work stations, touch screen computers, voice recognition systems, assistive communication software, as well as supportive specialized design and art software. Assistive technology will particularly assist our participants with sight and hearing impairments, Cerebral Palsy or other physical and learning disabilities which limit their use of standard equipment. In 2010-2011, GIH expanded pre-employment and computer based training for persons with more severe physical and learning limitations. Prevocational software and assistive devices were purchased to enhance two touch screen computers. To date, twenty-seven (27) participants have experienced the wonder of technology, learned basic computer skills and been introduced to pre- vocational software. Total Budget and Position Count Total Program Budget $45,000 Total Program Position Count 2 Total Agency Budget $3,000,000 Total Agency Position Count 96 *Total Agency Budget denotes Hawaii Island Branch only Program Objectives: Janitorial Program NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 4 Goodwill Industries of Hawaii, Inc. — Agency Name Work Experience Program — Program Name 1) Enroll 15 participants in the Work Experience Janitorial Program. 2) Instruct proper work techniques for each workstation to be assigned, by review of the workstation development form during the first week of training. 3) Develop motivational skills and attitudes for success, self-confidence and problem solving skills throughout the training period. 4) Conduct time measurement study for participants during the first 2 weeks of entry into the program. 5) Review outcomes with the participant upon completion of the time study. 6) Continue to instruct and reinforce correct work procedures. 7) Track work hours, daily or as scheduled to work. 8) Pay each participant semi-monthly, according to hours worked. 9) Conduct time study for each participant every six months. 10) Update wages according to productivity level. 11) Instruct computer skills utilizing assistive technology for persons with physical disabilities (hearing loss, sight impairment, cerebral palsy, etc.) 12) Instruct on computer based programs which focus on creating resumes, completing applications and learning the fundamentals of the job search and job retention. Hawaii Design and Art Program 1) Enroll 20 participants in the Design and Art Program. 2) Determine interest and aptitude for each participant. 3) Customize training on electronic embroidery and sewing machines based on level of disability. 4) Instruct computer skills utilizing assistive technology for persons with physical disabilities (hearing loss, sight impairment, cerebral palsy, etc.) 5) Instruct on computer based programs which focus on creating project designs. 6) Instruct participants on developing and implementing a business plan. The emphasis of Work Experience Program is giving the participants the confidence and tools to maximize their abilities. Our philosophy is to provide an environment for people to believe they can succeed, achieve goals, develop skills and change the barriers they face every day. At GIH we believe in the power of work. We create hope, jobs and futures. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 5 Goodwill Industries of Hawaii, Inc. — Agency Name Work Experience Program — Program Name Through our program, participants learn specific vocational skills and work environment behaviors. Individuals choose the work that matches their abilities and interests and earn wages based on productivity. Participants in the custodial services program perform a variety of cleaning duties in restrooms and offices. It is anticipated that participants in the design and art program will express their creativity through designs of saleable items such as Hawaii craft items, greeting cards and art work. Participants will learn how to develop a business plan and explore avenues for selling their creations through local venues and the internet. Program Highlights: 1) Enrolled 17 participants in the Work Experience Program in 2010/2011. 2) In a random audit of program participants we found an average 20% increase in productivity for participants since their entry into the program. 3) Instructed participants in proper work techniques for each workstation. 4) Developed motivational skills and attitudes for success, self-confidence and problem solving skills for each participant. 5) Conducted time measurement study for each participant within 2 weeks from date of entry into program. 6) Reviewed outcome of time study with each participant upon completion of study. 7) Instructed and reinforced correct work procedures with each participant. 8) Tracked work hours, daily or as scheduled to work. 9) Paid participants on a semi-monthly basis, according to hours worked. 10) Conducted time study of each participant every six months. 11) Updated wages according to productivity level. 12) Purchased assistive technology devices and software to meet the needs of all levels of disability. 13) Assisted one individual to continue her goal of self-employment. Through participation in the Work Experience Program, six participants have gained valuable job skills and have transitioned to competitive, self or volunteer employment. The GIH Aina Keepers, a rotating team of ten participants, paints over graffiti in the community. Another team of six participants work on a gardening project learning sustainability skills, while another team serves food to the homeless one day per week. Participants learned how to take direction, follow through on their work and how to work as a team. As they progressed in the program they demonstrated strong work ethic, attention to detail and positive attitude. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 6 Goodwill Industries of Hawaii, Inc. — Agency Name Work Experience Program — Program Name Another trainee continued to maintain her own business, designing, sewing and selling Hawaiian crafts. Her cultural creations are showcased on a website of products and services provided by persons with disabilities on the Big Island. This trainee was able to sell her products as quickly as she designed them and made them. She had a successful booth at the Abled Hawaii Arts festival and at the Maku'u market. All of the participants in the Work Experience Program look forward to receiving a paycheck. Earning a paycheck provides them with opportunities to budget, save and make decisions on where and how to spend their money. The power of work allows participants to gain self-esteem and develop the following qualities that are important for job retention: • Confidence • Initiative • Willingness to learn • Desire to work • Cooperation • Good attendance • Communication skills • Team play • Flexibility • Honesty • Respect for coworkers, workplace, and equipment Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Work Experience Program $25,000 $10,000 $45,000 GIH's Outcome Management System evaluates program services by asking persons served, employers, and referring agencies to complete a follow-up survey used to evaluate the satisfaction and effectiveness of services. Upon program exit, each participant, employer and referring counselor will be asked to complete a satisfaction survey. Parties are asked to respond to questions in several areas including the quality of services received, the service outcomes, level of satisfaction regarding the program, and suggestions for changes. Satisfaction surveys are compiled and analyzed on an annual basis. The results are shared with funding sources and GIH's Board of Directors. Recommendations for needed changes are analyzed. Plans for improvements are then developed and implemented as a result of this feedback. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 7 Goodwill Industries of Hawaii, Inc. — Agency Name Work Experience Program — Program Name For the most recent year 2010-11, the Work Experience Program participants that were also enrolled in the Home & Community Based Services Program indicated a participant and advocate satisfaction rate of 100% in the categories of "Very Good" to "Excellent". Participant's comments included: • I like the friends I make and the fun activities. • I learned a lot on the computer. • It helps me choose the services I need with respect. Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages $17,153 $9,400 $20,000 Professional Fees 6,094 Operations Equipment $1,210 $500 _ $22,000 Other (Payroll $543 $100 $3,000 Processing Charges)# Total $25,000 _ $10,000 $45,000 * If applicable #Please explain in detail on separate sheet Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2011-12 Actual * Budget * Estimate County of Hawaii Non-Profit Grant $ 25,000 $10,000 $45,000 Goodwill Industries of Hawaii $1,000 State of Hawaii $280,000 $250,000 $250,000 Total $305,000 $260,000 $296,000 *If applicable Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self- sustaining? NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 8 Goodwill Industries of Hawaii, Inc. — Agency Name Work Experience Program — Program Name The Work Experience Training Program is a component of a much larger service provided to persons with disabilities, through the State of Hawaii. The funding provided by the County allows trainees to earn money while gaining valuable work experience in a structured learning environment. As they gain the necessary experience they transition out of the program. While this funding pays the direct salary, it does not cover overhead, supervision, and case management. GIH leverages the County funding to provide a full-range of services for the trainees. Although we do not have alternative funding for the program at this time, we are looking into expanding the program for trainees who possibly qualify for Federal funds and using the County grant for trainees who have no other sources of funding. The County grant serves as funding of last resort for our trainees, who have no other options. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant Submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 9 Goodwill Industries of Hawaii, Inc — Agency Name Work Experience Program — Program Name understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013 must be returned to the County of Hawai'I within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. l Signa ure of :oard President/Chair Dat- Or Agency Di ector Actita. A) 51,,,,,jeu Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 10 30 Grassroots Community Development Group Kea'au Youth Business Center Grassroots Community Development Group- Agency Name Kea'au Youth Business Center- Program Name Agency Director: Trina Nahm-Mijo/Lily Chan-Harris Phone No.: 808-966-6354 Contact Person: same Phone No.: same Mailing Address: PO Box 1772, Kea'au, HI 96749 Facility/Site Address: 16-540 Kea'au-Pahoa Highway, Ste. 6 Kea'au, HI 96749 Fax No.: do 808-974-7757 Email Address: nahmmijo @hawaii.edu Name of Accountant/CPA (include name of firm if applicable): John Carbonaro/Carbonara CPA &Assocs. Phone No.: 808-968-1002 Mailing Address: PO Box 4372, Hilo, HI 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $45,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $50,000, $45,000 $35.000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 9 Agency Mission Statement: To strengthen our communities through the cooperative development of programs and services for all of Puna. To provide quality programs for youth. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 9 Grassroots Community Development Group - Agency Name Kea'au Youth Business Center- Program Name Program Description: This free or low-cost program was first started through a HUD Alaskan Native/Native Hawaiian Institutions Asssisting Communities grant in 2007 in response to the ice epidemic and the low social-economic standing of the Puna community. The target population is youth,12-18 year olds, predominantly from the Puna area. The program is held at Kea'au Youth Business Center located in Kea'au Town Center which has a state-of-the-art multimedia computer lab; the largest fully equipped sound recording studio on the Big Island; and a certified mobile kitchen on wheels. The Running Start/Middle College day program offers skill building in digital media arts, graphic and publishing arts, music and sound recording, and culinary arts and dual college and high school credit which prepares juniors and seniors in high school for both college and the workforce. Besides the skill building training, participants learn business, teaming and entrepreneurial skills as well as community engagement which gives them tools to survive and thrive in a 21st century global economy and to add to the social and economic capital of their communities. The program is held all day Fridays and is currently serving students from Pahoa High School, Kua 0 Ka La Public Charter School, Hawai'i Academy of Arts and Sciences, and Connections Public Charter School. The After-School program is held MWF from 2-5 p.m. and offers the same curriculum in a modularized format to a broader age range of students,14-18 years, and takes on real world clients as a work training component. There is also a middle school After-School component held on Tuesdays and Thursdays for students aged 12-14 yrs. in collaboration with the Boys and Girls Club. In this program, students are introduced to the three skill building areas available at the Center as well as taught pro-social skills with a strong Hawaiian values/multi- cultural approach and environmental stewardship emphasis. Total Budget and Position Count Total Program Budget 161,000 Total Program Position Count 5 PT Total Agency Budget 161,000 Total Agency Position Count 5 PT Program Objectives: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 9 1) Prevent drug use and other anti-social behaviors in Puna area youth by providing pro-social skill development, promoting cultural values and identity, and bonding with one's community; 2) Provide skill development in digital media arts, music and sounc recording, culinary arts, and business/entrepreneurship; 3) Cultivate the talents and economic viability of area youth; 4) Provide Youth leadership opportunities through community engagement, entrepreneurial training, and product and talent development; 5) Promote sustainability, healthy (lifestyles, and wise choices; 6) Provide a pathway to higher education and opportunities to connect with other youth globally. Program Highlights: (from Fiscal Year 2010-11) 1) A new partnership was forged with Kua 0 Ka La Public Charter School for the Running Start/Middle College program. We successfully worked with 20 of their students to do skill building in the three skill building areas of culinary arts, music/sound recording, and digital media arts. Thirteen of these students participated in the dual credit program with Hawaii Community College. They successfully created 5 videos on Tobacco Prevention; Healthy Relationships; Alcohol Abuse Prevention; Protection of Mauna Kea; and Beach Clean-Up and did a community showing at the Akebono Theater on May 4, 2011. 2) KYBC also increased its collaboration with other schools in its After- School Program. Connections PCS sent 14 students to the Culinary and Sound Recording trainings and gave them high school credit for their work. About 40 youth from five high schools (Waiakea, Hawaii Academy of Arts and Sciences, Kea'au, Kamehameha, Connections and 2 home schooled students earned certificates in the 3 skill-building areas . 3) The Digital Media program increased its reputation as a source for other organizations to train youth as well as produce high-quality video products. Notably, Malama 0 Puna came to the Center to train 5 teachers and 20 elementary students in video production for their watershed protection project. The County of HI hired KYBC to produce their Fair Housing video used for training purposes in spring 2011. 4) Researchers from Hawaii Pacific University and John A. Burns School of Medicine began collaborating with KYBC to use their students to be Production Assistants on a video project being funded by the National Institute of Drug Abuse (N IDA) to create culturally sensitive videos using local actors and scenarios for their research project to begin in fall 2011. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 9 • 5) The Hawai'i Alliance for Community Based Economic Development (HACBED) hired KYBC to cater two of its workshops for Kea'au Elementary students about financial literacy. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 9 Grassroots Community Development Group - Agency Name Kea:au Youth Business Center - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate 70 Youth develop video/graphic arts 110% 90% 100% skills 60 Youth develop music/sound 75% 80% 85% recording skills 60 Youth develop culinary arts skills 85% 85% 90% 80 Youth develop workforce, 100% 100% 100% business, and/or entrepreneurial training *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 56,226 60,000 60,000 Professional Fees 13,398 14,000 12,000 Operations 28,565 30,000 34,000 Equipment 3,261 5,000 5,000 Other# Rent: 36,000 Rent: 36,000 Rent: 39,000 Total $137,450 $145,000 $150,000 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 9 Grassroots Community Development Group - Agency Name Kea'au Youth Business Center - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate HI Tobacco Prevention and $75,000 $75,000 $37,500 Cessartion Trust Fund County of Hawaii $45,000 $35,000 $45,000 Other Grants $14,564 $20,000 $30,000 Contributions $7,321 $7,000 $7,000 Program Income $19.376 $15,000 20,000 Fundraising $4,000 $10,500 Total $161,261 $156,000 $150,000 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Our agency has plans to increase its capacity to produce projects that come into the Center. by collaborating with other businesses and organizations. We project that we can become self-sustaining in 3 years. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. N/A NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 9 Grassroots Community Development Group - Agency Name Kea'au Youth Business Center - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 9 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. f 'V71— Ar , .0 ( 2q l2 Signature of Bo rd Presioent/C air ' ate or Agency Director //7•1,li 2•• "..-- Signature of Execu ive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 9 31 Green Will Conservancy Inc., The Hui Mana'o The Green Will Conservancy Inc. Hui Mana'o Agency Director: Frank Capatch Phone No.: 808-965-5349 Contact Person: Frank Capatch Phone No.: 808-938-6565 Mailing Address: P.O. Box 1341 Pahoa, HI 96778 Facility/Site Address: 14-803B Seaview Rd. Pahoa, HI 96778 Fax No.: 808-965-5036 Email Address: frangipon @aol.com Name of Accountant/CPA (include name of firm if applicable): Nancy Jean Kramer, CPA/CVA Phone No.: 808-965-2729 Mailing Address: 15-2984 Pahoa Village Road P.O. Box 1519 Pahoa, HI 96778 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $35,000.00 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0.00 $0.00 $1,000.00 Agency Mission Statement: To empower the People with skills and practical methods to persevere and sustain; to work towards sustainability of the environment, individuals and communities by integrating social work research and practice in small scale programs. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 15 The Green Will Conservancy Inc. Hui Mana'o Program Description: Green Will Conservancy's program, "Hui Mana'o", means "Thinking Together and Sharing Knowledge". Since January of 2011, Green Will Conservancy has operated and sustained Hui Mana'o, a psycho-educational integrated program based on Sustainability, Health and Productivity. The program includes: 1) Sustainable, green lifestyle practices, 2) Social, mental and physical health programs, and 3) Youth habilitation/job preparation. The program is a weekend and summer day program on 2 acres of rain forest outside of the Town of Pahoa in the Puna district of The Big Island, Hawai'i. Hui Mana'o has shown measured success for youth, ages 12-18 in the following: understanding sustainable living; better functioning in home, school and community involvement; meeting personal mental health treatment goals; acquiring pre-vocational and job skills as well as decision-making competence for living a clean and sober lifestyle. After an initial mental health assessment, teens meet on-site with licensed therapists; they work and walk the land together, engaging in healthy exercise and individual counseling. The counseling addresses at least 2 treatment goals that focus on individual barriers to success. Substance abuse or addiction and tobacco awareness and prevention are addressed as well; tobacco is treated as a gateway drug in the program. Problem spheres may include social and/or individual domains such as school, family, low self-esteem, depression, teen violence and eating disorders, alcohol/substance abuse and teen suicide. Participants attend a weekly, 6-hour group gathering on Sundays. These gatherings include gardening activities, meal preparation and sharing of nutritious food as well as social and pre-vocational curriculums. There are four Levels to the Program Design: 1. Initially participants will focus on: a) Social and pre-employment skills, like typing, b) Exploring their pre-vocational interests and learning job skills such as following directions, being on time and dressing correctly, and c) The healthy living curriculum; gaining awareness of exercise and eating patterns; 2. The participants eventually progress to higher levels; based on monitoring through staff, community input, and their own self-monitored progress. Some examples of skills learning include personal money management, community involvement and volunteerism. Participants begin more formal vocational training at the GWC site, in areas of their expressed interests including: • Sustainable and healthy food practices and diet • Small-scale edible landscaping and gardening • Water collection systems NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 15 • Solar and other green technology • Sustainable environmental practices • Learning to make soil or reuse materials • Construction project: Cultural heritage arts and crafts, using invasive species for materials such as using Albezia wood to craft projects • Computer website: curriculum/presentation design and video production Note: Participants learn by the "tell, show, do" method. Competencies develop in giving presentations to their peers, practicing green methods and choosing healthy living actions. A goal is for participants to take these presentations into the community; into their schools and other youth organizations. This prepares the participants to establish leadership skills based on their innate capacities practiced within their community. Secondly, the GWC program value is charitably shared. Stipends offer incentives for progress. 3. Graduates of GWC have opportunities to be mentored into developing their own cottage industries and businesses (i.e. landscaping business, food products, website design) and/or be placed in internships. After the participants leave the program they are monitored yearly and are offered membership as an alumni member of Hui Mana'o's Trade Association wherein they may act in an advisory role for the program and monitor the quality of Hui Mana'o. A long term goal is for the Trade Association to improve networking, engage the alumni with the Business Networking International [BNI] as well as other Small Businesses and to consider longitudinal studies. 4. Hui Mana'o seeks an Annual Youth Leadership Conference Program where 3 regional youth during the summer after their junior year in high school, may be chosen to participate in a unique travel and cultural/community exchange opportunity in New York State. The Need & Reasons Why We chose this population: Native Hawaiians in this community have suffered (as have other worldwide Indigenous cultures that are local to East Hawaii) for centuries as a result of traumatic experiences endured due to colonization. In 2009, Browne, Mokuau, & Braun reported in their article, "Adversity and Resiliency in the Lives of Native Hawaiian Elders" that in the United States alone, indigenous groups such as Native Americans, Native Alaskans and Native Hawaiians share similar experiences of "forced incorporation into the dominion and the trauma of colonized peoples". Although native peoples today may not have experienced these traumatic events first-hand, there is often a sense of unresolved grief that is suffered by the ancestors of those who did. This phenomenon is referred to as Historic Trauma (HT). HT is often accompanied by symptoms such as: survivor guilt, trauma, anger, depression, and sadness. It often involves self-destructive behavior with alcohol NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3ofl5 and substance abuse, suicidal thoughts and gestures, anxiety, low self-esteem, as well as difficulty recognizing and expressing emotions. HT symptoms may also reveal themselves as somatic (physical) symptoms, with high mortality rates, as was reported by Yellowhorse Braveheart & DeBruyn in their 1998 article, "The American Indian holocaust: Healing historical unresolved grief". Browne, Mokuau, & Braun also reported in their above-mentioned article, that other effects of HT among Native Hawaiians include obesity, and a high prevalence of chronic diseases such as: cancer, diabetes, and heart disease. Furthermore, in 1972, Pukui, Haertig, & Lee argued in "Nana i ke kumu: Look to the Source" that, for Hawaiians, these symptoms could be viewed as internalized oppression as "every Hawaiian has a built-in inferiority complex". The foundation upon which the Hawaiian culture grew from was oppressed, resulting in a loss and confusion of culture and identity, and erosion of the Hawaiian culture. Hui Mana'o strives to address HT and its symptoms in the local population by focusing on healthy living and building on the strengths of the community's Hawaiian leaders, general community and family ties through an habilitation [education] model. Also, according to the Hawaii Department of Health's, "2000 Hawaii Student Alcohol, Tobacco, and Other Drug Use Study", the Puna area of East Hawaii is home to young people who are among the most at-risk youth in the state. Risk factors include some of the highest figures in the state of drug use, school violence and families on food stamps. According to a 2010 study published by the Hawaii Center on Family, Puna ranks second highest in the state in child poverty. Additionally, the numbers of high school students that are accepted into colleges are among the lowest in the state. It is common knowledge that since the economic downturn the challenges facing the community have increased. Also, resources to meet the needs of the area are declining; according to the "2009 State of Social Services" in Hawaii by R. Stotzer, the County of Hawaii in particular now reports the least manageable caseload of all the Islands. We chose this population also because we live here; this is our home and we are striving for greater quality of life for our East Hawaii neighborhoods. This population will benefit from the program's new generation of potential leaders who are able to achieve greater well being, both physically and mentally as well as financial and environmental re-centering and cultural reclamation. Other organization(s) or community group(s) that are partnering on the project: Alliances have been formed with Alu Like, Family Court and Teen Court. We are using our membership in the local Business Network International [BNI] group to fundraise, network and build relationships with others funders. We are a member of the local Hawaii Island's Food Bank, have received funding from The County of Hawaii and are partners with a number of Behavioral Health Service Reimbursement Agencies including HMSA, HMMA, Aloha Care, TRICARE, TriWest and CHAMPVA. We are also building relationships with: 1.)Hawaii NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 15 Alliance for Community Based Economic Development, from whom we are interested in requesting funding and also partnering with to build community assets by treating our local population and 2.) Hawaii Island United Way. We also partner with the Hawaii DOE and DOH to service this population. How the project promotes engagement and extends existing resources: •Money as incentive. The project is currently (and has been for over two years) funded by a stream of consistent revenue from: 1) Funds from 3rd party billing of participant's medical insurance and, 2) Donations from supportive community therapists who donate a percentage of their income to the project. •Experience as resource. Professional value exists in the form of highly trained and committed staff with a combined 60+ years of work in the human service field. •Transportation as resource. The program provides transportation to and from the facility. This is an important factor considering the poverty with a lack of reliable transportation for the population served. Additionally, parents' who work, are able to still provide service access by negotiating with the GWC Program. •Family support as resource. The Youth Program is supported by GWC's parents' and Kupunas' group; they meet regularly and use the same healthy living goals as the Youth Program. This Ohana-style of program design involves the entire family and meets the populations' need for family involvement. •Food as resource. The program feeds the participants and educates them about nutrition. The program utilizes a pot-luck style as well as providing essential nutritious foods. This promotes the sharing of learning how to prepare essential foods. •State of the art media technology as resource. Participants create structured curriculum and presentations with staff, producing tracking of progress of participants. This is a pari passu learning action i.e. both staff and participants are giving and receiving the learning. Finally, this leads to submitting materials to the GWC internet site wherein others can access and replicate the materials for their own purposes. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 15 The Green Will Conservancy Inc. Hui Mana'o Total Budget and Position Count Total Program Budget $94,915.00 Total Program Position Count 6pt Total Agency Budget $105,115.00 Total Agency Position Count 6pt Program Objectives: 1) Hui Mana'o's goal is to build a small scale comprehensive and replicatable social service model, which assists at risk youth, 14-17 and their families in overcoming obstacles to developing the skills necessary to be productive and contributing members of the community, with the following objectives for the next year (2012-2013) being: 2) To provide 20-30 teens and their families with licensed, professional intake and assessment services in order to match family and individual needs with appropriate interventions and/or resources. 3) Increase youth's executive functioning in pre-vocational and vocational areas of their interest. 4) Increase youth's executive functioning in the school environment; 5) Decrease youth's substance abuse and occurances of youth violence; 6) Improve social and relationship functioning among 10 youth, their peers, their families and communities as expressed in individualized identified treatment goals. 7) Increase youth's knowledge and practice of sustainable and green technology, practices and lifestyle. Program Highlights: (from Fiscal Year 2011) • Stipends: "(1991 Wodarski Ph.D., John, State University of New York at Buffalo, School of Social Work)" Wodarski indicated that all Social Services in engaging and treating impoverished communities showed the greatest improvements when two elements are present: 1) Skills development both social and work related. 2) Payment through stipend or working for payment. We provide both elements as incentives and use small business networks such as BNI, Alu Like as a means of exercising Dr. Wodarski's points. • There were twenty (20) Green Will Participant Intakes of which fifty-five (55) to sixty (60) family and community members were engaged. Of the twenty (20) intakes, eight (8) continued past three months and received NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 15 stipend level. With the eight (8) participants, we also engaged an additional seventeen (17) family members. Of the eight (8) participants four (4) continued past two months. The four (4) participants and their eight (8) family members continued to be engaged in programming. • We saw an average improvement of 21% among the participants who reached stipend level, or three months in the program. • The greatest improvement in any one participant was of 50% over the course of nine months. • 2011's group of participants had successful experiences and they increased their GAF (Global Assessment of Functioning) scores by an average of 4.12%. • Chartiable services provided to families that have no financial resources in the form of sliding fee scales and donated services. • Chartiable services are donated in programming development, triage calls, and assessments for resources for people in need in the community. • Program Highlights include: • Successful operations of Board of Directors • Needs assessment of Puna area, including other areas where there are similar needs, ages 14-17 • Design of Hui Mana'o program, for youth 14-17 • Acquired 2 acres of leased land and secured for five (5) years • Volunteer Curriculum completely • Recruitment of 17 families and 3 fully engaged participants • 1 acre cleared and developed into "Healing Garden" • 1/4 acre cleared and temporary structure purchased and erected • Collaboration began with Grassroots Community Development Group/Kea'au Youth Business Center for vocational cross training, curriculum diversity and providing mental health services to both programs. • Alliances formed with Business Network International (BNI), Alu Like, United Way, Family Independence Initiative, Family Court and Teen Court. • Temporary arrangement with a business to pay for and cover all utilities for operations. • Connections made with community elders and Kupunas • Workshops started in cultural arts and crafts with Kupunas and community members • Program staff, interns, and volunteers provide transportation and fuel costs for 50-75% of the program participatants. • Reaching out to those without suffucent monatary resources and still provide services based on a sliding fee scale as chartiable activity. • Received Public Support in the form of: • Public support/funds that have passed through GWC directly onto the participants and families: $2,957.48 • Volunteer hours: A total of 590 hours have been volunteered in kind NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7of15 • Interns: A total of 528 hours of intern services • Board of Directors Volunteered 660 hours in kind. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 15 The Green Will Conservancy Inc. Hui Mana'o Performance Measures: FY 2010-11* FY 2011- FY 2012-13* 12* Teens and their families: • 1-4 sessions Same Same 1. Participate in structured of intake. levels of licensed, professional intake and • 2 sessions assessment weekly: 1 a. Are matched with individual, & appropriate 1 group interventions and/or resources for • Stipends for achieving higher level successful of functioning. progress b. Impact measured by monthly before and after measures of Global • Measured Assessment quarterly Functioning [GAF] Program Participants: • Initial GAF Same Same 1. Improved GAF score. assessment • Semi- annually • Measured by comparison 2. Decrease in Drug and Alcohol • Initial Same Same use/are Drug and Alcohol free assessment by self, family, and other • Monitored reports. monthly • Measured Quarterly NONPROFIT GRANT APPLICATION FISCAL YEAR 201.2-13 Page 9 of 15 Performance Measures Continued: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate 3. Increase functioning level in • At Initial school targeted by individual assessment program goals i.e. • Individual a) Regular attendance intervals set b) Passing grades as per c) No suspensions treatment d) No violence plan • Measured semi- annually 4. Increase positive behaviors • At Initial Same Same with family targeted by assessment individual program goals. • Individual intervals set as per treatment plan • Measured semi- annually 5. Improve in pre-vocational • At Initial Same Same skills learning. assessment a) Successful coordination of • Individual transportation intervals set b) Participation as per c) Attendance treatment d) Preparedness plan e) Leadership). Assessed • Measured through before and after semi- program comparison and annually monthly. 6. Engaged in one community • Measured Same Same participation project semi- annually *If applicable NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 15 Program Expenditures FY 2011 FY 2012 FY 2012-13 Actual * Budget * Estimate Salaries and Wages $7,814.40 $26,000.00 $30,000.00 Professional Fees $4,253.96 $24,600.00 $26,500.00 Operations $15,482.87 $29,165.00 $35,000.00 Equipment $0.00 $13,500.00 $5,000.00 Other# $0.00 $0.00 $0.00 Total $27,551.23 $93,265.00 $96,500.00 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 15 The Green Will Conservancy Inc. Hui Mana'o Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2011 FY 2012 FY 2013 Actual * Budget * Estimate Professional Services Payments: $29,778.67 $55,000.00 $75,000.00 Sliding Fee Payments $1,500.00 $1,000.80 $2,750.00 Grants* $1,000.00 $35,000.00 $10,000.00 Donations $ 2,852.88 $2,227.00 $3,500.00 SEE Program Employee $1,687.20 $1,687.20 $0.00 Reimbursement** Fundraising $289.95 $0.00 $0.00 Total $37,306.70 $94,915.00 $91,250.00 *Grant of$1,000 from the County of Hawaii was awarded to us for 2011. **Hired a SEE Program Employee in 2011, reimbursements were disbursed over 2011/2012. Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The program is currently able to generate an average of $3,108.89 a month which equals $37,306.70 total in income for 2011. We received funds through third party billing for mental health services for its participants, grants, donations, and community supports. Although the program shows promising figures, the professional services provided via sliding fee scales, charitable work is provided to families in need who have little/no monetary resources, this status far exceeds the earned revenue. With the amount of chartible cases we are in need of subsity beyond the scope of earned revenues. While this revenue source is encouraging and has funded a number of initial projects, the program still needs additional money to further our focus on the exercise and nutritious eating part of the curriculum. We continue to work towards the goal of being sustaniable and self- sufficient. Sustainability plan: 1. Continue to bill private insurance for the professional services counseling/mental health component that is done through our program 2. Recruit families, kupuna's, and community members to volunteer their time and resources to educate and help us with land development, so that we are able to use fruits and vegitables from our garden to reduce expenses NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 12 of 15 3. Further develop therapist chairty and sliding fee scale program by implementing pro-bono efforts from the professional service providers 4. Continue to facilitate media technologies a. To stay informed about healthy diet and exercise patterns b. To promote public education about this program as a model c. To increase public awareness about various models for sustanability 5. Transportation Reach out plan: a. Secure a working, safe, reliable vechicle b. Fundraising for fuel c. Fundraising for maintanence costs Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. None NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 13 of 15 The Green Will Conservancy Inc. Hui Mana'o I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 14 of 15 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. ignatur f o7rd Presid t/Chair Date or Agency Dir'�ctor F 'yal gain scan 31 , 2012 Signa ure of E -•utive \ector Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 15 of 15 32 Habitat for Humanity West Hawaii Homebuilding for Hope Habitat for Humanity West Hawaii- Agency Name Homebuilding for Hope- Program Name Agency Director: Patrick F. Hurney Phone No.: 8-0 ' 33,-8b)o Contact Person: Patrick F. Hurney Phone No.: ssos_331-goto Mailing Address: PO Box 4619 Kailua-Kona Hawaii 96745 Facility/Site Address: 73-5576 Kauhola Street, Kailua-Kona Hawaii 96740 Fax No.: 808-331-8020 Email Address: ed @habitatwesthawaii.org Name of Accountant/CPA (include name of firm if applicable): Alex Smith, CPA Phone No.: 877-257-6484 Mailing Address: 1403 Frank Street, Honolulu, Hawaii 96816 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$42,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $30,000 $15,000 $20,000 Agency Mission Statement: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of Yo Habitat for Humanity West Hawaii — Agency Name Homebuilding for Hope — Program Name Agency Mission Statement: Habitat for Humanity West Hawaii is a non-profit, faith-based organization whose mission is to empower families and build community and hope through home ownership opportunities for low-income partner families. Our vision is that all residents of West Hawaii will achieve that through our affordable homebuilding efforts. We serve the entire west side of the Big Island of Hawai`i from Hawi to South Point, where the lack of low-income sustainable housing has been extensively detailed at both the County and State levels. Granted affiliation with Habitat for Humanity International in 2002, this affiliate is a volunteer driven organization with only four (5) full-time staff, including Executive Director, Resource Development Director, Accountant, Community Relations Director, and the ReStore Manager. The home building projects are undertaken by a committed group of local community volunteers. A dynamic and involved Board of Directors, comprised of 10 members, provides overall leadership to the affiliate. Funding comes from individual, foundation, agency and corporate donations. Habitat for Humanity West Hawaii stands out from other providers of low income housing in several significant ways. A Habitat mortgage is designed so that no family is paying more than 21% of their monthly income on their housing, - 30% with utilities, taxes and insurance. Habitat builds homes for families earning between 40-80% of the median income for the County on a no-interest, no-profit basis and requiring only a 1% down payment. Families are required to perform a minimum of 500 hours of "sweat equity". The family support component of the Habitat program provides assistance with budgeting, house repair and maintenance for the duration of the mortgage. The Habitat model allows for the family to have a low monthly mortgage rate (between $350.00 $450.00) and to use the remainder of their income for reliable transportation, quality food, adequate health care, education and recreation. In this way, we seek to break the cycle of poverty for our partner families, helping them to acquire an asset that they can pass on to their children. Habitat for Humanity West Hawaii also operates a `green' social enterprise, the ReStore, which accepts donations of new and used building materials and sells them to the public at deeply discounted prices. Over 300 tons of materials are kept out of the landfill on an annual basis through this type of recycling. Profits pay operating costs and are used to build more local Habitat houses. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-2013 Page 2 Habitat for Humanity West Hawaii— Agency Name Homebuilding for HOPE — Program Name Program Description: This project is designed to expand the capacity of our homebuilding program by creating the flexibility to build multiple homes simultaneously. Each year, our affiliate grows and strives to increase its building capacity. In its short history of building homes, Habitat for Humanity West Hawaii (HFHWH) has earned a 'Home Builder" affiliate status—building 3-4 homes a year;-the organization is now ramping up to earn "Neighborhood Builder" affiliate status in 2012, where 10 or more low-income families will be placed into homes of their own annually; and also provided with the support services necessary to ensure their successful transition into sustained home ownership. In recognition of the steady increase in capacity of our affiliate, and to acknowledge the increasing number of low-income families living in substandard housing, HFHWH has been selected as the official site of the next Habitat "Blitz Build" in September, 2012. This involves an accelerated building schedule where five homes are built in a 10 day period. In addition to the five homes built during the Blitz Build, at least two other homes will be under regular construction at the same time. Following the Blitz Build, we are preparing to complete three additional houses in 2012—for a total of 10 homes to commemorate and celebrate the 10th anniversary of our affiliate, and to achieve Neighbourhood Builder status from Habitat for Humanity International. Our 2012-33 project to complete 10 homes can therefore be described as "Homebuilding for HOPE": Hana me nã `Ohana 'Oiwi i ka Pono, no ka 'Ea oka `aina ("Working with the native families for the right reasons for the life of the land") Habitat for Humanity West Hawaii is seeking $42,000 to fund seven (7) Site Supervisors with professional building skills to supplement the capacity of the Construction Manager (hired with funds from the County in fiscal 2010-11). This will allow the affiliate to undertake multiple builds simultaneously, and will enable the recruitment and training of volunteers for future builds. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 Habitat for Humanity West Hawaii- Agency Name Homebuilding for HOPE — Program Name Site Supervisors with professional building skills will also ensure that HFHWH adheres to its strategy for sustainability— providing housing using methods, products, and processes that create healthy homes and communities that are less expensive to operate, more durable, and that conserve resources throughout construction and after. This sustainability strategy recognizes that Habitat partner families are least able to afford the escalating costs of energy and compromising environmental conditions. The goal is to make each home financially sustainable for the family, both in terms of initial cost, but more importantly, in terms of its life cycle cost of the home and utilities. (Note: County funds in 2011-12 allowed the affiliate to fund 3 site supervisors, allowing us to undertake three builds simultaneously for the first time, and to see the benefits of dedicated site supervision.) We believe that this request is aligned with the priorities of the County, General Plan—addressing the lack of affordable housing, and ensuring energy efficiency and environmental quality. Total Budget and Position Count: Total Program Budget $42,000 Total Program Position Count 7 Total Agency Budget $675,000 Total Agency Position Count 7 FT and PT NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 Habitat for Humanity West Hawaii- Agency Name Homebuilding for HOPE — Program Name Program Objectives: These part-time site supervisors are critical to meeting the needs of an ever-increasing number of native Hawaiian families whose opportunities for home ownership have always been limited and have decreased due to rapid increases in building costs. The following objectives will be met: o There will be a greater ability to build multiple homes simultaneously o Each build site will have a dedicated supervisor with professional skills who will ensure the smooth flow of operations at the site,thereby eliminating scheduling conflicts and missed deadlines. o The site supervisor will determine the most cost-effective plan and schedule for each individual house,thereby eliminating unnecessary waste. The Construction Manager will be freed up to build economies of scale into the expanding operations o At each build site, the site supervisor will recruit and train a cadre of volunteers to work with trade contractors to complete specific pieces of construction. This will not only provide marketable skills to the volunteers, but also ensure a corps of trained individuals in preparation for future builds o Habitat for Humanity West Hawai'i is committed to building 'sustainable' building, and the site supervisors will ensure the incorporation of the following measures at each site: 1. Minimize the depletion of natural resources 2. Decrease the amount of construction waste going to landfill 3. Control erosion and minimize the impact on natural resources 4. Increase energy efficiency and conserve water in construction 5. Incorporate the use of landscaping strategies to complement the built environment 6. Reduce maintenance costs by using innovative and durable materials 7. Improve indoor air quality by providing proper ventilation 8. Ensure smart site planning and land use 9. Assess the life cycle costs and benefits of sustainable building NONPROFIT GRANT APPLICATION FISCAL YEAR 2011-12 Page 5 Habitat for Humanity West Hawaii- Agency Name Homebuilding for HOPE — Program Name Program Highlights (from Fiscal Year 2011-12) o 13th home completed; construction of 14th home is about to commence o Seven families approved by Family Selection Committee; 3 in progress o Full-time Resource Development Director hired o Corporate Engagement Strategy approved by BOD; Part-time Corporate Engagement Coordinator hired o Second annual signature fundraising event held with positive outcome o 5 Year Strategic Plan is on track—includes goals for homebuilding; partnerships; financial capacity; recruitment and retention; volunteer management, etc. o Awarded Pualu Award by Chamber of Commerce for environmental awareness o 300 tons of building material saved from landfill NONPROFIT GRANT APPLICATION FISCAL YEAR 2011-12 Page 6 Habitat for Humanity West Hawai`i - Agency Name Homebuilding for HOPE — Program Name Performance Measures: for fiscal 2012-13 Objective Activity Measure Responsibility Outcomes Hire Site Place Ad in West Multiple homes Supervisors Hawai'i are built Today and Craigs Executive simultaneously; List; Site Director and more families are Supervisors Construction served Review hired Manager, with applications; assistance from Construction is Building efficient and Interview and hire Committee focused on "green" practices Homebuilding costs are reduced through economy of scale Recruit and Volunteer Construction Trained volunteers train recruitment Manager and Site are available for volunteers campaign Supervisors multiple builds for builds Select a cadre of 10 -12 volunteers Volunteers gain in 4—6 Corps of 10- Construction marketable skills communities; 12 trained Manager and Site volunteers Supervisors Assess skills are available needed and in several match volunteers West Hawai'I Site Supervisors with appropriate communities professionals NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 Habitat for Humanity West Hawaii - Agency name Homebuilding for HOPE — Program Name Program Expenditures: ( **specific to this program only) FY 2010-11 Actual FY 2011-12 Budget FY 2012-13 Estimate Salaries Professional fees 20,000 42,000 Operations Equipment Other Total $20,000 $42,000 Program Funding Sources: Identify all funding sources (**specific to this program only) Revenue Source FY 2010-11 Actual FY 2011-12 Budget FY 2012-13 Estimate County of Hawaii 0 20,000 $42,000 General Operating 0 Total 0 $20,000 $42,000 Note: Because Habitat for Humanity West Hawai'i has only one "program" —the homebuilding program for low-income families, - the overall Homebuilding Program expenditures and revenues are listed on a per houses basis on the following page. This will indicate the context of the current request for funding from the County. The Family Selection Committee has selected7 families with 3 more being reviewed, and this request reflects the desire of the affiliate to increase its capacity and volunteer resources by building concurrently. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 Habitat for Humanity West Hawai`I — Agency Name Homebuilding for HOPE — Program Name Homebuilding Program - •Per House Expenditures and Revenue Expenses: Per build HPM Package Home 34,000.00 Solar(est.) 5,000.00 Grading/Driveway 17,000.00 Concrete 1,000.00 Plumbing 5,000.00 Electrical 5,000.00 Drywall and Finishing 5,000.00 Environmental Assessment 1,000 Site Supervisor(3000 in beg.And 3000 at completion) 6,000.00** Administration Fee 7,800.00 Total 86,800.00 Funding Sources Amount Office of Hawaiian Affairs 20,000.00 State Revolving Loan Fund 20,000.00 Federal Home Loan Bank 12,000.00 Softwood Lumber Grant 8,500.00 Habitat Restore/grants and donations 20,000.00 Total 80,500.00 NONPROFIT GRANT APPLICATION FISAL YEAR 2011-12 Page 9 Habitat for Humanity West Hawaii - Agency Name Homebuilding Program — Site Supervision — Program Name Explain what plans, if any,your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self- sustaining? Sustainability for the Homebuilding Program is very close: o The popularity of the ReStore has resulted in increased donations and increased revenue each year. o With each new home built, the affiliate's "Fund for Humanity" continues to grow. This fund is fed by the mortgage payments received from the affiliate's partner families, which then revolve back into home building. The more Habitat homes built,the faster and greater the fund grows. This is also the mechanism by which our partner families "pay it forward"to help other low-income families obtain a safe, decent, and affordable home. o The Board of Directors has endorsed a five-year Strategic Plan that specifically addresses fiscal solvency. o A Full-time Resource Development Director has been hired, and a staffed corporate engagement strategy is underway, in addition to regular grant writing activities. o The affiliate hosted its second signature fundraising event in December, with positive results. This is now an annual event. o By the end of 2012,the affiliate hopes to share a new warehouse with another non-profit agency. This will reduce rent and create efficiencies in administrative operations,thereby allowing more funding to go directly into the building of Habitat homes. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii N/A NONPROFIT GRANT APPLICATION FISCAL YEAR 2011-12 Page 10 Habitat for Humanity West Hawaii - Agency Name Building for Hope - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135—2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 7 Any funds unused by June 30, 2013 must be returned to the County of Hawai'i within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. 1 (c v( Signature of Board President/Chair Date or Agency Director 3/z/z. Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 7 enceHabitat for Humanity° West Hawaii Job Title: SITE SUPERVISOR Reports to:, CONSTRUCTION PROJECT MANAGER Summary: A site supervisor is sometimes called a house leader. On a multiple house build, there is a house leader for each house on each workday when volunteers or staff will be working. The following are a summary of responsibilities: • Site supervisors organize and manage the full volunteer construction team so that goals are met by the end of the day. • Site supervisors list tasks needed to be accomplished that day and match volunteer crew leaders with volunteer crew members to do each task. • Site supervisors are responsible for the day's schedule,job safety and maintaining the quality of workmanship. • A site supervisor typically will not be present on site on a day when only subcontractors are working. Additional Responsibilities • In accordance with Habitat for Humanity West Hawaii Plans, Specifications and quality requirements, supervises overall construction activity and provides leadership to construction activity, including all paid sub-contractors and volunteer builders. • Under the direction of the Construction Project Manager, trains house leaders and crew leaders. • Tool coordination and transportation • Coordinate with Community Relations Director and Construction Project Manager volunteer needs • Supervise volunteers on site (including crew leader) • Layout (prepare for Construction Manager review) • Responsible for site safety • Work with Volunteer Coordinator to identify crew leaders • Responsible for site log • Gather volunteers together at the beginning to each day for safety talk and prayer • Meet weekly with the Construction Manager(Volunteer scheduling, updates, materials, etc.) • Works closely with purchasing manager to ensure materials and service needs are provided in a timely manner to the job sites. • Treats pattern families with respect and dignity. Strives to make their construction involvement meaningful and reminds house leaders of this ministry requirement. • Supervises job site on each designated workday. • Understands elements that contribute to successful volunteers and helps ensure that volunteers have a consistently good experience thus motivating them to return. • Anticipates problems and issues typical of this ministry and personally acts on same if necessary to help ensure schedules are met and work plans are enabled. • Evaluates and implements good safety practices and constantly stresses same with house leaders and volunteers. • Ensures that communications to volunteers are accurate and timely. • Identifies volunteer jobs/needs not currently filled and communicates needs to Construction Manager. • Trains all volunteers utilizing others on his/her team. • Suggests potential advantageous building practices and material cost saving opportunities to construction chairperson as identified. • Supervises all site preparation and layout. • Supervises all warranty complaints and repairs. • Meets long and short term goals established with the Building Committee and Executive Director. Skills Required: • Considerable knowledge and experience in the construction/contracting business. • Construction management experience preferred. • Team-building experience a real plus. Personal Attributes: • Must be a good listener and be able to engage in well-considered discussions. • Must have good anticipatory abilities and personally act on same as needs arise. • Must be willing to understand the big picture of the Habitat Ministry and know that construction is only a part of the larger goal. Signature: Date: .40PN, Habitat for Humanity® ty West Hawaii "Building houses, building hope" General Duties: Construction Manager • Coordinate with the Executive Director to do budget • Make Build Schedule • Site plans and house plans with Executive Director • Get bids • Call and coordinate sub contractors • Get permits • Take off for materials • Order materials and coordinate delivery • On site for deliveries • Make cut lists (lumber) • Layout • Coordinate with office (Community Relations Director) for volunteers • Coordinate with Site Supervisors • Attend building committee meetings • Maintain quality of construction • Call for inspections • Understand all code requirements • Notice of completion/final inspection/all utilities are operable ` -� ri , . „_., ,no. . ,, ,,., „, ,. . ,,,.A.,. .,,,.., •, ,,,.---T .,.. -.. ..-.. •-•:',.-;-'44-,..-- -;:...,-.\-;,s.:-.,,e...-...„..tt:-<•,..::.-‘i;..,:,,.:, _:-.,-•:— :,,,;:' -.:144.4,34"..k. ..,..' • ', ' 7' , .'-', ^41--— '''-',:* --;''', ..:','' --,',.'', ''' ' .. .,, A •. , i: 'Y,'.'''? :Ii!.4k..,''' .. s...... :'.,.'':.:.'.4.1.,.,,:::'.'fi ..'''''''*=',:'• ''' i I - ' --. 1 ,...;4_4, tr.; '1 .Z'. ,..';`,'. 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' - 33 Hamakua Health Center The Amazing Tooth Brush School Outreach Program Hamakua Community Health Center Amazing Tooth Bus Outreach Program 2012-2013 Grant Application Hamakua Health Center The Amazing Tooth Bus School Outreach Program Agency Director: Patrick Linton Phone No.: 808-930-2721 Contact Person: Patrick Linton Phone No.: 808-930-2721 Mailing Address: 45-549 Plumeria Street Honoka'a, HI 96727 Facility/Site Address: 45-549 Plumeria Street Honoka'a, HI 96727 Fax No.: 808-775-1206 Email Address: plinton @hamakua-health.org Name of Accountant/CPA: CW Associates, CPA Phone No.: 808-531-1040 Fax: 808-531-1041 Mailing Address: 700 Bishop Street, Suite 1040 Honolulu, HI 96813 Amount of Request for County Grant-in-Aid funds: $15,000.00 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $0 $0 Agency Mission Statement: Hamakua Health Center, Inc. is a community owned and governed 501(c)(3) corporation whose mission as a federally qualified community health center is to provide accessible, quality health care and education services which emphasize individual and community wellness, regardless of an individual's ability to pay. Page 1 of 9 Hamakua Community Health Center Amazing Tooth Bus Outreach Program 2012-2013 Grant Application Hamakua Health Center The Amazing Tooth Bus School Outreach Program Program Description: Hamakua Health Center(HHC), which also includes the Kohala Family Health Center in Kapa'au, has been part of the Hamakua Coast and Kohala areas since the early plantation days. Beginning in 2009 all Federally Qualified Community Health Centers are required under the Public Health Service Act to provide oral health services that are integrated with primary medical care and behavioral health services. HHC added these services by acquiring The Amazing Tooth Bus through a CDBG grant in February of 2009. The Amazing Tooth Bus is a 38 foot mobile dental van equipped with three operatories, digital x-ray equipment, computerized electronic dental record systems, and disposable supplies. It is staffed by a qualified general dentist, two dental assistants, and a dental manager. The mobile unit travels in a three-month rotation between the Honoka'a and Kapa'au clinic sites to service patients by appointment in those areas. The Amazing Tooth Bus targets dental services to the underserved, low income populations in the North Hawaii region including children and adults. During our successful outreach efforts in 2009 at Honoka'a and Waimea Elementary Schools we served over 300 children - preschool through sixth grade. We know first hand the huge disparity in access to oral health screening and treatment services for low- income and uninsured children that exists in North Hawaii. In order to reach these under- served children and greatly improve access to oral health services, an expanded program of outreach services provided in the van directly at school locations is being proposed. There are currently 13.5 FTE dentists on the Big Island who report that they are available to serve the low-income population. From that group, 6.5 report that they serve Medicaid patients, yet only one of these dentists practices in our primary service area of North Hawaii. This leaves a huge gap in oral health services for low income children. Our children's oral health remains among the worst in the nation. Studies of common oral health indicators for children, such as untreated dental caries and baby bottle tooth decay, show Hawai'i with rates up to four times worse than the national average. Children in vulnerable populations fare even worse than indicated in the already poor state averages. These vulnerable children include those from certain geopraphic areas and from specific ethnic and economic populations. Lack of access to oral health services for the low-income is the leading reason for such poor oral health status. HHC is requesting$15,000 from the County of Hawaii to improve the oral health and well being of low-income children in North Hawaii by expanding our program geographically and bringing The Amazing Tooth Bus to Waimea Elementary School for a two week period to provide dental screenings, education, comprehensive and urgent dental services to many children who would not otherwise have access to dental care. Page 2 of 9 Hamakua Community Health Center Amazing Tooth Bus Outreach Program 2012-2013 Grant Application Hamakua Health Center The Amazing Tooth Bus School Outreach Program Total Budget and Position Count Total Program Budget $24,807 Total Program Position Count 5 Total Agency Budget $5,367,900 Total Agency Position Count 56 Program Objectives: 1) Perform preliminary visual dental screening of 200 under-served children kindergarten through the fifth grade using the Waimea Elementary School campus as the outreach location by June 30, 2013. 2) Provide oral health education to 200 under-served children kindergarten through fifth grade by June 30, 2013. 3) Provide comprehensive and emergency dental services for 100 under-served children, kindergarten through fifth grade that would not otherwise have access to care by June 30, 2013. 4) Provide free oral hygiene kits ("Goody Bags") to 200 under-served children, kindergarten to fifth grade by June 30, 2013 (contents to include toothbrush, toothpaste, dental floss, dental timers, fluoride, disclosing tabs, dental bags and fun stickers). Page 3 of 9 Hamakua Community Health Center Amazing Tooth Bus Outreach Program 2012-2013 Grant Application Hamakua Health Center The Amazing Tooth Bus School Outreach Program Program Highlights (from Fiscal Year 2010-2011): Although not funded by the County of Hawaii for this fiscal period, we do have several success stories to share In 2011 we targeted low income children at Waimea and Honokaa Elementary Schools to complete dental screenings. Our results found the following: Waimea Elementary: Total Screened: 168 # students with visible cavities: 106 # students who needed urgent treatment: 27 Honokaa Elementary: Total Screened:46 # students with visible cavities:23 # students who needed urgent treatment: 8 As evidenced from these screening results, many children clearly are in need of continuing dental treatment or urgent care. Even though all children screened and treated were provided information to become patients and receive additional services, only a handful (10%) actually signed up with our program and began treatment. The conclusion is obvious: although providng brief screening services by dental staff directly at school locations is helpful, it is not nearly as effective in reaching under-served children as rotating the Amazing Toogh Bus to provide general and urgent dental care for a more prolonged period at school locations. Our proposed expanded outreach to the schools will benefit those students whose parents do not take them to the dentist for various reasons. The Amazing Tooth Bus officially opened May 2nd 2011 in Honokaa. Since that date we have provided services to: # children 1-20 yrs: 281 # adults 21+ yrs: 125 Page 4 of 9 Hamakua Community Health Center Amazing Tooth Bus Outreach Program 2012-2013 Grant Application Hamakua Health Center The Amazing Tooth Bus School Outreach Program Performance Measures: The Amazing Tooth Bus FY 2010-11 FY 2011-12 FY 2012-2013 Dental Mobile Outreach Program Actual* Budget* Estimate 1. Visual dental screenings of 200 200 children low income children kindergarden will be through fifth grade will be identified and conducted to collect baseline Oral screened at the Health data and identify children Waimea most in need of services. Elementary School site Target population will be the dentally underserved: low income uninsured and Quest-Medicaid insured. 2. Comprehensive dental services will 100 children be given to 100 children identified identified as in the pre-screen as most in need most in need of care and will be provided by our will be served dental team. at the Waimea Elementary Services will include dental School site exams/x-rays, prophylaxis, fluoride applications, sealants, restorations and extractions. 3. Oral Health Education seminars 200 children will be given to the target will be given population. Oral health supplies oral health such as toothbrushes, dental floss education . and toothpaste will be given to each child. *If applicable: Page 5 of 9 Hamakua Community Health Center Amazing Tooth Bus Outreach Program 2012-2013 Grant Application Hamakua Health Center The Amazing Tooth Bus School Outreach Program I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copies documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Page 8 of 9 Hamakua Community Health Center Amazing Tooth Bus Outreach Program 2012-2013 Grant Application Hamakua Health Center The Amazing Tooth Bus School Outreach Program By signing below, you are acknowledging that you have read and understand these requirements. AAA ,6 / Nt h,. ,[i.. 01 Je: i Navarro Si. ature of Board President/Chair Date Patrick Linton Signature of Executive Director/CEO Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! Page 9 of 9 34 Hamakua Youth Foundation Hamakua Youth Center Hamakua Youth Foundation- Agency Name Hamakua Youth Center- Program Name Agency Director: Vikki Catellacci Phone No.: 8087750976 Contact Person: T. Mahealani Maikui Phone No.: 8087750976 Mailing Address: POB 381 Honokaa, HI 96727 Facility/Site Address: 45-3396 Mamane St. Honokaa, HI 96727 Fax No.: Email Address: HamakuaYouthCenter @gmail.com Name of Accountant/CPA (include name of firm if applicable): Aloha Business Services Phone No.: 808-329-9220 Mailing Address: 74-5596 Pawai PI. #3E, Kailua-Kona, HI 96740-1688 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $20,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $15,000 $10,000 $15,000 (YWCA/HYC) (HYC) (HYC) Agency Mission Statement: The Hamakua Youth Foundation (HYF) is a community based organization dedicated to creating no-fee,nurturing youth service programs for ages ten through eighteen during non-school hours, engaging youth in environmental sustainability and stewardship, providing Hawaiian culture and arts education, developing youth leadership, and connecting youth and their families with local social services agencies. Hamakua Youth Foundation - Agency Name Hamakua Youth Center- Program Name Program Description: In our fifteenth year of serving youth in Hamakua, the Hamakua Youth Center (previously administered by Hawaii Island YWCA) came under the administration of the Hamakua Youth Foundation, a community grass-roots organization, which received 501(c)(3) status on September 15, 2009. The Hamakua Youth Center (HYC) is a drop-in youth and community program open after school Monday through Friday 10am to 6pm during school intersession and summer break. Our no-fee services to youth and families serve 350 youth annually with 150 participating on a weekly basis (with emphasis on primary focus on services for teenage youth). Our doors are open to children as young as 6 if they are accompanied by an older sibling. This request is for the continuing support from the County of Hawaii for programs and activities conducted at the Hamakua Youth Center. The Hamakua Youth Center (HYC) is operated by the Hamakua Youth Foundation. We are a grassroots all volunteer organization making a passionate effort to provide much needed quality afterschool recreational and educational programs daily and during the intersession periods throughout the the year. We are now entering our third year operating our community's youth center. The Hamakua Youth Foundation is the only community run and supported program in North Hawaii. We hope to continue to grow and create a model for other local rural communities to follow. "Our House", passionately nicknamed by our participants, is open to keiki of all ages with particular program emphasis on youth ages 11-17. Participants are register annually. Our programs are free and no-fee is ever collected to participate. Our House provides an adult supervised, safe place to gather with friends in a fun learning environment. Our programs and activities are expanding and they include a computer lab for completing homework assignments, tutoring from staff and volunteers, music room (where participants can sing their hearts out), arts and crafts, a pool table, group games (scattegories, clue? etc.) board games, and special events (peace parade, open house, girls/boys night etc.) Other Special Progamming: Many Participants and their families continue to experience the effects of the difficult economic times that are present in the Honoka'a area. Healthy foods are available daily at no charge to our keiki. Much of it are received from donations from local farmers, the Hawaii Food Basket and the generous contributions of community members. The keiki participate in the food preparation and clean-up. This provides true learning experience and contributes to our efforts to build a sense of personal responsibility, involvment and an overall goos feeling about oneself. The HYC staff have scheduled once a month gender specific Boys/Girls night. Guests include recognized community people that facilitate age appropriate discussions on topics of interest to the participants, most of whom are in the intermediate school transitional age of personal growth. A Center Youth Council continues to grow in importance participating in the planning, organizing and leading specially scheduled events and acting as mentors to younger keiki. HYC staff continue to have a working relationship with the juvenile and teen court systems receiving court referrals for community service. We take our obligation seriously in ensuring that the assignments not only provide us wth needed help, it is also beneficial to the community service participant. We are seeing an increaseing amount of parent and family involvement as volunteers at the Center, something that has not occurred in the past. Family nights are being planned which may include movies and opportunities for participants to showcase their creative talents. Our Approach: The HYF Board and Staff believe that the true measures of success in youth programming include creating experiences where youth work in concert with other youth and adults to build long term self concept, where individual growth prevents unhealthy behaviors such as teen alcohol and drug use and unwanted pregnancy, which are unfortunate challenges in our community. Our approach in conducting programs is based on Hawaiian cultural values with staff and volunteers acting as positive role models. Emphasis is also focused on our desire to build future leaders and life long learners who will practice and share these values: Aloha Kekahi I Kekahi (Love One Another), Kokua Aku-Kokua Mai (Give Help-Help Returns), Malama I Kou Kuleana (Take Care of YOUR responsibilities), Mahalo I Ka Mea Loa'a (Be thankful for what you have). Total Budget and Position Count Total Program 106,000 Total Program Position 4 Budget Count _ Total Agency 150,000 Total Agency Position 6 Budget Count Program Objectives: The Primary objectives of the Hamakua Youth Center are to provide a safe adult supervised place for youth K-12 to come and participate in a variety of recreational and educational programs and activities which contribute to learning, fun and provide and environment which motivates youth to share their experiences with others. Model and place emphasis on Hawaiian cultural values including: Aloha kekahi i kekahi (love and respect one another), Malama I kou kuleana (taking care of responsibilities), Kokua aku-Kokua mai (Give help - Help Returns), and Mahalo I ka mea loa'a (be thankful for what you have). Create opportunities which help facilitate personal growth and self concept for our youth participants. Provide a much needed place in the community for youth during non-school which provides positive alternatives to unhealthy ones such as drug and alcohol use, teen pregnancy and other obstacles in their journey to adulthood and future lives. Program Highlights: (from Fiscal Year 2010-11) 1) Participants have a sense of ownership they have renamed and passionately call the center"Our House". 2) Increase in daily participant drop-in 25 to average 35-40. 3) No New pregnancies among girls who regularly visit the Center. 4) Participants who are engaged in cultural value activities have made better choices. 5) The Centers environment encourages harmony and prevents participants from acting out. 6) Quality adult supervision has significantly reduced risk-taking behavior. 7) Providing couseling as a preventative tool to avoid unhealthy choices. 8) Health, dental, counseling referrals, court dates, transportation and advocacy for youth's needed services. 9) Gender specific Girls and Boys Nights, which include subjects of interests to kids. 10) Lo'i restoration in Waipi'o Valley, which provides participants to get reconnected with their culture. 11) Jewelry making, arts and crafts, letting participants expand their creative side. 12) Completed the development of the strategic plan. 13) Creation of a newly formed Youth Council which plans, organizes and leads in Center actitvities. Hamakua Youth Foundation - Agency Name Hamakua Youth Center - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 A ctual * Budget* Estimate Average Daily Attendance by 30 35 40 youth Total Number of youth served 300 350 400 annually Total Number of Waivers/ 150 200 300 Orientations on file signed by parents of youth participants AG/Mahi'ai Comm. garden 40 50 70 Backpack Program/Family food 35 45 55 Distribution Council/Boys or Girls Nights 30 50 80 Community Service Projects 45 60 70 Hawaiian Culture Programs 60 80 100 MultiMedia/Music 50 75 100 Scholarships 0 2 3 Total Number of Volunteers 20 25 35 *If applicable Eng= Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 79,098.51 103,690 95,000 Professional F ees 10,482.54 9,572 10,028 Operations 22,954.29 19,080 21,017 Equipment 0 130 250 Other# 13,301 12,415 23,705 Total 125,836 144,887 150,000 If applicable Please see Attachment A for details Hamakua Youth Foundation - Agency Name Hamakua Youth Center - Program Name Program Funding Sources: Identify all funding sources (spescjfic to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate County of Hawaii 10,000 15,000 20,000 HAPA Fund 2,500 2,000 2,000 Hawaii Island United Way 13,333 10,000 10,000 Atherton Family Foundation 10,000 10,000 10,000 Change Happens Fund 4,000 4,000 4,000 John Ross Fund 5,000 4,000 5,000 WalMart 0 30,000 . 30,000 Community Donations/ 21,734.33 24,951.35 24,000 Fundraisers North Hawaii Rotary Club 1,300 650 1,000 Total *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? We will use our Strategic Plan as a vehicle for long term sustainability including increase in partnerships with other local organizations, expanding list of long term HYF financial supporters, semi-annual major fund raising events, proposals to private foundations, receiving special contribution from the business community, effective use of volunteers, continued involvement of a working Board of Directors, keep administrative costs to a minimum, continue to seek private contributions of office and program materials, expand our network for food donations, continue media exposure which highlights our accomplishments and success stories, schedule presentations at community groups such as community associations and service clubs. Future Program Support: The Hamakua Youth Foundation (HYF) has completed their strategic planning process what focuses on long term sustainability and address the needs of the Hamakua Youth Center (HYC) over the next 3-5 years. We will continue to seek funding from the North Hawaii community through an annual fundraising campaign which includes special events sponsored by it's fundraising arm, the Friends of the Hamakua Youth Center. The all-volunteer Hamakua Youth Foundation Board of Directors work in concert with staff in grant writing, media, marketing and community outreach. HYF is fortunate to receive regular donations of food from the Hawaii Island Food Basket, Queen Lili'uokalani Children's Center, B. Ikeuchi & Sons, JJ Andrade Meat Market, local farmers etc. We recognize the importance of collaboration with local businesses and other non-profit organizations and collaboration is the best and most effective use of limited resources. Supporters: Working Partners- ARC of Kona Honokaa High, Inter and Elem. School Hamakua Harvest Hamakua Health Center Hawaii Sustainable Education and Research Center Community Garden Kanu o ka 'Aina Learning 'Ohana North Hawaii Drug Coalition North Hawaii Education and Research Center Honokaa Peace Day Committee Salvation Army Waipi'o Circle YWCA Hawaii Island Hawaii Island Food Basket Community Supporters- Hamakua Times Honokaa Business Association Hawaii Community Foundation ILWU Hawaii Island Local 142 Queen Lili'uokalani Childrens Center North Hawaii Hospice North Hawaii Rotary Many anonymous community members who contribute through the Friends of Hamakua Youth Foundation fundraising efforts. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. NONE Hamakua Youth Foundation - Agency Name Hamakua Youth Center - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135—2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 gays after Jude 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely,,complete, and accurate year-end report will i_pact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/ grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. i e .�L..1� _ - 3ctntia,r-yy31, 4'0 l2- Si•ir re of : . - • President/Chair Dbte or •ency Di ► or ALI Ok; Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! �o�aitokua Malaria M Lej HamakuaYouth Foundation,Inc. Attachment A Emgranalapendinzglxplanation County of Hawaii Non-Profit Grant FY 10-11 Food&Beverages $2,306 Fundrasing Expenses $250 Program Supplies $8,406 Program Travel $2,339 Total FY 10-11 $13,301 FY 11-12 Food&Beverages $3,596 Fundraising Expenses $2,447 Program Supplies $3,289 Program Travel $3,083 Total FY 11-12 (so far) $12,415 Hamakua Youth Center P.O. Box 381,Honokaa,Hawaii 96727 Phone/Fax: (808)775-0916 Email:info @hamakuayouth.org 35 Hawaii Centers for Independent Living Independent Living Services Hawaii Centers for Independent Living- Agency Name Independent Living Services- Program Name Agency Director: Mitchell "Kimo" Keawe Phone No.: 522-5400 Contact Person: Thayer Goya Phone No.: 522-5400 Mailing Address: 414 Kuwili St. Suite 102 Honolulu, HI 96817 Facility/Site Address: 1055 Kino'ole St. Suite 202 Hilo, HI 96720 Fax No.: 808-522-5427 Email Address: kimok @pacificil.org and thayerg @pacificil.org Name of Accountant/CPA (include name of firm if applicable): Dennis Ikawa, CPA Phone No.: 808-944-9270 Mailing Address: 1481 S. KING ST. STE 232, Honolulu, HI 96814 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$15000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $15000 $10000 $10000 Agency Mission Statement: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 13 "The Hawaii Centers for Independent Living 's mission is to offer and promote programs designed to empower people with disabilities to take personal responsibility so they may achieve or continue independent lifestyles within the community." NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 13 Hawaii Centers for Independent Living - Agency Name Independent Living Services- Program Name Program Description: The Hawaii Centers for Independent Living (HCIL) is a non profit organization operated by and for people with disabilities to ensure their rights to live independently and fully integrated in the community of their choice, outside of institutional care settings As a non-profit, State and County-wide resource, HCIL serves people of any age with a permanent disability. HCIL was founded in the civil rights movement encouraging empowerment for people with disabilities, equal access to opportunities, and choices in life no matter how severe their disability. HCIL actively seeks systems change and promotes self-advocacy to accomplish our goals. On the island of Hawai'i, HCIL services are centered in Hilo. Our staff are tasked with servicing the entire island both in the office and on "Outreach". Currently HCIL-Hilo employs four staff with two focused on doing "Outreach" services where they go out into the community to service consumers. The Philosopy That Guides HCIL is Three-Fold: 1. HCIL's objective is to present information on options from which individuals with disabilities can make their own personal choice. 2. The needs of people with disabilities can be met effectively by comprehensive programs encompassing personal care, housing, transportation, employment, and recreation to name a few. If the consumer has a specific request we will try our best to develop their independent living request. 3. Those who know best the needs of people with disabilities, and how to meet those needs, are people with disabilities themselves. It is the strong belief in this peer relationships that distinguishes HCIL and its services. Total Budget and Position Count Total Program Budget 182,114 Total Program Position Count 32 Total Agency Budget 1,174,890 Total Agency Position Count 35 Program Objectives: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 13 1) Provide landlord /tenant rights training, how to complete a housing application, how to locate housing and how to maintain their housing situation. This will reduce risk of being homeless and dependance on others. These services will provided to 60 individuals. Timeline: 7/1/12 - 6/30/13. 2) 2) Provide consumers with personal care attendant referrals whom we have screened and interviewed to assist them with their personal care, chores, etc. Provide consumer training on how to interview, hire and fire an attendant. This prevents institutionalization and dependence on family, friends, and neighors. This services will be provided to 60 individuals. Timeline: 7/1/12 - 6/30/13 3) 3) Proivde one on one independent living skills training to assist consumers in carring out their everyday activities such as housekeeping, shopping, laundry, cooking, money management, etc. This will reduce dependence on others. These services will be provided to 50 individuals. Timeline: 7/1/12 - 6/30/13. 4) 4) Provide consumers with information on their legal rights and provide access to consumers to encourage self-advocacy. These services will be provided to 50 individuals. Timeline: 7/1/12 - 6/30/13. 5) 5) Provide one on one training on video relay services for the deaf. Also, serve as a location where consumers can file complaints if they have problems with 711 services. These services will be provided to 15 consumers. Timeline: 7/1/12 - 6/30/13. 6) 6) Provide consumers with housing referrals to acquire a place to live. This will increase their independence and decrease dependency on family and/or friends. These services will be provided to 25 people. Timeline: 7/1/12 - 6/30/13 7) 7) Provide consumers with job readiness skills. These skills include resume writing, mock job interviews, locating opportunities, and providing job requirements. This will provide consumers with skills to acquire employment and become more independent. These services will be provided to 20 consumers. Timeline: 7/1/12 - 6/30/13. 8) 8) Provide consumers with basic computer skills to include email, Microsoft Word, filing documents, and use of the internet. This will create access for the consumers in their community. These services will be provided to 12 consumers. Timeline: 7/1/12 - 6/30/13. 9) 9) Provide consumers with knowledge of their entitlements. This will enable consumers to maximize the amount of benefits that they can receive. These services will be provided to 40 consumers. Timeline: 7/1/12 - 6/30/13. 10) 10) Provide consumers with information and referral services to increase their knowledge of various resources in the community. This will increase their independence. These services will be provided to 150 consumers. Timeline: 7/1/12 - 6/30/13. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 13 Program Highlights: (from Fiscal Year 2010-11) 1) A consumer who was released from the Hilo Medical Center after having a heart attack and admitted to the Hale Anuenue Care Home. He was eventually released to go home, but he was confused about all the different medications he had at home. I advocated for the consumer with his physician to explain the medications and write lists of what he has to take. I arranged for Evercare field representatives to arrange a home visit and advocated for the consumer to get PA services. They were very negative about what services this consumer needed. I advocated for him and he explained how long it takes him to perform some ADL and he listed some he could not do anymore. He received the services which included personal care and chore services. I arranged for the Public Health nurse to come and pre-sort his medications. After a while, he was able to keep track of his medications himself. He is still living independently in the community with assistance from the home health care providers. 2) An elderly consumer, who is a widow and lives alone, came to the HCIL office with one of her friends. Her friend brought her to every possible agency to ask for help. He wanted her in a nursing home. He said he can't deal with the constant interruptions and phone calls at all hours. Adult Protective Services, the Public Health Nurse, Services for seniors and other agencies were contacted. The consumer was forgetful, but able to accomplish every ADL. She refused to go to a care home. I referred a PA to her to assist her with shopping, making shopping lists, bring her to the doctor and other activities. The consumer showed me her Last Will and Testament, and I noticed the name of a person who is not of good character. I referred this to Adult Protective Services who did an investigation and affirmed my suspicion. With the help of Legal Aid Society the consumer had a new Will written. She also has an Alert Alarm Button, a lockbox at her door and the Emergency personnel have the number to enter. She called the emergency number too often and APS suggested more PA hours. Her PA now works with her twice a day. 3) A 61 year old that suffered a stroke wanted to find affordable housing he found a one bedroom in Hilo Town where he now lives he was homeless living on the beach but now he has his own place. He completed his program goals and working is on his second goal. 4) A 50 year old female was home bound because her right arm and left finger were amputated and she suffered from depression. She was unable to care for herself she needed a PA. I obtained PA services with Care Resources and now she is happy. 5) A 26 year old man with a head injury wanted to find affordable housing he found his own place and is currently living on his own in a 1 bed room NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 13 apartment. He completed his program goals and filled out Satisfaction Survey with assistance of our receptionist. 6) A 75 year old man lives along and cares for himself and uses his wheelchair to get around because he has an orthopedic impairment. He needs a wheelchair to be mobile. His wheelchair broke and he was unable to get around like shopping, cooking for himself and doing his daily activity. He called and asked me can I get him a manual wheelchair HCIL had one manual wheel chair to fit his needs so the manual wheelchair was given to him on 8/12/11. He was then able to take care of his daily needs again. He completed his goal in getting a manual wheelchair. 7) A 20 years old young lady with a learning disability and mental disability was unable to manage her time and money. I gave her several classes on time management. After the classes she was able to stop sleeping all day and do something with her time each day. She also had trouble with counting money and spending too much money. I provided her with money management classes that helped her learn how to count money and how to manage to spend a little at a time. She completed her time management goal and she completed her money management goal. Consumer Satisfaction Survey was filled by consumer with the assisting of our Receptionist. 8) A blind consumer contacted HCIL for an assistant in finding housing. He also requested to correspond via email. So with an HCIL assistant the consumer found and moves into permanent affordable 2 bedroom within one week. 9) A consumer moved from an assisted living home specialized for TBI patients in Oregon to Hawaii. He said he had a friend and 6he didn't think it was difficult to live here. He was referred to me by the Bay Clinic, the County Council person and the Neighborhood Place of Puna. He had nothing set up or transferred. I got into contact with his previous counselor in Oregon and she gave me the information he didn't have. He has a severe memory problem. He was able to move into a cabin at his friend's place. With HCIL assistance, he was signed up for Food Stamps, Medicaid, and the Bay Clinic. I accompanied him to several doctor appointments, because he didn't want to ask questions when he didn't understand. We prepared question lists and he followed them. I then provided him with the Hele on bus schedule and the Food Basket information. He then asked if I can assist him re-learning using his computer. We did many hours of Independent Living Skills Training, but, as the end result, he was able to go on the internet, use e-mail and did research. He then booked his own flight to Oregon to see his doctor. I reminded him, but he did not set this up with the doctors here. I explained the Medicaid programs are different in every state. He ignored me. When he got there, he said he has no medical. I gave him the numbers in Hawaii to call. I also called a few homeless programs, because he had no place to stay. He did get into a shelter. He got his medical checkup and came back. Now he was frustrated about having to do all the changes again. He NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 13 decided to move back to Oregon where he is closer to the specialized care he needs. 10) I worked with a consumer who also had a TBI. She needed housing and assisting with legal affairs. I assisted her with finding housing. Then I accompanied her to a class that taught how to do your own divorce. We wrote all the steps for her to follow down. She last called me to let me know that the Divorce Papers have been successfully given to the (future) ex-husband. He was very happy about having accomplished this. 11) I assisted a consumer with bi-polar disorder in housing services and moral support and she found a place to live and began volunteering and working in the community helping others to get their lives together, too. After about six months, she called because the landlord wasn't going to renew her lease and she just needed to talk and she wanted housing listings but she found another place to live and went on with her life again. She always appreciated the support and the resources that she has gotten from HCIL. 12) 34 year old consumer with Developmental Disability needed to find housing. Her mother contacted HCIL to assist her daughter to learn how to become independent. Her income is SSI $674 a month. This consumer lived in Kamuela area and there is no low income housing available. IL Specialist contacted HUD projects in Hilo. Set up appointment for consumer to come to Hilo and meet with property management. Consumer was able to obtain low income housing. She also needed some assistance with chore services. She was referred to an agency that is currently assisting her with house cleaning and PA services. 13) 81 year old female with speech impairment requested assistance to help her pay for car repairs. This consumer was on a limited income from social security and couldn't afford to repair her car. Transportation on the Big Island is very limited. IL Specialist assisted this consumer apply for a grant that covered all her repairs and goals were achieve. 14) 80 year old male with multiple disabilities was homeless. His primary disability was right side slightly paralyzed due to stroke. He needed a unit that is accessible; he uses a cane on good days. Some times he needs to use a wheel chair. He was staying in a hotel and sometimes he stayed at the Hilo Hostel. He is on limited income social security retirement. This consumer has severe speech impairment due to a stroke. He asked IL Specialist to assist him with finding affordable and accessible housing. Assist with filling out housing applications. Speak to landlords for him due to speech impairment. After 2 housing referral appointments consumer reached his goal and moved into an accessible and affordable home he was no long potentially homeless. 15) For two months July 19 - Sep 19 HCIL needed to furlough our entire staff due to a budget shortfall. During the furlough, HCIL covered all of our staffs medical and dental premiums. For the first two days all HCIL offices were closed. Due to the devotion of our staff we were able to open all offices on July 21 with volunteers which were furloughed staff. During the furlough HCIL was able to sustain full operations and service our NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 13 consumers. The shortfall was due to liabilities incurred from the prior administration, reductions in grant funding, and higher than expected expenses. For fiscal year 2012 HCIL does not expect a budget shortfall. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8ofl3 Hawaii Centers for Independent Living - Agency Name Independent Living Services - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Landlord/Tenant rights traning 42 50 60 Personal Care Attendant referrals 33 40 60 Independent Living Skills 46 38 50 Empower self-advocacy 38 50 50 Training on video relay services 16 15 15 Housing referrals 22 25 25 Job readiness skills 13 10 20 Basic computer skills 15 12 12 Entitlement education 31 40 40 Information and referral services 136 40 150 ALL PERFORMANCE MEASURES ARE SPECIFIC TO SERVICES PROVIDED IN HAWAII COUNTY *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 159,205 178,807 177,084 Professional Fees 2,500 2,500 2,500 Operations 55,882 51,140 52,000 Equipment 7,754 8,000 8,000 Other# 0 0 0 Total 225,341 _ 240,447 239,584 *If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 13 Hawaii Centers for Independent Living - Agency Name Independent Living Services - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Fed Title VII - Statewide 25,660 30,000 30,000 State ILP - Statewide 137,056 182,114 181,251 Fed ARRA - Statewide 25,660 0 0 Fed ARRA - Outreach 13,632 0 0 Hawaii Count Non-Profit Grant 10,000 15,000 15,000 Hawaii Island United Way 13,333 13,333 13,333 Total 225,341 240,447 239,584 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Since the currect HCIL administration took office the primary focus has been on sustainability. HCIL was fortunate to receive ARRA funding but those funds were almost fully exhausted by the end of 2011. In July 2012, HCIL plans on starting a pilot program with a group of non-profits to support all of our consumers with short-term housing, job training, and job-placement. Many businesses aren't prepared to support the needs of person's with disabilities in the workplace. HCIL will create various businesses that employ our consumers maximizing their abilities. These businesses will be for-profit and compete with commercial enterprises. These for-profit businesses will not be subsidized, except for management oversight and accounting. It will provide many of our consumers with the ability to lead, manage a business, learn responsibilities and gain their own independence. The pilot program will begin on Oahu but once established, the for-profit businesses will be able to function on all islands. We anticipate a three year period before all islands will be able to benefit from this program. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 13 Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. None NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 13 Hawaii Centers for Independent Living - Agency Name Independent Living Services - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 12 of 13 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. 1/) 7/I Signature of Board President/Chair Date or Agency Director 1 /62 1// 2- Sign: - •f Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! • NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 36 Hawaii County Economic Opportunity Council Language Arts Multicultural & Stem HAWAII COUNTY ECONOMIC OPPORTUNITY COUNCIL LANGUAGE ARTS MULTICULTURAL & STEM PROGRAM Agency Director: Lester Seto Phone No.: (808) 961-2681 x 203 Contact Person: Bettie Wagstaff Phone No.: (808) 961-2681 x300 Mailing Address: 47 Rainbow Drive Hilo, Hawaii 96720 Facility/Site Address: 47 Rainbow Drive Hilo, Hawaii 96720 Fax No.: (808) 935-9213 Email Address: seto hceoc@hotmail.com Name of Accountant/CPA (include name of firm if applicable): Carbonaro CPA& Associates Phone No.: (808) 968-1002 Mailing Address: P.O. Box 4372 Hilo, Hawaii 96720 You are responsible to keep the above information current Amount of Request for County Funds: 119,890.00 Prior Year(s) Award of County Nonprofit Grants-in-Aid funds: 10-11 11-12 $75,000 58,000 Agency Mission Statement: Applicant's mission is the alleviation, elimination and prevention of poverty in the County of Hawaii by: • Mobilizing and channeling private and public resources into antipoverty action; • Stimulating new and effective approaches to the alleviation of poverty; • Strengthening communication, mutual understanding with residents; • Planning the coordination and implementation of antipoverty program; • Educating children and youth to become responsible contributing adults; • Assisting the poor to attain economic self-sufficiency. • NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 6 HAWAII COUNTY ECONOMIC OPPORTUNITY COUNCIL LANGUAGE ARTS MULTICULTURAL & STEM PROGRAM PROGRAM DESCRIPTION This funding request is to continue and enhance the Language Arts Multicultural Program (LAMP) during fiscal year 2012-2013. The LAMP curriculum is exclusively designed for school-referred underachieving 2nd through 4th graders in language arts, writing and speaking, the basis required for extending learning to other area. An enhanced LAMP program will target interested 4-6th graders in a STEM (Science, Technology, Engineering, and Math) based program Both programs seek to provide a high-quality, comprehensive opportunity for low-income youth, which addresses both remediation and enrichment opportunities. The HCEOC LAMP program is unique in that it is not only an after school program, but it is also an in-class tutoring program. Through collaboration with State of Hawaii Department of Education (DOE), the LAMP staff work with the classroom teachers assisting with the day- to- day class material. Students who are experiencing problems with their school work may be helped at the time they are experiencing the difficulty. In some cases, the LAMP staff simply works with the child at his desk; in other cases, the LAMP teacher provides in-depth individualized assistance away from the classroom. Through a mix of recreational, arts, and enrichment activities, the program provides a positive environment for students to develop good interpersonal skills and self confidence. Students are provided age-appropriate learning opportunities designed to improve math, reading, and writing skills. Because a large number of the students are English Language Learners, phonetics and speaking are important foci of the program. Field trips and excursions expand the student's knowledge of the community. Students are transported home from after school activities and to and from weekend excursions as many of the households do not have transportation. The provision of transportation insures equal access to services and benefits the participants, the household and the community The STEM-based curriculum emphasizes science and math and provides the student enhanced opportunities for developing the science and math skills (stem knowledge and competencies) required today and in the future for technology and advancement. A combination of hands-on experience and exposure to technology will help prepare the students for more advance science and math education. Scientific experimentation will provide students the opportunity to learn the skills crucial to the new century: teamwork and problem solving. Science will be integrated into other afterschool activities such as gardening and recreation. Frequent presentations by persons working in the field introduce the students to future career possibilities. The Program will serve two (2) elementary schools in Hawaii County: Keonopoko Elementary and Naalehu Elementary School. Each school will have 2 teachers and 2 aides. Previous year, only one school with only one class was served. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page2 of 6 HAWAII COUNTY ECONOMIC OPPORTUNITY COUNCIL LANGUAGE ARTS MULTICULTURAL & STEM PROGRAM Total Budget and Position Count Total Program Budget $239,781.00 Total Program Position Count 8 Total Agency Budget $2,301,296.00 Total Agency Position Count 60 Program Objectives: 1) Gain a minimum of 2 percentile points per year as measured by the Stanford Diagnostic Reading Test, Reading Comprehension subtest for 70% of the program participants. 2) Attain 4.5 in writing or gain one (1)point in writing skills as measured by the SAT Writing Assessment on a seven(7) point scale, one being low, for 80% of the program participants. 3) Improve socialization skills by 10% as determined by the pre and post teacher administered Student Socialization Evaluation for 90% of program participants. 4) Assist 50% of the students in the program to meet the HSA standards in reading and math. 5) Insure 15 of 30 register STEM students complete six months in a STEM-based curriculum. Program Highlights: (from Fiscal Year 2010-2011) 1. All students (32) met the SAT Writing Assessment program Objective. 2. 90% of the students met the program objective in speaking and listening. 3. 96% of the students met the socialization objective. 4. 74% of the program's students met the HSA standard in both reading and math compared to 42% of all 3rd and 4th graders in the school. 61% of the program's ELL students met proficiency objectives compared to 21% for the school. 5. 71 % of the LAMP students met proficiency objectives in math compared to 33% for the school. Of LAMP's ELL students 64% met proficiency objectives compared to 23% for the school. 6. 12.5% of the program students exceeded HSA standards Performance Measures: FY 2010-11 FY2011-12 FY 2012-13 Actual Budget Estimate Gain a minimum of 2 percentile points per year as measured 70% 70% 75% by the Stanford Diagnostic Reading Test, Reading Comprehension student for 70 % of the program student. Attain 4.5 in writing or gain one(1)point in writing skills 80% 80% 85% as measured by the SAT Writing Assessment on a seven(7) point scale, one being low,for 80% of program students. Achieve 80% on the teacher applied LAMP Teacher's 80% 80% 80% Attitudinal Observation worksheet or make an increase of 10%between pre and post scores for 80% of students. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 6 HAWAII COUNTY ECONOMIC OPPORTUNITY COUNCIL LANGUAGE ARTS MULTICULTURAL & STEM PROGRAM Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Budget* Budget Estimate Salaries and Wages $ 69,832 57510 161593 Professional Fees $ 0 0 0 Operations $ 5,168 18480 25362 Equipment $ 0 0 0 Other# $ 0 18800 52826 Total $ 75,000 94790 239781 #Please explain in detail on separate sheet(see page 6) Program Funding Sources: Identify all funding sources (specific to this program only) FY2010-11 FY 2011-12 FY 2012-13 Budget* Federal CSBG (Requested)* 0 26489 119891 Agency funds 0 0 0 Available Federal, State, Foundation Grants 0 0 County Funding $75,000 57981 119890 *If applicable Explain what plans, if any,your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? As a non-profit organization, HCEOC has in the past 36 years competed for and received federal, state and local funding to sustain the Youth MENTORING-Language Arts Multicultural Program. A concerted effort is been made to identify funding organizations and fundraising opportunities to enable this program to become self-sustaining. The current economic situation does not allow the agency to predict with any certainty when the program will become self- sustaining. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawai'i. n/a NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 6 HAWAII COUNTY ECONOMIC OPPORTUNITY COUNCIL LANGUAGE ARTS MULTICULTURAL & STEM PROGRAM I(we) have read and understood all of the eligibility requirements, grant conditions; award procedures; and records , reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135-2-1-142.2 Hawaii County Code, relating to Appropriations of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statues. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the Legislative auditor within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from awarding of the grant, a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report will impact the evaluation of your programs or agency's future funding requests. I (we) understand that there is no provision for further notification to submit the final report. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2012 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are cknowledging that you have read and understand these requirements. T. /72-(e7/2_ Signat of oard President/Chair Date Ztw d I/.24 iz Signature of Executive Director Date NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 6 HAWAII COUNTY ECONOMIC OPPORTUNITY COUNCIL LANGUAGE ARTS MULTICULTURAL & STEM PROGRAM PROGRAM EXPENDITURE DETAIL Position No FTE Annual salary Amt chg. to grant Program Manager 1 0.25 37,440 9360.00 LAMP Teacher 2 .875 34320 60060.00 Lamp Teacher 2 .60 34320 41184.00 Lamp Aide 4 .50 20800 41600.00 Director, 1 0.10 52,200 5,220.00 Operations/Community Services Executive Director 1 0.05 65000 3,250.00 Senior Accountant 1 0.10 50000 5,000.00 Accountant 1 0.03 34320 1,029.00 161,593.00 Justifications: Salaries and Wages are based on a compensation survey conducted in June 2009 and are compatible with salaries of other a 1 encies with comparable functions. Operations 25,362 Justification: Operation charges include the administrative and program support costs associated with the program and include the prorated charges for the agency-wide audit, payroll services, mileage, postage and shipping fees, utilities, telephone services, publications and printing, transportation of students and supplies. Equipment 0.00 No equipment will be bought for this grant. Other* 52,826.00 Justification: These are payroll taxes and assessments and are as mandated by federal and state laws. They include cost for SSN (11,668.00), Unemployment (6,116.00), Worker's compensation (4,362.00) TDI (1,937.00). Health insurance (20,590) and Pension (5,338.00) are also included. They are paid at a rate approved by the HCEOC Board of Directors and comply with the state required health insurance coverage for all employees who work 20 hours or more each week. TOTAL: $ 239,781.00 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 6 37 Hawaii County Economic Opportunity Council Youth Mentoring & Drop Out Prevention Hawaii County Economic Opportunity Council Youth Mentoring& Drop Out Prevention Program Agency Director: Lester Seto Phone No.: 961-2681 ext 203 Contact Person: Bettie Wagstaff Phone No.: 961-2681 ext 300 Mailing Address: 47 Rainbow Drive, Hilo Hawaii 96720 Facility/Site Address: 47 Rainbow Drive, Hilo, Hawaii 96720 Email Address: seto hceoc @hotmail.com Name of Accountant/CPA: Carbonara CPA&Associates, Inc Phone No.: (808) 968-1002 Mailing Address: P 0 Box 4372 Hilo Hawaii You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $107,348 Prior Year Award of County Nonprofit Grants-in-Aids funds: 09-10 10-11 11-12 $65,000 0 Agency: Mission Statement: Applicant's mission is the alleviation, elimination and prevention of poverty in the County of Hawaii by: • Mobilizing and channeling private and public resources into antipoverty action; • Stimulating new and effective approaches to the alleviation of poverty; • Strengthening communication, mutual understanding with residents; • Planning the coordination and implementation of antipoverty program; • Educating children and youth to become responsible contributing adults; • Assisting the poor to attain economic self-sufficiency. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 6 Hawaii County Economic Opportunity Council Youth Mentoring& Drop Out Prevention Program Program Description The Drop-Out Prevention Program) is a youth mentoring program providing educational and social support to at-risk youths. Participants are referred to the program by teachers, administrators and the courts because of truancy, failing grades and behavior problems. Geographic Area Served: Hilo, Keaau, Honoka'a, and Konawaena. The schools are selected because of high dropout rates, poor graduation rates, poor attendance, or at the request of the school's principal. Target Population: At risk youth ages 13-18 who are referred because of truancy, poor academic achievement, disciplinary problems and poor behavior. Target population includes economically and culturally disadvantaged youths, many from single parent households, on public assistance, with limited English proficiency and/or homeless. Program Design: Locally designed with collaboration between HCEOC and DOE. DOPP operates during school, after-school, weekends and during school breaks. Goals and objectives of the DOPP stress students' academic performance, school attendance and social skills. Report cards, attendance and suspension records are reviewed and intervention measures are initiated when appropriate. Pre- and post-attitudinal assessment tests are administered to parents and students to assess communication and social skills. The goals are to reduce the dropout rate at and thereby improve the graduation rate of low-income high school students; improve students' academic achievement and thus increase the percentage of youth who are promoted to the next grade and decrease the number of students who are suspended from school. Data and reports are analyzed using statistical analysis to determine program effectiveness. Personnel with primary responsibility for insuring the goals and objectives of the DOPP are met are the DOPP Mentors/Facilitators and the Community Facilitator. The DOPP Mentors/Facilitators monitor student attendance weekly, student grades and meet with school counselors on a regular basis. They provide one-on-one and group counseling sessions; develop and maintain cooperative relationships with school personnel, probation officers, youths and parent; plan and implement activities for youths; assist with homework and provide support and guidance to youths; and act as a role model for youths in program. The Community Facilitator works primarily with potential drop out students' parents, providing resources for parents and working with DOE representatives, probation officers and representative from other social services agencies to coordinate services for families Activities include individual and group consultation session; educational and cultural activities, afterschool mentoring and tutorial sessions to help students meet requirements for graduation and/or promotion, develop positive attitudes toward school and increase self-esteem. Program Excursions that seek to broaden the youth's knowledge and experience as well as introduce alternative career options are provided throughout the year. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 6 Hawaii County Economic Opportunity Council Youth Mentoring& Drop Out Prevention Program Students meet to discuss issues and develop skills for making positive choices. Career options are discussed throughout the year and trips to a variety of business activities and organizations to provide career options. Transportation is provided for all excursions. Total Budget and Position Count Total Program Budget $109,965 Total Program Position Count 6.5 Total Agency Budget $2,301,296 Total Agency Position Count 60 *Total Program Position Count is 6.5 full time equivalent positions. Program Objectives: 1) Graduate 95% of high school seniors in the program by the end of the school year. 2) Assist 60% of the referred high school students to pass all courses necessary for promotion. 3) Improve 75% of the referred high school student's attendance by 65% or better. 4) Assist 70% of the referred high school students to complete the school year without any suspension exceeding three days. Program Highlights: (from Fiscal Year 2010-2011) 1. 98% of the senior clients at all the DOPP schools graduated. 2. 78% of all DOPP project students in grades 9-11 passed all courses necessary for promotion and/or made a 10% improvement in Grade Point Average (GPA) between the beginning and end of their entry into the program. 3. 77% of the entire DOPP clients at all schools had an attendance of 65% or better. 4. 83% of the DOPP clients as a whole finished the school year without any suspensions exceeding three days. This exceeded the stated goal by 13%. Performance Measures: FY 2010- FY 2011- FY 2012- 11 12(Actual) 13 (Actual) Estimate Graduate 95% of high school seniors in the program by 82% Data not the end of the school year (9/11) available Enable 60% of the referred high school students to pass 93% Data not all courses necessary for promotion (43/48) available Improve 75% of the referred high school students 95% Data not attendance by 65% or better (59/65) available Assist 70% of the referred high school students to 83% Data not complete the school year without any suspensions available exceeding three (3) days * if applicable NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 6 Hawaii County Economic Opportunity Council Youth Mentoring& Drop Out Prevention Program Program Expenditures FY 2010-11 FY 2011-12 FY 2012-2013 Actual Actual Estimate* Salaries and Wages 59463 147,298 Professional Fees 0 0 Operations 5537 19100 Equipment 0 0 Other# 0 25041 Total 65000 214697 * If applicable #Please explain in detail on separate sheet (See page 6) Program Funding Sources: Identify all funding sources (specific to this program only) FY 2010-11 FY 2011-12 FY 2011-12 Requested Federal CSBG) $238,627 107349 County of Hawaii Non-Profit Grant Funds 0 0 107348 * If applicable Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? As a non-profit organization, HCEOC has in the past 36 years competed for and received federal, state and local funding to sustain the Youth MENTORING-Drop-Out Prevention Program. A concerted effort is being made to identify funding organizations and fundraising opportunities to enable this program to become self-sustaining. The current economic situation does not allow the agency to predict with any certainty when the program will become self-sustaining. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawai'i. I(we) have read and understood all of the eligibility requirements, grant conditions; award procedures; and records , reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135-2-1-142.2 Hawaii County Code, relating to Appropriations of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s)pursuant to law. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 6 Hawaii County Economic Opportunity Council Youth Mentoring& Drop Out Prevention Program I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statues. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the Legislative auditor within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from awarding of the grant, a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report will impact the evaluation of your programs or agency's future funding requests. I (we) understand that there is no provision for further notification to submit the final report. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2012 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you e acknowledging that you have read and understand these requirements. j / • ,/Z4/ly Si re g Board President/Chair Date /A Veit Q1 / 2C / i2 Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 6 Hawaii County Economic Opportunity Council Youth Mentoring& Drop Out Prevention Program PROGRAM EXPENDITURE DETAIL Position No FTE Annual salary Amt chg. to grant Program Manager 1 0.25 37,440 9,360.00 DOPP Facilitator 4 1 31,200 124,800.00 Dir, Community Services 1 0.05 52,200 2610.00 Office Manager 1 0.05 24960 1,248.00 Executive Director 1 0.05 65000 3,250.00 Senior Accountant 1 0.10 50000 5,000.00 Accountant 1 0.03 34320 1,030.00 Total 147,298.00 Justifications: Salaries and Wages are based on a compensation survey conducted in June 2009 and are compatible with salaries of other agencies with comparable functions. Operations 19,100.00 Justification: Operation charges include the administrative and program support costs associated with the program and include the prorated charges for the agency-wide audit, payroll services, mileage, postage and shipping fees, utilities, telephone services, publications and printing, and supplies. Equipment 0.00 No equipment will be bought for this grant. Other* 48,299.00 Justification: These are payroll taxes and assessments and are as mandated by federal and state laws. They include cost for SSN (11,668.00), Unemployment (6,116.00), Worker's compensation (4,362.00) TDI (1,937.00). Health insurance (20,590) and Pension (5,338.00) are also included. They are paid at a rate approved by the HCEOC Board of Directors and comply with the state required health insurance coverage for all employees who work 20 hours or more each week. TOTAL: $ 214,697.00 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 6 38 Hawaii Island Adult Care, Inc. Adult Day Care Centers Hawaii Island Adult Care, Inc. - Agency Name Adult Day Care Centers- Program Name Agency Director: Paula Uusitalo Phone No.: 961-3747 Contact Person: Paula Uusitalo Phone No.: 961-3747 Mailing Address: 34 Rainbow Drive Hilo, HI 96720 Facility/Site Address: Same as above Fax No.: 961-3740 Email Address: puusitalo @hawaiiislandadultcare.org Name of Accountant/CPA (include name of firm if applicable): Jennifer L. Gossert, CPA Phone No.: 969-3115 Mailing Address: 688 Kinoole Street, Suite 201, Hilo, HI 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $25,000.00 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $20,000.00 $20,000.00 $15,000.00 Agency Mission Statement: To provide quality community based care for elders and challenged adults and support for their families on the island of Hawaii. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 7 Hawaii Island Adult Care, Inc. - Agency Name Adult Day Care Centers- Program Name Program Description: Adult Day Care Centers, in Hilo and Honomu, provide a safe socially active daytime program for aging elders and disabled adults. Hilo is open six days per week, Honomu currently two days per week. Currently enrollment is 106, with daily attendance of 60 to 75. Seventy two percent are over 80 years old, the majority are frail with some dementia, the remainder are stroke debilitated, have Alzheimer's disease, or other conditions. Total Budget and Position Count Total Program Budget 1,192,750 Total Program Position Count 32 Total Agency Budget 1,678,080 Total Agency Position Count 46 Program Objectives: 1) To provide a safe, caring daytime program with mental stimulation and physical activity for kupuna who can no longer take care of themselves at home, who need a safe place to be during the day. These participants are no longer eligible for the senior center programs or Alu Like programs around the island. Many are under doctor's orders to attend or their families are concerned about their safety at home alone during the day. The programs are geared for each participant's skills and need as much as possible, the goals are to alleviate depression and maintain self care and self-worth. They have something to look forward to every morning, and spend their day with their peers. 2) To provide the opportunity for aged kupuna to live at home as long as possible, have independence, to have dignity at this often difficult time in their lives, to be with family and in the community hopefully for the rest of their days. 3) To deter premature institutionalization into long term care facilities. This also significantly lessens the burden on the Medicaid tax dollars. Almost ninety percent of all patients of long term care facilities (LTC) are Medicaid patients, within three months of entry most become eligible for Medicaid having spent their life savings. About 40 percent of adult day care participants would be in a LTC if not for day care, because of the severity of their mental or physical conditions. For every 10 participants of adult day care who would be in a LTC, we save the state over 3/4 million Medicaid dollars annually, comparing $1,000 per month, per person - adult day care, to $7,445/per month per person - LTC. 4) The fourth objective and just as important is to support the caregivers. Adult day care gives them the opportunity to continue their employment or give them relief/respite and the time to be with their peers, thus giving them energy for their NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 7 caregiving evenings and most importantly deterring burnout. Burnout can lead to premature institutionalization into LTC facilities or physical or mental abuse. 5) To provide adult day care to all who need it regardless of ability to pay. The majority of our kupuna are in the low income group, thus ineligible for Medicaid to pay for needed services, yet do not have enough income to pay full costs. This grant along with other grant sources provides the cost share for these elders to attend. Each tuition assistance application is reviewed for eligibility, income, expenses, savings, only those with little savings are eligible. Each low income participant pays a different cost share depending on their income & expenses. 6) The programs are geared for mental stimulation and physical activity, fun and enjoyment, a scheduled day program with variety from day to day, participants chose what they like to do, and all occasions and holidays are celebrated in style. Music, arts, crafts, old-time dancing, auctions, excursions, many more activities fill each day, along with breakfast, lunch and snacks. Happy hearts! Program Highlights: (from Fiscal Year 2010-11) 1) Opened second satellite program at the Hilo Coast United Church of Christ in Honomu on July 1, 2010 with two participants (first was in Kona, in 1988). It is open two days per week, with excursions from the Hilo Adult Day Center to make the program an active one for all participants. 2) For the year, 137 total participants throughout the year. 50 new participants, 40 discharged, 70 attended all year. 6 participants passed away while living at home, a success story for both the kupuna and family who fulfilled their caregiving duties to the end. Ages: 72% over 80 years old, 86% over 70 years Economic: 76& low income or poverty level or below. Reached 100 enrolled for the first time ever in March 2011. 3) Maintained funding levels to meet the challenges of the number of low income participants; submitting with applications to varied sources of funding. Continued collaboration with other agencies providing for the vulnerable elder population. 4) The Rotary Club of Hilo Bay and the UHH Rotoract club with the Weinberg Friends project, fixed screens, painted walls, entry way, patched floors, etc. (February, March) 5) Nordic PCL (builders of Target) gave back to the community with two Saturdays of patching, fixing more screens, painting GHW wing, ramp, and much more. (April, May) 6) HIAC celebrated 35 years of adult day care service to the community, during the 35 years, started the Kona Adult Day Center along with other programs to address the needs of the aged kupuna. Officially January, actually celebration held June 2011. 7) Finished feasibility project for a new building, formed partnership with Hawaii Island Community Development Corporation (HICDC), they will build it on their new senior housing site in Hilo. The board had reviewed all other options prior to considering a new building. Partnering with HICDC follows the Maui model of building adult day care centers with senior housing to fit the aging in place concept to the utmost. 8) Applied to the Keaau Hongwanji for an adult day care site, their board felt they had too many other activities there already. Worked with the Hamakua Partners in Eldercare, still looking for a site in Honokaa as well. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 7 Hawaii Island Adult Care, Inc. - Agency Name Adult Day Care Centers - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate 98 137 96 Average monthly Attendance 94 96 1 45 8 Total participants full year 1 Participants continue to live in their 121-88% 124 own homes Participants maintain improve self care 133-97% 135 140 alleviate depression 68 Family/caregivers continue their 62-45% 65 employment Family/caregiver receiving respite 107-78% 110 140 Caregiver satisfaction 130— 94% 135 Participants continue after six months , 102 15 110 0 0 78 Participants continue after one year Fiscal yr savings on Medicaid for those $335,025.00 who entered long term care during the year (based on how long attended adult day care during the year) Overall Medicaid savings years 2,132,992.50 attended adult day care (two attended day care 3 yrs, 1 ten years-stroke, severly depressed, all private pay) *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 776,792 797,372 795,000 Professional Fees 10,836 9,600 9,900 232,428 235,000 230,273 Operations Equipment 3,982 4,100 4,300 Other1t(D1ect 011ent assistance) 156,513 149,250 153,250 Total 1,178,396 1,192,750 1,197,450 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 7 Hawaii Island Adult Care, Inc. - Agency Name Adult Day Care Centers - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Tuition/Fees 721,479 716,400 730,000 State 108,505 97,500 100,000 Federal 108,505 97,500 100,000 County of Hawaii 20,000 20,000 20,000 Hawaii Island United Way 16,72Q 18,000 20,000 Templeton Hopper Fund 78,887 71,250 71,250 Other Grants: Mclnerny/HHA 43,305 49,000 42,000 Charity Walk/Friends of HI, etc. Donations 8,869 12,700 9,000 USDA lunch reimbursement/donations 68,891 68,000 69,200 PIN Grant Management 4,700 6,200 3,000 Fundraising/Int./Sales 25,847 31,200 30,000 SEE program 9,147 5,000 3,000 Total 1,214,855 1,192,750 1,197,450 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Low income elders are the largest economic group of our kupuna over 60 years old, they are above poverty level (often not by much) thus ineligible for Medicaid to pay for adult day care. Unless the federal or state government recognizes that they need to help keep our kupuna out of long term care facilities, by providing cost share for this economic group to attend adult day care, (and thus save on large amounts of Medicaid dollars spent on long term care), we have not option but to continue requesting funds to assist this group to get the care they need. Not getting the care they need has a typical scenario: it leads to a fall at home being alone, then hospitalization, and if recovery is not successful, into a long term care facility. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. No employee has any affiliations with the County of Hawaii, one board member of thirteen is employed by the county (computer technician). NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 7 Hawaii Island Adult Care, Inc. - Agency Name Adult Day Care Centers - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 7 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. a ,/ ,,,, b._. Sig/ature of Board President/Chair Date or A gency Director ignature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 7 Hawaii Island Adult Care, Inc. County of Hawaii Nonprofit Grant Application 2012 -13 Attachment Explanation Page 4: Program Expenditures Other: Direct Client Assistance: it is the tuition assistance, grant funding, to help cover tuition costs for low income participants who cannot afford full costs. These participants are above poverty level and therefore do not qualify for Medicaid programs which do pay for adult day care among other things. There are seven sources currently, each one is significant. Each application is reviewed for income, expenses, savings and assets. Only those with little or no savings and no assets except own home and/or vehicle (couples) are eligible. Income and expenses are compared and the cost share is derived from the comparison generally allowing only $50 remaining for other expenses monthly. 39 Hawaii Island Cardiovascular Services, Inc. Remote Cardiovascular Screening Agency Name: Hawaii Island Cardiovascular Services Program Name: Remote Cardiovascular Screening Project Agency Director: James Wille Phone No.: 707-237-5282 Contact Person: James Wille Phone No.: it Mailing Address: 64-1067 Mamalahoa Hwy B4 Kamuela, HI 96743 Facility/Site Address: This program involves a mobile screening process that will take place at locations throughout Hawaii County including churches, community centers, and similar sites. Fax No.: 808-885-8511 Email Address: jamesncheryl @mediacombb.net Name of Accountant/CPA (include name of firm if applicable): Stacy Chun, Stacy's Bookkeeping Phone No.: 808-885-8589 Mailing Address: P.O. Box 7096, Kamuela, HI 96743 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $145,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $ n/a $ n/a $ n/a NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 PAGE 1 of 11 Agency Name: Hawaii Island Cardiovascular Services Program Name: Remote Cardiovascular Screening Project Agency Mission Statement: To markedly improve the general health of Hawaii County Native Hawaiians, Residents, and Visitors by fulfilling un-met needs through directly providing diagnosis and treatment of the causes and manifestations of cardiac and vascular diseases. Program Description: Program Summary Hawaii Island Cardiovascular Inc., a Hawaii non-profit corporation, (HIC) proposes to bring remote cardiovascular screening services to the Big Island. Program Background The need for cardiovascular services in Hawaii County has been definitively documented in the publications "the Burden of Cardiovascular Disease in Hawaii 2007 (BCDH)" and the SHPDA document "Hawaii Health Performance Plan 1998 (H2P2)."Additionally, statewide figures on health insurance show that 17.5 percent of the Big Island population between the ages of 35 and 64 are uninsured; making it less likely those Big Island residents will seek care on neighbor islands. Although there are several cardiologists who practice in Hawaii County, there is no targeted screening program to help at-risk residents and visitors to become aware of their condition or need for diagnosis and treatment. Cardiovascular screening is of the utmost importance given that the Big Island cannot meet the national patient safety goals for care of acute heart attack; in particular the standard of coronary intervention within 90 minutes of arrival in a local emergency room, when the treatment includes a high risk transport to Oahu or Maui. Hilo Hospital has attempted to address this situation with an upgrade of an older existing angiography suite completed in 2007. During the most recent year for which statistics are available this catheterization lab performed 30 diagnostic NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 PAGE 2 of 11 Agencv Name: Hawaii Island Cardiovascular Services Program Name: Remote Cardiovascular Screening Project studies in an entire year, and no interventions on acute heart attack patients. Most recently the single cardiologist using this facility has left Hawaii County and the lab is unused for cardiac work. Program Strategy The program strategy is the implementation of a remote screening service. This will allows out-reach in various settings with medical screening equipment that can be easily transported and set up in any number of remote sites including vacant store fronts, clinics, churches etc. allowing for various "point of care" blood screening, as well as a variety of blood pressure measurements, screening ultrasound, EKG and oxygen consumption measurements. Staffed by nursing and ancillary help, there will be real time connectivity to cardiologists to accommodate any immediate referrals. Ancillary staff will be able to enroll patients in Quest or other appropriate insurance or government programs at the time of service. Access to specialty care, in this case cardiac care, is scarce. Much of the underserved population lives on the southern part of the Big Island and transportation issues further stymie access to cardiac care. Against this background, HIC is proposing a screening service to reach out to the most remote areas of the Big Island. Donations, community participation, and various kinds of funding support will facilitate the implementation of this critically needed project. Goals and Purposes 1) Provide a portal to underserved populations of Big Island residents for: • Providing cardiac and vascular screening of underserved populations • Referrals to primary care physicians for chronic conditions • Referrals to specialty care physicians for advanced cardiac and vascular treatment • Referrals for procedural treatment to local (Big Island) available acute care facilities (cath lab) to avoid travel to Oahu • Enrollment in government and other available programs for ongoing health care (Quest etc) NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 PAGE 3 of 11 Agency Name: Hawaii Island Cardiovascular Services Program Name: Remote Cardiovascular Screening Project • Education in home care (diet, exercise, lifestyle modification) to residents with chronic and acute cardiac and vascular disease 2) Become integrated with the local culture through: • Use of Hawaiian cultural influences on health care • Building and maintaining working relationships with physicians and practitioners in the community • Sponsoring educational programs on cardiac and vascular health locally in communities • Participating in other community educational programs related to the health and well being of Big Island residents • Filling necessary staff and volunteer positions with qualified local applicants Facilities This is a mobile project and our staff will be using existing community facilities, at different locations, in outlying areas throughout the Big Island Services Staff will network with community groups to increase participation, gain trust, and credibility with the populous. Local press and flyers will be used to notice local neighborhoods about services and visit schedules. Walk-ins will be welcome. Appointments will be scheduled to make the services more convenient for users. Services will be available two days per week initially. As program needs are established, expanded days and weekend coverage will be scheduled. Staffing Two staff members will be utilized, a nurse intake coordinator and ultrasound technologist. This will allow the screening ultrasounds, EKGs as well as screening blood work to be performed. The staff will be trained to facilitate NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 PAGE 4 of 11 Agency Name: Hawaii Island Cardiovascular Services Program Name: Remote Cardiovascular Screening Project enrollment in Quest, medical assistance and insurance programs. Staff will also complete out-reach, networking, fundraising, scheduling, filing, book- keeping and office administration. Intake/assessment Intake will be by standardized health screening forms. Those patients not appropriate for cardiovascular screening services will be referred to local physicians. This will not be a medical clinic. HIC screening will be set up to provide cardiac and peripheral vascular screening only. A risk score, using standardized cardiac risk assessment tools, will be calculated and a file initiated. Testing Depending on the assessment, screening can include blood work, EKG and/or ultrasound testing. Once the screening is complete a referral sheet with the data printed will be provided to the individual. Communication with healthcare providers Our staff will be able to provide real time communications and screening results to cardiologists located in their offices, or other appropriate medical personnel. Follow up referrals The referral options range from help to enroll in medical assistance programs, insurance programs, referral to licensed practitioners accepting new patients, follow up referrals to an affiliated cardiologists or cath. labs for a future appointment, or transfer to hospital emergency departments for immediate care. Transfer will be by local ambulance service. It is our belief that although remote screening does not provide medical care, this will be a portal for access to medical care and cardiac care specifically serving a well identified and chronically underserved population. Timing and Funding The remote cardiovascular screening project is expected to begin operations within one calendar year of the Certificate of Need (CON) approval, in the event it NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 PAGE 5 of 11 Agency Name: Hawaii Island Cardiovascular Services Program Name: Remote Cardiovascular Screening Project is required, and identification of funding. The remote screening program is envisioned under our 501 c3 corporation and HIC has received pledges of$50,000 in cash, and $100,000 in equipment donations for the program's first year of operation, as well as substantial in-kind donations of physician and administrative time. The cash and in-kind donations are documented by attached letters of commitment. Hawaii County Job Creation As a result of the recent demise of the Honolulu Medical Center, where a large number of Hawaii County residents have had heart procedures, the need for a facility on the Big Island has become still greater. One of our directors, Dr. Larry Derbes, a well-qualified interventional cardiologist from Honolulu, has agreed to office part time in Waimea starting the first week of February 2012. He anticipates our proposed screening operations will produce sufficient patient flows to enable him to move to the Big Island and develop the additional necessary associates. Additionally, some of the redundant personnel from Honolulu Medical Center are now available to provide more qualified cardiology staff here. All of this adds up to additional job opportunities for Hawaii County residents. Future Vision In the future, HIC expects to support the development of cardiovascular clinic staffed with cardiologists. Chronic precursors to cardiac disease can be followed here by cardiologists working with primary care providers. Thereafter, this project will support the development of a modern cardiac catheterization lab. A potential investor for the catheterization lab has been contacted and real interest has been shown. Talks are underway. This will be adjacent to the clinic in either a fixed site or new modular construction. At the outset, this lab will be used for scheduled diagnostic work and more importantly emergent/urgent treatment of acute heart attack. To meet national patient safety goals and standards of practice, this will require 24/7 staff and cardiologist availability to begin a procedure within 30 minutes of the call to action. This will require some structured coordination with an existing hospital. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 PAGE 6of11 Agency Name: Hawaii Island Cardiovascular Services Program Name: Remote Cardiovascular Screening Project This expansion of the program will allow diagnostic electrophysiology studies to be performed in the lab; additionally, cardiac rhythm control devices can be implanted. This is the fastest growth area in cardiac medicine today and shows great promise in reducing sudden cardiac death. Total Budget and Position Count Total Program Budget $410,000 Total Program Position Count 9 Total Agency Budget $26,610 Total Agency Position Count 3 Program Objectives: The program objectives, expressed as S.M.A.R.T. goals (specific, measurable, attainable, realistic and time-bound) are: 1) Indentify and purchase refurbished ultrasound, EKG and other equipment within the first 30 days. 2) Identify and contract with all staff members, and arrange van rental, within the first 45 days. 3) Complete employee training, Quest signup, testing protocols, results routing and archiving; establish initial sites for screening; arrange insurance coverage and establish cell phone contract within the first 60 days. 4) Make physician liaison and medical director arrangements by the end of the first 75 days. 5) Begin screening service by the end of the first 90 days. Program Highlights: (from Fiscal Year 2010-11) n/a Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget* Estimate #of people screened n/a n/a 500 # of physician referrals provided 100 # of cases of severe disease it 50 discovered in time for treatment NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 PAGE 7 of 11 Agency Name: Hawaii Island Cardiovascular Services Program Name: Remote Cardiovascular Screening Project Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget* Estimate Salaries and Wages n/a n/a $120,000 Professional Fees $ 85,000 Operations $ 95,000 Equipment $110,000 Other* ,, Total $410,000 Please explain "other" on a separate sheet Program Funding Sources (ALL sources specific to this program) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget* Estimate Hawaii County Grant n/a n/a $145,000 In-kind donations $115,000 Cash donation $ 50,000 Equipment donations $100,000 Total $410,000 Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Future project phases involve an MD-staffed clinic and a oath lab for procedures, which have the potential to fund the screening program long term. There are some years between now and those projected phases, however, and in the near term the screening program will be sustained through donations and various forms of in-kind support. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 PAGE 8of11 Agency Name: Hawaii Island Cardiovascular Services Program Name: Remote Cardiovascular Screening Project Provisions of The Patient Protection and Affordable Care Act that will be enacted in 2013-2014 will provide for a strong emphasis on preventive care and screening, which should provide additional avenues for sustainable cash flow. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. None NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 PAGE 9 of 11 Agency Name: Hawaii Island Cardiovascular Services Program Name: Remote Cardiovascular Screening Project I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2- 142.2, Hawaii County Code, relating to the Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not by accepted as original documents. If awarded a grant from the County of Hawaii. I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include and explanation of the public benefits derived from the awarding of the grant, a complete accounting of al expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 PAGE 10of11 Agency Name: Hawaii Island Cardiovascular Services Program Name: Remote Cardiovascular Screening Project understand there is no provision for further notification to submit the final report. No Late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantsapps/html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request ad may request in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. q��i "7 _ — 1-30-2012 Sig of Board President/Chair Date or Agency Director l` 1 7A- 1-30-2012 Sign ture of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 PAGE 11 of 11 40 Hawaii Montessori, Inc Tuition/Financial Aid Hawaii Montessori, Inc — Agency Name Tuition/Financial Aid — Program Name Agency Director: Angeline Geldhof Phone No.: Kona: 808-329-0700 Kamuela: 808-885-7683 Contact Person: Angeline Geldhof Phone No.: 808-936-1857 Mailing Address: 74-978 Manawale`a Street, Kailua-Kona, HI 96740 Facility/Site Address:Kamuela Campus:64-1058 Mamalahoa Hwy. Kamuela, HI 96743 Kona Campus: same as mailing address Fax No.: Kona: 808-334-0327 Kamuela: 808-885-4633 Email: angeline(a�hawaiimontessori.org Agency Info: Hawaii Montessori Inc. is made up of two campuses. One in Kamuela, established in 1980 and the second in Kailua-Kona, established in 1992. The Financial Aid Program is used at both campuses. Name of Accountant/CPA (include name of firm if applicable): Financials and Quarterlies are done by Dianna Lally, CPA Phone No.: 808-756-0788 Mailing Address: 73-1341 Oneone Place, Kailua-Kona, HI 96740 FYI:Audit and tax returns are done by Rozanne Connell of Carbonaro CPA & Associates, P. O. Box 4372, Hilo, HI 96720 Tel.: 808-968-1002 Amount of Request for County Grant-in-Aid Funds: $40,000.00 Prior Year Award of County Nonprofit Grants-in Aid funds: This is our first year applying for the County Grant-in-Aid Funds. 09-10 10-11 11-12 $0.00 $0.00 $0.00 Agency Mission Statement: Our Mission at Hawai'i Montessori Schools is educating children for life by providing a nurturing prepared environment where children, parents, and staff joyfully develop their esteem, inner discipline, independence, motivation and sense of community involvement to their fullest potential. Hawai'i Montessori Schools offers carefully planned, stimulating environments for learning. The curriculum covers a broad range of topics, including social skills, social and natural sciences, language, math and the arts. The materials used are designed to provide specific learning experiences to meet the unique needs of children at each stage of their development. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 6 Hawaii Montessori, Inc — Agency Name Tuition/Financial Aid — Program Name Program Description: Providing quality early childhood education is expensive, however we believe Early Childhood Montessori Education should be available to all children, regardless of their families'income. Currently, for the 2011-2012 school year, we have 100 students enrolled, of which 36 are receiving some kind of financial aid from us. To date, we have provided a total of$57,481 in financial aid for the 2011-12 SY and we anticipate that, if funding is available, we will continue to give financial aid to qualified new families as they become enrolled. We write grants to help supplement our Financial Aid Program as well as raising money through our own fund raising efforts, donations from individuals, and keeping our cost to essentials. It is clearly apparent that income from outside sources for scholarships must go up, or financial aid must go down. However, we know that as financial aid goes down, many needy families will be not be able to afford a high quality education for their children. Our mission includes creating a model of the highest quality education and care that can be available to ALL children, thusly, last year's financial assistance to deserving children was funded in part through the school's operating budget. In order for families to qualify for financial aid, they must fill out our Financial Aid application and provide us with supporting documentation showing income; custody; residency; child's age; and if parent is going to school a copy of registration form, or if unemployed a copy of active work search verification. Families are awarded financial aid based on income and number of people in the family unit. Funds are distributed on a sliding scale and on a first-come, first-served basis. Total budget and Position Count Total Program Budget: $75,000. Total Program Position Count: 55 Total Agency Budget: $851,200. Total Agency Position Count: 126 Program Objectives: By obtaining Financial Aid Grants we will be able to: 1). Provide Financial Aid to families in need who are seeking to enroll their children into a quality preschool program, thereby giving them an increased chance for success in their future educational career. We are looking to give partial tuition assistance to 55 children ranging from 5% - 20% of the full tuition cost during the 2012-13 School Year. When we look at the Hawaii State School Readiness Assessment results in West Hawaii, which includes the Honoka'a and Kealakehe Complexes, 52% of the students entering Kindergarten have never been in an early learning setting. Now, with Hawaii being one of the "Race to the Top"states, there will be more pressure for these young children to succeed in school and if they have not had the opportunity to attend a early learning environment, they will start their elementary school career at a disadvantage. Since we know the many benefits of a child having even one year of preschool experience, it is imperative that we provide their families with the assistance needed so that their children can attend an early childhood education program prior to attending Kindergarten. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 6 Hawaii Montessori, Inc - Agency Name Tuition/Financial Aid - Program Name 2). Enable us to fill the school to capacity, therefore providing job security to our current staff and allow us to open up more employment opportunities. We have a capacity to educate 126 students. For the 2011-12 school year there are currently 100 enrolled. By having the ability to give more financial aid we can enroll 26 more students, thus creating two more full-time staff positions. 3). Reduce the need to tap into the school's operating budget, thereby allowing us to move forward with our large improvement projects, provide cost-of-living raises to employees and provide staff professional development/continuing education options. Program Highlights: (from Fiscal Year 2010-11) 1). In the 2010-11 school year we were able to give $54,864 in Financial Aid to 48 students. 2). Our Kona Campus was re-accredited with the National Association for the Education of Young Children for another 5 years. NAEYC is a nationally acclaimed accrediting agency that ensures high quality standards are being met in early childcare centers. Our Kamuela campus is currently in the final stage of the accreditation process. One of the standards for accreditation relates to Families. Our ability to give financial aid demonstrates that we advocate the importance of providing quality early childhood education to all students no matter what their socio-economic background may be. Performance Measures: FY 2010-11 FY 2011-12 FY2012-13 Actual* Budget* Estimate Students who received FA 48 36 55 Amount of Financial Aid $54,864 $42,000 $75,000 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY2012-13 Actual* Budget* Estimate Salaries and Wages Professional Fees Operations Equipment Other#: Financial Aid Disbursement $54,864 $42,000 $75,000 TOTAL $54,864 $42,000 $75,000 *If applicable #Please Explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 6 Hawaii Montessori, Inc - Agency Name Tuition/Financial Aid - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY2012-13 Actual* Budget* Estimate Mclnerny Foundation FA Grant $30,000 $30,000 $15,000 G. N. Wilcox Trust FA Grant $ 7,500 $ 0 $ 5,000 Samuel N. & Mary Castle Foundation $ 3,333 $12,000 $15,000 County of Hawaii Grant-In-Aid N/A N/A $40,000 HMI PTA/PTO Fundraisers $ 9,231 $ 0 $ 0 HMI Operations $ 4,800 $ 0 $ 0 Total $54,864 $42,000 $75,000 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self- sustaining? Due to the current economic situation in the State of Hawaii, the percentage of children on financial aid will remain high. Our Board, Staff and parents are committed to maintaining high quality programs for Hawaii's children. Our fundraisers have been successful because of the tremendous commitment of our staff, families and the overwhelming support of local merchants and countless members of our community. Although we have such a strong backing from our families, staff and community, we are still in need of additional support for the financial aid program. It is our hope that as the economy improves the need for Financial Aid will not be as high. Hawaii Montessori, Inc. believes that quality education and care should be available to all children. For many families, attendance at our school would not be possible without the Financial Aid we offer. If it were not for foundations such as the G. N. Wilcox Trust, Mclnerny Foundation and the Samuel N. & Mary Castle Foundation we would not be able to offer the needed financial support for our families and still maintain the quality and integrity of an excellent educational program. It is particularly important at this time, as the DOE is planning on phasing out the Jr.K program, therefore pushing many of the children born after July 31'into unlicensed daycare situations. In addition, it is essential that the student body is diverse so that optimum learning can take place. Financial aid is awarded on a basis of need without regard to gender, religion or ethnic background. We generate financial aid funds by soliciting donations, writing grants and conducting fund raisers each year. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. None of our Employees or volunteers have an affiliations with the County of Hawaii. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 6 Hawaii Montessori, Inc - Agency Name Tuition/Financial Aid - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135-2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County Personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) undersigned that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by the County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 6 Hawaii Montessori Schools — Agency Name Tuition/Financial Aid — Program Name Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements.__D_________, 1 \ :.)-- -- c i Signatu,e of Board President/Chair Date or Agency Director 1 2 1 Z,. Signatur liNtlf\:'L of Executive Director Da e UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 6 41 Hawaii Island HIV/AIDS Foundation Multi-Disciplinary HIV Case Management, Hilo Hawaii Island HIV/AIDS Foundation- Agency Name Multi-Disciplinary HIV Case Management, Hilo- Program Name Agency Director: Tina Clothier Phone No.: 331-8177 Contact Person: Tina Clothier Phone No.: 331-8177 Mailing Address: 75-240 Nani Kailua Drive, Suite 5 Kailua-Kona, HI 96740 Facility/Site Address: 16-204 Melekahiwa Place, Suite 1 Keaau, HI 96749 Fax No.: 331-0762 Email Address: tina©hihaf.org Name of Accountant/CPA (include name of firm if applicable): Carbonaro CPA & Associates for fy ending 6/30/11 Phone No.: 968-1002 Mailing Address: P.O. Box 4372, Hilo, HI 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$15,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $15,000 $15,000 $10,000 Agency Mission Statement: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 15 The Hawaii Island HIV/AIDS Foundation (HIHAF)is a non-profit organization dedicated to assisting those affected by HIV/AIDS to maximize their qualilty of life, and to end the spread of HIV. We also utilize the lessons learned in the HIV epidemic of care and advocate for others in the fight against related diseases. Our vision is to build a healthier, stronger and more sustainable community, supporting all its members as we focus on HIV issues. HIHAF has been providing services to people at risk for, infected with, and affected by HIV/AIDS, since 1986. Our Foundation has an efficient and effective system to provide a comprehensive continuum of prevention, care, and support services with regard to HIV/AIDS to the entire Big Island. We refer to the Kona office as "HIV Foundation - Kona". As reported by the Hawai'i State Department of Health, Hawai'i County has the 2nd highest number of AIDS cases in the state. The number of people living with HIV/AIDS continues to climb steadily with each passing year of the epidemic, and the modes of transmission are changing. HIV is no longer present primarily in high risk populations. In fact, half of the 65,000 new annual infections in the United States take place as a result of heterosexual transmission. Half of these new infections are occuring among people aged 15-23. This indicates to us that we will continue seeing a rise in clients and their needs will change as the epidemic continues to shape our client population. Presently, HIV Foundation - Hilo provides multi-disciplinary team HIV case management, advocacy, information and referral, food pantry, client financial assistance, and other support services for more than 135 PLWHA (People Living with HIV/AIDS) and affected persons in East Hawai'i monthly. Our case load for the entire island is an average of 250 PLWHA monthly. Over the course of the year of December, 2010 through November, 2011, a total of 194 clients have been cared for in Hilo. Care team members support client independence and self-determination by providing a range of supportive services. These include knowledge and assistance in accessing a variety of public and private benefit programs, medical and nursing services, housing, food, emergency financial assistance, transportation, employment counseling, and other forms of assistance as appropriate to help and support a client's retention and active participation in primary medical care. The services received by each client are monitored regularly to determine the effectiveness of the service plan, identify emerging needs, and measure the outcome(s) of service delivery. HIV Foundation - Hilo proposes to continue its provision of high quality multi- disciplinary team HIV case management. As in past years, we continue to experience ZERO increases in State of Hawai'i Department of Health funding allocated to HIV/AIDS case management services on all islands with a growing case load. Regardless, we will continue to do our very best, as always, to provide the highest quality of services to all our clients, despite the static funding available to us. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 15 Perhaps the greatest challenge that case management has had to face in the last three years is the continued island-wide loss of primary and HIV-treating physicians. Many doctors providing treatment to HIV-positive individuals in East and West Hawaii have left private practice and the island. As recently as December 2011 we lost Dr. Brown , one of the last HIV specialist in Hilo. Speciality care for those with HIV at one point was almost non-existent on the Big Island. Thus we have had to cobble together treatment for people with HIV. One solution we have brokered is having the physicians from the AIDS Clinical Trials, through John Burns Medical School on Oahu, see patients on a monthly basis in both East and West Hawaii. This has brought high quality HIV treatment to many of our clients who are currently without a physician. At the present time they are seeing over 70 HIV+ clients on the Big Island. In addition to specialty care, these clients need a primary care physician locally. With so few doctors available, those remaining are being overwhelmed by the influx of new patients. Some physicians have limited their practice and are not accepting patients on Medicare or some other types of insurance. Finding a primary physician who understands or is willing to learn the complicated nature of clinically treating HIV, often alongside other health issues, adds to the scope and complexities of HIHAF's care team work. Currently the wait time for seeing a primary care physician at Bay Clinic is 3 weeks. Our care team not only educates doctors on resources for the treatment of HIV, they act as a liaison between clients and their health care providers. They are advocates for comprehensive treatment of the medical and psycho-social needs of our clients in this rural underserved area. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 15 Hawaii Island HIV/AIDS Foundation - Agency Name Multi-Disciplinary HIV Case Management, Hilo- Program Name Program Description: HIV and AIDS still carry a debilitating stigma in our society and clearly here on the Big Island. As a result, many of those who are infected with, affected by, and at-risk for HIV hide their challenges concerning the disease and managing it in their lives. HIHAF is the only place where HIV-positive individuals do not have to hide, where they are understood, and where all their needs can at least be addressed, if not fully resolved. A multidisciplinary team composed of two full-time (2.0 FTE) case managers,(a Treatment Advocate, RN; and a Benefits Specialist); one half-time (0.50 FTE) housing specialist and one half- time (0.50 FTE) client services facilitator provide direct care services for PLWHA residing in East Hawai'i. (The housing specialist also serves clients on the west side of the island.) The monthly average active caseload for the East Side office of the Foundation this past year is one hundred and thirty (130) clients. Thirty-three percent (33%) of the HIV Foundation - Hilo's clients are homeless, multiply diagnosed, drug misusers and/or mentally ill. Eighty-eight percent (88%)fall into two or more special population categories as defined by the federal Ryan White CARE Act Title II. Addressing clients' HIV and AIDS needs often begins and ends in completely different arenas. HIHAF's care team negotiates and juggles relationships with clients and their families, social service agencies, and state and federal agencies and programs. They reach across Hawai'i and into other states to build relationships with other AIDS service organizations to find medical and benefits records, and to establish client histories and needs. They are active in statewide and nationwide care coalitions to enable us to bring the latests and most up to date information and treatment to our clients. Due to the complex nature of treating HIV, HIHAF advocates will continue to work with as many doctors and care providers in the area as possible. Maintaining strong relationships with professionals and agencies that serve a myriad of social and other needs is only one small part of our advocates'jobs. Our care teams' holistic care for and dedication to working with all our clients needs is driven by HIHAF's mission of serving people who are living with HIV to have the fullest most complete life possible. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 15 For many people, living with HIV and the financial and logistic difficulties of managing their disease is very difficult at best. Their lives are further complicated by fear and stigma. Several of our older, female, Hawaiian clients feel that HIHAF is the only safe place for them to let down their barriers, speak of their fear for themselves and their families, and discuss how this disease and their possible death will affect them. In the safety of our facility, they can show the depth of their feelings, they can find necessary, life-saving, and disease- monitoring clinical care and life saving HIV drugs. They also find a shoulder to lean on and resources for themselves and their families. Over the holidays our entire organization again rallied to make sure that each and every client and family had the resources to have a wonderful meal for both Thanksgiving and Christmas and that each child had at least one gift for Christmas. We were assisted in this effort by the Toys for Tots program as well as the MCC Church in Pahoa and a tiny congregation in Puako. We were extremely fortunate and were able to truly share the intent of these holidays with our less fortunate clients. Holidays are sometimes very difficult for those who are ill or isolated from their community and family. Our Care team members spent a substantial amount of time calling all clients to ensure they were doing well and determining if there was anything further we could do to assist them. Individuals with mental health issues are at a greater risk of acquiring and transmitting HIV. Many of our clients have mental health problems which complicates their ability to care for themselves and take their medications properly. There are very few psycholigists on the Big Island who have experience with people with HIV. We have initiated monthly visits by such a qualified individual to provide therapy to our most affected clients. This psychologist practices and lives in Honolulu so it is necessary for him to come to the Big Island twice each month to see our clients. The benefit is that our most affected individuals have adequate mental health care and the more stable they become the less chance that they will pass on this disease to others. We are very proud of this program and have seen the difference it has made in the lives of our clients with serious mental illness. Another substantial challenge for our care team is to educate clients about the federal prescription drug plan legislation (Medicare D). This program while on the surface is designed to help those in need of medication help, it also greatly complicates accessing necessary medicines through multiple layers of complex eligibility criteria, and constant changes to plan structures. In order to enable clients to acquire their medications at the lowest possible cost through Medicare Part D, care team members must understand the client's current income and drug coverage plan, know what drugs the client needs and which plans cover it. They must have knowledge of the client's other medical needs, understand which pharmacies will accept which drug coverage program, NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 15 and have an understanding of HIV and other pharmaceuticals to compare pricing. This year many of the companies offering Medicare D moved the drugs necessary for the treatment of HIV to and even higher more costly level. The impact of that change put a significant number of clients into the "donut hole" within 2 months. Our Hawaii Drug Assistance Program for HIV is funded by federal Ryan White Funding. Because of this change, more and more individuals will move into the HDAP program leaving less of these federal funds for other areas of need. As the number of clients continues to grow, the burden on our care team to provide adequate care also grows. Many of our clients face multiple health issues and need medications to suppress HIV, need other drugs to address side effects of HIV drugs, and need additional drugs to treat opportunistic infections related to HIV. Most clients who are taking medications, take from 6 to 10 drugs daily or multiple times a day. HIHAF's care team members are compassionate and talented. For them, treating someone's HIV encompasses the entire person - not just the disease. For our clients, many who live with fear and stigma, who deal with other medical and social issues, and face declining access to medical services in Hawai'i, HIHAF is the only place to come for support. HIHAF's care team members are often the only people that HIV positive individuals on this island know and trust. They are sensitive professionals who navigate the complications that HIV brings to the body and soul. In order to best serve the needs of our clients, a written service plan is developed cooperatively by the client and the care team annually. The service plan identifies client needs, defines the specific goals and objectives that address identified needs, and lists the action steps required to accomplish the client's stated goals and objectives. The service plan is developed and implemented within two weeks following the intake of a new client and then updated quarterly or more frequently, if necessary, until the client is discharged. In addition to service plan updates, clients are contacted at least once a month to monitor their health status and identify emerging needs. Acute clients in need of more frequent contact can receive telephone calls and/or office or home visits three to four times per week. A minimum of one hundred and sixty (160) service plans will be developed or revised during the upcoming FY 2012-2013 grant period in the East Hawaii office. A similar amount will be completed in the West Hawaii office. To ensure appropriate access the Foundation's hours of operation are Monday through Friday, 8:00 a.m. to 4:00 p.m. Staff frequently visit clients in their homes, at the hospital, during their monthly physician's visits and outside of both home and office, if that is what is necessary to help clients engage in their own care. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 15 HIHAF provides invaluable support to HIV-infected individuals to assist them in keeping their loved ones free of HIV. Primary HIV prevention is based upon a culturally appropriate harm reduction methodology. When a new client begins their relationship with HIHAF, we take care to assess their current relationships and activities they may participate in that might put others at risk for HIV infection. Care team members either provide such interventions themselves or make referrals to the HIV Foundation - Hilo's prevention department. Care team members also offer anonymous HIV-antibody counseling and testing for family members and significant others. QUANTITATIVE EVALUATION: Quantitative evaluation measures for multi-disciplinary team case management services include the collection, tabulation and entry of service data into a computer tracking system provided by the State of Hawai'i (E-2). Data routinely tracked include: number of clients, types of service provided, and the number of services provided by service category as well as the costs for these services. Planning estimations for service delivery during the FY2012-2013 currently project that a total of twenty-six (26) separate case management services will be individually provided to a minimum of 160 clients living with HIV/AIDS. Services include, but are not limited to: intake, assessment, treatment advocacy, mortality and morbidity tracking, benefits counseling, volunteer referrals, hospital and home visits, medical liaison, crisis intervention, emergency financial assistance, housing assistance, home care and transportation. Data collection consists of counting the number of written service plans that are developed and/or revised each quarter. Computer reports indicating number and kinds of services delivered by each case manager are generated on a monthly basis. If projections are met or exceeded, service delivery is considered successful. The service component is also considered successful if ninety-five percent (95%) of clients have a medical care provider and adhere to their treatment routine resulting in stable health. QUALITATIVE ANALYSIS: A client satisfaction survey is mailed to all clients in December. Completed surveys are returned anonymously. Tallied survey results are distributed to HIHAF' s Board of Directors, staff, clients and state and federal granting organizations by the end of February. Executive Director and/or board members may, on an unannounced basis, meet with clients to discuss their satisfaction with services. The Foundation has three client representatives on the Board to bring forward issues specific to clients needs and desires. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 15 CHANGES FOR 2012 The economic downturn continues and has resulted in the loss of employment of a significant number of clients a decrease of income for many others. Various support programs have closed during the last year which is putting more and more stress on programs, such as ours, to pick up the slack. One of the major programs that support our clients is the State of Hawaii Drug Assistance Program which initiated a waiting list which extended for approximately 6 months. It has been reinstated, but we have been informed, that it is probable that unless more funding is found, this program will again initiate a waiting list later this year. To the best of our ability we are meeting those needs, but not all. Our grant oversight committee is looking carefully at each and every request and focusing on those items which make the greatest difference, i.e., requests for medical care, medicine, housing and food. As was the case last year, dental care was not offerred in 2010/11 due to a lack of funding. In all cases, every possible funding source for client care is being pursued. HIHAFcontinued with cost cutting activities during the past year in response to the declining economy and in anticipation of funding decreases. We are planning two furlough days for all full time staff in 2012 unless we are able to secure additional funding. On a positive note, we secured a new funding source for our food pantry and are able to supplement our clients shopping with addtional essential protein rich foods. We also plan to add an exercise and clean water service component for clients in need In addition, we were able to negotiate a 3 year lease renewal for our Hilo office which is well below the average price in the community. Total Budget and Position Count Total Program Budget Total Program Position Count 3 356,228 Total Agency Budget 996,050 Total Agency Position Count 14 Program Objectives: 1) Objective One: By July 30, 2012, and within twenty-five (25) days following a determination of need, identify and secure appropriate financial resources to pay health insurance premiums for no less than ninety percent (90%) of all PLWHA whose access to high quality primary care, ancillary health care and specialty medical care would otherwise be in jeopardy. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 16 2) Objective Two: By July 30, 2012 and within twenty-five days following a determination of need, assist no less than ninety percent (90%) of all eligible PLWHA who request or demonstrate a need for substance misuse treatment, mental health counseling, HIV-related medication, and food and to obtain such goods and services through appropriate referrals and practical support. 3) Objective Three: By July 30, 2012 and within twenty-five days following a determination of need, forestall homelessness by providing financial support and/or housing relocation assistance for no less than ninety percent (90%) of all eligible PLWHA requesting or demonstrating a need for emergency shelter, or either short-term or long-term shelter or housing assistance. 4) In addition,HIV Foundation - Hilo shall provide the types and levels of case management related supportive services for its consumers, listed below: 5) Benefits assessment/counseling 6) Client family counseling 7) Progressive case notes 8) Crisis intervention 9) Health care assessment/counseling 10) Field /office visits 11) Medical treatment referrals 12) Home visits 13) Housing assessments 14) Intake/assessments 15) Legal document assistance 16) Financial benefits 17) Funeral/estate coordination 18) Generic assistance/counseling 19) Housing assistance 20) Health care benefits 21) Legal advocacy assistance 22) Client monitoring/assessment 23) Nutritional assessment/counseling 24) Risk assessment/counseling 25) Mental health assessment/counseling 26) Service coordination 27) Mental health counseling referrals 28) Transport activities 29) Substance abuse assessment 30) Substance abuse treatment referrals (as available) 31) Total number of service categories: 26 32) Timeline: Service plans are developed within two weeks of the initial intake session and reviewed quarterly. Service delivery will be on-going during FY 2012-2013. The services listed above represent baseline service projections. Client-centered Outcome(s): A mimimum of one NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 15 hundred sixty (160) clients and their families will access critical services including medical, financial, social, care givers, legal, nutritional, etc. through the HIV Foundation - Hilo's case management and volunteer team. With the assistance of our case managers, at least ninety percent (90%) of clients will secure a primary care physician and remain in medical treatment. Program Highlights: (from Fiscal Year 2010-11) 1) During FY 2010-2011, medical case management services included one hundred ninety four(194) clients who received medical assessment, patient education, treatment advice, nutrition, medical liaison, dental liaison. 2) As of December 2011, all clients are receiving the highest quality primary medical care; however, 30% are receiving care through public health clinics, which at times cannot meet all their needs. 3) We have maintained all individuals previously on the housing program and added more as funding became available. We presently have a waiting list of 8. 4) The number of hospital visits during this fiscal year remained at approximately 1-2 per month. We presently have 3 clients with end-stage cancer. 5) The Director of Programming continues to support a smooth, seamless experience for all clients and staff. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 15 Hawaii Island HIV/AIDS Foundation - Agency Name Multi-Disciplinary HIV Case Management, Hilo - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate # and types of case management 26 26 27 services provided 194 170 200 # of clients receiving case management services # of Risk behavior assesment, 388 250 400 transmission prevention education x 2 per year (minimum) *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 161,590 145,000 150,000 Professional Fees 2,500 2,500 2,500 Operations 126,558 134,544 128,180 Equipment Other# 75,728 75,728 75,728 Total 366,376 357,772 356,228 * If applicable Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 15 Hawaii Island HIV/AIDS Foundation - Agency Name Multi-Disciplinary HIV Case Management, Hilo - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate County of Hawaii 15,000 10,000 15,000 AIDS Community Care Grant 75,728 75,728 75,728 Foundations 20,000 13,000 15,000 Fundraising 15,000 15,000 20,000 HIUW 17,000 25,000 unk DOH Care Grant 192,808 192,808 192,808 HIUW EFSP 5,000 5,000 Macy's 5,000 5,000 Ironman 5,000 1,000 unk HUD SPNS 15,000 15,000 15,000 Total 355,536 357,536 343,536 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Unfortunately, the HIV/AIDS epidemic shows no sign of ending, and indeed continues to grow. There is often a misrepresentation of facts about the epidemic in the media, indicating a lessening of urgency in dealing with this epidemic. The fact is, there are still a minimum of 65,000 new cases in the US each year, and half of these new infections occur through heterosexual transmission and in the age group of 15-23 year-olds. Each newly infected individual presents with a myriad of challenges to be met and overcome. Because the epidemic continues to grow, we do not see a specific point at which our program might become self-sustaining. We continue looking at development of various income producing businesses which could help to support the activities of our non-profit. We continue seeking colloborators for various aspects of our program, i.e., housing, food, etc. which would help maximize funding for both NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 12of15 parties and benefit the community at large. We have received level or decreasing funding from our main revenue source, the State of Hawai'i Department of Health, for the last 16 years. During this time, the number of people we are caring for has almost tripled. At present rates of infection the number of people seeking services may increase an additional 50% over the next 10 years. The costs for personnel, health insurance, rent, utilities, etc. have risen dramatically over the past few years and no funder seems to recognize the kind of stress this creates for the non-profit sector. We are endeavoring to be creative in our approach but the reality is that many organizations may be stretched to the point that they cannot continue. As the only AIDS Service Organization on the Big Island this would be devastating to those living with HIV/AIDS here. An additional stressor is that our clients live longer now because of the availability of new drug treatments. This is wonderful in that it allows those who are infected to live longer. Simultaneously, it also raises challenges for us as a Foundation to continue to support their health so that they can live and hopefully be productive. Few, however, are well enough to work full time and thus their income level puts them into a position of continuing to need our services. We are very grateful that we have this support from the County, and we want to thank you for this opportunity to apply to you for funding. We will do everything possible to maximize the use of County funds, if awarded. # Note to Program Expenditures: Other: these funds are from a Ryan White Grant and go directly to pay for medicine, medical care, housing, etc. for our clients and are pass through only. No funds are provided for overhead of any kind. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. none NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 13 of 15 Hawaii Island HIV/AIDS Foundation - Agency Name Multi-Disciplinary HIV Case Management, Hilo - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 14 of 15 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you ar- acknowledging that you have read and understand these re• • - - ts. J Signature o •oar esi►en ' hair D.te or Agenc, Director 7 Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 15 of 15 42 Hawaii Island HIV/AIDS Foundation Transmission Prevention for HIV + Women in West Hawaii Hawaii Island HIV/AIDS Foundation- Agency Name Transmission Prevention for HIV+ Women in West Hawaii- Program Name Agency Director: Tina Clothier Phone No.: 331-8177 Contact Person: Tina Clothier Phone No.: 331-8177 Mailing Address: 75-240 Nani Kailua Drive, Suite 5 Kailua-Kona, HI 96740 Facility/Site Address: same Fax No.: 331-0762 Email Address: tina @hihaf.org Name of Accountant/CPA (include name of firm if applicable): Carbonaro CPA & Associates Phone No.: 968-1002 Mailing Address: P.O. Box 4372, Hilo, HI 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$15,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $15,000 $15,000 $10,000 Agency Mission Statement: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 13 The Hawaii Island HIV/AIDS Foundation (HIHAF)is a non-profit organization dedicated to assisting those affexted by HIV/AIDS to maximize their qualilty of life, and to endign the spread of HIV. We also utilize the lessons learned in the HIV epoidemic of care and advocate for others in the fight against related diseases. Our vision is to build a healthier, stronger and more sustainable community, supporting all its members as we focus on HIV issues. HIHAF has been providing services to people at risk for, infected with, and affected by HIV/AIDS, since 1986. Our Foundation has an efficient and effective system to provide a comprehensive continuum of prevention, care, and support services with regard to HIV/AIDS to the entire Big Island. We refer to the Kona office as "HIHAF - Kona". As reported by the Hawai'i State Department of Health, Hawai'i County has the highest number of AIDS cases outside of O'ahu, with 13% of all AIDS cases reported in the state since the beginning of the epidemic coming from the Island of Hawai'i. The number of people with HIV/AIDS climbs steadily upward every year of the epidemic. In the US alone, there are 65,000 new cases of HIV every year. Currently, we know that half of all these new infections occur through heterosexual transmission, putting women at a very high risk of HIV infection. The proportion of cases diagnosed in women has been increasing steadily over time, and we have little reason to believe it will decrease anytime soon. This is a distressing increase in infection among women. The female population in other US and global communities continue to bear the brunt of new HIV infections. Women's rights are often compromised within relationships and, due to gender imbalances within relationships, women continue to be more vulnerable to HIV infection than men. Our Foundation believes in upholding a strong focus on prevention programming, and specifically targeting women and populations vulnerable to HIV infection. Through working with HIV-positive women and addressing their behaviors and empowering them through education and prevention activities, we continue working towards stopping the spread of HIV and AIDS. Without aggressive prevention intervention many more individuals in our community might become infected by the actions of a single individual. We are also actively involved with the most vunerable members of society such as the young women residing in the domestic violence shelter in West Hawaii. These young women have already been exposed to risky behavior by nature of their relationships and perception of lack of power in those relationships. In addition many of them have low self esteem, little or no education, and see themselves as worthless. By working with these young women, getting them tested for HIV and other sexually transmitted diseases, and showing them their NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 13 self worth we can break the cycle of unprotected sex, possible drug use and other destructive behaviors. • NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 13 Hawaii Island HIV/AIDS Foundation - Agency Name Transmission Prevention for HIV+ Women in West Hawaii- Program Name Program Description: The Hawai'i Island HIV/AIDS Foundation - Kona is proposing to continue funding for the HIV transmission prevention programs for all HIV+ women in West Hawai'i County, including individual and group protocols and counseling and testing of women at risk. This program is designed to STOP HIV at the source, with individuals who can transmit the disease to others. The program also provides early treatment for newly diagnosed HIV positive women, maintenance of stable health and well being for all HIV+ women in West Hawai'i County, long term planning for health maintenance, and transmission prevention interactions. Our on-going SISTA Program, "Sisters Informing Sisters about Topics on AIDS" continues to be the cornerstone of reaching at risk women who may already be HIV+ and unaware of their status. This program is directed to low income women at high risk for infection and transmission of HIV. Many of them already suffer from illegal drug use, abusive partners, domestic violence, sexual abuse, poverty, and lack of minimal medical care. This program is an in-depth behavioral change program. Our Women's Outreach Specialist leads this social skills, health promotion, training intervention, aimed at reducing HIV sexual risk behavior among low income minority women who are at highest risk for HIV and other sexually transmitted diseases. The program consists of five once-a-week two-hour sessions, and includes a sixth, "booster" session one month after the women graduate at the fifth session. Most of the women participating are reached through outreach or referred to the program from other local agencies and organizations serving women and families in the community. To date, all the SISTA programs have been extremely well received, with very positive feedback for the program, the facilitator, as well as HIHAF for offering such a comprehensive culturally appropriate program. We include the SISTA Project in this application because it is instrumental in helping us reach women who may already be HIV positive. It allows them to get tested, and if positive, into care services immediately. This program has been developed by the U.S. Centers for Disease Control and Prevention and has been found to be one of the most effective for minority women. We tailor each intervention to be appropriate to the woman we are working with. It is a harm reduction non judgmental approach that meets women "where they are", not NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 13 "where we want them to be" in terms of their behavior. The end result is the empowerment of women by giving them the tools and the ability to direct their lives and health. QUANTITATIVE EVALUATION: Quantitative evaluation measures for this program includes the collection, tabulation and entry of participant data into a computer tracking system provided by the Centers for Disease Control (e2Hawaii). Data routinely tracked include: number of clients, ethnicity, social status, risk categories, type of intervention, number of interventions, outcome information during program and additional follow up 30 and 60 days after completion of program. Planning estimations for interventions and programing for women FY2012-2013 are as follows: SISTA a minimum of one hundred and ninety eight women (198) will participate in at least five (5) sessions and one (1) follow up session. For HIV+ women: a minimum of thirty five (35) women will have assessment sessions, quarterly reviews and quarterly individual prevention sessions. QUALITATIVE ANALYSIS: Data is gathered during outreach and individulized one on one sessions with all participants. For HIV+ women a prevention plan is developed and monitored on a monthly basis to assist the woman at the initial stages of dealing with her new status as HIV+. Later these sessions may be quarterly as she develops the skills necessary to protect herself and her partners. Participants in the SISTA program fill out a pre-test at the beginning of the program. They also fill out knowledge level questionnaires at the end of each session. A final post test is administered to determine level of knowledge, increase or decrease in self awareness of actions, consistency of condom use, level of negotiation skills, etc. A participant satisfaction survey is also administered to determine the efficacy of the presenter, the material, the setting, etc. All of the above data is reported quarterly to the Centers for Disease Control and the Dept. of Health of the State of Hawaii. Additional data is kept on the number of Rapid HIV tests administered, as well as Hepatitis C screenings along with the results each month. All the above information is also provided to the Board of Directors, staff, and other interested parties to help us improve the quality of our prevention programs. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 13 CHANGES FOR 2012: Our Board of Directors has also made an even greater commitment to this Foundation and through their efforts, our signature event Taste of Life netted almost 40% more than the year before. New Funding Sources: The board has also committed to launching HIHAF's inaugural Big Island AIDS Walk in the spring of 2012. They are giving more of their time and talent to make sure that we weather this difficult time and grow as an organization at the same time and they recently successfully met a challenge grant to raise $20,000 for the SISTA program. New collaborations: This year we are teaming up with Child and Family Services and presenting our program to their domestic violence shelter residents. Total Budget and Position Count Total Program Budget 70,000 Total Program Position Count 2.5 Total Agency Budget 996,050 Total Agency Position Count 14 Program Objectives: 1) Review each HIV+ woman's transmission prevention service plan in first month of program, and/or initiate new transmission prevention plan for newly infected women. (Estimated 40 women, 1-2 hours per client.) 2) Refer women to appropriate providers if needed, i.e. mental health providers, substance abuse treatment, etc. within the first month. These providers can deal with some of the behaviors which place these women at risk of transmitting this disease. These professional counseling sessions are paid for by other funding sources. 3) Initiate transmission prevention protocol (estimated 40 clients, 1 hour each) immediately. Reinforce at each meeting until client is stable. Quarterly thereafter or as problems arise. 4) Document progress and adherence to transmission prevention protocol with input from client quarterly (40) NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 13 5) Weekly/Monthly/quarterly support for HIV+ women dealing with self- esteem, negotiation, sexual issues, transmission prevention as needed by individual client. 6) Referral to other women who may be at risk of contracting or transmitting HIV to others by program participants. Referral to result in HIV counseling and testing by prevention outreach staff and screening for participation in the SISTA program if appropriate. 7) Increasing the number of SISTA programs in West Hawaii including 5-2 hour sessions and 1-booster session for a minimum of 198 at risk women in Hawaii County. Program Highlights: (from Fiscal Year 2010-11) 1) Achieved a review of care prevention service plans for twenty nine (29) women during first half of funding year 2010-2011 2) . 3) Referred women to specialized care for health and/or prevention issues during first half of the funding year. 4) Reviewed and updated health and prevention plans for all participants quarterly. Five new female intakes, one pregnant, had more intensive interventions 5) Initiated in-depth transmission protocols with all participants, and met with each participant on a one-to-one basis quarterly. 6) More than seventy-five (75%) percent of HIV+ women and participants in the Sista program have reported 100% compliance with prevention protocols by fourth session (i.e., use of condoms or other protection during all sexual encounters.) 7) Twenty-five (25%) percent of participants have reported compliance 80% of the time to date, with the goal of 100% compliance by the end of the year. 8) Ninety (90%) percent of participants are documented to have benefited from the program by maintenance of good health, increased self-esteem, and ability to interact with sexual partners in a safe manner, thereby decreasing the possibility of sexual transmission. 9) As of December 2011, zero transmission of HIV by any participants in either program. Stable health reported by all HIV+ participants as a partial result of this program. 10) A total of 67 women of unknown HIV infection status have participated in the SISTA Project training sessions as of December, 2011. 11) On going associations and collaborations with Turning Point for Families, the Women's Shelter, Big Island Substance Abuse Council, Kealakehe High School GRAD Program,The Friendly Place, and various other programs that provide services to women in our community. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 13 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8of13 Hawaii Island HIV/AIDS Foundation - Agency Name Transmission Prevention for HIV+ Women in West Hawaii - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate HIV+ individual transmission 29 40 60 prevention session (assesment) Health prevention plan review 29 40 60 Quarterly individual transmission 116 160 240 prevention sessions (1 hr each) Quarterly review and 116 160 240 documentation of program SISTA Program participation #s 72 100 198 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages 38,516 35,000 45,000 Professional Fees 1,153 _ Operations 13,063 25,000 25,000 Equipment Others Total 52,732 60,000 70,000 If applicable Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 13 ran Hawaii Island HIV/AIDS Foundation - Agency Name Transmission Prevention for HIV+ Women in West Hawaii - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate County of Hawaii 10,000 15,000 15,000 Omidyar Ohana Foundation 0 20,000 20,000 Foundations 5,000 10,000 15,000 Fundraising 5,000 15,000 15,000 HIUW 5,000 0 5,000 DOH/CDC Prevention Grant 16,500 0 0 Total 41,500 60,000 _ 70,000 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? As of January 1, 2012 the Centers for Disease Control through the State of Hawai'i Department of Health will no longer fund HIV/AIDS prevention services for women, youth and TGs in the state of Hawaii. This is reflected in our Program Expenditures and Program Funding Sources tables. Not with standing these challenges we continue to do our very best to reach as many women as possible and provide them with high quality services. Our committed prevention staff is representative of the women we serve and are a great example to the participants of what they can become if they make the right choices. The $20,000 gift from the Omidyar Ohana, plus the $20,000 matching raised along with a promise from Hawaii Island United to fund the program if they reach goal, NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 13 gives us confindence that we will be able to sustain the program into 2013 with the County's support. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. none NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 13 Hawaii Island HIV/AIDS Foundation - Agency Name Transmission Prevention for HIV+ Women in West Hawaii - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 12 of 13 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these require' ents. / /Z4 7/--1■ 4 "ature . Board esident/Chair Date or Age y Director 1^_..e.___ i (7_696? Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 13ofl3 43 Ho'oulu Lahui Solar Dryer for Food Security Ho'oulu Lahui- Agency Name Solar dryer for Food Security- Program Name Agency Director: Keikialoha Kekipi Phone No.: 965- 5098 Contact Person: Susie Osborne Phone No.: 640- 3439 Mailing Address: P.O. Box 2177 Pahoa, HI 96778 Facility/Site Address: 14-5322 Kaimu Kapoho Road Fax No.: 808 965-9618 Email Address: pualaa @ilhawaii.net Name of Accountant/CPA (include name of firm if applicable): Cabenero CPA Rozanne Connell Phone No.,: 968-1002 Mailing Address: Box 4372, Hilo You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$25,000.00 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 8 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $20,000.00 $0 $0 Agency Mission Statement: Ho'oulu Lahui is a Native Hawaiian 501(c)3 founded in 1995 with the purpose of awakening Hawaiian culture, values, beliefs and lifestyle in partnership with the community to achieve unity, harmony and total well-being (lokahi). NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 8 Ho'oulu Lahui - Agency Name Solar dryer for Food Security- Program Name Program Description: Students (grade 6-12) from partnering Kua 0 Ka La PCS will learn how to build a commercial grade solar food dryer This will be used by our agriculture, forestry and culinary class in an effort to retain and enhance local and traditional food sources and practices resulting in value-based products. Total Budget and Position Count Total Program Budget 25,000.00 Total Program Position Count (2) .5FTE Total Agency Budget 290,000.00 Total Agency Position Count 4 Program Objectives: 1) Build (1) a commercial grade solar food dryer over the course of one year. Construction skills will be learned. A functional heavy duty solar dryer will be the end product. 2) Document progress and produce (200) informational newsletters r to be distributed to (200) community members educating them on the need, use and function of solar dryers. Program Highlights: (from Fiscal Year 2010-11) 1) Produced a cookbook that uses ONLY locally grown foods for all of the ingredients! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 8 Ho'oulu Lahui - Agency Name Solar dryer for Food Security - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Materials:Purchase wood hardware 8,450.00 and components (air systems and vents) to build commercial drying unit Purchase solar system to be put 4,750.00 together to power the unit; batteries, inverter, solar panels, charger etc. Construction teacher to work with 8,000.00 students 40 days x $200.00 per day Produce and print educational 800.00 newsletters to be distributed to the community x 200 Computer, printer, camera and ink 1,750.00 to document process and for making flyer Fiscal and progress reports 1,250.00 submitted in a timely manner *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 8,000.00 Professional Fees 1,250.0 Operations NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 8 FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Equipment 4,750.00 Other# 11,000.00 Total 25,000.00 *If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 8 Ho'oulu Lahui - Agency Name Solar dryer for Food Security - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Kua 0 Ka La PCS agriculture 20,000.00 20,000.00 Lo 006.OD instructor to produce food for drying Total 20,000.00 20,000.00 20 000 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The students will be able to use this infrastructure to begin to dry food. The solar dryer will be put to work immediately to begin studying the feasability of product development. The dryer will be built, completed and project will be integrated into core programs. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. .none NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 8 Ho'oulu Lahui - Agency Name Solar dryer for Food Security - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 8 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. aaetZ- eiif. vc r I- 30-2012 Signature of Board President/Chair Date or Agency Director (-?(/ __. ,...\ / , 1-3o-2o12 Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 8 44 HOPE Services Hawaii Beyond Shelter Transitional Housing HOPE Services Hawaii, Inc. Beyond Shelter Transitional Housing Agency Director: Brandee Menino Phone No.: 808-933-6013 Contact Person: Katherine Nawahine Phone No.: 808-933-6038 Mailing Address: 1315 Kalanianaole Ave., Hilo, HI 96720 Facility/Site Address: 110 Ululani St., Hilo, HI 96720 Fax No.: (808) 935-3794 Email Address: bmenino @hopeserviceshawaii.org Name of Accountant/CPA (include name of firm if applicable): Gail Shioshita (808) 933-6048 1315 Kalanianole Avenue, Hilo, HI 96720 CW Associates Phone No.: (808) 695-4014 Mailing Address: 700 Bishop Street, Suite 1040 Honolulu, HI 96813-4124 Amount of Request for County Grant-in-aid Funds: $15,000.00 Prior Year(s) Funding: 09-10 10-11 11-12 $15,000 $15,000 $10,000 Agency Mission Statement: On October 1, 2010, the Office for Social Ministry, Care-A-Van Department of the Diocese of Honolulu, became HOPE Services Hawaii, Inc. (HOPE). HOPE manages the same services and programs to those most in need in our community with the same dedicated staff and support from the Diocese of Honolulu. Bishop Larry Silva remains committed to helping the homeless and the incorporation of the Care-A-Van Department into HOPE Services Hawaii, Inc. will allow us to be more visible in our community and be more effective in our delivery of services. HOPE's mission is to bring to life the gospel values of justice, love, compassion and hope through service, empowerment, and advocacy. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 HOPE Services Hawaii, Inc. Beyond Shelter Transitional Housing Program Description: The Beyond Shelter Transitional Housing Program was established in 2006. The shelter consists of eight private apartment units, to be occupied by families. There are six (6) — 2 bedroom /2 bath units, one (1) — 1 bedroom / 1 bath unit and one (1) — studio with a bath. Program participants are expected to participate in skill building activities and classes, pay program fees on time, be courteous neighbors, and commit to seeking employment or higher educational opportunities. Our transitional housing program is based on a seamless continuum of care model as advocated by the Department of Housing and Urban Development (HUD). Our target group consists of families with at least one minor child that have been unsheltered or living in an emergency or transitional housing program/shelter. In order to ensure safety for all program participants, we prohibit access to families who have active, unresolved domestic violence or substance use issues. Families are selected based on the following criteria; motivated to continue to make positive life changes, willingness to engage in life skill building activities including credit repair, financial literacy, health education, family enrichment, neighborhood watch; commitment to pay program fees and the willingness to observe House Rules. The Care Coordinator, Case Advocate and Shelter Specialists engage with families weekly to develop individual family service plans that incorporate extensive linkages to agencies throughout our community. The objective is to assist families in accessing educational and vocational training; job placement; transportation support; linkages to substance abuse and mental health treatment; assistance with family reunification; extracurricular and age appropriate enrichment activities for the children; life skills and financial skills training for the whole family; culturally appropriate activities; housing placement assistance; and one year of aftercare after placement in permanent housing. Total Budget and Position Count Total Program Budget 115,320.00 Total Program Position Count 1.5 Total Agency Budget 4,064,986.00 Total Agency Position Count 43 Program Objectives: 1) 10% of program participants will enroll in a post-secondary higher education institution. 2) 50% of unemployed program participants to enroll in higher/further educational opportunity including college courses, continuing education classes, vocational training or job- readiness/employment programs. 3) 80% of employed participants will maintain employment for at least three months. 4) 80% of participants who transition to permanent housing will remain in housing for at least six months. 5) 90% of program participants will test clean during random drug testing. 6) 75% of school age children residing at Beyond Shelter will have participated in at least one extra-curricular activity throughout their program stay. 7) 75% of school age children residing at Beyond Shelter will have received tutoring and homework assistance services. 8) 25% of school age children residing at Beyond Shelter for at least one year will improve their grades (or grading marks) by at least one higher grade/mark NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 HOPE Services Hawaii, Inc. Beyond Shelter Transitional Housing Program Highlights: (from Fiscal Year 2010-2011) 1. HOPE's YOUTH program was implemented in January 2011 targeting youth between the ages of 14-17 that were residing at one of our transitional housing programs. This program utilizes the Kahuawaiwai Financial Literacy Curriculum to teach youth culturally appropriate life skills in regards to earning money, networking, and asset building. We partnered with Hawaiian Community Assets (HCA) and Bank of Hawaii (BOH) to provide (5) of our youth with a 3:1 matching grant. HCA has committed to providing each of the (5) youth a matching grant up to $300, while BOH has agreed to provide and maintain IDA accounts. We assisted the (5) youth in developing a small recycling business as a means to earn money. The youth have set-up recycling bins at HOPE sites and are responsible for weekly pick-ups, processing and redeeming of the Hi-5 recyclables. Although we cannot provide all youth with a matching grant and IDA account, we have expanded the Kahuawaiwai Curriculum to include all youth between the ages of 11-17 and are currently establishing an age-appropriate curriculum for children ages 5-10 in partnership with Hawaii Federal and State Federal Credit Union. We have also implemented an incentive program for children between the ages of 2-17 to give them the opportunity to earn money through chores and grade improvements. All children will be required to open a Youth Savings Account and will deposit their incentive money on a monthly basis. 2. HOPE is also an active member of the Ho'owaiwai Network, a group of private and public organizations, community practitioners, financial institutions, and families and youth in Hawaii that organize actions to address asset poverty and build the wealth and financial stability of Hawai'i's working families. The Network consists of over 130 members from every island across the state. Ho'owaiwai Network members work to build strategies and tools to increase family and community assets within the unique context of Hawai'i. We are building our wealth together — our way. The mission of the Ho'owaiwai Network is to encourage family and community self sufficiency through asset-building policy and practice. 3. Maintained partnerships with the Boys and Girls Club, Salvation Army and County of Hawaii Department of Parks and Recreation. This affords children the opportunity to engage in extra-curricular activities and remain active during the after-school hours and school intersession. 4. Care Coordination provided at Beyond Shelter on a long term basis (up to 2 years maximum). The goal is to provide families with necessary life skills needed to stabilize the family unit by providing opportunities to practice healthy communication, discipline, community awareness, and family strengthening activities. Care Coordinator also refers families to mainstream programs to ensure that families are receiving all services that they may be eligible for in order to further stabilize the family unit and succeed once in permanent housing. Mainstream programs include Department of Human Services for SNAP/TANF/FTW benefits, Developmental Disabilities, Children and Adolescent Mental Health Division, Turning Point for Families, Child and Family Services, Foster Family Program, Parents Inc, Adult Mental Health Division, Division of Vocational Rehabilitation, Big Island Substance Abuse Council (BISAC), Lokahi, HCEOC, medical and dental providers, Social Security Administration (SSA) and Veteran's Affairs (VA). NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 HOPE Services Hawaii, Inc. Beyond Shelter Transitional Housing 5. Adult participants are encouraged to pursue higher education with the intent to increase the family's future stability through higher earning power, increased income, employment stability and "family-friendly" work hours, particularly for single parents. Although higher education is encouraged, all families must obtain and maintain an adequate amount of income to pay for their program fees and other monthly expenses on a regular basis. All unemployed adults in the household are required to actively seek employment or enroll in an employment/job training or vocational training program. Those who are unable to work due to a disability are linked to appropriate job training programs, adult day care programs, or volunteer opportunities. 6. Families maintain the three garden beds on-site, alternating responsibilities for the garden which promotes nurturing and encourages responsibility for their living area. The vegetables and herbs are available for participants to use freely to supplement household meals and to start a garden of their own once they transition to permanent housing. Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual* Budget* Estimate Number of persons placed in emergency or 70 75 0** transitional housing Number of persons placed in permanent housing 29 20 75 Number of persons completed training or education 14 10 15 program Number of persons who were placed into 6 3 5 drug/alcohol treatment. Number of persons who retained employment for a 8 10 12 minimum of six months Number of persons receiving mental health care & 44 40 40 case management *If applicable **We intend to transition this program from "transitional housing" to permanent supportive housing (fair market rentals with rental subsidies). Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 25,996.00 21,261.00 15,704.00 Operations 92,304.00 89,519.00 99,616.00 Total 118,300.00 110,780.00 115,320.00 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 HOPE Services Hawaii, Inc. Beyond Shelter Transitional Housing Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Hawaii County 15,000.00 15,000.00 15,000.00 Hawaii State HPHA-DHS Stipend 60,400.00 57,380.00 60,000.00 Hawaii Island United Way 4,500.00 4,500.00 4,500.00 Beyond Shelter Program fees 38,400.00 38,400.00 40,320.00 Total 118,300.00 110,780.00 115,320.00 *If applicable Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self- sustaining? We will continue to search additional federal funding opportunities to help sustain our housing programs. We have also initiated a Volunteer Program to help increase volunteerism opportunities to serve within our programs and maximize our human resources in the community. We are also exploring the possibly in converting these transitional housing units to a permanent supportive housing program through tenant based rental assistance or project based rental assistance funding programs or the acquisition of this property through HOME and or CDBG funding. Total in-kind resources leverages in Calendar Year 20114243,103.75. Of that amount, $43,763.75 in value of non-cash items was donated for program and client use while $199,340.00 in value of volunteer hours was also tracked. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Program Manager, Kate Nawahine, is a relative of Councilman Angel Pilago. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135—2-1422, Hawai'i County Code, relating to Appropriation of Funds to nonprofit organizations. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to the Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 HOPE Services Hawaii, Inc. Beyond Shelter Transitional Housing I (we) understand that information supplies herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013, must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. r3//' Signature of Board re ':=nt/Chair Date or Agency Director B!/ Via- /144/Lifijid3ignature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 45 HOPE Services Hawaii Care-A-Van Homeless Outreach HOPE Services Hawaii, Inc. Care-A-Van Homeless Outreach Agency Director: Brandee Menino Phone No.: 808-933-6013 Contact Person: Carol Weiser Phone No.: 808-933-6035 Mailing Address: 1315 Kalanianaole Ave., Hilo, HI 96720 Facility/Site Address: East HI: 116 Kapiolani Street, Hilo, HI 96720 West HI: 74-5593 Pawai Plc., Kailua-Kona, HI 96740 Fax No.: (808)935-3794 Email Address: bmenino @hopeserviceshawaii.org Name of Accountant/CPA (include name of firm if applicable): Gail Shioshita (808) 933-6048 1315 Kalanianole Avenue, Hilo, HI 96720 CW Associates Phone No.: (808) 695-4014 Mailing Address: 700 Bishop Street, Suite 1040 Honolulu, HI 96813-4124 Amount of Request for County Funds: $20,000.00 Prior Year(s) Funding: 09-10 10-11 11-12 $20,000.00 $20,000.00 $10,000.00 Agency Mission Statement: On October 1, 2010, the Office for Social Ministry, Care-A-Van Department of the Diocese of Honolulu, became HOPE Services Hawaii, Inc. (HOPE). HOPE manages the same services and programs to those most in need in our community with the same dedicated staff and support from the Diocese of Honolulu. Bishop Larry Silva remains committed to helping the homeless and the incorporation of the Care-A-Van Department into HOPE Services Hawaii, Inc. will allow us to be more visible in our community and be more effective in our delivery of services. HOPE's mission is to bring to life the gospel values of justice, love, compassion and hope through service, empowerment, and advocacy. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 HOPE Services Hawaii, Inc. Care-A-Van Homeless Outreach Program Description: For nearly nineteen years, the Office for Social Ministry (OSM) has been the primary homeless service provider on the Big Island. OSM has always strived to help the most vulnerable in our community "reach their full potential, achieve self- sufficiency, and live in a just and compassionate society". On October 1, 2010, HOPE Services Hawaii, Inc. (HOPE) was created with the task of continuing the mission of OSM, utilizing the same values and beliefs, but with a focus on ending homelessness. Care-A-Van's mobile homeless outreach program is the only outreach program on Hawaii Island that specifically targets the unsheltered homeless population. Our primary goal is to support the unsheltered homeless and help them to get into healthier and more stable living conditions. With the support of our funders, community associates, and HOPE staff members, the homeless outreach program has been able to serve about 1,500 persons throught Hawaii county. HOPE owns and operates four-wheel drive vehicles, which allows our outreach workers to travel to areas where homeless people congregate. These areas include, but are not limited to, beaches, parks, woods, lava fields, emergency shelters, domestic violence shelters, and in or around downtown Hilo, Puna, Hamakua, and Kailua-Kona. Upon contact with a homeless person, outreach workers strive to establish trust and rapport as a first step towards improving the individual's housing situation and general well-being. Once a trusting relationship is established, case management services commence. Outreach staff will support their homeless consumers through an intake process to assess their housing situation and mental health status. Outreach staff provide services such as helping consumers to obtain legal identification documents, emergency food and hygiene supplies, linkage to medical and dental health care, linkage to mental health care, transportation, and assistance with legal issues. They will also help consumers to obtain educational and employment goals. The purpose of this program is to connect homeless consumers to mainstream community programs and ultimately, to gain housing and self-sufficiency. Aside from our traditional outreach approach, HOPE has established Drop-In sites in Puna and Kailua-Kona. Drop-In sites include an emergency food pantry, clothing bank, emergency household and hygiene supplies, case management services, phone and computer/internet use, mail services, life skills classes, and referrals to community resources. These drop-in sites have been established as another method towards identifying and supporting those who are experiencing homelessness. The Friendly Place Drop-in Center, includes breakfast five days a week, an emergency food pantry, clothing bank, provision of emergency NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 HOPE Services Hawaii, Inc. Care-A-Van Homeless Outreach household/hygiene supplies, case management services, phone use, mail service, showers, book exchange, laundry facilities, life skills classes, renters' education classes, and referrals and linkages to community service providers. A housing specialist is on staff, and housing applications are available to assist with permanent housing. Further, a representative payee assists participants with their finances. These drop-in sites have been established as another method towards identifying and supporting those who experience homelessness. We partner with community churches where two churches presently are serving lunch twice a week, and on the last two Fridays of each month. Once a week a physician from West Hawaii Community Health Center (WHCHC) sees participants at the Friendly Place Drop-in Center and offers follow up visits at their clinic. The Public Health Nurses administers HEP C immunization shots, and HEP C prevention education materials. Case managers offer outreach & interim case management services for individuals in need of mental health support. Staff provide support to individuals by retrieving a mental health assessment from the Department of Health, Adult Mental Health Division (AMHD) and WHCHC. If indivduals are deemed eligible for services through AMHD, then our staff link these indivduals with a mental health case management provider. If individuals are not found eligible, then our staff will support these individuals with appealing the decision or help them with identifying the best available services for their mental health needs through their insurance carrier. Staff also assist unisured homeless individuals to the State Quest program as an initial step towards receiving health care services. HOPE partners with WHCHC who offers mobile dental services at the Friendly Place Drop In Center twice a week for urgent dental care needs. PReventive care services are offerred as time allows. Total Budget and Position Count Total Program Budget 2,393,374.00 Total Program Position Count 11 Total Agency Budget 4,064,986.00 Total Agency Position Count 43 Program Objectives: 1) 50% of program participants will engage in case management services by implementing real budget planning and seeking out community programs for which they may be eligible. 2) 50% of program participants will enroll in higher educational opportunities, including GED program, college courses, continuing educational classes, vocational training or job-readiness employment programs. 3) 80% of participants who enrolled in shelter programs will remain there until more permanent housing is secured. 4) 90% of eligible program participants who receive monthly rental subsidies will pay their rent on time for at least six months. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 HOPE Services Hawaii, Inc. Care-A-Van Homeless Outreach 5) 90% of AMHD-eligible participants will enroll in at least one AMHD- contracted program. 6) 80% of program participants will not violate the terms of their lease or be evicted for at least six months. 7) 75% of eligible program participants will take 6 classes of renter's education in our housing program to sustain in healthy relationships with landlords. Program Highlights: (from Fiscal Year 2010-11) 1. Homeless Outreach Specialists conducted 1,170 intakes for new homeless individuals. 698 homeless individuals received emergency supplies, including blankets, hygiene items and clothing; 1,162 homeless individuals received emergency food. 365 homeless people were placed into emergency or transitional housing programs. 262 homeless people were placed into permanent housing. 178 individuals were referred for job training and/or employment during this period; 43 obtained employment. 43 individuals were enrolled in substance abuse treatment programs. 2. Homeless Outreach staff also attended many community meetings and events, including the Disability Awareness Forum, Healthy Keiki Day, Heart Walk, the Department of Health's Adult Mental Health Division (AMHD) Community Forum, Rural Outreach Services Agency Briefing, Veteran Outreach Event, Honokaa Peace Festival, and Mental Health Awareness Day. HOPE Services Hawaii, Inc. also coordinated the National Hunger and Homelessness Awareness Luncheon and Community Fair in Hilo & Kailua-Kona last November and actively participated in the same event in Pahoa. 3. CAV Homeless Outreach staff also collaborates and coordinates services with many other social service providers and community agencies, such as the Department of Human Services, AMHD, Care Hawaii, Workforce Development, Under His Wings Street Ministry, Hale Ohana, Community Policing, Office of Housing, Neighborhood Place of Puna, Hilo Medical Center, Kona Community Hospital, etc. 4. Due to difficult economic times, many more individuals and families are facing homelessness. Outreach Specialists will oftentimes find people living in substandard housing situations, with no running water, electricity or other essential utilities. Other families are at risk of losing their homes due to loss of income. The Homeless Prevention and Rapid Re-housing (HPRP) Program which began in September of 2009 provided financial assistance that included short-term and medium-term rental subsidies and utility payments. The program exhausted its subsidy funds in October of 2010, only one year into the three year program. HOPE Services Hawaii restructured the program/staffing to eliminate two full-time positions and NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 HOPE Services Hawaii, Inc. Care-A-Van Homeless Outreach recycled those funds back into the subsidy program. The two staff were assimilated into other programs and remain employed. At this point in time, the program has again depleted its funds and will need to undergo further restructuring in the near future. Since September of 2009, the HPRP program has provided assistance to 785 individuals who were either at risk of losing their housing or had already lost their housing needing to be re-housed. 5. Outreach staff has been seeing more and more families with children living in public Parks, in their cars, as well as in substandard housing conditions. The TANF Housing Placement Program for TANF eligible families has housed 413 people, including 259 children, during this time period. 6. The Kukui Shelter Plus Care Program provides tenant based rental assistance and supportive housing services for unsheltered homeless who have been diagnosed with a severe and persistent mental illness, a developmental disability onset before age 18, chronic substance abuse, or HIV/AIDS. During this time period, HOPE provided Kukui Shelter Plus Care services for 87 individuals. 7. New Direction, another Shelter Plus Care Program similar to the Kukui program, targets the chronically homeless. This program started in May of 2010 and is currently providing tenant based rental assistance and supportive housing services for 7 chronically homeless individuals. A chronically homeless person is defined as an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more OR has had at least four (4) episodes of homelessness within the past three (3) years. 8. The Representative Payee Program provides money management services for 200 Individuals living with severe and persistent mental illness. Representative Payees manage the finances of eligible participants by paying their monthly bills, such as rent, utility, and other expenses. They also provide budget classes to teach participants how to manage their own money. 9. The SNAP Outreach Program helps SNAP eligible individuals and families to complete new applications and re-certifications. During this time period, SNAP Outreach Workers completed 269 new applications and 214 re- certifications. By assisting with these applications/re-certifications, the SNAP Outreach Program has helped to generate $1,173,201.00 in SNAP benefits (no stats for June & July 2011), resulting in an economic benefit to the community of$2,158,689.84! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 HOPE Services Hawaii, Inc. Care-A-Van Homeless Outreach Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Number of participants placed in 365 223 250 emergency or transitional housing. Number of participants placed in 262 335 300 permanent housing. Number of participants who 43 48 50 obtained employment. Number of persons who enrolled in 40 48 50 job readiness/training programs. Number of persons who received 1,026 1596 1500 emergency supplies & food Number of persons referred for 522 779 800 medical or dental care (duplicated). *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages 1,008,587.99 1,200,823.00 1,244,917.00 Professional Fees 253,024.61 228,284.00 193,032.00 Operations 1,725,861.78 1,084,436.00 955,425.00 Equipment 3,117.14 3,200.00 Other' Total 2,990,591.52 2,516,743.00 2,393,374.00 * If applicable Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 HOPE Services Hawaii, Inc. Care-A-Van Homeless Outreach Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate State/DHS 712,500 712,500 612,500 HPRP 309,162 235,950 108,533 SNAP 41,498 70,493 73,812 TANF 528,000 528,000 528,000 Hawaii County 20,000 15,000 20,000 Hawaii County- Pahoa 20,000 20,000 AMHD 66,670 100,000 100,000 AMH-Rep Payee 182,400 192,000 192,000 New Direction 36,960 36,960 Kukui 437,928 465,048 483,168 HIUW 20,000 HCF - SNAP 68,667 70,492 73,812 HCF - HPRP 50,000 50,000 50,000 SHEG 42,750 SHEG Child Care Grant 450,000 Other Grants 61,016 Diocese Support 20,300 34,589 Pahoa Kupuna Shelter 60,000 Total 2,990,591 2,516,743 2,393,374 *If applicable Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? We will continue to search additional federal funding opportunities to help sustain the outreach program. We have also initiated our Volunteer Program to help increase volunteerism opportunities for our programs and for our community. Although. We will also continue to assess areas of cost savings, energy efficiency, and education and maximize our community partnerships. We also have focused plans to increase our direct asks, event fundraising, website/online donation campaign and seek out foundation grants. We also intend to increase our private/business partnerships to help leverage additional cost savings from their donated time, talent and treasures. Total in-kind resources leverages in Calendar Year 2011=$243,103.75. Of that amount, $43,763.75 in value of non-cash items were donated for program and client use while $199,340.00 in value of volunteer hours were also tracked. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 HOPE Services Hawaii, Inc. Care-A-Van Homeless Outreach Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Program Manager, Kate Nawahine, is a relative of Councilman Angel Pilago. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-1422, Hawai'i County Code, relating to Appropriation of Funds to nonprofit organizations. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to the Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplies herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report will impact the evaluation of your program's or agency's future fundinq requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013, must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 HOPE Services Hawaii, Inc. Care-A-Van Homeless Outreach will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. �' 11.3//2- Signature of Board Pre id: t/ air Dat or Agency Director gnature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 46 HOPE Services Hawaii Hope Resource Center HOPE Services Hawaii, Inc. HOPE Resource Center Agency Director: Brandee Menino Phone No.: 808-933-6013 Contact Person: Katherine Nawahine Phone No.: 808-933-6038 Mailing Address: 1315 Kalanianaole Ave. Hilo, Hawaii 96720 Facility/Site Address: 116 Kapiolani Street Hilo, Hawaii, 96720 Fax No.: 808-935-3794 Email Address: bmenino @hopeserviceshawaii.org Name of Accountant/CPA (include name of firm if applicable): Gail Shioshita (808) 933-6048 1315 Kalanianole Avenue, Hilo, HI 96720 CW Associates Phone No.: (808) 695-4014 Mailing Address: 700 Bishop Street, Suite 1040 Honolulu, HI 96813-4124 Amount of Request for County Funds: $20,000.00 Prior Year(s) Funding: 09-10 10-11 11-12 $20,000 $15,000 $12,000 Agency Mission Statement: On October 1, 2010, the Office for Social Ministry, Care-A-Van Department of the Diocese of Honolulu, became HOPE Services Hawaii, Inc. (HOPE). HOPE manages the same services and programs to those most in need in our community with the same dedicated staff and support from the Diocese of Honolulu. Bishop Larry Silva remains committed to helping the homeless and the incorporation of the Care-A-Van Department into HOPE Services Hawaii, Inc. will allow us to be more visible in our community and be more effective in our delivery of services. HOPE'S mission is to bring to life the gospel values of justice, love, compassion and hope through service, empowerment, and advocacy. NONPROFIT GRANT APPLICATION FISCAL YEAR 2011-12 Page 1 • HOPE Services Hawaii, Inc. HOPE Resource Center Program Description: The mission of the HOPE Resource Center (previously known as Ponahawaiola) is to reduce potential obstacles for men and women formerly incarcerated and/or are experiencing homelessness in Hawaii County. "E Malama Kekahi I Kekahi/Taking Care of Our Own" is an article which was published by the Hawaii Island Correction Advisory Committee in 2003. The purpose of the article is to advocate a "seamless reintegration program" which is the best approach to reducing these obstacles. Since then, the Going Home Consortium created a plan to address re-entry issues. Housing is listed as a priority for persons returning to our community from incarceration. As the Homeless Outreach provider of Hawaii Island, it became apparent that minimal to no discharge planning was happening from jail to our community. When asked why they were homeless, an increasing number said they lacked the housing resources and support upon discharge, have strained their family relationships due to their previous behaviors and thus, not welcomed back home or the ex-offenders supervising authority did not approve their housing situation due to known previous drug related incidents at those identified locations. HOPE staff works collaboratively with public safety and judiciary agencies to recognize offenders at-risk for homelessness and arrange for placement in our transitional housing program prior to their release from incarceration. At the onset of program entry, an initial assessment of the participant's needs is identified. Referrals and linkages to community mainstream programs are made including mental health care, general health care, outpatient substance abuse treatment, application to financial assistance, employment readiness training, and/or enrollment in education programs. Appropriate steps are then made to create an individual support network for each participant. Addition services offered on-site include daily life skills training, re-development and encouragement, gender specific groups, Meth Relapse Prevention groups, linkages to AA support groups, transportation, mentorship, culturally appropriate activities; employment search, housing placement assistance; and one year of aftercare once placement in permanent housing is achieved. The HOPE Resource Center will have a total of fourteen (14) single room occupancy units. In April 2011, HOPE Services Hawaii transitioned our program participants to a new facility at 116 Kapiolani Street. It is a 6,000+ sq ft multi-use building and the previous home to Glad Tidings Church. We hope to complete construction of fourteen (14) 120 square foot single room occupancy units and shared restrooms and showers by July 2012. Each room will be furnished with a single bed, chest of drawers, apartment sized refrigerator, microwave, a small table and chair. The facility is equipped with a certified kitchen; computer lab with 5 computers for participants use; ADA bathrooms; and a fully functional conference center for community and HOPE program use. Currently the residential area is a large hall with 14 beds and miscellaneous household furniture. Future plans include enhancing the program with physical fitness equipment on site to improve and encourage healthier living, a culinary job training program to build real work skills to market themselves in the employment field, and structured positive recreational activities and fellowship. Total Budget and Position Count Total Program Budget 286,360.00 _Total Program Position Count 6 Total Agency Budget 4,064,986.00 Total Agency Position Count 43 NONPROFIT GRANT APPLICATION FISCAL YEAR 2011-12 Page 2 HOPE Services Hawaii, Inc. HOPE Resource Center Program Objectives: For FY 12-13: 1. Maintain clean and sober housing for 100% of program participants; 2. Decrease violations of conditions of supervised release for 65% of program participants; 3. Increase participation in substance use treatment and mental health services for 70% of program participants; 4. Assist in obtaining employment and education placement for 65% of participants; 5. Assist with increased child support and general family contact for 70% of participants. Program Highlights: (from Fiscal Year 2010-11) 1) Decreased rate of recidivism - Of the 55 participants that left the program during this funding period, 90% exited back into the community, while only 10% were re- incarcerated directly from the program. This translates into an increase of public safety as a result of this program. 2) Streamlined our intake process to include a comprehensive needs and assessment to determine individual needs, strengths, barriers, and establish linkages for substance abuse, medical and or mental health treatment that all homeless programs applicants may be eligible for. This information also allows us to foresee any potential barriers our participants may encounter, allowing us to develop a plan to meet and overcome any challenges. 3) Partnerships established with a number of local realtors to provide housing placements with no background checks further reducing housing barriers and increasing housing opportunities for persons with criminal histories. 4) July 2011, five program participants attended the Recycle Service Worker Training course. The goal of the program is to assist participants with gaining the skills employers want in the recycle industry. The 5-day class provided an introduction into the recycling industry, customer service training, OSHA 10 Hour certification, basic math and cashier training, and forklift certification. At the completion of the course, participants received a certificate of professional development from Hawaii Community College and will have the various skills necessary to be employable at the many recycling stations around the island. Attendance was made possible through scholarships offered by Hawaii Community College, Office of Continuing Education and Training. 5) Weekly house meetings provide participants opportunities to discuss and offer solutions to issues that arise as part of a group living arrangement. Ongoing life skills classes also addressed daily living skill building such as budgeting, healthy communication and coping skills, developing and maintaining healthy relationships, and leisure activities. These leisure activities provided participants with sober and structured socialization activities. 6) Hope Services maintained community partnership with New Hope Church. Participants continue to engage in the Community Softball League. This league consisted of community agencies and churches. Participants were afforded the opportunity to network and develop relationships with pro-social community citizens. Participants also NONPROFIT GRANT APPLICATION FISCAL YEAR 2011-12 Page 3 HOPE Services Hawaii, Inc. HOPE Resource Center took part in the following community events: Domestic Violence Vigil, Native American Pow Wow, Substance Abuse Recovery Events, Hawaii Island Food Basket Spring Food Drive, and the Hawaii Island Business Bureau Charity Walk. 7) Continued to utilize cognitive restructuring classes utilizing the Hazelden Model and curriculum, gender specific group meetings and motivational interviewing methods which served to increase program effectiveness aimed at targeting criminogenic need and reducing recidivism rates. 8) Established network of partnerships for participants through ongoing in-services provided by community agencies for our participants. Topics include domestic violence awareness, cultural sensitivity, community empowerment, politics and responsible citizenship and stewardship. 9) Maintained relationships with volunteer/advocate Charles Baird to educate participants on topics such as healthy relationships and co-dependency issues. Maintained relationships with volunteer/advocate Ann Chipchase of Ohana Health Care to educate participants on health related issues. Thomas Gadd, volunteer/advocate also continues to facilitate weekly Meth Recovery Support Group for participants. 10)"PILR" group continues to function. PILR is primarily operated by program participants with support available from staff as needed. This group relied on the team approach to ensure that it runs properly and meets every morning. Discussions focused on current events and provided real-life solutions that increased participants' opportunities for self- sufficiency. PILR efforts are aimed at reducing barriers to employment, education and housing. Peers supporting peers. Outcomes included leadership development, succession planning, community events, business planning, problem solving and fundraising. Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Number of persons placed in transitional housing 46 40 40 Number of persons placed in permanent housing 14 15 15 Number of persons who obtained employment 19 20 20 Number of persons receiving education/job training 38 40 30 assistance Number of persons accessing health services 22 30 30 (nutrition, medical, gerontology, therapeutic massage, aerobic) Number of persons accessing mental health 38 20 20 services Number of persons accessing substance abuse 30 30 30 counseling services NONPROFIT GRANT APPLICATION FISCAL YEAR 2011-12 Page 4 HOPE Services Hawaii, Inc. HOPE Resource Center Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 261,271.00 306,334.00 146,346.00 Operations 315,409.00 273,266.00 140,014.00 Total 576,680.00 579,600.00 286,360.00 * If applicable Please explain in detail on separate sheet Program Funding Sources: Identify all funding sources (specific to this program only)= Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate County of Hawaii 20,000.00 20,000.00 20,000.00 State of Hawaii DHS 436,800.00 414,960.00 207,480.00 Hawaii Island United Way 40,000.00 40,000.00 20,000.00 Hawaii Hotel Industry Visitor Walk 5,000.00 Kaneta Foundation 5,000.00 5,000.00 7,000.00 Ponahawaiola Program fees 74,880.00 99,640.00 26,880.00 Total 576,680.00 579,600.00 286,360.00 *If applicable Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? 1) We will continue to search additional federal funding opportunities to help sustain our housing programs. We have also initiated our Volunteer Program to help increase volunteerism opportunities for our programs and for our community. 2) We have acquired new property with the intent to relocate the program. Rent and utility costs will be considerably reduced. Occupancy have decreased by half 3) We continue to search for additional funding opportunities to equip the property with a photovoltaic system, further reducing utility costs. 4) Secured Americorp grant to fund a staff position. 5) Consolidated Management and decreased administrative staff in preparation for decreased government funding. 6) Increased efforts to diversify our funds and increase funding from foundations, direct mail and website donations. Built a current and functional website. Tools are in place. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Program Manager, Kate Nawahine, is a relative of Councilman Angel Pilago. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-1422, Hawai'i County Code, relating to Appropriation of Funds to nonprofit organizations. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article NONPROFIT GRANT APPLICATION FISCAL YEAR 2011-12 Page 5 HOPE Services Hawaii, Inc. HOPE Resource Center 25, Sections 2-135 – 2-142.2, Hawaii County Code, relating to the Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplies herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013, must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. i 3i Signature of Board Pre ide • air Date or Agency Director (7/c?//,9— ignature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2011-12 Page 6 47 HOPE Services Hawaii Kihei Pua Emergency Shelter HOPE Services Hawaii, Inc. Kihei Pua Emergency Shelter Agency Director: Brandee Menino Phone No.: 808-933-6013 Contact Person: Katherine Nawahine Phone No.: 808-933-6038 Mailing Address: 1315 Kalanianaole Ave. Hilo, Hawaii 96720 Facility/Site Address: 115 Kapiolani St. Hilo, Hawaii Fax No.: 808-935-3794 Email Address: bmenino @hopeserviceshawaii.org Name of Accountant/CPA (include name of firm if applicable): Gail Shioshita (808) 933-6048 1315 Kalanianole Avenue, Hilo, HI 96720 CW Associates Phone No.: (808) 695-4014 Mailing Address: 700 Bishop Street, Suite 1040 Honolulu, HI 96813-4124 Amount of Request for County Funds: $15,000.00 Prior Year(s) Funding: 09-10 10-11 11-12 $20,000 $15,000 $10,000 Agency Mission Statement: On October 1, 2010, the Office for Social Ministry, Care-A-Van Department of the Diocese of Honolulu, became HOPE Services Hawaii, Inc. (HOPE). HOPE manages the same services and programs to those most in need in our community with the same dedicated staff and support from the Diocese of Honolulu. Bishop Larry Silva remains committed to helping the homeless and the incorporation of the Care-A-Van Department into HOPE Services Hawaii, Inc. will allow us to be more visible in our community and be more effective in our delivery of services. HOPE'S mission is to bring to life the gospel values of justice, love, compassion and hope through service, empowerment, and advocacy. NONPROFIT GRANT APPLICATION FISCAL YEAR 2011-12 Page 1 HOPE Services Hawaii, Inc. Kihei Pua Emergency Shelter Program Description: Kihei Pua Emergency Shelter has been operated by the Office for Social Ministry (OSM), now HOPE Services Hawaii, for four (4) years. It is the only program on the island of Hawaii that is specifically designed to support individuals and families who are either unsheltered, at-risk of becoming homeless, or residing at an emergency or transitional program/shelter. It is a face-paced (6) six-week program with a goal of supporting homeless individuals and families to achieve healthier more stable living conditions. In an effort to achieve this goal, we offer an array of supportive services. Our program provides life skills classes that teach homeless participants how to budget their finances, become responsible, clean, accountable tenants, maintain sobriety and respect others. In addition, we have an on-site care coordinator and case advocate that provide one on one goals setting and counseling, referrals and linkages for case specific services including, mental health services, medical, dental & prescription services, substance abuse treatment programs, temporary employment agencies, educational and vocational training opportunities, elderly care services, public entitlements, social security benefits, and/or HOPE housing placement programs. Our program provides 24-hour services, 7 days a week, to assess and support the needs of our homeless participants. Total Budget and Position Count Total Program Budget $614,454.00 Total Program Position Count 6 Total Agency Budget $4,064,986.00 Total Agency Position Count 43 Program Objectives: 1) Provide 300 program participants with emergency housing and case management. 2) Maintain clean and sober housing for 100% of program participants. 3) Assist 75 program participants in obtaining permanent housing. 4) Assist 20 program participants in obtaining transitional housing. 5) Assist 20 program participants in obtaining employment. 6) Assist 50 program participants in obtaining placement in job training or education programs. 7) Assist 10 program participants in accessing to substance use treatment services. 8) Assist 60 program participants in accessing mental health services. NONPROFIT GRANT APPLICATION FISCAL YEAR 2011-12 Page 2 HOPE Services Hawaii, Inc. Kihei Pua Emergency Shelter Program Highlights: (from Fiscal Year 2010-11) 1. All children within the age range of 0-5 years old were referred to YWCA Healthy Start, In Peace Keiki Steps, YWCA Preschool or Head Start. Keiki Play Groups and Loving Solutions parenting classes facilitated by Mr. Mukai. 2. HOPE sponsored tuition fees for children to participate in after-school activities at the Boys and Girls Club and for their summer & teen programs offered through the Department of Parks and Registration. Some children have participated in other extracurricular activities such as canoe paddling, flag football, wrestling and Kamehameha's summer youth camps. Our aim is to provide the children in our programs with structured activities, community involvement and opportunities to succeed despite their families current struggles. 3. Family activities are planned regularly throughout the month to increase family strengthening thus stabilizing the family unit. Such activities include nightly family dinners, family game nights (2) two times monthly and family movie nights (2) times monthly. Participants agree and plan how to celebrate traditional family holidays with staff support and supplies available as needed. Birthdays and accomplishments (i.e. finding employment or securing housing) are also planned by the individual family with staff support and supplies available as needed. Donated gifts, birthday cakes, and food are also available for families as needed. 4. Health Education classes were offered on site through the University of Hawaii at Hilo Nursing Department. Exercise classes were also offered to participants. Participants were given opportunities to join staff in regular walks around Coconut Island, swimming at Kawamoto Pool, and Zumba with B. Klarin, who is a AAFA Certified Instructor. 5. Established strong partnerships with Child Welfare Services (CWS), Child & Family Services (CFS) and Parents Inc. Families were given a safe and structured living environment and opportunities to acquire the life skills necessary to obtain and maintain family reunification and stability. Space was made available for families to meet privately with their workers from other agencies during their stay at the shelter. 6. Staff and families maintain two garden beds on-site. The gardens provide vegetables and herbs for participants to use for their household meals or nightly family dinners. Participants acquire skills to maintain a small garden and are encouraged to take plant clippings from the garden when they transition to permanent housing. 7. Maintained partnerships with Bay Clinic, Hui Malama Ola Na Oiwi, Urgent Care, Dr. A. Camblor, Shiigi Drug and Windward Pharmacy to provide non-emergent medical care to uninsured and under-insured participants at a reduced fee. Continue schedule appointments for regular and emergency dental care utilizing the mobile dental services offered through the Bay Clinic system. NONPROFIT GRANT APPLICATION FISCAL YEAR 2011-12 Page 3 HOPE Services Hawaii, Inc. Kihei Pua Emergency Shelter Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Number of persons placed in emergency shelter 291 300 300 (persons served) Number of persons exited to permanent housing 111 80 90 Number of persons exited to transitional housing 46 20 30 Number of persons enrolled in job training or 38 30 50 higher education programs Number of persons who obtained employment 24 20 25 Number of persons who participated in substance 13 10 10 abuse counseling services Number of persons who accessed mental health 20 10 15 services Number of meals served 5,044 5,000 6000 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 410,976.00 361,011.00 363,156.00 Operations 224,486.00 240,240.00 251,298.00 Total 635,462.00 601,251.00 614,454.00 * If applicable # Please explain in detail on separate sheet Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Hawaii Public Housing Authority— DHS Stipend 20,000.00 15,000.00 20,000.00 Emergency Shelter Grant 525,600.00 493,050.00 520,000.00 Supportive Housing Grant 62,850.00 62,850.00 40,454.00 Hawaii Community Foundation 11,500.00 11,500.00 15,000.00 County of Hawaii 15,512.00 18,851.00 19,000.00 Total 635,462.00 601,251.00 614,454.00 NONPROFIT GRANT APPLICATION FISCAL YEAR 2011-12 Page 4 HOPE Services Hawaii, Inc. Kihei Pua Emergency Shelter Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self- sustaining? We will continue to search additional federal funding opportunities to help sustain the shelter programs. We have also initiated our Volunteer Program to help increase volunteerism opportunities for our programs and for our community. Although program fees are an additional source of revenue, we do not have any plans to increase our program participant's program fees this year. Instead, we will continue to assess areas of cost savings, energy efficiency education and maximize our community partnerships. We also have focused plans to increased our direct asks, event fundraising, website/online donation campaign and seek out foundation grants. We also intend to increase our private/business partnerships to help leverage additional cost savings from their donated time, talent and treasures. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Program Manager, Kate Nawahine, is a relative of Councilman Angel Pilago. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-1422, Hawai'i County Code, relating to Appropriation of Funds to nonprofit organizations. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to the Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplies herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. NONPROFIT GRANT APPLICATION FISCAL YEAR 2011-12 Page 5 HOPE Services Hawaii, Inc. Kihei Pua Emergency Shelter If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further noticiation to submit the final report. No late or incomepite reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013, must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. 73/.)-o/ I f Signature of Board Presiden iC air Date or Agency Director "LA,K1,,,0 OS,/_ i ignature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2011-12 Page 6 48 HOPE Services Hawaii West Hawaii Emergency Housing Program HOPE Services Hawaii, Inc. West Hawaii Emergency Housing Program Agency Director: Brandee Menino Phone No.: 808-933-6013 Contact Person: Kate Nawahine Phone No.: 808-933-6018 Mailing Address: 1315 Kalanianaole Ave., Hilo, HI 96720 Facility/Site Address: 74-5593 Pawai Place, Kailua-Kona, HI 96745 Fax No.: (808) 935-3794 Email Address: bmenino @hopeserviceshawaii.org Name of Accountant/CPA (include name of firm if applicable): Gail Shioshita (808) 933-6048 1315 Kalanianole Avenue, Hilo, HI 96720 CW Associates Phone No.: (808) 695-4014 Mailing Address: 700 Bishop Street, Suite 1040 Honolulu, HI 96813-4124 Amount of Request for County Grant-in-aid Funds: $ 20,000.00 Prior Year(s) Funding: 09-10 10-11 11-12 $0 $10,000 $0 Agency Mission Statement: On October 1, 2010, the Office for Social Ministry, Care-A-Van Department of the Diocese of Honolulu, became HOPE Services Hawaii, Inc. (HOPE). HOPE manages the same services and programs to those most in need in our community with the same dedicated staff and support from the Diocese of Honolulu. Bishop Larry Silva remains committed to helping the homeless and the incorporation of the Care-A-Van Department into HOPE Services Hawaii, Inc. will allow us to be more visible in our community and be more effective in our delivery of services. HOPE's mission is to bring to life the gospel values of justice, love, compassion and hope through service, empowerment, and advocacy. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 HOPE Services Hawaii, Inc. West Hawaii Emergency Housing Program Program Description: The County of Hawaii completed the construction of the West Hawaii Emergency Housing Facility and hosted a blessing and grand opening on October 18, 2010. Soon thereafter, HOPE Services Hawaii gained fiscal and operational responsibilities of the West Hawaii Emergency Housing Facility. This facility was added to the Campus of "The Friendly Place" and expands the efforts of the Drop-In Center at 74- 5593 Pawai Place in Kailua-Kona. The County of Hawaii completed the construction of the facility and hosted a blessing and grand opening of this facility on October 18, 2010. This program provides emergency housing for up to 31 individuals at one time. The West Hawaii Emergency Housing Program will be a service-enriched emergency shelter for single individuals experiencing homelessness, with a target stay of no more than 3 months. During the duration of the program, life skills workshops and house meetings are facilitated on-site to better prepare participants to live independently. Life skills workshops include budget management, a comprehensive renter's education program, communication, relationships, goal setting, and informational meetings and presentations about community resources. This program is a critical resource for the community as there is no other emergency housing program in West Hawaii for single men and women experiencing homelessness. This is the first of its kind for all of Hawaii Island. The emergency shelter is open 365 days a year for 15 hours a day, 7 days a week, opening at 5pm each night and closing at 8am each morning. The emergency shelter is staffed 15 hours a day. The West Hawaii Emergency Housing program is a service-enriched emergency shelter program with its ultimate goal to assist individuals move into permanent housing and work towards becoming self-sufficient. Additional case management services are provided in partnership mental health providers and HOPE's Outreach Specialists at the Drop-In Center. Target Group: Single men and women who are experiencing homelessness, include the unsheltered homeless, those living in emergency and transitional housing programs/shelters, and those at-risk of homelessness with a 45-day eviction notice willing to stay clean and sober and seek outpatient treatment if applicable. Total Budget and Position Count Total Program Budget 414,168.00 Total Program Position Count 5 Total Agency Budget 4,064,986.00 Total Agency Position Count 43 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 HOPE Services Hawaii, Inc. West Hawaii Emergency Housing Program Program Objectives: For FYI2-13: 1. Provide 50 unduplicated individuals with emergency housing and case management services; 2. Maintain clean and sober housing for 100% of program participants; 3. Assist 50% of program participants in obtaining transitional or permanent housing; 4. Assist 50% of program participants in obtaining employment (ex. seasonal, part-time of full-time); 5. Assist 25% of program participants to enroll in training or education programs (examples: job-readiness programs, obtain a GED, higher education); 6. Assist 25% of program participants' access mental health and substance use treatment, supportive services or after-care programs. Program Highlights from July 1, 2010 — June 30, 2011: *Program began occupancy of shelter beds November 2011. 1. Kona Outdoor Circle: A memorandum of agreement was entered with KOC to plan, design and install a container garden on site as the County's budget for landscaping was eliminated. With the sponsorship of supplies and materials by area businesses and a grant from Hauoli Mau Loa (through Office for Social Ministry) and volunteer labor from current residents and homeless persons and KOC volunteers, under the direction of KOC master designer students, and beautiful garden was developed. 2. Increased Volunteerism: Focused our agency resources and efforts to formalize and develop a Volunteer Program. Reached out to the University of Hawaii Manoa, Hilo, Hawaii Community College, community members and faith-based groups. 3. Developed faith-based partnerships with St. Benedicts, Calvary Community Church, St. Michaels Church, the Lutheran Church of the Holy Trinity and the Kona Church of the Nazarene. These partnerships have increased the provision of hot meals served at the shelter resulting in decreased operational costs. 4. In our initial year of operation, we served 88 individuals. The need for emergency care and stabilization to regroup and have the space and time to recuperate and move on to more permanent housing is great. Of those that exited the program, 65% moved into permanent housing. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 HOPE Services Hawaii, Inc. West Hawaii Emergency Housing Program Performance Measures: FY 2010-11 FY 2011 -12 FY 2012-13 Actual* Budget* Estimate 1. No. of unduplicated participants served and 88 50 75 provided emergency shelter 2. No. of unduplicated participants exited to 37 20 20 transitional or permanent housing 3. No. of unduplicated adults in need of substance abuse treatment enrolled in a 9 10 10 phase of such program 4. No. of unduplicated participants in need of mental health services accessing such 17 15 15 services 5. No. of duplicated participants enrolled in training or education program (e.g. GED,job 23 15 15 training, etc.) 6. No. of unduplicated participants obtained g 15 15 employment * If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 117,705 233,055.00 Operations 95,147 181,113.00 Total 222,852 414,168.00 * If applicable #Please explain in detail on separate sheet Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual* Estimate Estimate Hawaii Public Housing Authority— DHS Stipend 114,608 250,000 Emergency Shelter Grant 44,792 44,792 Supportive Housing Grant 17,412 24,376 Hawaii Community Foundation 9,000 10,000 County of Hawaii 10,000 20,000 Hawaii Island United Way 5,000 10,000 Program Fees 12,040 45,000 Fundraising 5,000 10,000 Total 212,852 414,168 *If applicable NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 HOPE Services Hawaii, Inc. West Hawaii Emergency Housing Program Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? We plan to take a four prong approach this year to become self-sustaining. They are: 1. Pursue further fundraising efforts including direct mail; "friend raise"; ask individuals and parishes for donations of time, talent and treasures; coordinating a special event and participating in the West Hawaii Civic Center's Brick Project. 2. Expand our volunteer program by increasing volunteer opportunities. 3. Increase donations of necessary program supplies to decrease operational costs. 4. Seek partnership with West Hawaii Health Center to explore Medicare & Medicaid reimbursement options to provide emergency housing for our common patients (residents of the emergency housing program) experiencing homelessness. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Program Manager, Kate Nawahine, is a relative of Councilman Angel Pilago. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-1422, Hawai'i County Code, relating to Appropriation of Funds to nonprofit organizations. I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to the Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplies herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 HOPE Services Hawaii, Inc. West Hawaii Emergency Housing Program I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013, must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. 3i / -� Signature of Board Presi. - hair Date or Agency Director ignature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 49 Hospice of Hilo Transitions Pre-Hospice Hospice of Hilo- Agency Name Transitions Pre-Hospice Program- Program Name Agency Director: Brenda S. Ho Phone No.: (808) 969-1733 Contact Person: Misae Wela Phone No.: (808) 969-1733 Mailing Address: 1011 Waianuenue Avenue Hilo, Hi 96720 Facility/Site Address: 1011 Waianuenue Avenue Hilo, HI 96720 Fax No.: (808)969-4863 Email Address: misaew @hospiceofhilo.org Name of Accountant/CPA (include name of firm if applicable): loana Agasa, CPA Phone No.: (808) 981-2405 Mailing Address: 230 Kapualani St., Hilo, HI 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $117,660.00 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $0 $0 Agency Mission Statement: To be an integral part of the community, providing compassionate, quality end-of-life care through support, counseling and education. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 11 Hospice of Hilo - Agency Name Transitions Pre-Hospice Program- Program Name Program Description: In 2010, in order to meet the growing need to provide service to individuals that did not meet the six-month prognosis Medicare requires for hospice admission, Hospice of Hilo instituted the Transitions program. It was for these individuals, that were falling through the cracks in the system; who were not qualified for hospice care and not qualified for home health, that Transitions, an innovative, volunteer-driven program designed to increase the quality of life for those facing any life threatening illness or injury, with a prognosis of 12 months or less, was initiated. Transitions, through care coordination services at no cost to the client, addresses the increasingly complex needs that can easily overwhelm clients with acute, life threatening conditions, affecting the quality of their daily lives. Unlike hospice care, clients can access Transitions services when they are undergoing curative treatment. There is no requirement that a client transfer to hospice care at any time. The choice of support services is always completely up to the client and caregiver. The Transitions model of care coordination is individualized, culturally sensitive and client centered. There are five components to the program: 1. Case management/care coordination for the client. 2. Emotional support for the clients and their families. 3. Volunteer support for practical, emotional, and social needs. 4. Client and Community education on Advanced Health Care Directives (AHCD) and Physician Orders for Life Sustaining Treatment(POLST). 5. Bereavement support. The Transitions Coordinators: • Coordinate community services and resources. • Provide client/family support and intervention. • Handle case coordination. • Offer guidance in discussing health concerns with medical professionals. • Support individuals' choices for care and treatment. • Educate on Advance Health Care Directives and POLST. Transitions Volunteers offer: • To Do Errands. • Light Housekeeping. • Transportation. • Food Preparation. • Companionship. • Emotional Support. • Family Relief. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 11 Hospice of Hilo - Agency Name Transitions Pre-Hospice Program- Program Name Total Budget and Position Count Total Program Budget $64,378.00 Total Program Position Count 1 FTE Total Agency Budget $3,275,700.00 Total Agency Position Count 47 Program Objectives: The Transitions Program aims to: 1. Expand the high quality care coordination and support services to individuals and their families facing any life threatening illness or injury with a prognosis of 12 months or less. • Increase census from current caseload of 21 clients to 40 clients by end of fiscal year 2012-2013. • Increase community awareness about the Transitions Program and community's ability to access the available services,through a campaign of radio and print ads, as well as increased public and targeted presentations by Transitions Team to: o Health Care agencies and clinics o Physicians,discharge planners, oncology centers o Social service organizations--Office of Aging o American Heart Association, Ke Anuenue Health Center, Hawaii HIV AIDS Foundation,American Cancer Society o Hilo Medical Center • Continue to remove barriers to care (i.e. lack of transportation, difficulties in communication, lack of access to community services and resources). o Transitions Team will work closely with Hawaiian organizations such as Hui Mama, Alu Like, and Queen Lili'uokalani Children's Center, utilizing native Hawaiian resources to ensure the delivery of culturally correct referrals, interventions and coordination. Services will address specific needs of native Hawaiians and other populations at risk by accessing leaders within cultural communities and doing educational presentations. o Transitions Team will continue to develop and expand upon the list of resources available to struggling clients (i.e. Services for Seniors, free meal/food programs, financial aid programs, support groups, veterans services, bereavement services, transportation—share ride taxi/Coordination for Elderly). NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 11 Hospice of Hilo - Agency Name Transitions Pre-Hospice Program- Program Name • Recruit and train a larger pool of volunteers. Transitions'goal is to have 1.5 volunteers per client. Current client census numbers of 21 show the volunteer pool of 15 to not be meeting the need. Use of radio and print ads, as well as continued articles in Hospice of Hilo's newsletter, mailed to 13,000 homes, and the Hawaii Tribune Herald will support further recruitment. Also, recruiting and training the unemployed to serve as volunteers will provide job skills training and aid the county in its workforce development efforts. • Increase the number of student interns that serve the program from two to four, drawing from talented Psychology, Sociology and Family Counseling students at the University of Hawaii at Hilo and Argosy University, also aiding the county in its workforce development efforts. 2. Expand the effort to educate the community on Advanced Health Care Directives (AHCD) and Physicians Orders for Life Sustaining Treatment (POLST), honoring client's wishes across all settings of care, reducing avoidable procedures and lowering the financial burdens on the healthcare system. • Transitions Team will continue educating Transitions' clients on AHCD and POLST. • Transitions Team, along with trained volunteers, will expand AHCD and POLST awareness and use through public and targeted presentations. • Transitions Team, in collaboration with East Hawaii Independent Physicians Assemble (EHIPA)and HMSA, will create the Advanced Health Care Planning Pilot Project, to provide consultation services to identified, at risk, patients in physicians' offices. Program Highlights: (from Fiscal Year 2010-11) 1) Hospice of Hilo's Transitions Program has seen steady growth in its client census in the Fiscal Year 2010— 2011. • From April 2010 to October 2010 there were a total of 10 admissions (active clients)to the Transitions Program • From November 2010 to February 2011 there were 17 active clients in the Transitions Program. A new Transitions Coordinator was brought onboard at the end of August 2011. On her first month of reporting, September 2011, there were 12 active Transitions clients. From October 2011 to December 2011 the numbers are as follows: • October 2011--16 active clients • November 2011--20 active clients • December 2011--21 active clients NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 11 Hospice of Hilo - Agency Name Transitions Pre-Hospice Program- Program Name 2) In fiscal year 2010-2011, the Transitions Program received referrals from the following: • Hawaii Pacific Oncology Center • Hilo Medical Center social workers • Hilo Medical Center discharge nurses • State Public Health Nurse • Hospice of Hilo • Private Physicians • Evercare • The American Lung Association • The internet(Hospice of Hilo website) • Self referrals 3) Transitions Volunteers provided 199 hours of support for clients from January 2011 to December 2011. 4) The following are a few stories from the field which highlight the tremendous services the Transitions Program provides to those in the East Hawaii community facing the daunting task of living with a life- limiting illness or injury, who fall through the cracks, getting lost in the confusing gaps of the healthcare system. • Client# 1: 57-year old female, Esophageal Cancer. o Client lives in rual Puna,without running water or electricity, in a windowless 8 X 8 structure. o Client has no relatives on the island and few friends. o Client began chemotherapy and radiation treatment after being admitted to Transitions. Transitions would meet and sit with her during long chemotherapy sessions at the Hawaii Pacific Oncology Center or at her home. Transitions provided emotional support during these times as client cried, got weaker and felt scared, alone, nauseated and in pain. o Client had many, many questions about her treatment, diagnosis and prognosis. Transitions helped client to write out her questions to ask the doctor and was present as the doctor gave her the news that she had a 20% chance of survival, even with chemotherapy and radiation. o Client also wanted to have bereavement counseling for anticipatory grief and Transitions was able to make a referral to the Community Bereavement Counselor from Hospice of Hilo. o Client is on disability and gets $695.00 a month to live on. o Transitions got financial aid for client for cancer supplies such as Ensure and adult diapers. o One organization sends client$50.00 a month which does not seem like a lot but makes a huge difference for client. o Transitions also applied for a gas card worth $50.00 and a one-time$100.00 check for home care. 0 0 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 11 Hospice of Hilo - Agency Name Transitions Pre-Hospice Program- Program Name o Transitions also provided a referral to The American Cancer Society where client can get free wigs and scarves as client's hair is now gone. Client is also able to get cancer education and support there. o Client will want volunteer help for errands and transportation as her disease progresses. • Client#2: 67-year-old male, COPD (Chronic Obstructive Pulmonary Disease) and skin cancer. o When client entered Transitions he was quite functional, but things changed quickly. Client is getting weaker. His breathing is labored and he has to be careful of falls. He can only stand for short periods. He becomes angry and agitated as he talks about his home being foreclosed. o Client is functionally illiterate. Client used to drive but recently had to quit as he passed out while driving. This has been a big blow to this fiercely independent man. While Transitions was visiting one day,client was unable to breathe and Transitions had to call an ambulance. o Client was admitted to the hospital, got worse and stayed longer than expected, extending through the Christmas holidays. Transitions visited client several times and provided support during this period. o Client left hospital, his spirits were good and health was somewhat improved. A day later, the Sheriff came to serve him eviction papers, putting client into a deep depression. o Transitions coordinates with the public health nurse and Services for Seniors to make sure client has regular meals and other services, providing some transportation due to client's inability to drive. o Transitions has helped client to secure financial aid ($50.00 a month for supplies, $100.00 check for home care and a $50.00 gas card.) • Client#3: 62-near old bed bound male with AIDS and involuntary neuropathy (a disease of the nervous system). His caregiver/partner of 30+years finds weekly relief as Transitions provides three to four hours a week of companionship so that the caregiver may be able to rest, relax, and find distraction from the required 24 hour care that theTransitions' client needs. • Client #4: A Chronic Obstructive Pulmonary Disease client found laughter with volunteer who sat and offered to help assemble years of photographs and memories into a manageable system. • Client #5: A caregiver receives the gift of sleep when Transitions Volunteers come play cards and draw in coloring book with caregiver's mom who suffers from dementia. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 11 Hospice of Hilo - Agency Name Transitions Pre-Hospice Program - Program Name Performance Measures: Public and Client Benefits Indicators: FY 2012-13 Estimate* More individuals facing life-limiting • Increased census numbers illnesses or injuries are aware of and • Increased referrals utilize Transitions services Quality client care coordination and • Increased use of available resources education • Client surveys indicate understanding of • Decrease in hospital available resources readmissions • Clients show increase in self-management of • Decrease in ER visits care • Decrease in Physician office visits Caregiver respite and education • Surveys indicate level of respite received and awareness of available resources Larger pool of trained volunteer support • Increased number of trained volunteers, meeting the goal of 1.5 volunteers per client Valuable skills attained by volunteers • Increased number of trained volunteer and and student interns student interns The community is educated on • Increased number of attendance at advanced advanced care planning:Advanced health care planning presentations Health Care Directives(AHCD) and • Increased awareness shown by entrance and Physicians Orders for Life Sustaining exit surveys Treatment(POLST) The community has completed advanced care planning:AHCD and, if needed, POLST form. • Patient has more control over • Increased number of individuals who have his/her end-of-life care completed advanced care planning • Reduction in avoidable procedures • Decreased emergency room visits • Decreased hospital readmissions • POLST aids first responders ability to quickly assess crisis situation Assisting physicians in communicating • Increased number of individuals who advanced health care planning complete advanced care planning at information to their patients physicians' offices * In the process of expanding the Transitions Program for FY 2012-13, data collection methods will be implemented to effectively track the progress of the program and will be a critical component in showing quantifiable success. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 11 Hospice of Hilo - Agency Name Transitions Pre-Hospice Program - Program Name Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget Estimate Salaries and Wages $29,774.00 $42,432.00 $80,870.00 Professional Fees $0 $0 $0 Operations $4466.00 $12,466.00 $17,330.00 Equipment $0 $0 $0 Other# $5033.00 $9480.00 $19,460.00 Total $39,273.00 $64,378.00 $117,660.00 *See Appendix A: Budget Narrative Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget Estimate Hospice of Hilo Reserve Fund Entire Entire Entire Program Program Program* *Hospice of Hilo's Reserve Fund is also currently supporting the upcoming in- patient facility and the on-going indigent care program. Given the needs of the in-patient facility and the indigent care program, Hospice of Hilo's ability to continue the support of the valuable Transitions Program through its reserve fund is uncertain. Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Transitions' Advanced Health Care Pilot project, in partnership with HMSA and EHIPA will demonstrate the effectiveness of advanced health care planning, helping to create better outcomes for patients and families by improving the quality of care and contributing to lower health costs. Increased revenues to support the Transitions Program will be achieved through a combination of partial insurance reimbursements for advanced health care planning consultations that take place in physicians' offices, and potentially, due to the decrease in physician's office overhead, the Transitions Program may be able to receive payment out of savings from the physician's profit pool. The Hospice of Hilo development team will continue to apply for grants and seek donor support. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 11 Hospice of Hilo - Agency Name Transitions Pre-Hospice Program - Program Name With the pilot project's demonstrated successful impact and future plans for the Transitions Program to become an integral part of the upcoming Palliative Care Center, estimated sustainability will be achieved in two to three years. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Brenda S. Ho, MS, RN—Chief Executive Officer, sits on the Hawaii County Mayor's Healthcare Sustainability Taskforce. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 11 Hospice of Hilo - Agency Name Transitions Pre-Hospice Program - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply, with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 11 Hospice of Hilo - Agency Name Transitions Pre-Hospice Program - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135—2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 11 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. �7 � ' I" ' , 1 3O ( 2. Signature of Board President/Chair Date or Agency Director —6//undla— 5:1 ( Signature of Chief Executive Officer Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 11 Hospice of Hilo- Agency Name Transitions Pre-Hospice Program- Program Name Appendix A-Budget Narrative: Fiscal Year 2010-2011-Actual (Total: $39,273.00) * Salaries and Wages--$29,774.00 Operations--$4466.00 covers: Other--$5033.00 covers: • One full time Transitions • Office space • Printing-$505.00 Coordinator, salary plus • Phone/Fax • Mileage Reimbursement- benefits • Photocopies $2048.00 • Utilities • Cell phone stipend-$480.00 • Office supplies • Training/staff development- $2000.00 *For nearly six months the Transitions Program was without a coordinator. During that time the program was being sustained through the efforts of Hospice of Hilo's Volunteer Manager. Fiscal Year 2010-2011 numbers reflect the lower salary, lower operations costs and lower other expenses of the program. Although under staffed, the program was still successful in making a vital difference to the East Hawaii Community. Fiscal Year 2011-2012-Budget (Total: $64,378.00) Salaries and Wages--$42,432.00 Operations--$12,466.00 covers: Other--$9480.00 covers: • One full time Transitions • Office space • Printing-$1000.00 Coordinator, salary plus • Phone/Fax • Mileage Reimbursement- benefits • Photocopies $2500.00 • Utilities • Cell phone stipend-$480.00 • Office supplies • Training/staff development- $3500.00 • Public Awareness-$2000.00 Fiscal Year 2012-2013-Estimate (Total: $117,660.00) Salaries and Wages--$80,870.00 Operations--$17,330.00 covers Other--$19,460.00 covers increased use of: • One full time Transitions • Office space • Printing/Education Materials- Coordinator, salary plus • Phone/fax $5000.00 benefits at$37,440.00 • Photocopies • Mileage Reimbursement- • Utilities $3500.00 • Per diem .8 position plus • Office supplies • Cell phone stipend-$960.00 benefits at$29,952.00 • Training/staff development- $5000.00 • Public Awareness-$5000.00 50 Hui Malama Ola Na 'Oiwi Community Health Education Traditional Medicine copy Hui Malama Ola Na Oiwi - Agency Name Community Health Education Traditional Medicine (New) - Program Name Agency Director: Michelle M. Hiraishi Phone No.: (808)969-9220 Contact Person: Kelsey Hiraishi Phone No.: (808)969-9220 Mailing Address: 69 Railroad Avenue Hilo, Hawaii 96720 Facility/Site Address: 69 Railroad Avenue Hilo, Hawaii 96720 Fax No.: (808) 961-4794 Email Address: Kelsey @huimalamahawaii.com Name of Accountant/CPA (include name of firm if applicable): CW Associates Phone No.: (808)861-1174 Mailing Address: Topa Financial Center 700 Bishop St, STE 1040 Honolulu, Hawaii 96813 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $10,200 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $0 $0 Agency Mission Statement: '0 Hui Malama Ola Na `Oiwi makou We are the group that takes care of the health of Hawaiian people. Eia ke kuleana: Our mission is: Ho`oulu ola o ka lahui Hawai`i To uplift the health of the Hawaiian nation O keia ka mana`o: We will: Malama is moku o Keawe Take care of Hawai`i Island Malama i na kua`aina Take care of country and rural areas Malama I kou olakino Take care of your physical, spiritual, and mental body Malama I na mea Hawai`i Take care of Hawaiian culture and practices E ho'oikaika a ola ka lahui Hawai`i. We envision a strong and healthy Hawaiian nation. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 8 Hui Malama Ola Na Oiwi - Agency Name Community Health Education Traditional Medicine (New) - Program Name Program Description: Hui Malama Ola Na `Oiwi (HMON`O), the Native Hawaiian Health Care System for Hawaii Island, is a 501 (c) 3 nonprofit organization designated through the Native Hawaiian Health Care Improvement Act of 1988, Public Law 100-579. Incorporated in 1991, the agency's basic thrust is to provide access to health services for the island's Native Hawaiian community. Accessibility to health care on Hawaii Island remains a huge disparity for Native Hawaiian residents. With 47 permanent staff in five locations around the island in Hilo, Pahoa, Ka`u, Kona, and Waimea, HMON'O provides primary care, medical transportation, health care monitoring, education and support to enhance the quality of life of Native Hawaiians and their families. HMON'O has spend a number of years collaborating with our local Native Hawaiian Traditional Healers in working side by side at health fair events to promote the cultural medicine perspective to health care. In HMON'O's history, traditional medicine has been integrated into our programs with referrals to La'au Lapa'au (Native Hawaiian herbal medicine), Lomilomi (Native Hawaiian art of massage and healing) and Ho'oponopono (Native Hawaiian art of "making it right" as a means of conflict resolution. Our proposed program will focus on connecting with our local traditional healers who have been blessed with the gift of healing through a lineage of ancestors and the spirits of their family gods or 'aumakua with the our island's population. HMON'O has served as the federally recognized Native Hawaiian Health System now for 21 years and most of our services have revolved around "western medicine" and the clinical standards and practices via the various schools of medicine. When we approached our healers, much of our enlightenment revolved around the fact that Native Hawaiian Medicine has been labeled as "alternative medicine". A traditional healer shared that it is the western based medicine that is the alternative because traditional healing has been around long before western medicine. Historically according to historians, dieticians and our traditional healers Hawaiians were considered to be the healthiest people on earth but that has changes over history with lots of reference to the change in foods and nutrition with western and eastern influences. Our proposed program will look to organize community based workshops in Puna, Hilo, Ka•u, Kona, Kohala and Hamakua where our Native Hawaiian Traditional Healers can share the art of their gift of healing with the island's population. As a designated medically underserved island and constantly hearing the articulation of "shortage of providers", HMON'O believes that a part NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 8 of our mission to take care of the people of this island is reflected in educating our people about traditional Hawaiian medicine and healing practices. Our program has been blessed with the work of healers and their willingness to this point in accepting referrals to their practices in which they never required monetary payment. Our vision to begin the age of enlightenment with community based opportunity to hear, feel and touch the many aspects that has gifted our culture with natural and spiritual healing practices. We understand that traditional healing is not always the choice for many of our people but those that connect their mind, body and spirit with traditional medicine will be connected with our practitioners for healing. Our programs longer term goal is to create and develop a means for traditional practitioners to have a place where they can open doors for people to come and visit on a one to one basis the healing that is needed. Traditional healing practices have been present in our communities and there are many people who do not know about it. As we have sat side by side with our practitioners at health fair and community events, we have always witnessed the interest and the embrace of the people who stop by the traditional practitioners table and spend a lot of time learning and sharing mana'o or thoughts. HMON'O clients were approached with the question; "If HMON'O established a Hawaiian Traditional Healing component, would they be interested?" The unanimous response was "Yes"! In summary, many of us remember growing up when our grandparent treated our colds with herbal tea or took seaweed and placed it on our cuts to stop the bleeding and prevent infection. There may have been times when a bee sting was treated by breaking of the aloe plant in the yard or taking honey and lemon mixed with hot water to treat sore throat. Well, native Hawaiian traditional healing takes this foundational practice to a greater level where practitioners are equipped with generational learning of ancestors handed down over time and guided spiritually to better the health of people. HMON'O is requesting support for this opportunity to reach and better the health of our island's population. Total Budget and Position Count Total Program Budget $22,992 Total Program Position Count 3 Total Agency Budget $3, 014,116 Total Agency Position Count 47 Program Objectives: Increase the awareness of Native Hawaiian Traditional Medicine as a means of bettering one's health. Performance Measures: • Workshops by Native Hawaiian Medicine Practitioners will be implemented in Kona, Ka'u, Kohala, Hamakua, Puna and Ka'u. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 8 • The art of La•au Lapa'au will be shared at every workshop provided. • The art of Lomilomi will be shared at every workshop provided. • The art of Ho'oponopono will be shared at every workshop provided. Program Highlights: (from Fiscal Year 2010-11) In the year FY 2010-2011 a total of 28 opportunities for clients to learn, experience and in some cases directly consult with traditional Native Hawaiian Medicine Practitioners were reported in our annual Uniform Data Systems report to the federal government. HMON'O staff has used referral processes to Native Hawaiian Practitioners over the years and in some of HMON'O's transitional phases participated in Ho'oponopono sessions as our means of healing. Native Hawaiian Medicine Practitioners has been an integral part of community based events such as the Na Pua Noe'au -Family AfFair and HMONO's Ladies Night Out event. HMON'O administration has been meeting with our healers over the course of the past few years to establish the practice of traditional medicine for our island communities. Performance Measures: Objective: Increase the awareness FY 2010-11 FY2011-12 FY 2012-13 of Native Hawaiian Traditional Actual Estimate Estimate Medicine as a means of bettering one's health. 1. Workshops by Native Hawaiian N/A N/A 6 Medicine Practitioners will be implemented in Kona, Ka'u, Kohala, Hamakua, Puna and Ka'u. 2. The art of La'au Lapa'au will be N/A 3 6 shared at every workshop provided. 3. The art of Lomilomi will be shared at N/A 3 6 every workshop provided 4. The art of Ho'oponopono will be N/A N/A 6 shared at every workshop provided. *If applicable NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 8 Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages N/A N/A $12,792 Professional Fees N/A N/A $0 Operations N/A N/A $10,200 Equipment N/A N/A $0 Other# N/A N/A $0 Total $0 $0 $22,992 * If applicable #Please explain in detail on separate sheet Hui Malama Ola Na 'Oiwi - Agency Name Community Health Education Traditional Medicine (New) - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate U.S. Department of Health and N/A N/A $12,792 Human Services Health Resources Services Administration (HRSA) Hawaii County Grant N/A N/A $10,200 Total $ $ $22,992 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Hui Malama Ola Na `Oiwi (HMON`O) will follow through with the following plan to increase revenues to sustain the Community Health Education Traditional Medicine Program: 1. HMON`O will seek grant funding from the Hawaii Tourism Authority and Office of Hawaiian Affairs for promotion and preservation of traditional Hawaiian cultural practices. 2. HMON`O will explore use of funds from HRSA to continue workshop focused community presentations. 3. HMON`O plans to work with Native Hawaiian Traditional Medicine Practitioners on calabash/donation concept for exchange of services with NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 8 clients of HMON'O. Traditional practices included fish or poi for services of healers and healers never charged for services but relied on the "giving" of those that received their services. HMON`O is anticipating another year of federal funding and is currently increasing the fundraising efforts as an organization to build up our financial base. Fundraising funds can be allocated to continuance of this program and the tradition it brings to our culture, the people we serve and the greater under-served population on the island of Hawaii. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. none NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 8 Hui Malama Ola Na 'Oiwi - Agency Name Community Health Education Traditional Medicine (New) - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 8 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Signature of Board President/Chair Date or Agency Director Cpl At la Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 8 51 Hui Malama Ola Na 'Oiwi Kokua Hall Health Transportation c py Hui Malama Ola Na Oiwi - Agency Name Kokua Hali Health Transportation - Program Name Agency Director: Michelle M. Hiraishi Phone No.: (808)969-9220 Contact Person: Kelsey Hiraishi Phone No.: (808)969-9220 Mailing Address: 69 Railroad Avenue Hilo, Hawaii 96720 Facility/Site Address: 69 Railroad Avenue Hilo, Hawaii 96720 Fax No.: (808) 961-4794 Email Address: Kelsey @huimalamahawaii.com Name of Accountant/CPA (include name of firm if applicable): CW Associates Phone No.: (808)861-1174 Mailing Address: Topa Financial Center 700 Bishop St, STE 1040 Honolulu, Hawaii 96813 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$20,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $20,000 $20,000 Agency Mission Statement: '0 Hui Malama Ola Na `Oiwi makou We are the group that takes care of the health of Hawaiian people. Eia ke kuleana: Our mission is: Ho`oulu ola o ka lahui Hawai`i To uplift the health of the Hawaiian nation O keia ka mana`o: We will: Malama is moku o Keawe Take care of Hawaii Island Malama i na kua`aina Take care of country and rural areas Malama I kou olakino Take care of your physical, spiritual, and mental body Malama I na mea Hawai`i Take care of Hawaiian culture and practices E ho'oikaika a ola ka lahui Hawai`i. We envision a strong and healthy Hawaiian nation. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 9 Hui Malama Ola Na Oiwi - Agency Name Kokua Hali Health Transportation - Program Name Program Description: Hui Malama Ola Na `Oiwi (HMON`O), the Native Hawaiian Health Care System for Hawai`i Island, is a 501 (c) 3 nonprofit organization designated through the Native Hawaiian Health Care Improvement Act of 1988, Public Law 100-579. Incorporated in 1991, the agency's basic thrust is to provide access to health services for the island's Native Hawaiian community. Accessibility to health care on Hawaii Island remains a huge disparity for Native Hawaiian residents. With 47 permanent staff in five locations around the island in Hilo, Pahoa, Ka`u, Kona, and Waimea, HMON`O provides primary care, medical transportation, health care monitoring, education and support to enhance the quality of life of Native Hawaiians and their families. HMON`O is requesting funding from the County of Hawaii for fiscal year 2012- 2013 to continue "KOkua Hali" health transportation program to provide access to essential health care on the island. HMON`O has provided this specialized service to clients living in more rural areas like Hawaiian Acres, Hawi, Opihika'o, Na'alehu as well as clients living in all districts on the island. Previous years funding allowed HMONO to hire and retain a designated driver who has coordinated deployment schedules with each of our site location staff to provide door-to-door transportation for registered clients to get them to and from physician, diagnostic lab, pharmacy, dialysis, and other health-related appointments. HMON`O prides itself in perpetuating local values of"ho'okipa" (hospitality) and ho'omalimali" (soothe and flatter) each client as they often are faced with the health stressors that increase their anxiety and reluctance to take the steps to seek medical health care. Our Transportation Specialist will accompany and assist clients from time of pick-up to drop-off to make sure they arrive safely and on time. As a secondary function, this Transportation Specialist would serve as a backup driver between the different HMON`O sites to accommodate spikes in demand for health-related transportation. HMON'O's transportation service operates Monday through Friday by appointment only with scheduling flexibility to accommodate client needs. The Need: The need for the Kokua Hali continued transportation services has not changed much in Hawaii County as our island continues to be designated a medically underserved community with a shortage of providers in rural areas.' Increasing access to medical services on the island is of particular concern to Hawaii County because of its large geographic area, low population density, higher poverty rates, limited public transportation, and aging population.2 U.S.Department of Health and Human Services Health Resources and Services Administration,Health Provider Shortage Area, September 30,2009 s Center on the Family Data Center,Comparative Data,Hawaii County,Census 2000,September 30,2002 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 9 U. S. Census Bureau data shows Hawaii County's resident population has grown to well over 185,000 and we continue to see through our Kokua Hali statistics that much of our island residents rely on our services to get to a variety of health services. HMON'O's five offices around the island continue to received inquiries or requests for health transportation from transportation and mobility disadvantaged clients using wheelchairs or walkers. The agency continues to have active registered clients who will readily benefit from the specialized transportation service, and several live in rural areas requiring four-wheel-drive access. In our most recent County award for this program we were very grateful for the covering of a Transportation Specialist position as the funding allocation. Hearing the County Council share with us that funding a "position" is not the best practice for county funds, we are looking to the county for support in the non-personnel cost for this program that is so much needed as consistent and diligent travel of our vehicles has worn and torn our fleet to require some necessary repairs and maintenance to keep our program running at full speed. The travel abuse on our vehicles has forced many repairs and the high number of miles being placed on our vehicles is beginning to affect our budget. Our request is to seek financial support from our County to help in the maintaining of our fleet and keep our transportation fleet well maintained and operational so we can provide services much needed. The Response: HMON'O's KOkua Hali Health Transportation Program will continue to find every avenue to retain funding for the designated Transportation Specialist to coordinate and provide transportation for clients island-wide. County funding in the current year has proven to be wisely allocated and showing an impact on caring for this target population. HMONO has also seen an increase in enrollment for many of our health education and support groups with a growing population of mobility challenged individuals who now feel comfortable to take advantage of transportation and many more community residents that so gratefully appreciate our ability to serve them in this capacity. Especially for residents of more remote areas like Upper and Lower Puna, Kohala, Waimea, Kai], and South Kona, a passenger trip commonly starts with a client being picked up at his home then taken to a physician's visit followed by a diagnostic lab screening and a stop at the pharmacy before returning home. As evidenced in HMON`O transportation logs, a single trip with multiple destinations (transports) like the one described can take up to six hours long. For mobility disadvantaged transports, trip duration is further extended by the additional time required for loading and unloading multiplied by the number of stops a client needs to make. Keeping in mind that our transportation out of Waimea, Kohala, South Kona, Ka'u and Puna requires a long trip that takes up most of our client's day due to the distance required to get to the doctor offices, pharmacies and other health professionals. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 9 HMON'O will continue to support our island's need to get people to medical related appointments and make every effort to address the medically underserved population and the inability or lack of accessibility to care. Total Budget and Position Count Total Program Budget $258,310 Total Program Position Count 6 Total Agency Budget S3, 014,116 Total Agency Position Count 47 Program Objectives: Hui Malama Ola Na `Oiwi's KOkua Hali Health Transportation Program will achieve the following objective in fiscal year 2012-2013: Objective 1: Decrease health risk factors by providing accessibility to care. a. Provide transportation for 500+ island residents to health related appointments. Program Highlights: (from Fiscal Year 2010-11) Hawaii County grant funding for the current fiscal year 2010-11 allowed HMON`O to recruit and retain a designated ADA van Transportation Specialist From July 1 to December 31, 2010, Hui Malama Ola Na 'Oiwi (HMON`O) reported 98 unduplicated clients taking advantage of the transport services. The ADA Transportation Specialist traveled a total of 10, 187 miles during the period. HMON'O is required to submit calendar year statistics to the federal government and this is some of the most recent tabulation during the calendar year 2011. The KOkua Hali Program overall transported a total of 492 clients. This is an unduplicated number meaning each passenger is counted only once to give a clear picture of how many clients we served. Approximately 80% of our clients receiving transport services continue throughout the year. In assessment of our fleets growing repair expenses, special tabulation using odometer logs and transport logs showed that our fleet traveled a combined 126,860 miles in transporting clients to health related appointments. Significant numbers were registered in Ka'u and Puna with travel miles for Ka'u registering 33,317 miles and Puna with 37,230 miles. The successes and testimonials of the clients we serve continues to be positive and the relationships built between HMON'O staff and each client is best described as one of"lokahi" or unified. Driving clients on a daily basis have been appreciated by our agency and the families we serve with monetary donations forwarded to our offices in "thankfulness" for the program delivered. Our growing demand for our health education program classes and case management program has challenged each of our site location site managers to work on creative and flexible schedules for our drivers. Our increase in the year for NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 9 classes and community appointments deployed drivers as early as 5am in the morning and sometimes ending their day at 10pm. Often our drivers accumulated so much time in the first 4 working days of the week they were forced to take a Friday or an additional day off so not to go over a full time w40 hour week. The year 2011 posed much challenges in the wear and tear of our vehicles. Insurance plans became a savior in coverage of scheduled transports when vehicles broke down we were able to get a loaner to keep our client's booking. Performance Measures: FY 2010-11 FY2011-12 FY 2012-13 Actual Estimate Estimate Objective 1: Decrease health risk factors by providing accessibility to care. a. Provide transportation 457 500 550 for 500+ island residents to health related appointments. *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages $152,240 $190,782 $190,782 Professional Fees Operations $67,345 $67,528 $67,528 Equipment Other# Total $219,585 $258,310 $258,310 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 9 Hui Malama Ola Na 'Oiwi - Agency Name Kokua Hali Health Transportation - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate U.S. Department of Health and $199,585 $238,310 $238,310 Human Services Health Resources Services Administration (HRSA) Hawaii County Grant $20,000 $20,000 $20,000 Total $219,585 $258,310 $258,310 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Hui Malama Ola Na `Oiwi (HMON`O) will follow through with the following plan to increase revenues to sustain the Kokua Hali Transportation Program: 1. HMON`O is currently in process of getting approval of this program to collect reimbursements from health insurance providers for health education reimbursements that meet the criteria and captures billed revenue to subsidize program expenses. 2. HMON`O plans to shift cost in supplies from funded to recycled materials, business donations, community support and align program with innovative and traditional means to avoid the need for funding. 3. HMON`O plans to collaborate with West Hawaii Community Health Center and Hamakua Health Center in subsidizing the operational cost that can be enhance their efforts to provide a continuum of care for those patients requiring some form of diabetes management education classes. Resources in qualified staff form both community health centers and HMON`O can only serve to compliment program services to our west Hawaii communities. 4. As one of the five Native Hawaiian Health Care Systems throughout the state, HMON`O continues to be part of a statewide resource development workgroup consisting of representatives from each system. The primary objective of the workgroup is to explore and develop a comprehensive fund development strategy that looks at sustainability via annual donor NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 9 campaigns, foundation and government grants, endowments, and planned giving. HMON`O is anticipating another year of federal funding and is currently increasing the fundraising efforts as an organization to build up our financial base. Continued efforts by program staff and management is being made to assess each programs unique impact on our communities and finding the necessary funds specific to continuing and mirroring programs that are working and showing positive health outcomes. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. none NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 9 Hui Malama Ola Na 'Oiwi - Agency Name Kokua Hall Health Transportation - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 9 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation ofyour agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Signature of Board President/Chair Date or Agency Director j:441 / 124-4-4‘' t t Signature of Executive Director ate UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 9 52 Hui Malama Ola Na 'Oiwi Mai Ka Mala'ai Diabetetes Management COPY Hui Malama Ola Na Oiwi - Agency Name Mai Ka Mala'ai Diabetes Management - Program Name Agency Director: Michelle M. Hiraishi Phone No.: (808)969-9220 Contact Person: Kelsey Hiraishi Phone No.: (808)969-9220 Mailing Address: 69 Railroad Avenue Hilo, Hawaii 96720 Facility/Site Address: 69 Railroad Avenue Hilo, Hawaii 96720 Fax No.: (808) 961-4794 Email Address: Kelsey @huimalamahawaii.com Name of Accountant/CPA (include name of firm if applicable): CW Associates Phone No.: (808)861-1174 Mailing Address: Topa Financial Center 700 Bishop St, STE 1040 Honolulu, Hawaii 96813 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$28,855 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $0 $5,000 Agency Mission Statement: '0 Hui Malama Ola Na `Oiwi makou We are the group that takes care of the health of Hawaiian people. Eia ke kuleana: Our mission is: Ho`oulu ola o ka lahui Hawai`i To uplift the health of the Hawaiian nation 0 keia ka mana`o: We will: Malama is moku o Keawe Take care of Hawai`i Island Malama i na kua`aina Take care of country and rural areas Malama I kou olakino Take care of your physical, spiritual, and mental body Malama Ina mea Hawai`i Take care of Hawaiian culture and practices E ho'oikaika a ola ka lahui Hawai`i. We envision a strong and healthy Hawaiian nation. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 11 • Customary diabetes clinical information: Via weekly "Diabetes 101" sessions presented by the CDE equivalent/RN, clients are educated about the basic facts of diabetes (types, symptoms, blood sugar levels, basic management, etc) • Local community Specialists: Each week a different Specialist from the community provides information in the management of diabetes within their area of expertise, followed by a question and answer session. These Specialists provide this service for free. These Specialists and their topic discussions include: Exercise Specialist: Fitness Podiatrist: Foot Care Optometrist: Eye Care Pharmacist: Medication Management Medical Doctor: Kidney Health Dentist: Oral Health Psychologist: Coping Skills Registered Dietician: Well Balanced Meals; Recipe Modification Agricultural Specialist: Planting Seeds-Growing Healthy Plants; Fertilizers; Maintaining and Refreshing Your Mala. (Other specialists may be recruited as clients' needs warrant) • Mala (Garden) Construction: Each client is provided with a mala built at their home, and numerous vegetable seedlings for planting. Over the course of the class, an Agricultural Specialist provides information for growing vegetables, utilizing fertilizers (both store-bought and homemade), maintaining and sustaining a mala, and harvesting. Native Hawaiians have a very strong respect for and spiritual connection with the 'aina, the land; it is a value that is ingrained in all aspects of Hawaiian culture. The mala provides clients the opportunity to connect with the land, supplement their food supply, and exercise. (Graduates of the class have credited their mala as giving them "purpose": one client cited his mala as part of his substance abuse sobriety plan, another cited her mala as the reason she progressed out of a wheel chair and into a walker, "I needed to be able to get to my mala.") • Meal: As a "topic" of each class, clients are served (by HMON'O staff) a healthy meal. This is an opportunity for clients to "see it all in action": healthy food choices, including vegetables they bring in from their mala, and appropriate portion size. The evening's presenting Specialist joins in the meal, providing an opportunity for clients to ask further questions, talk-story, and get to know the Specialist they may visit in their disease management. The value- added byproducts of the meal include building of the client's self-esteem (feeling pampered by being served), and increasing their support network by enjoying a meal and talking story with other clients. Friendships are formed. • Support group: Upon completion of the Mai Ka Mala'ai class, clients are offered the opportunity to join the on-going Diabetes Support Group. The group meets bi-monthly (daytime and evening groups are offered), and again shares a meal together. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 11 HMON`O is requesting funding from the County of Hawaii for fiscal year 2012- 2013 to expand the Mai Ka Mala 'ai Program to residents island-wide. The Need Diabetes is generally more common among the aging population. The proportion of Hawaii residents aged 65 years and older rose from 5% in 1970, to 8% in 1980 to 14% in 1999 (HMSA Foundation, 2001) and in 2008 Hawaii County statistics showed 14.5% of the island population were 65 years and older. Therefore, the state of Hawaii faces great challenges due to the diabetes burden among its relatively large population of middle-aged and elderly citizens. From 2000 to 2002, on annual average, 8,185 Hawaii residents died at age 18 years or older, caused directly or indirectly by various kinds of diseases, injuries or poisoning, including 191 cases where diabetes was the underlying cause of death and 761 cases where diabetes was the contributory cause of death. In 2005 more than one third of all stroke and coronary heart disease hospitalizations were diabetes related. Hawaiians had the highest mortality rates for diabetes as the underlying cause of death (37), contributory cause of death (134) or the both (171), of all ethnic groups. HMONO has observed an increase in the number of diabetes diagnosed patients who have come in to our primary care clinic to visit our physicians and those diabetic patients who have registered and completed physician diabetes counseling and diabetes management classes. Patient feedback indicates an urgent need for patients to control their diabetes and have on-going opportunity to learn as much about diabetes as they can. In 2009 diabetic patients totaled 384 and physicians reported 316 diabetes related visits. In 2010 the number of newly diagnosed patients increased and the number of clinical encounters for diabetes doubled from 2009. We understand that this is reflective of patients under our Primary Care physicians and have witnessed referrals to our program from private physicians and Bay Clinic in East Hawaii. This growing trend increased the number of people signing up for our classes in East Hawaii where we have reached our capacity and a waiting list has been established. HMONO's request is to expand this program to each of our site locations across the island. The Response To address the need in management of diabetes for the growing diabetic population in Hawaii County, HMONO will organize and implement the Mai Ka Mala'ai Program in Pahoa, Hilo, Ka'u, Kona and Waimea. HMON'O is projecting to plan and implement a total of 12 groups throughout the funding year with 10 groups projected under County of Hawaii funding. Diagnosed diabetics will afford the opportunity to deal with the everyday health issues surrounding their chronic disease by increasing protective factors through established routines such as exercise, nutrition and diet intake, recognition of possible symptoms of diabetics in eye care, foot care and kidney care. We will address mental health issues of participants with possible mind-set and life skill tools to deal with emotions and 1 Department of Health: Hawaii Health Survey(HHS), 2008 Report. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 11 stressors of disease in themselves, their families and friends. To address the risk factors related to the socio-economic crisis where many of our residents are unemployed, some homeless and little or no means to provide healthy meals, we will assist to implement cost effective garden areas using recycled pallets, maintaining healthy compose and using everyday natural products to create fertilizers as a means of self sustainable food produce for their families. In more detail, the 10 week curriculum consist of 2 sessions on sustainable gardening, 2 classes titled Diabetes 101 where the basic understanding of diabetes and other contributing health factors are shared by a diabetes specialist, 1 session on physical exercise, 1 session on foot care, 1 session on eye care, 1 session on mental health, 1 session on healthy diet practices & nutrition, 1 session on modifying recipes and 1 session on the various pharmaceutical medicines. Based on the dynamics and needs of each group HMONO has been very flexible in retaining local professionals who provide in-kind hours as presenters in the program. Each of our West Hawaii sites can provide transportation on a limited basis for class participants. Total Budget and Position Count Total Program Budget $103,439 Total Program Position Count 17 Total Agency Budget S3, 014,116 Total Agency Position Count 47 Program Objectives: Hui Malama Ola Na `Oiwi's Mai Ka Mala 'ai Program will be implemented island wide and achieve the following objectives in fiscal year 2012-2013: Objective: Increase protective factors of those clients medically diagnosed with diabetes in management of their diabetes 1) Register 145 diabetes diagnosed participants into the Mai Ka Mala'ai Program of which 130 will complete the 10 week class. 2) 100% of class participants wanting a garden box or similar will be provided with a box, soil and seedlings. 3) 115 of class participants completing the 10 week class will demonstrate improvement in at least 5 of the 10 clinical screen results assessed in the program. 4) 90 of participants completing the class will complete a 3, 6 and 12 month follow-up screening and assessment. Program Highlights: (from Fiscal Year 2010-11) A total of 58 participants completed the 10 week Mai Ka Mala 'ai Program curriculum in FY 2010. Many of these participants had an accompanying family member who attended classes and supported the 'ohana centered value instilled in their respective families. A total of 3 groups were completed with 95% of the clients demonstrating improvement in at least 3 areas of screening which included monitoring of blood pressure, total cholesterol levels, HBA1c, blood glucose levels, 02 count, weight loss NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 11 and/or body mass index (BMI), Triglyceride (saturated fats), fruit and vegetable intake and increase in daily physical exercise. 70% demonstrated improvement in 5 or more of the clinical screening categories. The clinical area showing the highest level of improvement was in HBA1c Fasting Blood Sugars. Pre and post screen results showed that 49 of the 58 participants recorded HBA1 c count of 9% or less. Blood pressure reading also reported 46 of 58 participants with a blood pressure reading <140/90 and an additional 10 showing improvement in lowering their blood pressure. 53% of the participants improved their cholesterol counts and 31 % showed improvement in their BMI. Triglyceride or saturated fat counts continue to be an area of concern with only 13% showing improvement. 90% reported personal improvement in increasing fruit and vegetable intake and physical activity. Over the year a total of 58 garden boxes were delivered to clients as their own 'ohana's "mala"(garden). A total of 29 clients from previous groups had follow- up visits by staff and community professionals who repaired and gave credible guidance to maintain and for some restore their malas. Time was spent planning the launching our first MKM class in Kona scheduled for the start of the new FY 2011. HMON'O was appreciative of the County of Hawaii's $5000 award to plan the upcoming FY MKM in Kona. Although the funding was minimal compared to the request, HMON'O sought other possible funding and were able to gather some viable resources to plan the West Hawaii launch of MKM. Feedback from participants yielded positive results not only in clinical screening but in rapport building with health professional presenters and their expertise area as related to diagnosed diabetics. The "coconut wireless" or "word of mouth" appears to be an advocate for our most recent demand for this signature program. Aside from the West Hawaii request we encountered much feedback in the FY asking us "when" we were bringing the MKM program to the other parts of the island. Request from Waimea and Ka'u specifically has been a focus for HMON'O to take this program island-wide. In summary, it is our belief that we have a Mai Ka Mala'ai program that is very successful in management of diabetes and self empowerment. Expanding this program island wide is a vital piece in building healthier communities here on the island of Hawaii and meet the request from our rural communities for this signature program. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 11 Hui Malama Ola Na 'Oiwi - Agency Name Mai Ka Mala'ai Diabetes Management - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Objective: Increase protective Projected 50 Projected 50 factors of those clients medically clients clients diagnosed with diabetes in management of their diabetes 1. Register 145 diabetes diagnosed participants into the 58 88 145/130 Mai Ka Mala'ai Program of which 130 will complete the 10 week class. 2. 100% of class participants wanting a garden box or similar 100% (58) 100% (85) 100%(130) will be provided with a box, soil 3 not and seedlings. allowed by landlord 3. 115 of class participants completing the 10 week class 41 66 115 will demonstrate improvement in at least 5 of the 10 clinical screen results assessed in the program. 4. 90 of participants completing the class will complete a 3, 6 46 62 90 and 12 month follow-up screening and assessment. _ *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages $46,459 $71,584 $71,584 Professional Fees Operations $19,497 $26,470 31,855 Equipment Other# $2,275_ Total $68,231 $98,054 $103,439 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 11 Hui Malama Ola Na 'Oiwi - Agency Name Mai ka Mala'ai Diabetes Management - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate U.S. Department of Health and $65,701 $90,054 $70,584 Human Services Health Resources Services Administration (HRSA) Hawaii County Grant $0 $5,000 $28,855 In Kind contributions (UH H $2,269 $3,000 $4,000 Agriculture Department) UH Contribution $261 Total $68,231 $98,054 $103,439 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Hui Malama Ola Na `Oiwi (HMON`O) will follow through with the following plan to increase revenues to sustain the Mai Ka Mala'ai Diabetes Management Program: 1. HMON`O is currently in process of getting approval of this program to collect reimbursements from health insurance providers for health education reimbursements that meet the criteria and captures billed revenue to subsidize program expenses. 2. HMON`O plans to shift cost in supplies from funded to recycled materials, business donations, community support and align program with innovative and traditional means to avoid the need for funding. 3. HMON`O plans to collaborate with West Hawaii Community Health Center and Hamakua Health Center in subsidizing the operational cost that can be enhance their efforts to provide a continuum of care for those patients requiring some form of diabetes management education classes. Resources in qualified staff form both community health centers and HMON`O can only serve to compliment program services to our west Hawaii communities. 4. As one of the five Native Hawaiian Health Care Systems throughout the state, HMON`O continues to be part of a statewide resource development workgroup consisting of representatives from each system. The primary NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 11 objective of the workgroup is to explore and develop a comprehensive fund development strategy that looks at sustainability via annual donor campaigns, foundation and government grants, endowments, and planned giving. HMON`O is anticipating another year of federal funding and is currently increasing the fundraising efforts as an organization to build up our financial base. Continued efforts by program staff and management is being made to assess each programs unique impact on our communities and finding the necessary funds specific to continuing and mirroring programs that are working and showing positive health outcomes. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. none NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 11 Hui Malama Ola Na 'Oiwi - Agency Name Mai Ka Mala'ai Diabetes Management - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 11 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. /2/4,2_ Signature of Board President/Chair Date or Agency Director /3/ Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 11 53 Hui Malama Ola Na 'Oiwi Outreach Case Management - Hele Mai Ai © j_D)y Hui Malama Ola Na Oiwi - Agency Name Outreach Case Management - Hele Mai'Ai - Program Name Agency Director: Michelle M. Hiraishi Phone No.: (808)969-9220 Contact Person: Kelsey Hiraishi Phone No.: (808)969-9220 Mailing Address: 69 Railroad Avenue Hilo, Hawaii 96720 Facility/Site Address: 69 Railroad Avenue Hilo, Hawaii 96720 Fax No.: (808) 961-4794 Email Address: Kelsey @huimalamahawaii.com Name of Accountant/CPA (include name of firm if applicable): CW Associates Phone No.: (808)861-1174 Mailing Address: Topa Financial Center 700 Bishop St, STE 1040 Honolulu, Hawaii 96813 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $7,344 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $0 $0 Agency Mission Statement: '0 Hui Malama Ola Na `Oiwi makou We are the group that takes care of the health of Hawaiian people. Eia ke kuleana: Our mission is: Ho`oulu ola o ka lahui Hawaii To uplift the health of the Hawaiian nation O keia ka mana`o: We will: Malama is moku o Keawe Take care of Hawai`i Island Malama i na kua`aina Take care of country and rural areas Malama I kou olakino Take care of your physical, spiritual, and mental body Malama Ina mea Hawai`i Take care of Hawaiian culture and practices E ho'oikaika a ola ka lahui Hawaii. We envision a strong and healthy Hawaiian nation. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 10 Hui Malama Ola Na Oiwi - Agency Name Outreach Case Management - Hele Mai'Ai - Program Name Program Description: Hui Malama Ola Na `Oiwi (HMON`O), the Native Hawaiian Health Care System for Hawaii Island, is a 501 (c) 3 nonprofit organization designated through the Native Hawaiian Health Care Improvement Act of 1988, Public Law 100-579. Incorporated in 1991, the agency's basic thrust is to provide access to health services for the island's Native Hawaiian community. With 47 permanent staff in five locations around the island in Hilo, Pahoa, Ka`u, Kona, and Waimea, HMON`O provides primary care, medical transportation, health care monitoring, education and support to enhance the quality of life of Native Hawaiians and their families. Hui Malama Ola Na 'Oiwi (HMON'O) Health Enhancement Services will provide for a comprehensive health education, management, and monitoring program for Native Hawaiians and other populations at risk (including the uninsured.) The Outreach Case Management Program (OCMP) is the core or "Piko" of our services directly benefiting the people of Hawaii Island. Outreach Case Managers (OCM) have provided direct patient services over the past 21 years of existence and has blossomed from a few OCM staff to 11 across the island. They are dispersed across the island in Captain Cook, Kona, Hilo, Pahoa, Na'alehu, Ka'u and Waimea. As our island Native Hawaiians and other populations facing huge health disparities in: diabetes, hypertension, cardio-vascular disease, obesity, and cancer as well as socio-economics, mental health and the everyday struggle to work in such a world wind of a nation, Health care has evolved into a very diverse and difficult island environment with a multitude of barriers that many of island population face on a day to day basis. This is the exact reason why our OCMP is needed on Hawaii Island. Hui Malama Ola Na 'Oiwi has an established history on Hawai'i Island of providing quality health promotion services to Native Hawaiians and their 'ohana and other populations at risk. HMON'O OCMP staff is professional and adept in their clinical skills, and welcoming, gentle and supportive in their interpersonal skills. Staff expertise in connecting with each of the communities they serve range 3 staff that has been with HMON'O for 21 years and many who have been with us for 10+ years. They are well respected within the community, and have a reputation among health care entities of being able to effect a change with the most difficult of clients. Likewise HMON'O's OCMP compliment and provides the caveat of success we have encountered in our Health Education and Primary Care Clinic Programs. Much of our Outreach Case Manager's (OCMs) success is attributable to their incorporation of"Western" clinical interventions, curriculum, and societal parameters of health care with Native Hawaiian values, traditions, and philosophy. Teaching and working hand in hand with our local populations NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 10 effectively motivate and support overall health changes when you are blessed with direct service staff like our case managers who can connect with the people and work alongside them to meet and address the challenges they face. Inclusive of the role of this OCMP is the implementation of our Hele Mai 'Ai nutrition education classes conducted island wide by each of our OCMs. Hele Mai 'Ai consists of: - 3 class sessions covering 6 modules utilizing a standardized curriculum. - Vitals (ht, wt, BMI, BP) collected at regular intervals Referral to RN educators for one-on-one follow-up as necessary Clinical data and anecdotal information to PCP HMON'O's Hele Mai 'Ai (Come Eat) nutrition education class is 3 day class curriculum covering 6 modules. The course was developed by the State Department of Health, and visually enhanced by HMON'O OCMs. Hele Mai 'Ai promotes disease prevention and risk reduction behaviors. It is the philosophy of Hele Mai 'Ai that traditional Hawaiian dietary practices can serve as models for good eating and lifestyle habits. The course utilizes powerful visuals to show the fat, salt, and sugar amounts in our island's typical diet (including fast foods and traditional Hawaiian foods.) Class objectives include reducing dietary fat intake, increasing complex carbohydrates and fiber-containing foods, and decreasing sugar and sodium intake. The class includes: • Vital screen (baseline) of vitals (ht, wt, BMI, BP) at each of the 3 classes. • Follow-up screen at 3-months; coaching with client • Follow-up screen at 6-months; coaching with client • Follow-up screen at 1 year; coaching with client • Mo'olelo (story) sharing: time built into each class for sharing of stories and asking questions • A healthy snack utilizing traditional Hawaiian foods (i.e. sweet potato, taro, etc.) The Need It is a known fact that Hawaii Island is faced with alarming statistics in most aspects of health. Physical, mental and socio-economic health factors continue to plague our island's population. Chronic disease data indicates and rates high statistics in almost every area of disease for the island and in comparison to the state and in some instances the nation we are some of the least healthy people. The health professional world where health services are provided for our population is also suffering with a shortage of providers, specialist and adds to our medically underserved community status. The need is tremendous in finding as many avenues or venues that can help us care for our island's people. Clients we currently serve and those that we have had contact with in our communities across the island have grown weary and tired of struggling to care for their health and have reverted to use of our emergency rooms as their means of dealing with their health and often it is only done in extreme emergency NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 10 situations. Families continue to have little choices in health care when faced with $20 to spend or save for rent, food, co-pay, medication, utilities or other living cost. Many of our clients in this type of dilemma spend their $20 on food as the basic need for their families. The problem arises when the $20 is spent on unhealthy foods served at fast food franchises that provide $1 menus and capture the audience that spends all they have at their establishment because the $20 goes a long way and feeds everyone. We ask ourselves, "Where do these people go when they are stuck in this dilemma?" Many of them are old school and say "Poho" or "Never mind go doctor, no sense because I no can afford it, plus I gotta take care of stuff for my family." We have seen the statistics, we witness the communities we serve struggling and this continues to reaffirm our commitment to take every avenue we can to better the lives of our island community. Families revert to the unhealthy purchases that are affordable and are often unaware of the unhealthiness of the foods and have not had opportunity to learn about eating healthier and "how" to leverage their limited funds to feed their families healthier meals. The Response Hele Mai 'Ai As outlined in the brief description section, Hele Mai 'Ai is HMON'O's response to helping our clients and the community heighten their awareness of not only the dangers of unhealthy foods we consume on a daily basis but the effect on our overall health. Hele Mai 'Ai promotes for all those who attend an opportunity to look at changing some of their basic mind-sets and work towards eating healthy and "how" they can accomplish this change. Label reading, altering the cooking styles to increase nutritional value of foods and sharing of health recipes are some ways that the Hele Mai 'Ai program has benefited people. HMON'O selected the implementation of these classes to be specifically administered by the OCMs because they have thrived over the past 10 years in enhancing and conducting these classes for our clients and at a host of public and private elementary schools on Hawaii Island as well as community events that allowed them to share displays and present Hele Mai 'Ai to the greater public. HMON'O have found that Hele Mai 'Ai compliments our Community Health Education chronic disease classes and lays a basic foundation of thoughts and practices that motivate participants to make changes that prepare them for the more chronic disease management practices they must undergo. Total Budget and Position Count Total Program Budget $105,201 Total Program Position Count 12 Total Agency Budget $3, 014,116 Total Agency Position Count 47 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 10 Program Objectives: Hui Mama Ola Na 'Oiwi's OCMP — 17 class groups of the Hele Mai 'Ai program will be implemented island-wide projecting enrollment of 151 total clients. The following objectives and performance measures are projected in fiscal year 2012- 2013: Objective 1: Reduce health risk factors and increase health protective factors in basic health Performance Outcomes: 1. 151 clients will complete 6 modules of the Hele Mai 'Ai Program. 2. 120 clients will complete all 6 scheduled vital screening sessions. 3. 96 clients will improve towards blood pressure of <140/90 4. 78 clients will improve BMI towards 18.5 to 25. Objective 2: Promote basic health nutrition education to youth and community at large. Performance Outcomes: 1. 5 School based Hele Mai 'Ai presentations will be completed in the funding period. 2. 10 Community based Hele Mai 'Ai presentations will be completed in the funding period. Program Highlights: (from Fiscal Year 2010-11) HMON'O's OCMs have conducted 15 Hele Mai 'Ai groups in 2010-2011 with a total of 78 participants. In addition HMON'O staff conducted program presentations at EB DeSilva, Kaumana Elementary, Hilo Union, and Kanu 0 Ka Aina charter school. A total of 103 youth were in attendance for the Hele Mai 'Ai presentations. In FY 2010 HMON'O completed 28 Hele Mai 'Ai community presentations at various health fairs, community associations and with other organizations throughout the island. Hele Mai 'Ai groups so far in FY 2011-2012. A total of 60 participants have completed the program and this being the first year HMON'O have included vital screening as part of the class, we anticipate our next scheduled set of 3 month and 6 month follow-up encounters will yield positive changes in vital baseline numbers. HMON'O is fortunate to receive Hawaii Island BEACON funding that will allow us to implement our Hele Mai Ai program through December 31st, 2012 in our Kona and Waimea offices. Hilo, Pahoa and Ka'u offices have already scheduled Hele Mai 'Ai classes beginning July 1, 2012 and our hope is the County of Hawaii can support the implementation throughout the county funding period and support continuance of the Hele Mai 'Ai programs in Kona and Waimea from January 1, 2013 thru June 30, 2013. So far in the FY HMON'O has completed 3 community based presentation and is projecting 13 more throughout the remainder of the year. In the funding period a total of 18 presentations are projected. Feedback from those who have taken the class or visited us at our community presentation continue to share how the NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Hui Pono Holoholona- Agency Name Subsidized Low Cost Spay/Neuter Clinics- Program Name Agency Director: Frances P. Pueo Phone No.: (808) 968-8279 Contact Person: Frances P. Pueo Phone No.: (808) 968-8279 Mailing Address: PO Box 943 Mt. View, Hi 96771 Facility/Site Address: 11-3436 Hibiscus Street Mt. View, Hi 96771 Fax No.: (808) 968-8279 Email Address: webmistress @hphhawaii.org Name of Accountant/CPA (include name of firm if applicable): Vivian S. Toeliner Phone No.: (808) 345-2753 Mailing Address: PO Box 6894, Hilo, Hi 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$20,000.00 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $ $ $11,000.00 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 8 Hui Pono Holoholona - Agency Name Subsidized Low Cost Spay/Neuter Clinics- Program Name Program Description: HPH advertises periodic Spay/Neuter clinics & works directly with the community to provide traps, transportation, and assists individuals with trapping when necessary. We also have daily phone contact & maintain lists of people in need of our assistance. For example, from 2007 until now we spayed/neutered over 1,900 cats. This preventative measure has potentially decreased the cat population in general by 10,620,900. These grant funds we are requesting will be used to maintain & increase our efforts as our operation is outgrowing our donations. Total Budget and Position Count Total Program Budget 20,000.00 Total Program Position Count 12 Total Agency Budget 15,000.00 Total Agency Position Count 5 Program Objectives: 1) Sponsor low cost Spay/Neuter clinics for the public (individuals who meet low income financial criteria). 2) Transport animals biweekly to and from Spay/Neuter clinics. 3) Transport traps & bait food to and from homes of individuals of low income & elderly. 4) Purchase medical supplies for the Spay/Neuter clinic. 5) Purchase additional traps, pet carriers, kennels & other supplies. 6) Seek homes for adoptable animals. Program Highlights: (from Fiscal Year 2010-11) 1) HPH is saving lives of innocent animals who would be euthanized or left to suffer in an inhumane environment. We have found homes for many of those animals through our adoptive service program. We have effectively managed a potentially exponential explosion of the cat population at managed colony locations such as the Keaau transfer station and NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 8 numerous other sites, which would have become an extreme problem at public facilities. HPH sponsored educational Spay/Neuter clinics with Dr. Kozuma of the University of Hilo for pre-vet sutdents to observe & participate hands on with high school students in attendance. The objective was to inspire high school sutdents/volunteers to participate in future HPH activities & seek careers in animal medicine. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 8 Hui Pono Holoholona - Agency Name Subsidized Low Cost Spay/Neuter Clinics - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Dr. Lyle Brooksby 252 210 300 Hilo Veterinary Clinic/ Dr. Castro 9 12 20 Kilauea Vet Services / Dr. Seeske 4 6 20 Dr. Celina Hatt 77 150 500 Neuter Scooter/ Dr. Peavey 102 75 239 Dr. Kim Kozuma 17 30 50 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages -0- -0- Professional Fees -0- -0- Operations 12,999.30 35,000.00 Equipment -0- -0- Other# -0- -0- Total 12,999.30 35,000.00 *If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 8 Hui Pono Holoholona - Agency Name Subsidized Low Cost Spay/Neuter Clinics - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Walmart Sales 304.80 Volcano Parade Sales 38.46 County Fair Sales 154.34 Paw-blic Affair Hilo High 77.19 Yard Sale 409.40 Donation Boxes 644.05 Donations by Mail 5,806.51 Food Basket Fund 381.14 Walmart Days 377.00 Recycle ARC 32.08 Clinic Checks 4,023.73 HSUS Photo Contest 341.47 Give Aloha Program 652.28 County of Hawaii Grant 5,500 Total 18,748.57 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Continuation of donations and fundraising as we have been doing since our inception. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. None NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 8 Hui Pono Holoholona - Agency Name Subsidized Low Cost Spay/Neuter Clinics - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 8 • Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. ignature of Board President/Chair / Date o .Agency Director Signature of Ex-cutive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 8 55 Innovations Public Charter School Foundation Planting Wellness for our Keiki & Community Innovations Public Charter School Foundation- Agency Name Planting Wellness for our Keiki & Community - Program Name Agency Director: Jennifer Hiro Phone No.: 327-6205 Contact Person: Lee Nelson Phone No.: 756-5492 Mailing Address: 75-5815 Queen Ka'ahumanu Hwy Kailua Kona, HI 96740 Facility/Site Address: 75-5815 Queen Ka'ahumanu Hwy Kailua Kona, HI 96740 Fax No.: (808) 327-6209 Email Address: leenelson.ipcs @konaimage.com Name of Accountant/CPA (include name of firm if applicable): Carbonaro CPA &Associates Phone No.: (808) 968-1002 Mailing Address: P.O. Box 4372 Hilo, Hawaii 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$30,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $0 $0 Agency Mission Statement: Innovations Public Charter School Foundation's mission is to provide facilities and support for Innovations Public Charter School. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 7 Innovations Public Charter School Foundat on - Agency Name Planting Wellness for our Keiki & Community - Program Name Program Description: Planting Wellness with our Keiki and Community is a middle school and community wellness program open to our middle school keiki, their parents and the community. The program will build community gardens through public / private partnerships. Total Budget and Position Count Total Program Budget 30,000 Total Program Position Count 0 Total Agency Budget 240,000 Total Agency Position Count 0 Program Objectives: 1) Innovations Public Charter School Foundation purchased 4.298 acres for a new middle school campus expansion in December 2011. The objective of this program is to make community gardens and a community fitness field on the campus. The fitness field will be used for soccer practices and other community events. The gardens will be supported and eventually fully sustained by the community. The 2012-2013 objective is to get the playfield and garden infrastructure in place, with irrigation, soil, rainbarrels, plants, garden starts, supplies etc. All of the work to plant and maintain the gardens and fitness field will be performed by middle school students, parents, and community volunteers. The garden and fitness field will be on the new Innovations Public Charter School Foundation Middle School Campus which is directly makai of the current Innovations Elementary School. Due to state budget cuts, the Innovations school does not have the funds to support this program. Thus, the foundation is soliciting donations and grants. Every effort will be made to make the gardens self sustaining. Gardens surrounding the classrooms will focus on indigenous, drought tolerant plants. Vegetable and fruit trees will be watered with drip and rain barrel systems. Irrigation systems will be installed and monitored to keep water usage at a minimum. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 7 Program Highlights: (from Fiscal Year 2010-11) 1) During 2009-2011, the Innovations School had a planting wellness with our keiki program on the elementary campus. This project was made possible by community donations and a grant from the Hawaii Department of Health. The elementary school developed fruit and vegetable gardens that continue to supply healthy snacks for the A+ afterschool program and excess fruits and vegetables are sold at school Friday farmer's markets with the proceeds benefitting the garden program. The elementary garden program is now fully sustatined by students and the aftercare program continues to reap the benefits of the wonderful fruits and vegetables. The Innovations Foundation goal is to seek grants and contributions to build community gardens and a community fitness field. Due to a significant decline in state funds, the school does not have the resources to support middle school gardens and a fitness field. Thus, the foundation's goal is to make community gardens and a fitness field that can be enjoyed by both the community and the 160 middle school students. A certified kitchen is currently planned for the middle school, so students will be able to incorporate their fruits and vegetables in the classroom. Garden Instructor, Krista Donalsson, has volunteered to solicit community members to help us plant and maintain the gardens. Kukio chef, James Silva, will donate instructional time in the kitchen. We are so excited. Innovations Public Charter School Foundation has been very successful with community partnerships. Innovations Foundation/School has partnerships with over 50 businesses in the community. All 7th and 8th grade students participate in community mentorship and service projects. Business and community partners that mentor Innovations students on a weekly basis for two to five hours include: Safeway, KWXX 93.7, Waimea Surf Classics. World Core Surf Shop, Kona Bay Books, KB Extreme Bowling, Kona Stories, Bike Works. Hospice of Kona, Memory Lane Thrift Store, Jack's Diving Locker, Intrigue Design Hair Salon, Paws University Dog Training, NPS Kaloko— Honokohau, Miranda's Pets, Hilton Dolphin Quest, See Through Window Tinting, Alii Vet, Keauhou Vet. Donkey Mill Art Center, Cory Foulk Architect, Kona Boys Kayak Rentals, Creative Day Pre-School, Adaptations Produce Distributor, Chris Johnson Kealakehe High School Band Director, Gregg Lupien Architect, Kailua Candy Company, Inter-island Solar Supply, West Hawaii Today, Moo Betta Yogurt Shop, Urs Leuenberger Woodworker, Kealaola Organic Lettuce Farmers, University of the Nations Preschool, Full Life Hawaii Disabillites, Advocats, Holualoa Ukulele Gallery, Michael Inman Photographer, Jenny Solmirin Kealakehe High School Teacher, Joe Danko Photographer, Kona Business Center, Nose for Adventure, Lindsey Kramer Marine Biologist, Robin Fisher Childcare, and Tom Neer Green Building. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 7 Innovations Publlic Charter Schcol Foundation - Agency Name Planting Wellness for our Keiki & Community - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate In-Kind Labor Donations 60000 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 0 Professional Fees 0 Operations 0 Equipment 20000 Other# 40000 Total 60000 * If applicable Please explain in detail on separate sheet Q7�1ec i.7cit14e, co G'e'-i �plrL'S (aC'1 AS J01�f i?�aci- of t�L(S,'.sue, le-a. bar/VS./ 1x460;°+ Suppliec1 Gati /barrow:)s1 ., NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 7 Innovations Publlic Charter School Foundation - Agency Name Planting Wellness for our Keiki & Community - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Bill Healy Foundation 5000 School Donors 10000 USDA 15000 County of Hawaii GIA 30000 Total 60000 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self- sustaining? 2012-2013 will be the start up year for the Innovations Foundation middle school gardens and fitness playfield. Our request is for equipment and other supplies which represent garden / irrigation supplies (i.e.sprinklers, macnut husk, trees, sod, etc.) Proceeds from community donors and in-kind labor donations will sustain the program. We anticipate sustainning the program by fiscal year 2013-2014. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. We have no affiliations with the County of Hawaii. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 7 Innovations Public Charter School Foundation - Agency Name Planting Wellness for our Keiki & Community - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 7 the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. CM^ C c-a_UI f 3 a a o Signature of Board President/Chair Date or Agency Director (11141 113oli2 Signat-e of ,-cutive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 7 56 Island of Hawaii YMCA, The IMPACT: Child & Youth Assets 2012-2013 The Island of Hawaii YMCA - Agency Name IMPACT: Child & Youth Assets 2012-2013 - Program Name Agency Director: Fred Yamashiro Phone No.: 935-3721 Contact Person: Fred Yamashiro Phone No.: 935-3721 Mailing Address: 300 W. Lanikaula Street, Hilo, HI 96720 Facility/Site Address: Hilo program center, 300 W. Lanikaula St., Hilo Kona program center, 77-522 Hamana Place #1106 Kailua-Kona, HI 96740 Fax No.: 935-8414 Email Address: Fred.Yamashiro @gmail.com Name of Accountant/CPA (include name of firm if applicable): Carbonaro CPA & Associates Phone No.: 968-1002 Mailing Address: PO Box 4372 Hilo, HI 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$40,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 11 09-10 10-11 11-12 $20,000 $20,000 $20,000 Agency Mission Statement: MISSION STATEMENT: Aloha Ke Akua - God is Love. "To bring God's Love to children, adults and families of all races and faiths by putting Christian principles into practice through programs that build healthy spirit, mind and body for all". YMCA CORE VALUES: We teach and demonstrate caring respect, responsibility and honesty. YMCA THEME: We build strong kids, strong families, strong communities. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 11 The Island of Hawaii YMCA - Agency Name Impact: Child & Youth Assets 2012 - 2013 - Program Name Program Description: The Island of Hawaii YMCA continued to strengthen its financial and programmatic resources during the 2011-2012 program year. We now estimate our loss for the period of July 1, 2011 to June 30, 2012 to be about$173,000. This is in sharp contrast to recent years when the YMCA loss was about $212,000. Several fundraising activities, as well as membership drives, are contributing to more cash flow; besides grants and gifts. Calendar year 2012 may be the breakthrough year where we begin to have more positive financial balances. Meanwhile, our child and youth programs have continued to stretch beyond their typical activities, by exposing them to learning and cultural experiences they may not have otherwise been exposed to. These experiences are conducted within a supportive social environment where caring and patient adults and young adults are guiding them in a respectful and encouraging manner. The kids might think they are just having some fun, but a lot more is deliberately going on. A significant advance is planned with the introduction of highly respected curriculum packages; one for the preschool and the other for the teens. The preschool's curriculum package is called Creative Curriculum (now in transition to a new name, Teaching Strategies GOLDTM). Its website says it "is seamless. It's research-based. And it's grounded in 38 objectives that are predictors of school success and aligned to state early learning standards. " The teen curriculum is called The Developmental Assets®. Its website describes it as "40 common sense, positive experiences and qualities that help influence choices young people make and help them become caring, responsible, successful adults. Because of its basis in youth development, resiliency, and prevention research and its proven effectiveness, the Developmental Assets framework has become one of the most widely used approach to positive youth development in the United States." Such curriculum advances also benefit the faculty since they get exposed to tested and refined materials, moving the kids beyond lessons they are already familiar with and also challenging their commitment to a range of values. The younger children are located at our preschool and various school sites for afterschool care. They are provided with a structured and safe environment where they can enjoy enrichment and socially positive activities. The preschool, especially, prepare the young ones for later social and academic success with basic school day routines, etiquette, and creative activities. The teens in Hilo start their afternoons with homework time. Some of the homework subject matter can be challenging so a close relationship is NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 11 developing with the University of Hawaii at Hilo, and other institutions, for college students to serve as volunteer interns to tutor kids as needed, especially in math and chemistry. The book learning then gets expanded after that time period to hands-on activities that can enrich their theoretical knowledge. In the back of the Hilo YMCA building is a vegetable and herb garden where the teens have been producing basketfuls of produce; beans, beets, lettuce, chili pepper, cabbage, basil, tomatoes, eggplant, strawberry, and more. If prodded enough, at least some of them will reluctantly reveal that they have learned about chemical fertilizer formulations like 10-30-10, what those chemical percentages refer to, and how those chemicals affect roots, green leaves, or fruit/flower. A kid may not know what mountain (Mauna Loa) he is standing on, but he has learned the difference between sandy and loamy soil. Some girls may shyly comment that they learned that the reason they removed the flower portion of the basil plant was to redirect the nutrients to other parts of the plant. These comments come from kids who mostly do not have a garden at home. All these topics may have remained just boring textbook theories until they had a chance to get their hands dirty and actually apply the theories. A further development planned for the near future is to have an entrepreneurial aspect by having the teens start seedlings that could be sold. Some of the fresh vegetables from the garden are brought into the YMCA certified kitchen for the teens to use in their culinary curriculum; where they are trained by a retired DOE Home Economics teacher. They have made delicious tossed salads for YMCA events. Other culinary specialties they have created have included spaghetti, breads, spam musubi, chicken cordon bleu, lasagna and baked goods. One girl said that she didn't cook before and now she occasionally helps with meals at home. The students have learned food safety, kitchen safety, basic nutrition, food service skills, cooking skills; and entrepreneurial matters such as product appearance, standardized sizes and customer appeal. Combining their interest in cars with entrepreneurial lessons, the teens have a car detailing activity; where they offer an informal detailing business for a few dollars per vehicle. They wash, dry and clean a vehicle. They have understood that a good job results in a happy and returning customer. A scratched vehicle means loss of income and a poor business reputation. The positive or negative consequence of their work quality is realized quickly. It is not vaguely theoretical. It will literally be felt in their treasury. Important messages and themes from one afterschool program of the Y can have deep impact on its other afterschool programs. Since the afterschool program at Keaukaha School is near the ocean and surrounded by Native Hawaiian homesteaders, one outstanding activity they have is to go to the shoreline and have a cultural practitioner demonstrate the traditional skills, knowledge, values and attitudes of Native Hawaiians when approaching the ocean shore for net fishing. The educational outing might begin with very serious practical lessons such as to never face away from the approaching unpredictable waves. Other lessons would cover the traditional protocol in expressing humble gratitude to the bounty of the sea and the avoidance of wasteful taking. These NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 11 ancient lessons tie in wonderfully with modern concepts such as nature conservation, ecological balance and sustainability. These basic practices get transplanted into other activities of the Y's various afterschool programs; respect for the planet, respect for life, sharing resources, honoring the wisdom from the past generations and learning from each others' cultures. Plans are forming for additional activities; such as having a computer lab and learning how to use sewing machines. These all follow one of the underlying educational themes: to learn, enjoy and apply practical skills that can enrich their lives in both emotional and economic ways. Many of our students are economically disadvantaged and they are learning ways to increase their education as well as home income, without realizing it; they are having too much fun. Total Budget and Position Count Total Program Budget $659,174 Total Program Position Count 38 Total Agency Budget $1,003,689 Total Agency Position Count 50 Program Objectives: 1) Collaborate activities during the program year with the Hawaii Island United Way, Boys and Girls Club, Queen Liliuokalani Children's Center and other programs. 2) Receive evaluations by the end of the fiscal year that at least 75% of responding parents in after school programs will express being satisfied with the program. 3) Receive evaluations by the end of the fiscal year that at least 75% of responding children in after school programs will express being satisfied with the program. 4) Determine by the end of the fiscal year that at least 75% of responding children in after school programs will agree, or strongly agree, that they are expected to try harder and do their best. 5) Determine by the end of the fiscal year that at least 75% of responding children in summer day camp will agree, or strongly agree, that the Y activities help them to learn how to be a leader. Program Highlights: (from Fiscal Year 2010-11) NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 11 1) Collaborated with the Hawaii Island United Way by participating with other nonprofits in the Hui sessions that meet monthly on the first thursdays to learn about common concerns, such as marketing. 2) During the Summer of 2011, a tour was done around the island of Hawaii, using the YMCA's bus, with the leaders of the Boys and Girls Club, the YWCA, Girl Scouts, Boy Scouts, and United Way. Visits were made to resources such as the Girl Scouts campsite near Pohakuloa along the Saddle Road, the YMCA aquatic center in Kawaihae, and the Boy Scouts camp in Honokaia. The leaders agreed that their attitude should not be about competing with each other but about sharing resources for the good of the Big Island community. 3) Collaborated with the Boys and Girls Club by participating in Friendship Day, a twice a year games and snack fun day. 4) Collaborated with the Queen Liliuokalani Children's Center in the Ala Kai Malama teen leadership and conflict resolution training. 5) In a survey, 85% of responding parents in Keaukaha A+ (YMCA's biggest afterschool site) said they "strongly agreed"AND 15% "agreed" about being satisfied with the program; with 0% disagreeing. 6) Served over 400 children in the summer and intersession (out-of-school) programs in Hilo and Kona. 7) Served over 230 children in the 9 month after school programs in Hilo and Kona. 8) Served over 800 children island wide. 9) Served children at the Hilo program center who lived as far away as the communities of Pahoa and Laupahoehoe. 10) Major events and activities during the year were: a) Overnighters held three nights during the year; six dances held during the year; five camps held at Kawaihae during the year; ministore held twice a week for snacks, ukulele lessons held twice a week all year; a small band was formed and started practicing; some staff participated in YMCA's float/marching unit in Hilo Christmas parade; and up to 15 cars detailed. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 11 The Island of Hawaii YMCA - Agency Name Impact: Child & Youth Assets 2012 - 2013 - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Total Served 1,850 2000 2,200 Hilo YMCA Branch 1,175 1200 1,300 Kona YMCA Branch 675 800 900 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages see Schedule A see Schedule B see Schedule C Professional Fees Operations Equipment Other# Total * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 11 The Island of Hawaii YMCA - Agency Name Impact: Child & Youth Assets 2012 - 2013 - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate see see see Schedule A Schedule B Schedule C Total *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The YMCA has four major sources of revenues: membership/program fees, fundraising activities, gifts, and grants. Ideally, membership/program fees (and member gifts) should be our main source of revenue. However, our membership list is very small for a YMCA of our size in this demographic area; so there has been an over-reliance on the other sources. A large, strong and supportive membership base is the fundamental goal to attain self-sustaining status. Several different membership recruiting promotions and discounts are being developed to make membership more attractive. We optimistically plan to achieve a minimum sustainable membership size by the end of 2012. Simultaneously, we will continue to have fundraising activities, welcome gifts and apply for grants. Efforts will also be made to reduce expenses and to increase productivity with our limited resources. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 11 Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. (none) NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 11 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. ga WL• h‘)w. •--/ / i/2 Signature of Board President/Chair Date or Agency Director / Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 11 57 Ka Hale 0 Na Keiki Inc Families at Risk Ka Hale 0 Na Keiki Inc- Agency Name Families-At-Risk- Program Name Agency Director: Kathy Oshiro Phone No.: 808 -775 - 9870 Contact Person: Paula Seguerre Phone No.: 808 - 775 - 9870 Mailing Address: 45-3668 Honokaa-Waipio Rd Honokaa HI 96727 Facility/Site Address: SAME Fax No.: 808-775-9870 Email Address: 808paulaj @gmail.com Name of Accountant/CPA (include name of firm if applicable): Andrade Accounting Services Phone No.: 808-775-1319 • Mailing Address: 46-1068 Kinimaka Rd Honokaa HI, 96727 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $10,000.00 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $6,000.00 $10,000.00 $8,000.00 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1of10 Agency Mission Statement: • At Ka Hale 0 Na Keiki it is our mission to help children develop a lifelong love of learning through a program that encourages freedom, individualism, and creativity. Our carefully prepared environment provides children with an opportunity to explore their surroundings, challenge their thoughts, and enjoy and love the people and world around them. Through a positive interaction among the children's developmental characteristics, their school, practices, family, and community, children will be ready to have successful learning experiences that will last throughout their lifetime. Above all, our children come first. • • • NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 10 Ka Hale 0 Na Keiki Preschool - Agency Name • Families-At-Risk- Program Name Program Description: The Families-At-Risk Project allows our school to remain open between 2:30 and 5:30 pm daily, year round (including Summers and holidays), providing a safe, stimulating, and caring environment for children ages 24 months to 6 years. This frees parents to work at their jobs, and allows the unemployed to seek work and pursue training and educational opportunities, particularly working parents transitioning from welfare assistance. We serve the working poor. These families are likely to be cut off from the mainstream community because of poverty, racism, lack of education, unemployment, and/or the inability to timely access community and human services. They are therefore at risk of being unable to take care of their basic needs and those of their nuclear family. It is important to understand that our school's positive stimulation of children's brains during these critical first years lays the foundation for the child's future ability to learn, develop language skills, and interact with others. While under our trained, caring, and gentle care, children at risk learn self confidence, initiative, self-worth, and independent thinking. Our teachers, all trained in Early Childhood Education (ECE), understand child development and excite our children about learning, as well as provide them, and their families, with basic health and nutritional information and referrals. We promote positive social behavior and conflict resolution, as well as actively engage parents in their children's care and education. Drug abuse is our worst nightmare here on the Hamakua Coast. We are the anti-drug. Numerous studies have shown that participation in a quality ECE program can actually prevent illegal drug usage in the future, because we teach these children, at a very early age, how to appropriately handle conflict resolution as well as help them attain good self esteem. If we are to break the cycle of drug abuse in our community, we must begin taking preventative action now, and intervene at the preschool-age level. Our community, our island, and our state also benefit, as it is estimated that for every $1 invested in high-quality ECE programs the public will save $7 in costs like remedial education, welfare, and incarceration. Children who attend high quality ECE programs are more successful in later life and more productive than their peers who did not attend. Studies are showing that children with access to quality programs demonstrate higher I.Q.'s, High School graduation rates, and success than their peers. Most preschools are not open more than eight hours per day because a second qualified teaching staff is required; and, such a service is just not economically NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3of10 feasible. Ka Hale 0 Na keiki is not "just another preschool", but a community organization that serves and meets multiple needs for the people of the entire area. With literally no other preschool available in our isolated area, parents Would have no where to place their child, except perhaps, in front of a neighbor's TV, if our Families-At-Risk Project was not available. And, obviously, our Families-At-Risk Project benefits our parents, as well as our children. Our low- income parents, leaving welfare rolls and entering the workforce, become more economically self-sufficient because they have been given access to reliable, quality care for their children. It is imperative, therefore, that we remain open at least 10 hours a day, and operate year round; otherwise, parents would have no where to send their young children for quality care and education. We agree that private funds are a key to our success, but those funds are very limited. Therefore, we also need additional public support in order to help these young children and their families towards a successful, productive future. We need the County's continuing financial support until financial stability is realized. • Our community understands and acknowledges the scarcity of County funds to non-profits, and we sympathize with the Council's difficult budgetary task. We are very grateful to the financial support we have received in the past from our County and truly believe that the County's continuing investment now in the Families-At-Risk Project will save the County ten-fold in future rehabilitation costs. In this time of Recession, the focus for all of us must be helping our keiki, for they are our future. No time has this belief been more critical for now. Total Budget and Position Count Total Program Budget 80,957 Total Program Position Count 7 Total Agency Budget 283,350 Total Agency Position Count 7 Program Objectives: 1) Make care and educational services available to at-risk families and their children between the hours of 2:30 and 5:30 pm daily. 2) Provide high-quality care and educational services to children of at-risk families of the under-serviced Hamakua Coast. 3) Provide monthly scholarship/tuition assistance to at-risk families. 4) Pursue other funding sources for the Families-At-Risk Project, to insure that the Project, and the school, will prevail. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 • Page 4 of 10 . 5) Maintain a developmentally appropriate learning environment among all students, ensuring progress in social, emotional, cognitive, language, and physical development. 6) Increase the parenting skills, and the understanding of the developmental and educational needs of children of the at-risk parents we serve. 7) Recognize the need for, and provide referral services for children of at-risk families who may need treatment for known or suspected health, psychological or developmental problems. 1) 8) Have the Families-At-Risk Program become financially self- sufficient, no longer a financial drain on the Day Program. Program Highlights: (from Fiscal Year 2010-11) 1) Remained open for the at-risk families until 5:30 pm daily, including during monthly holidays, holiday breaks, and Summer. 2) Provided a developmentally appropriate, high-quality childcare and educational facility to the working poor of the Hamakua Coast. 3) Obtained National Re-Accreditation, insuring that we are providing the best available care and education to our at-risk children, plus allowing us to obtain additional income from the State. 4) Provided seven jobs in our local community, in order to operate the Families-At-Risk Project. 5) Referred one at-risk children, and their families, to special services counseling, to meet their special needs, as identified by our teaching staff. 6) Offered scholarship/tuition assistance to thirty-one families using the Families-At-Risk Project. 7) Succeeded in keeping our budget for the Project low, within reason, and affordable to the families we serve while being able to increase our services to them. 8) Provided an authorized accredited preschool environment for two college students in order for them to fulfill their "lab" or student teaching requirements. 9) Despite State DHS Director Koller's budget cuts to the PRESCHOOL OPEN DOORS, CHILD CARE CONNECTIONS, and FIRST-TO-WORK programs, we were able to remain open and provide safe and healthy enrichment activities for children and their families, by making critical budgetary cuts, including lay offs and wage cuts. • NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 10 Ka Hale 0 Na Keiki Preschool - Agency Name Families-At-Risk - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Enrollment 32 33 36 Children enrolled 2:00-5:30 31 33 35 Families-At-Risk Program Families receiving financial 31 33 35 assistance from Ka Hale 0 Na Keiki for the Families-At-Risk Program • *If applicable • Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 38,700 44,467 . 42,857 Professional Fees 2,600 1,493 1,771 Operations • 12,800 17,606 35,729 Equipment 5,800 3,600 • 600 Other# 3,600 2,434 0 Total 63,500 69,600 80,957 * If applicable #Please explain in detail on separate sheet • NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6ofl0 Ka Hale 0 Na Keiki Preschool - Agency Name • Families-At-Risk - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Payment from Families-At-Risk 3,660 4,000 6,000 Program (family pmt) Donations and Fundraisers 6,940 3,400 5,057 County of Hawaii Grant 10,000 12,000 10,000 Young Bros. Grant 1,000 1,000 0 Friends of Hawaii Charities 2,500 2,500 2,500 Wilcox Trust 6,500 6,500 7,000 Hard Foundation 2,000 1,200 1,200 Mclnerny Foundation 11,900 14,600 14,000 Liberty Gives Foundation 10,000 2,500 2,500 In-Kind Labor and Materials 7,500 20,000 24,000 Rotary Club 1,500 1,500 1,000 Day Program payment from 0 0 0 families' portion allocated to Families-At-Risk Program Castle Foundation Grant 0 0 7,700 Total 63,500 69,200 80,957 If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Our absolute goal is to be financially independent of annual grants. With optimism, along with our State government's hopefully renewed interest in providing funds for Early Childhood Education and President Obama's ARRA monies for assistance to needy famliies, we hope to be financially solvent, and without need for continued County grant funds, within the next four years. • Recent drastic cuts in State funding for ECE supplements to families have made it impossible that our parents pay additional fees for our Families-At-Risk Project. Therefore, a temporary, one year increase in County funds assistance is critical for the survival of our Project. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 10 It must be remembered that our program is one that we were told "could not be done". We were told that our isolated community did not have the economic base to afford an early childhood center, and that our area could not provide the qualified teaching staff to run such a program. We are simply asking the County for their continued support for a few more years to help these children who are in desperate need. We have increased parent involvement as well as the number of fundraisers per year. Although the economy is down, our small community always supports.our efforts; be it buying cinnamon bread or volunteering to build and repair our facility. We have begun constructing an additional hale in order to house more children and are currently working towards adding a toddler room to our facility. Increasing our capacity potential is expected to generate increased tuition income for our Project. • In this time of recession, the focus for all of us must be helping our keiki, for they are our future. No time has this belief been more critical then now. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. None NONPROFIT GRANT APPLICATION • FISCAL YEAR 2012-13 Page 8 of 10 • Ka Hale 0 Na Keiki Preschool - Agency Name Families-At-Risk - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public • • according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of • the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing.of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 10 • 4* • • Any funds unused by June 30, 2013 must be returned to the County of Hawaii . within 30 days (July 30, 2013). Failure to return these funds in a timely manner . will impact-the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. • Signat of Board President/Chair Date or Agency Director • • / ` Signature of Executive Director Date • • UNSIGNED PROPOSALS WILL NOT.BE ACCEPTED! • • • • • • • • NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 • Page/0 oflO • 58 Ka 'Ohana 0 Honu'apo Honu'apo Park Programs 2012-2013 KA 'OHANA 0 HONU'APO- Agency Name HONU'APO PARK PROGRAMS 2012-2013- Program Name Agency Director: Lehua Lopez-Mau Phone No.: 929- 9891 Contact Person: Lehua Lopez-Mau Phone No.: 929- 9891 Mailing Address: PO Box 903 Na'alehu, HI 96772 Facility/Site Address: Honu'apo Park Na'alehu, HI 96772 Fax No.: None Email Address: Iehualz @yahoo.com Name of Accountant/CPA (include name of firm if applicable): Ronald Hawkes Phone No.: 939-7392 Mailing Address: PO Box 377633, Ocean View, HI 96737 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$22,740 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $0 $0 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 9 Agency Mission Statement: Ka 'Ghana 0 Honu'apo's (KOOH) mission is to "care for, restore, and protect the natural and cultural resources of the Honu'apo area." NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 9 KA 'OHANA 0 HONU'APO - Agency Name HONU'APO PARK PROGRAM 2012-2013- Program Name Program Description: Ka 'Ohana 0 Honu'apo's Honu'apo Park Program is a year-long series of events at Honu'apo Park. From July, 2012 to June, 2013, we are hosting 4 different "Sunday in the Park" events that will be held on Sundays from 1:00 pm to 4:00 pm at Honu'apo Park. Dates include: Sunday, August 19th, "Marine Science Sunday," (marine science demonstrations by volunteer scientists), Sunday, October 7th, "Ukulele Contest," Sunday, February 24, 2013, "Makahiki Games" (Hawaiian games demonstrations and contests), Sunday, May 19th, Na Mea Hawai'i, (Hawaiian crafts and hula demonstrations). Attendance is anticipated at up to 400 park visitors at each event. Keiki Workshops will be coordinated with students from local Boys and Girls Clubs and will be scheduled for August (before school starts), and during the fall and spring breaks. Keiki Workshops include 2 age-appropriate class demonstrations and story-telling in Hawaiian culture, Honu'apo history, and marine science information; the classes begin at 9:00 am, students have snacks during a mid-morning break and a lunch at 12:30 pm, and are allowed to play in the park until leave time at approximately 1:30 pm. Each workshop can accommodate up to 25 students and 12 parents and volunteers with free bus service to and from the park and free lunch and snacks. Total Budget and Position Count Total Program Budget $22,740 Total Program Position Count 1 Total Agency Budget $63,704 Total Agency Position Count 3 Program Objectives: 1) Educate at least 75 Ka'u elementary, middle, and high school students about the cultural, historical, and environmental resources and values of the Honu'apo area in age-appropriate workshops at Honu'apo Park, and involve at least 36arents and volunteers; 2) Provide educational and recreational events at Honu'apo Park for local families, visitors, and tourists by hosting 4 "Sunday in the Park" events, for up to 500 people per event. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 9 Program Highlights: (from Fiscal Year 2010-11) 1) Highlights for 2010-11, 1) Completion (after 2 years of work) of the Honu'apo Wetlands Habitat Restoration Plan; 2) "Honu'apo Ho'olaule'a"-- an all-day event held on Setptember 5, 2010, with music and hula, cultural demonstrations, 30+ sales and informational booths, contests, and fundraisers that attracted more than 3,000 people to the park; 3) 3 Keiki Workshops held at Honu'apo Park with more than 60 children and 40 parents and volunteers from Ka'u, 4) 2 community meetings to finalize and present the Wetlands Habitat Restoration Plan that attracted more than 50 local residents; and 5) "Sunday in the Park—Hawaiian Music Jam"--a family event held on Oct. 9, 2011, including Keoki Kahumoku from the Center for Hawaiian Music Studies who led the audience in an afternoon of Hawaiian music, more than 330 people attended. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 9 KA 'OHANA 0 HONU'APO - Agency Name HONU'APO PARK PROGRAM 2012-2013 - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Total Park visitors at approimately 84,000 96,000 108,000 7,000 individual visits per month Total attendance at all KOOH 3,152 1,130 2,100 programs in Honu'apo Park *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 0 0 0 Professional Fees $16,000 $10,000 $14,000 Operations $15,615 $4,115 $5,740 Equipment $1,000 $1,500 $3,000 Other# Total $32,615 $15,615 $22,740 *If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 9 KA 'OHANA 0 HONU'APO - Agency Name HONU'APO PARK PROGRAMS - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Queen Lili'u'okalani Chldrn Center $3,000 $3,000 $3,000 County CPEP $10,000 0 0 Total $13,000 $3,000 $3,000 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Ka 'Ohana 0 Honu'apo intends to charge attendance fees, booth fees, parking fees, and other event fees in the coming years to finance family events at Honu'apo Park. KOOH also has an on-going relationship with the Queen Lili'u'okalani Children's Center who pays for some of our food, water, and transportation/equipment expenses when we host events that provide activities for Hawaiian children in Ka'u. We also intend to sell t-shirts, food items, water bottles, and other items at our events in the future to help pay for expenses. If Bill 128 Funding for Maintenance on 2% Land Acquisitions passes on the November ballot this year, KOOH will eventually (by 2014) be able to apply for program funds for Honu'apo Park as the county originally contributed $500,000 toward the purchase of Honu'apo lands in 2006 to create Honu'apo Park NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 9 Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Ka 'Ohana 0 Honu'apo has a formal Memorandum of Understanding with the county's Parks and Recreation Department to assist in the improvement, maintenance, and programs of Honu'apo Park and we work closely with our P&R county liaison, Dennis Riordan, park supervisor, who also volunteers for our programs. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 9 KA 'OHANA 0 HONU'APO - Agency Name HONU'APO PARK PROGRAMS - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135—2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 9 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. 1/62_7 .2 0 a Signature of Bo- . -resident/Chair ate or Agency Direct, rub.-#.40; 7A-7A-0/2 Sig u of Exec ti a irff tor, Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 6 59 Keaukaha One Youth Development Youth Development Keauhaka One Youth Development- Agency Name Youth Development- Program Name Agency Director: Keahi Warfield Phone No.: 895-8666 Contact Person: Keahi Warfield Phone No.: 895-8666 Mailing Address: 101 Aupuni Street Hilo, Hawaii 9672 Facility/Site Address: Bayfront Hilo, Hawaii 96720 Fax No.: none Email Address: keahi@kaumeke.org Name of Accountant/CPA (include name of firm if applicable): Valerie Peralto, Peralto & Co. CPA Phone No.: 961-3462 Mailing Address: 180 Kinoole Street, Hilo, Hawaii 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $10,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $10,000 $10,000 $8,000 Agency Mission Statement: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 9 General scope of the activities for Keaukaha One Youth Development is to provide native cultural opportunities for local youth to reconnect them with the historic ocean experience here in Hawaii. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 9 Keaukaha One Youth Development - Agency Name Youth Development- Program Name Program Description: The specific purpose is to continue to reconnect children in the County of Hawaii with Hawaiian cultural heritage relating to ocean activities. Total Budget and Position Count Total Program Budget $10,000 Total Program Position Count 0 Total Agency Budget $10,000 Total Agency Position Count 0 Program Objectives: 1) Stresses physical fitness; 2) Provides instruftional use and maintenance of canoe 3) Strives for perfection of swimming skills 4) Provides training in physical fitness at Keaukaha Gym 5) Provides the use of Hawaiian canoes and volunteer coaching to mior children 6) Strives to coordinate these activites with local schools. Program Highlights: (from Fiscal Year 2010-11) 1) Keaukaha Canoe Club (KCC) opens the youth regatta season for another year at Palekai and Hilo One locations, working with youth ages 6 to 18. Keaukaha One Youth Development (KOYD) helps in supporting this program for equipment such as paddles, sand paper, expoxy and gas costs to maintain equipment for paddling. Students were able to get involved with re-varnishing iako, paddles and patching minor dings on canoes. 2) July/August 2011 - Girls 12, Boys 13, and Boys 14 qualified for State Championships held on Maui. At this event, KCC entered into the A division with a total of 6 crews, 3 of which were represented by youth paddlers. KOYD assisted in providing for plane fares, food and ground transportation need for youth paddlers. Our 13 boys won the title of State NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 9 Champions with 14 total undefeated races, including the state championship. 3) September 2011 -Boys 13 were recognized by Mayor Billy Kenoi for their hard work and continuous effort in bringing the State Championship home to Hilo. The boys and their coaches were honored with plaques as a reminder of their achievements. This success could not have been accomplished without the support of KOYD. 4) October 2011 - KOYD creates a new vision for a 21st century after-school program entitled Revealing Individual Strength Excellence (RISE) to help youths ages 12-18 in discovering their individual strengths and passions for excellence in future academic and career endeavors. Through the support of KOYD for supplies, one of the first projects conducted under RISE included the construction of paddles which were cut, sanded and glued by students. These paddles were individualized by students' artwork, which was drawn and then varnished and exhibited at the Imiloa Astronomy Center in Hilo. KOYD envisions RISE as the next step in providing for youth options that will foster positive well-being in the Keaukaha community. RISE is currently in the process of program development for Fall 2012. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 9 Keaukaha One Youth Development - Agency Name Youth Development - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate $10,000 $8,000 $10,000 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages Professional Fees $1 ,000 $1,000 Operations $4,500 $4,000 Equipment $5,500 $3,000 $2,000 Other# $7,000 Total $10,000 $8,000 $10,000 * If applicable Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 9 KEAUHAKA ONE YOUTH DEVELOPMENT - Agency Name YOUTH DEVELOPMENT - Program Name Program Expenditures Explanation for 2012-13 Equipment: Canoes $2,000 Other: Gas expenses $1 ,000 Bus rental $2,000 State Meet $4,000 $7,000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5a of 9 Keauaha One Youth Development - Agency Name Youth Development - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate County of Hawaii $10,000.00 $8,000 $10,000 David Lipp $2,000 Anonymous $20 Total $10,000 $10,020 $10,000 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The program continues to rely on contributions from the public and private sector in conjunction with fund-raising activities. We strive for community support to spread the word of the accomplishments of the youth, to garner interest from the community at large and benefactors to subsidize our cause of cultural development and physical well being. Our aspiration is to become a self- sustaining program; however, with the terrible economy, particularly in the Keaukaha/Pana'ewa area of Hilo, this has become increasingingly difficult. We continue to try our best. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 9 Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawai`i. None. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 9 Keaukaha One Youth Development - Agency Name Youth Development - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 9 o V Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. //30 Signature of Board resident/Chair Date or Agency Director CL-la /33/L./- Signature of Execut le Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 9 60 Kohala Animal Relocation and Education Service (KARES) Canine Spay and Neuter Kohala Animal Relocation and Education Service (KARES)- Agency Name Canine Spay and Neuter- Program Name Agency Director: Deborah Cravatta, President& Founder Phone No.: 808-333-6299 Contact Person: Deborah Cravatta, President Phone No.: 808-333-6299 Mailing Address: P.O.Box 44670 Kamuela, Hawaii 96743 Facility/Site Address: 59-241 Kipa Mai Place Kamuela, Hawaii 96743 Fax No.: 808-883-8479 Email Address: pets @kohalaanimal.org Name of AccountantlCPA (include name of firm if applicable): Frederic N. Pigott, Tax Associates Phone No.: 808-331-8555 Mailing Address: 75-5656 Kuakini Highway, Suite 302 Kailua-Kona, Hawai'i 96740 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$40,800 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 12 $ 0 $ 0 $ 0 Agency Mission Statement: KARES mission statement: A widespread interest to establish a "no kill" philosophy organization in North Kohala led to the creation of KARES. A primary focus of KARES is community education and relocation of healthy, adoptable animals. Bringing knowledge and awareness to the causes of overpopulation and providing alternative solutions is the key to changing the attitudes towards dealing with the animal overpopulation problem. Hawai'i's environment helps perpetuate the rapid population explosion with year-round cat and dog reproduction and abundant sources of food such as rats, chickens, fruits and vegetables to sustain feral populations. KARES provides assistance in the form of cat and dog food to low income families and to homeless people living on beaches and in forests who might otherwise surrender their companion animals to shelters because they cannot afford to feed them. KARES works with veterinarians to offer low-cost spay/neuter programs for low-income residents, establishs trap/neuter/release and maintain programs (TNRM) with feeding stations for free-roaming cats, and provides a networking of volunteers to foster cats and dogs until they are safely adopted. KARES is dedicated to defining these programs for other communities around the island to follow. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 12 Kohala Animal Relocation and Education Service (KARES) - Agency Name Canine Spay and Neuter- Program Name Program Description: - Program Summary Statement: Spay or neuter of 330 companion dogs in 2012 that are owned by low- income or economically troubled families who cannot afford these services. - Introduction and Overview: While trap, spay and neuter, return and maintain (TNRM) of colonies of sterized animals is proving to be a humane way of managing the feral cat population on Hawai'i Island, the stray dog population is increasing and may soon rival the overpopulation of cats leading to abuse, starvation and disease, destruction of personal property, live stock and family pets, lingering of dogs in shelter cages and euthanasia of many healthy, previously owned but lost or abandoned pet dogs. The single contributory factor to this plight is failure of pet owners to appreciate the importance of spay and neuter(S/N). Surgical sterilization by S/N is the most effective solution to prevent breeding, wandering and fighting. The KARES project will continue to take a positive step to impact the welfare of companion dogs with homes and prevent the unfortunate development of generations of feral dogs by implementing a "grass roots" effort to educate our island residents of the necessity to S/N their pet dogs and make dog S/N services accessible for families who need financial assistance for these S/N surgeries. Our economically-troubled families and our elderly folks frequently cannot afford to feed their families and certainly cannot afford to purchase spay/neuter vouchers from the Hawai'i Island Humane Society (HIHS). Veterinarians only make available a few appointments per month for these HIHS S/N vouchers because they earn so little money from the vouchers and therefore dogs often are actively breeding before an appointment occurs. The families on Hawai'i Island favor larger breeds of dogs and most families have several dogs. These larger dog breeds can have up to 8 to 12 puppies in a litter. - KARES Helping to Prevent Overpopulation of Dogs and Cats: Since June 2009 and to date KARES has sponsored many spay and neuter clinics and have sterilized almost 500 dogs, 40 owned cats and over 700 feral NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 12 cats. KARES has paid for the S/N of all of the feral cats and in-full or in-part for most of the cats and dogs belonging to families that could not afford these services. Monies for these programs were raised through private donations and grants to KARES. A recent grant award of$10,000 received in September 2011 provided the opportunity to substantially increase our S/N Program to allow increased efforts targeted for S/N of dogs, especially the medium to large breed dogs favored by the Hawai'i Island residents — American Pit Bulls, Rottweilers, Heelers and mixed breeds (poi dogs)with pit bull lineage and other hunting and working dog breeds. In the past two months since receipt of these monies, a total of 95 dogs from economically-troubled families have had spay/neuter surgeries. We have worked hard to negotiate reduced prices from local veterinarians to perform these services supported by KARES. - Canine Spay & Neuter Program Description: KARES plans to continue the momentum generated by our ongoing Canine S/N Program to make available low-cost and free S/N surgeries to families with companion dogs, and as well to sterilize rescued, free-roaming dogs. KARES will target pet owners with dogs of all sizes who cannot afford these surgeries and will dedicate special effort to reaching medium to large breed dogs that have large litters. KARES proposes to spay or neuter a total of 600 dogs during 2012 (January 1 to December 31, 2012). Our Hawai'i County Grant application request is for$40,800 to cover the cost of surgeries for 55% of all dogs to be sterilized under the Canine S/N Program; thus for 330 dogs . Our efforts will spare families and our community of the burden of care of a minimum 1300 or more dogs that can occur from the first generation of breeding of the 330 dogs if they would not be surgically sterilized. The veterinary costs for S/N are as follows: 150 dogs weighing more than 30 lb. 75 females @ $155 = $ 11,625 75 males @ $125 = $ 9,375 180 dogs weighing 29 lb or less. 90 females @ $120 = $10,800 90 males @ $100 = $ 9,000 Total cost for 330 dogs = $40,800 Note: In the event of female dogs being "in heat" or pregnant, the cost would be higher and thus less female or male dogs will be altered This Canine S/N Program will benefit the people of Hawai'i by 1) making available spay/neuter services for their pets, an expense that they cannot afford 2) allowing them to keep the pets that they have without the additional economic NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 12 burden of puppy litters for which they cannot cover the costs of food and veterinary care, and 3) will reduce the number of free-roaming (feral) dogs which cause damage to property and live stock and could cause potential health risks due to bites and the spread of disease. Total Budget and Position Count Total Program Budget $72,000 Total Program Position Count 10 projected for FY 2012 Total Agency Budget $105,000 Total Agency Position Count 30 projected for FY 2012 Program Objectives: 1) Provide assistance to economically-troubled families and elderly people living on modest, fixed incomes by making available low cost or free spay/neuter surgeries for their pet dogs. 2) To surgically sterilize a total of 330 companion or rescued dogs under the auspices of the County of Hawaii grant monies. This will represent 55% of the total of 600 dog surgeries projected to be accomplished by KARES in 2012. 3) Assure spay/neuter of rescued or free-roaming dogs to implement population control and prevent the creation of an over-population of dogs similar to that of free-roaming cats. 4) Reduce the damage to property, livestock and family pets caused by free- roaming (stray and feral) dogs fighting or foraging for food. 5) To educate our community residents of the importance of spay and neuter as a humane way to control the number of unwanted/unplanned litters of puppies. 6) To reduce the number of deaths by euthanasia of otherwise healthy but released or abandoned stray dogs who are unwanted, unadoptable or for whom there is no available safe temporary shelter. Program Highlights: (from Fiscal Year 2010-11) 1) In fiscal year 2011, KARES accomplished spay or neuter of 356 dogs from low income island families paying in full for these surgeries from funds NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 12 raised through grants, private donations and fundraisers. This represented a 300% increase in dog sterilizations sponsored by KARES as compared to fiscal year 2010. 2) Almost 70% of the monies to pay for S/N of the 356 dogs was raised by grants from Mainland USA foundations& corporations that were willing to help KARES and the people of Hawaii Island with the Canine S/N Program. 3) KARES negotiated discounted spay/neuter fees with five veterinary clinics therefore reducing the costs for KARES-subsidized surgeries. 4) The Canine S/N Program assured emotional stability to economicaly- distressed families who could not afford the surgeries and who would have had to give up the dogs or litters. 5) Prevented the birth of at least 720 to 1400 puppies (average of 4 to 8 puppies per dog) that could have been produced by reproductions from only half of the sterilized animals. 6) Prevented surrender and euhaniasia of unwanted/unplanned litters of puppies or the possible release of these animals to the wild (and their starvation, illness and death) which would then contribute to the next generation of feral dogs. 7) KARES now has a long waiting list of families wishing assistance with spay and neuter.....this we believe is a testimony to the success of our program to help the people of Hawaii and their cherished pets. 8) NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 12 Kohala Animal Relocation and Education Service (KARES) - Agency Name Canine Spay and Neuter - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Canine spay & neuter surgeries 100 Budgeted: 600 for 2012 performed 242 for 2011 Actual: 356 Total S/N surgeries 100 356 600 planned *If applicable Prouram Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages Professional Fees Operations $5,832 $11,500 Equipment 500 500 Other* $10,000 $60,000 spay/neuter spay/neuter Total $16,632 Actual 2011: $72,000 $44,660 Explanation provided on separate sheet *If applicable NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 12 Kohala Animal Relocation & Education Services (KARES) 2011 Canine Spay & Neuter Program Expenditures Explanation ($44,660) Salaries/wages $0 Administration $750 Bookkeeping/tax preparation Professional license fees Liability insurance Utilities $222 Water and Electric Medical $38,650 Canine spay/neuter surgery/veterinary fees (356 dogs) Emergency veterinary visits/follow-up visits after spay/neuter Medications (antiparasitic meds, antibiotics, pain meds) Operations $1,836 Telephone: owner contacts&follow-up, S/N clinic appointments Auto: inclusive of transport of animals, volunteers efforts Mailing costs Advertisement/promotions for spay& neuter clinics Equipment $1,131 Animal kennels&carriers; humane traps and fencing Maintenance&repair:traps, carriers, fencing Computers and printers Supplies $906 Disposable supplies for KARES sponsored S/N clinics (syringes, towels, gauze, saline infusion) Temporary provision of animal food/animal sanitary supplies; leashes & collars Printing paper& ink cartridges; office supplies Fundraising $1,165 Annual Fur Ball charity event costs, ads for dog washes, garage &bake sales Total: Canine Spay & Neuter Program FY 2011 $44,660 Total KARES Agency Income FY 2011 $92,759 NONPROFIT GRANT APPLICATION-FY 2012-13 Page 8 of 12 Kohala Animal Relocation and Education Service (KARES) - Agency Name Canine Spay and Neuter - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate FY 2010 Actual FY 2012 Income FY 2011 Corporate, community & private 750 $28,760 $50,000 foundation grants (restricted for canine S/N) Private donations 15,000 12,900 15,500 Fund raisers (FUR Ball event, dog 582 3,000 6,500 washes, garage sales) Total $16,332 $44,660 $72,000 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? KARES will continue to apply for community, corporate and foundation grants from organizations that have a mission to support spay & neuter of companion and free-roaming animals. In the past year the majority (-70%) of the grants for the program have been from Mainland USA organizations who were willing to support our Canine S/N Program on Hawai'i Island. We feel it is imperative to gain more financial support from our own Hawai'i Island residents and governmental agencies to help with this important work. Each year since 2009 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 12 KARES has realized almost a 100% increase in private donations - a substantial amount of these monies goes to support our Canine S/N Program. As the awareness of the Canine Spay/Neuter Program increases throughout the community we anticipate gaining acknowledgement and support from our island residents for the humane control of the dog population by spay and neuter. We anticipate the program to continue indefinitely because the need is very great but it is contingent upon funding to cover the cost of veterinary services for the spay/neuter surgeries. We will continue to provide either subsidized or full payment of these cost to our island families that are suffering economic hardship and who are not able to pay these fees for their animals. Only in this manner can we effectively reduce and control the canine population. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. KARES has only one volunteer that is also an employee of the County of Hawai'i. The KARES volunteer is Daylynn Kyles, Clerk Ill, Puna District (d kyles @co.hawai i.h i.us). NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 12 Kohala Animal Relocation and Education Service (KARES) - Agency Name Canine Spay and Neuter - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135—2-142.2, Hawai`i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 12 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Signature of Board Pres •ent/Chair Date or Agency Director ZAA4A !z WA,di/W //Z Signature of Executive Director . Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 12 of 12 61 Kona Adult Day Center Adult Day Care KONA ADULT DAY CENTER, INC.- Agency Name ADULT DAY CARE- Program Name Agency Director: ROWENA L. TIQUI Phone No.: 3? a`'7 (117 Contact Person: ROWENA L. TIQUI Phone No.: 2 ��'"7 9 77 Mailing Address: P. O. BOX 1360 KEALAKEKUA HI 96750 Facility/Site Address: 81-989 HALEKI'I STREET KEALAKEKUA HI 96750 Fax No.: 322-0614 Email Address: KADCROWENA @HAWAII.RR.COM Name of Accountant/CPA (include name of firm if applicable): RONALD G. HAWKES, CPA Phone No.: 939-7392 Mailing Address: P. O. BOX 2030 KEALAKEKUA HI 96750 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$20,000.00 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $15,000.00 $15,000.00 $15,000.00 Agency Mission Statement: "Our Mission is to provide social and recreational programs and activities that enable impaired adults to experience feelings of belonging, friendship, NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 9 acceptance, accomplishment and independence in a caring and secure social environment" NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 9 KONA ADULT DAY CENTER,INC. - Agency Name ADULT DAY CARE- Program Name Program Description: Adult Day Care is viewed as a promising long-term option because it provides regular and reliable respite to informal caregivers, while it fosters their continued participation in the workforce. Persons eligible for Kona Adult Day Care services are those adults 18 years and older, but particularly those 60 years and older, having either aphysical or cognitive disability requiring supportive care. These are persons with Alzheimer's disease, dementia or other memory related disorder,those with physical disabilities such as stroke, Parkinson's disease, and multiple sclerosis and those who are socially isolated. Day Care provides a less restrictive setting and a more cost effective program than other types of care, such as home nursing or institutionalization. Total Budget and Position Count Total Program Budget 287,165.00 Total Program Position Count 4.5 Total Agency Budget 287,165.00 Total Agency Position Count 4.5 Program Objectives: 1) For Individuals: a) Mentally and Physically impared adults are maintained at their highest level of functioning, thus preventing or delaying further deterioration. b) Maximum level of independence is assessed and maintained through the individual program planning. c) Client is able to associate with a place and a group corresponding to his/her sense of identity. d) Caregivers have access to knowledge of elderly services available in the community. e) Deter premature or inappropriate institutionalization in a nursing home or hospital. f) socializing, peer interaction and continued relationship with the community is ensured. g) Isolation and prejudice is often associated with frail and disabled adults is reduced. 2) For Families and Other Caregivers: a) Families that desire to keep elderly members in the home are given relief from full-time care of an impaired adult. b) Family members are enabled to continue productive carreers instead of being homebound with an elderly, disabled spouse, parent or other family member. c) Families and other caregivers are assured that elders depending upon them are being cared for appropriately during the day. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 9 3) For the Community: a) An integral component of thecommunity service network and of the long term care continuum is made available to the West Hawaii Community. b) The Medical community and other resources statewide are provided a liason in the Geriatrics, especially Alzheimer's disease and other related disorders. Program Highlights: (from Fiscal Year 2010-11) 1) Maintained 95% of participants at home for a minimum of six months with Adult Services. 2) Maintained or improved socialization and interaction skills od participants by 95%. 3) Maintained or improved hygiene and self care of participants by 95% 4) Survey satisfaction of caregivers. 5) Had many intergeneralizational interaction activities with communiity groups and schools. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 9 KONA ADULT DAY CENTER, INC. - Agency Name ADULT DAY CARE - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Clients served 37 47 60 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 157,308.58 146,448.00 160,000.00 Professional Fees 5,141.04 4,260.00 5,300.00 Operations 175,374.17 136,457.00 172,523.00 Equipment Other# Total 337,823.79 287,165.00 337,823.00 *If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 9 KONA ADULT DAY CENTER, INC. - Agency Name ADULT DAY CARE - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate DHS/NHWW 38,538.00 43,200.00 40000.00 HCOA/SFS 4,360.00 1,680.00 5,000.00 COUNTY OF HAWAII 10,000,00 15,000.00 13,000.00 TERESA HUGHES TRUST 25,145.00 18,000.00 22,00000 MAY TEMPLETON HOPPER 40,470.00 50,004.00 46,000.00 HI ISLAND UNITED WAY 7,179.86 14,000.00 9,000.00 OTHER GRANTS 1,000.00 1,500.00 1,500.00 TUITION 87,404.91 97,350.00 90,000.00 TUITION ASSISTANCE 670.00 0 1000.00 TRANSPORTATION FEES 10,400.00 14,000.00 12,000.00 BATHING,FEEDING,INTAKE FEES 6,200.00 7,980.00 7,000.00 FOOD PROGRAM 3,969.60 4,860.00 4200.00 FUNDRAISING/DONATIONS 38,546.50 28,196.00 40,000.00 OTHER 17,273.93 15,876.00 18000.00 Total 291,157.80 311,646,00 308,700.00 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? It is my goal to enroll 60 clients with an average daily participation of at least 40 and be able to maintain their level of care with no more than 9 employees. I beleive at that time we will be self sustaining. But only if the level of functioning is at level 1,which requires minimal supervision. As it is now, instead of the 6 clients to 1 employee as required by the state, It is taking 1 employee to 3 clients because of the level of care required, which is acute care. We have more clients in wheelchairs and using walkers and canes. We have more Alzhiemer's and dementia clients who are low fuctionuing and require a lot of cueing and supervision. In the last 10 years the level of care has increased progressively. I need to have at least 4.5 clients per employee per day to stay in the black. But as you can see the ratio doesn't work, it takes 1 employee to take care of 3 clients. But as I mentioned earlier I need 4.5 clients to offset the cost of each employee and other expenses. Unfortunately we cannot accept ONLY the clients that require minimal care. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 9 Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. 1) I am on the Mayor's Committee of the Office of Aging, headed by Alan Parker. 2) Barbara Kossow is on my Board of Directors, a volunteer position NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 9 KONA ADULT DAY CENTER, INC. - Agency Name ADULT DAY CARE - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that ! (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 9 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Signature of Board President/Chair Date or Agency Director e t Signature of xecutive Direr, for ate UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 9 62 Kona Alano Club Road to Recovery rri COPY Kona Alano Club Road to Recovery Agency Director: Vince Mott, President Phone No.: 937-1316 Contact Person: Al Gulick, Secretary Phone No.: 329-3886 Mailing Address: 74-5606 Pawai Place, Suite 101 Kailua-Kona, HI 96740 Facility/Site Address: 74-5606 Pawai Place, Suite 101 Kailua-Kona, HI 96740 Fax No.: None Email Address: magical @hawaii.rr.com (AI Gulick) Name of Accountant/CPA (include name of firm if applicable): Laura Brown, CPA Bean Counters Phone No.: 322-1600 Mailing Address: Box 630 Holualoa, HI 96725 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $ 40,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $ None $ None $ None Agency Mission Statement: To provide a continuous venue for participants recovering from alcohol and substance abuse, and a recreation area where people in recovery can find a clean and sober environment to relax and socialize with like-minded people. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 6 COPY Kona Alano Club Road to Recovery • Program Description: The Kona Alano Club, which opened in 2009, is acting to reduce substance abuse, domestic violence, and stressors on people in recovery. The rates for these issues escalate in poor economic times and although there are many active Twelve-Step programs in Hawai'i County that operate in many venues to reduce these rates, many are in temporary locations. The Kona Alano Club provides a permanent venue for many Twelve-Step . programs of recovery from substance and alcohol abuse, including Alcoholics Anonymous, Narcotics Anonymous, Alanon, and others that are effective because recovery, in part, is a process of "Keep Coming Back". The Kona Alano club provides: ➢ A recreation area where people in recovery can find a clean and sober environment to relax and socialize with like-minded people, and ➢ A meeting room for various 12-step programs and groups dedicated to the assistance of those in need of a helping hand. The club provides support, clean and sober activities, and is open 12 hours per day, 7 days a week. It is completely staffed by volunteers. The club not only offers the first steps in recovery but also offers maintenance and long term support to all who enter, including non-members. The goal of"Keep Coming Back" is accomplished by providing: 1) A meeting room for the current 28 to 32 Twelve-Step group meetings per week, including AA, NA, and Alanon, with potential for increasing use. 2) A clubhouse and coffee bar where those in recovery, their family, and friends gather for support, television, cards, and socializing. 3) Weekly and special clean and sober events such as karaoke, monthly barbeques, weekly pancake breakfasts, and holiday dances. 4) Monthly alcohol and drug awareness education in the form of movies, talks, and panel discussions. 4) Special programs about recovery geared to different segments of the West Hawai'i population. 5) A website that helps people maintain their recovery and attracts new people into recovery. Letters of support or appreciation are on file from State Senator Joshua Green, M.D.; Mayor Billy Kenoi; Hawai'i County Police Major Paul Kealoha; Drug Court Coordinator Warren Kitaoka; and The Honorable Ronald Ibarra, Chief Judge of the Circuit Court of Third Circuit. Total Budget and Position Count Total Current Program Budget $ -0- Total Current Program Position Count Total Current Agency Budget $45,435 Total Current Agency Position Count -0- NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 6 rzi COPY Kona Alano Club Road to Recovery Program Objectives: To provide a safe place for those in recovery, their families, and their friends, thus reducing the incidence of alcohol and substance abuse, the Kona Alano Club has identified several growth objectives: 1) To increase utilization of the club house for socializing by people that are like- minded, and clean and sober, thereby maintaining recovery. 2) To increase utilization of the facilities by expanding the number of attractive social events and activities, such as dances, movie nights, and the social club, which enhance and encourage sobriety. 3) To provide educational outreach to both West Hawai'i residents and to those in recovery to encourage sobriety. 4) To expand food and beverage offerings to increase sales and club usage. 5) To maintain a current website. 6) To approach financial self-sufficiency from food sales, dues, meeting room rent, and fundraising. 7) To increase daily operations and outreach through a paid program and education director. Program Highlights: (from Fiscal Year 2010-11) 1) Twelve Step meetings have expanded to 28-32 meetings each week, with a range of attendance from 6 to 55 and an average attendance of 25 to 30. 2) After existing for only two years, last year's annual income was approximately $32,000 from dues, donations, and special fundraising events. 3) Specialty programs have been started on different aspects of recovery, with meetings and brochures specially created for teens, women, and seniors. 4) A website was created with 10 web pages describing the club, events, and - meetings. The page on January 24 alone listed five AA meetings, one NA "Attitude Adjustment" meeting, and a Sunday pancake breakfast. The website also includes a donation page through PayPal; 24 links to other recovery programs; and store that links with Amazon.com. 5) Began corporate fundraising program. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page3of6 COPY Kona Alano Club Road to Recovery Performance Measures: CY 2010 CY 2011 FY 2012-13 Actual Budget Estimate Average 12-Step meeting attendance 560 600 750 (weekly) 2 Average 12-Step meeting attendance 29,120 31,200 39,000 (annual) 2 Dance Events Number of Events/year 2 2 12 Est. Attendance/event 50 60 60 Est. Attendance/year 100 120 720 Movie Nights Number of Events/year 4 0 24 Est. Attendance/event 30 0 30 Est. Attendance/year 100 0 720 Special Events (Karaoke, Valentine's Day, 150 150 800 St. Patrick's Day, Fourth of July, Halloween), Est. Attendance Christmas Alkathon 0 0 300 New Year's Alkathon 0 0 300 Pending funding 2 Many participants return for more than one meeting. Because of requirements for anonymity, cannot identify or count unique individuals. Program Expenditures ' CY 2010 Actual CY 2011 Budget FY 2012-13 Estimate Salaries and Wages 2 -0- -0- 30,000 Professional Fees -0- -0- 1,500 Operations -0- -0- 6,000 Equipment -0- -0- 2,500 Other -0- -0- -0- Total -0- -0- 40,000 Road to Recovery will be a new program and has had not stand-alone previous expenditures. Total agency expenditures were $53,983 (2010) and $38,886 (2011). Details for the agency funding are listed in the financial statements in the supporting documentation. 2 Salaries are partial year for 2012 because of lag time for hiring. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 6 crj Copy Kona Alano Club Road to Recovery Program Funding Sources: Identify all funding sources (specific to this • program only) ' Revenue Source CY 2010 CY 2011 FY 2012-13 Actual Budget Estimate Hawai'i County Nonprofit Grant -0- -0- 40,000 Total Change -0- -0- 40,000 Road to Recovery will be a new program and has had no previous stand-alone revenues. One objective of the grant is to increase other revenue sources for the program and agency, and those increases are listed in Increased Revenues & Self-Sustaining (below). Total agency revenues were $43,722 (2010), $32,678 (2011), and with the grant, estimated at $72,678 (2012-13). Details for agency funding are listed in the financial statements in the supporting documentation. Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self- sustaining? The Kona Alano Club views this grant as seed money for developing self-sufficiency within two years. This funding, and others, will be used to create an active club program that is supported in part by these changes: Item# Program Increase Unit Cost Annual Subtotal 1) Increased voluntary membership dues from 100 $ 10/month $ 14,400 lapsed then renewed members plus new members 2) Increased food and coffee sales $ 500/month $ 6,000 3) Increased meeting room rentals $ 160/month $ 1,920 4) Increased contributions from 16 social activities $ 475/each $ 7,600 5) Individual donation fundraising activities -- $ 5,000 6) Corporate donation fundraising activities -- $ 5,000 Total $ 39,920 Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. None I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 6 in COPY Kona Alano Club Road to Recovery Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. i (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded agrant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. i1 9 Si nature of Board President bate / / Signature of Board Secretary Date NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 6 64 Kona Historical Society Living History Program Operations Kona Historical Society- Agency Name Living History Program Operations- Program Name Agency Director: Jill R. Olson Phone No.: 323-3222 Contact Person: Ku'ulani Auld Phone No.: 323-3222 Mailing Address: P.O. Box 398 Captain Cook, HI 96704-0398 Facility/Site Address: 81-6551 Mamalahoa Hwy Kealalakekua, HI 96750 Fax No.: 323-2398 Email Address: khs @konahistorical.org Name of Accountant/CPA (include name of firm if applicable): Tone Lamkin, Kona Historical Society and Taketa, Iwata, Hara &Assoc., LLC Phone No.: 323-3222 Mailing Address: P.O. Box 398, Captain Cook, Hi 96704-0398 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$15,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $10,000 $8,000 Agency Mission Statement: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 10 To preserve the history of Kona to enrich our community and inform our visitors by nurturing an understanding of, and inspiring an appreciation for, Kona's unique island sense of place. We will do this through collecting, preserving, researching, interpreting, and disseminating Kona's history with an emphasis on the period after 1779. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 10 Kona Historical Society - Agency Name Living History Program Operations- Program Name Program Description: KHS has two unique sites and three great programs: 1. Kona Coffe Living History Farm (D. Uchida Farm), is a 6-acre 1920's era coffee farm in Captain Cook, which was homesteaded by Japanese immigrants from 1913-1994. The farm interprets the history of Kona's Coffee Pioneers and their family values, independence, and resourcefulness. Costumed interpreters demonstrate Japanese cooking using customary utensils and a wood-burning stove, and demonstrate how coffee is picked and the role of the donkey in coffee farming. Visitors leave the site with an appreciation of the critical role of the entire family in the success of the coffee farm, and the contrast between their own modern life and life in 1930's Kona mauka. 2. H.N. Greenwell Store, an 1890's general store in Kealakekua, was founded by H.N. Greenwell, an English immigrant. The Store presents typical 19th century shopping experiences by encouraging visitors to role-play actual multi-cultural customers from the period. Through this process costumed interpreters discuss topics including ranching, dairying, land use, ethnic groups, and trade with the outside world. Visitors are offered opportunities to touch, smell and taste items found in the Store, which is the oldest commercial building remaining in Kona. KHS offers living history tours of these two sites to school groups, visitors, academic researchers, and local residents. Both sites are listed on the State and National Registries of Historic Places. 3. Portuguese Stone Oven: in 2005 KHS launched a bread-baking program with an authentic, community sized, traditional oven, which was built makai of the H.N. Greenwell Store. Nearly 100 loaves of bread are baked weekly and sold to a steady stream of customers. Visitors, locals and school groups are invited to arrive early to help with the bread-making process, and to sample hot loaves right from oven. Participants gain a better understanding of Portuguese traditions, dairying, and how sweetbread became part of Hawai'i's culture. School children are offered the opportunity to learn how to make butter and then eat it on fresh bread with guava jelly, a traditional farm treat. Total Budget and Position Count Total Program Budget 161,700 Total Program Position Count 18 Total Agency Budget 375,000 Total Agency Position Count 25 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 10 Program Objectives: 1) Provide authentic, thoroughly researched, and engaging programs at historic sites. 2) Demonstrate how coffee was grown, picked and processed during the 1930's with the participation of all family members, even the children. 3) Convey the history of the 1890's multi-cultural Kona mauka ranching and mercantile community. 4) Demonstrate how general store customers chose and purchased goods through trade, exchange, credit, or cash, depending on what resources were available to them. 5) Continue the traditions of Portuguese ranching and dairying families with breadbaking in the rustic stone wood-fired oven. 6) Educate visitors to create an understanding of and appreciation for Kona's multi-cultural history. 7) Encourage visitors to participate in hands-on experiences at each site. 8) Demonstrate the themes of sustainability, resourcefulness, family values, and independence, which come alive as visitors participate in Living History activities. Program Highlights: (from Fiscal Year 2010-11) 1) An additional baking day was added to the regular Thursday baking schedule, and on that day only we bake a Garlic Country loaf and cinnamon rolls. These have proven to be extremely poplular with visitors 2) A Portuguese Festival (Oct 1, 2011), partially funded by HTA/County Department of Research and Development, was well attended by residents and visitors. Traditional saddle making and ukulele skills were highlights of the festival. 3) The bi-annual fundraising Palaka Party Gala Event was held in July 2011, raising much needed funds for administrative overhead and program development. 4) Funding was provided by Hawai'i Council of the Humanities to produce a children's book about Portuguese Bread baking. That book is scheduled for publication in February 2012. 5) In cooperation with the County, a free lecture series," Hanohano 'O Kona" will be scheduled throughout 2012, with a presentation on different topics each month. Presentations will occur at the West Hawai'i Civic Center. 6) A historical performance at the Aloha Theatre, "Talk Story with Mark Twain" and "Tea for Two at Kalukalu" was presented in November 2010. A sell out audience enjoyed Mrs. Greenwell and Miss Paris sharing local 1890's news, and Mark Twain reminicing about his visit to Kona. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 10 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 10 Kona Historical Society - Agency Name Living History Program Operations - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Number of Adult Visitors 5813 5877 5910 Number of School Children 738 752 775 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages 98,953 83,605 75,000 Professional Fees 6,661 20,249 22,000 Operations 61,723 46,662 48,000 Equipment 0 0 0 Other# 19,242 22,713 16,700 Total 186,579 173,229 161,700 * If applicable Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6of10 Kona Historical Society — Agency Name Living History Program Operations — Program Name Explanation of Program Expenditures on Page 5 Other Expenditures FY 2010-11 FY 2011-12 FY 2012-13 19,242 22,713 16,700 This expense includes employee Medical Insurance Benefits and FICA taxes. NOTE: Kona Historical Society's fiscal year runs from January through December. Therefore Program Expenditures shown are for: FY 2010 (actual) FY 2011 (preliminary) FY 2012 (draft budget) NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6-A Kona Historical Society - Agency Name Living History Program Operations - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Tours and Admission Fees 51,088 42,830 43,000 Sales of Publications and Gifts 12,319 8,308 8,500 Sales of Portuguese Bread 31,014 37,445 37,500 Sales of Retail Coffee 35,495 33,229 34,000 Coffee Crop Sales 1,485 1009 0 Macadamia Nut Crop Sales 1,548 0 0 Grant: State Fdn for Culture &Arts 18,823 17,823 13,762 Grant: County of Hawaii 5,000 4,300 4,000 Grant: Young Brothers Foundation 0 500 500 Donations 0 6,171 6,000 Investment Income 0 12 15 Total 156,772 151,627 147,277 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? During the last half of 2011 we observed that the number of visitors to our sites had increased slightly. And in the first quarter of 2012, there is an increase in scheduled group tours , which we hope will continue through the year. KHS has also completed negotiations with Roberts Travel for small group tours, that are expected to begin by June 2012. As well, HTA tourism projections continue to be optimistic. With increased visitors to our sites, we expect a corresponding increase in gifts and retail sales of Kona coffee, which had declined by 24% since 2009. While the visitors seem to be returning, it's clear that they are not spending as freely as they did prior to Fall 2008, but sales do seem to be picking up a bit. In addition, we are no longer selling the KHS coffee crop on a wholesale basis, as we have contracted for management of the coffee operation, resulting in an increase to operating costs. In 2011, KHS completed the update to its website and created a secure on- line store that will makes it easier to sell our products on-line, especially coffee. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 10 Also, since our bread sales had increased steadily, we added one additional baking day per month, which did increase sales in 2011. We are at capacity now in terms of bread sales, as we sell out nearly every baking day. We continue to take advantage of every free and low cost opportunity to publicize our programs, and have successfullypursued feature articles of activities and programs in local media. A staff member is responsible for making sure our programs and events are listed in publications catering to tourists, as well as in PSA's and local calendars. Our website is updated regularly by trained staff. We have also launched a Facebook page. In 2008 the Living History Programs overall were self-sustaining, in terms of direct costs. However, from 2009 through 2012, despite cuts in operating hours and operating expenses, revenue generated from program fees and gift and coffee sales did not cover costs. This necessitated a recent organizational restructuring resulting in the reduction of an administrive staff member with medical benefits. These changes have led to a conservative estimate of approximately $15,000 deficit in programs for Fiscal Year 2012, as compared to over $30,00 in FY2010. Given the factors outlined above, we hope to see a return of these programs to sustainability by Fiscal Year 2013. With these changes in process, Kona Historical Society is requesting $15,000 from the County to help cover the program shortfall projected in the 2012 Fiscal Year. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Megan Mitchell, County Employee, serves as a paid Docent for Christ Church Cemetery Tours on four occasions during October and November 2011 and again 2012. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 10 Kona Historical Society - Agency Name Living History Program Operations - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accented after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9of10 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your aaencv's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. 00120- LA-lalk_ 5C") B°) t Z Signature of Board President/Chair Date or Agency Director C 7. s i Sign- re 'f Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page of 10 ro 65 Kona Literacy Council Kailua Learning Center Kona Literacy Council- Agency Name Kailua Learning Center- Program Name Agency Director: Brenda Natina Phone No.: 329- 1180 Contact Person: Brenda Natina Phone No.: 329- 1180 Mailing Address: 75-5766 Kuakini Hwy 106A Kailua-Kona, Hawaii 96745 Facility/Site Address: same Fax No.: same Email Address: konalit @msn.com Name of Accountant/CPA (include name of firm if applicable): none Phone No.: Mailing Address: You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$2,500 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $2,000 $2,000 $2,000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 8 Agency Mission Statement: The Kona Literacy Council's trained volunteer tutors help any adult increase their basic reading, writing, math and communication skills to enable the learners to become better family members, workers, community members and lifelong learners. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 8 Kona Literacy Council - Agency Name Kailua Learning Center- Program Name Program Description: The Kona Literacy Council's trained volunteer tutors provide free, one-to-one, small group, and computer-assisted literacy services at the Kailua Learning Center to any adult who wants to improve their basic reading, writing, computation skills and computer literacy. Special programs designed to meet the specific needs of the learners are offered, such as: English as a Second Language, preparation for passing the GED or Competency Based High School Diploma, Citizenship preparation, keyboarding and computer literacy. All tutoring is at no cost to the student. All of the approximate 600 students, who have had lessons at the Kailua Learning Center since it opened in September 1992, have made remarkable progress in their basic skills; some have gained their High School Equivalency Diploma, passed the Citizenship exam, and have gotten better jobs. Reading improves the adults' self-esteem, thereby improving their lives and becoming better family members, workers and community members. Total Budget and Position Count Total Program Budget $5,250 Total Program Position Count 0 Total Agency Budget $5,250 Total Agency Position Count 0 Program Objectives: 1) Continue to provide free one-to-one, small group and computer-assisted literacy services at the Kailua Learning Center to any adult who wants to improve their basic reading, writing, computation and computer literacy skills. 2) Register, schedule, match learner with tutor, and prepare programs for 12 new students for the year. 3) Continue recruiting and training new tutors. 4) Continue networking with community agencies to provide free literacy assistance to their clients, i.e. Department of Human Services, Department of Labor & Industrial Relations, Kona Community School for Adults, various Vocational Rehabilitation Programs, Bridgehouse, Alternatiaves to Violence, court ordered participants, Family Support Services of West Hawaii, Hawaii Community College and the public libraries. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 8 5) Offer pre-employment skills, help in filling out application forms, resume writing and interview skills to enable our learners to get and hold jobs. 6) Improve family literacy services. 7) Continue offering the Kona Community School a free day time facility for the English as a Second Language classes and Adult Basic Skills program. Program Highlights: (from Fiscal Year 2010-11) 1) Tutored basic literacy students: 4 students (includes reading & math) 2) Prepared for high school equivalency class: 5 students. 3) Received High School Equivalency Diploma: 2 student. 4) TutoredEnglish as a Second Language students: 7 students. 5) Left the program and attained employment: 2 students. 6) Retained employment: 3 students. 7) Studying for the citizenship test: 11 students. 8) Increased involvement with children's education: 2 students. 9) Utilized 2 volunteer tutors, 4 auxiliary personnel, plus the Program Director. 10) Tutored approximately 375 hours of actual tutoring. 11) Contributed approximately 400 hours by volunteers in other areas. 12) Trained 1 new tutors. 13) Passed Citizenship Test: 7 students. 14) Provided court ordered community service: 1 male. 15) Study for Praxis: 1 16) Transition from incarceration: 2 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 8 Kona Literacy Council - Agency Name Kailua Learning Center - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Tutored Adult Basic Ed. Students 7 5 5 Tutored Pre-Equivalency HS 5 5 4 Tutored ESL Students 7 7 7 Citizenship Students 11 5 5 New Tutors 2 2 2 Newsletters 3 3 3 Board & General Public Meetings 3 3 3 TotalTutoring Hours 350 400 350 Total Non-Tutoring Hours 400 400 400 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 0 0 0 Professional Fees 0 0 0 Operations 4,135 4,500 4,200 Equipment 309 400 400 Other# Insurance 500 500 500 Total 4,944 5,200 5,100 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 8 Kona Literacy Council - Agency Name Kailua Learning Center - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate County Grant 2,000 2,000 2,500 Young Brothers 0 1,000 0 Ironman 1,000 1,000 1,500 Federal Pacific Campaign 294 600 400 Wal-Mart 0 250 200 Donations 300 500 500 Fundraising 0 100 100 Membership Dues 0 50 50 Total 3,594 5,500 5,250 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The Kona Literacy Council plans to participate in more fundraising and grant proposal writing. Since we do not charge our clients for our literacy services, we will have to continue to rely on the generosity of our community supporters. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. None NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 8 Kona Literacy Council - Agency Name Kailua Learning Center - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 8 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements.JA AfA AIL ...... //0,Z. 6 /c2.._ t Signat re of Bo':rd 're Al-nAV air D e or Age y Director f-t.‘"—/(4eL.1,-- //-e)/A-- ignature of EZecutive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 8 66 Kona Skatepark Assn Move on Wheels Kona Skatepark Association- Agency Name Move On Wheels- Program Name Agency Director: Mark Waldo, President Phone No.: 808 326-1771 Contact Person: Cynthia Hope, Treasurer Phone No.: 808 640-0588 Mailing Address: 76-6246 Alii Drive#365 Kailua-Kona, HI 96740 Facility/Site Address: Kona Hawaii Skatepark Old A's Fax No.: None Email Address: cynthiahope @aol.com Name of Accountant/CPA (include name of firm if applicable): Laura Brown, Kona Bean Counter Phone No.: (808) 322-1600 Mailing Address: 76-873 Hualalai Road Kailua-Kona, HI 96740 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $15,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Pam> 1 of 111 09-10 10-11 11-12 $0 $0 $0 Agency Mission Statement: The Kona Skatepark Association, an all volunteer 501 c3 non-profit organization, is dedicated to providing a venue for youth to participate in healthy individualistic exercise, participate in community park planning and design activities, and providing alternative activities to discourage unhealthy and destructive behaviors. KSA has actively been providing after school and school break activities for the kids of Kona. They have included contests, skate workshops and other activities such as art and dance expos. KSA feels that keeping kids active and engaged reduce tempatations to use drugs, alcohol and tabacco use. Getting the kids out and more active reduces tendencies towards obesity and related diseases such as diabetes. KSA created a temporary 5,000 sq ft skatepark at Kona's Old Airport Park in 2007. The park was built under an agreement with the County of Hawaii and with donations and volunteer labor. Throughout its 4-year history, after school classes in safety and skills and a myriad of events have been held at this venue. In 2008, KSA was allocated a 44,515 sq ft area in the new park to build a permanent skatepark and adjoining viewing and recreational area. Enough funds have been raised to build Phase I, a family picnic and BBQ area and Phase II, a keiki flowbowl, of the permanent skatepark. KSA is seeking funds to continue offering classes and events, and to broaden the opportunities for youth to participate in the organization of these events. KSA has conducted over 40 events and workshops in its 4 year history. It has been found that consistantly providing these kind of events keeps kids motivated to improve their sport and off the streets and out of trouble. The age group that these events attract, 6-14 year olds, are those who usually slip through the cracks of other organized activities. Please refer to Kona Skatepark Association's website www.konaskatepark.org. for information on these workshops and events. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Pam 7 r f 111 Kona Skatepark Association - Agency Name Move on Wheels- Program Name Program Description: There are four venues that KSA would use for this program,the basketball court at Kealakehe Intermediate School, Kona Skatepark at Old A's, West Hawaii Hockey Rink and Waimea Skatepark. This program is open to everyone. Every month there will be two, every two weeks, after school workshops. These will happen at Kealakehe Intermediate School, Kona Skatepark and West Hawaii Hockey Rink. These will teach kids skateboarding skills, skateboard maintenance and safety and provide a practice session. During the Spring, Summer and Holiday Breaks there will be events that would include 6 skate demos and contests. These allow the kids to show their improved skills and join other kids of the island for a fun time. These will be held at Kona Skatepark and Waimea Skatepark. Ramps from temporary park will be used at Kealakehe Intermediate School and West Hawaii Hockey Rink. Transportation will be provided to the Waimea event. Prizes will be provided by the community and/or the Kona Skatepark Association. Program personnel would include: 1 Program Coordinator 1 Skate Instructor/Workshop and Contest Coordinator 3 Judges for competitions 1 MC for events and competitions Schedule: 2nd Thursday of each month during in-school months(tentative)-Kealakehe Intermediate 4th Thursday of each month during in-school months (tentative)-Kona Skatepark or West Hawaii Hockey Rink(approximately 16 workshops). Spring Break Event- Summer Events-Go Skateboarding Day June 21,July and August Events Winter Holiday Events-December and January Event Events will include Game of Skate, Best Trick Demo Jam, Street Skate Jams (Kona) and Bowl Skate Jam(Waimea) Kona Skatepark Association has conducted over 40 events and workshops and has everything in place to stage these events. The speaker system for the events is in place. Tables, chairs and tents are available for the judges. It carries insurance for the actual event and transportation to events. The insurance includes the County and State of Hawaii, and West Hawaii Hockey NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Ann,. 1 of 1(1 The workshops include a simple ramp and cones. Beginners are walked through safety tips and basic moves. Intermediate skaters are coached in more advanced moves. More advanced skaters demonstrate and mentor the less skilled skaters. Total Budget and Position Count Total Program Budget Total Program Position Count 6 $16,500 _ Total Agency Budget $8,000 Total Agency Position Count 0 Program Objectives: Help combat a growing number of youth crimes and drug and alcohol use. The Hawai'i County Comprehensive Strategy for Juvenile Justice recommended that community programs be launched that provides students with a safe place away from the temptations of drugs. The Strategy further encourages student to pursue other aspirations and interests by allowing them to participate in the organizing of these The following are elements of skateboarding are positive influences for youth and young adults: Try Something New Skateboarding will challenge them in new ways and teach youth a new skill set. Trying new things and gaining new experiences is what keeps one's brains alive and active,which in turn gives kids new insights into the world and makes them a better,more interesting person. Strive for Fitness A huge part of skateboarding is balance,so participant's core will gain strength as they skate,as well as their legs. Skateboarding is also very aerobic. It's pretty easy to loose weight when doing something one enjoys. Make Friends This is true no matter what age.Encouraging kids to pursue other aspirations and interests promotes leadership and healthy peer interaction. Picking a hobby other than sitting on a couch watching TV will always make it easier to make friends. Meeting people at skateparks and making friends is effortless. Getting out and NONPROFIT GRANT APPLICATION congregating with peers in a healthy environment is an effective way to create beneficial relationships and learn important socialization skills. Teach Perseverance Youth learn if they stick with skateboarding and keep trying,they will succeed and learn the value of staying with something,even when ifs not easy. Life is tough especially for`at-risk' kids for whatever problem and learning to push through because the payoff is worth it will help in every way. Skateboard to Build Confidence When skateboarders have been practicing a trick for a long,long time,and they finally get it,they realize something. They learn that if you try hard,you can defy gravity,master harder and harder tricks,and succeed. This instills an understanding of how powerful he or she really is and help builds confidence, which is key to success. Have Fun Skateboarding is fun. With the pressures of today's society it good just to have fun and relieve some of the stress of kid's lives. Program Highlights: (from Fiscal Year 2010-11) 1) N/A NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Parrs C of 1fl Kona Skatepark Association - Agency Name Move on Wheels - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Number of participants 75 Number of events 22 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages N/A N/A 0 Professional Fees N/A N/A $11,500 Operations N/A N/A $4,000 Equipment N/A N/A $1,000 Other# N/A N/A 0 Total N/A N/A $16,500 *If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 PARPtiof111 Kona Skatepark Association - Agency Name Move on Wheels - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate County of Hawaii Non Profit Grant N/A N/A $15,000 Kona Skatepark Association $1,500 Total $16,500 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Kona Skatepark Association has actively applied for grants and worked with various orgnizations to provide these services and provide a venue for the community. Ultimately it would be KSA's hope that the Parks and Recreation Department would establish a youth program that would include these workshops and events similar to the programs that are currently put on and provided for the seniors. This has included the following contracts, agreements and restricted grant awards many of which can be approached for support again. Memorandum of Understanding (MOU)with the County of Hawaii to build a permanent skatepark on 44,515 sq feet of land at Makae'o (Old Airport) Park. Contact: Bob Fitzgerald, Director of County Park&Recreation,(808) 961-8311 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Pam. 7 of 111 Service delivery agreements with PATH for Wheelin' Free Life Skills®evidence-based anti-substance abuse classes and skateboard building mentorship; Contact: Laura Dierenfield PATH executive director, 808 936-4653 METH Hawaii,to deliver anti-substance abuse promotional material and involve youth in creating and delivering anti-METH advertisements. Cindy Adams, METH-Hawai'i executive director, (808) 529-6254. Bill Healy Foundation,2007& 2009, Grant awards totaling $50,000 to develop programs construct a temporary and permanent skatepark. Contact: Diane Hall, executive director. 503-222-1899. Change Happens Foundation, 2008, Grant award of$25,000 to construct a permanent skatepark. Contact: Michael Troxel,president. 808-443-0067. Atherton Family Foundation, 2008, $25,000 to construct a permanent skatepark. Contact: Amy Luersen, Director of Philanthropic Services. 808-566-5537 Kukio Community Fund, 2009, Grant award of$5,000 to provide afterschool activities and promotional opportunities for youth. Contact: Amy Luersen, Director of Philanthropic Services, 808-537-6333. Kealakehe Intermediate School, organization of after school programs, Contact: Rob Flemm. 808 854-4873. Hawaii Tourism Authority, 2008, CPEP, $5,000 Healing Our Island, County of Hawaii, 2009 $2000 for'Go Skateboarding Day" June 21st Hawaii Community Foundation-OCB Planning Grant, 2010, $5,000 Rotary Club of Kona,2006, $3000, project development funds Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. None NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Pam. 2 of 111 Kona Skatepark Association - Agency Name Move on Wheels - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Parr. Q of 1(1 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. /A-evile-- I /Z s�,� 6/rz Signature of Board President/Chair Date or Agency Director kr1 //z4,// Sign o Live r.Di ono_ ' Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 pane l n of 1 n 67 Ku Aloha Ola Mau Hui Ho'ola 0 Na Nahulu 0 Hawaii Ku Aloha Ola Mau- Agency Name Hui Ho'ola 0 Na Nahulu 0 Hawai'i- Program Name Agency Director: Lisa Cook Phone No.: 8085380704 Contact Person: Kelaukila Carter Phone No.: 8089829555 Mailing Address: 1130 N. Nimitz Hwy Ste. C302 Honolulu, HI 96817 Facility/Site Address: 15-1926 30th/Puakalo Street Hawaiian Paradise Park Kea'au, HI 96749 Fax No.: 808-982-9554 Email Address: Icook @kualoha.org kcarter @kualoha.org Name of Accountant/CPA (include name of firm if applicable): CW Associates, CPA's Phone No.: 808-531-1040 Mailing Address: 700 Bishop St, Ste 1040 Honolulu, HI 96813 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$10,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0.00 $0.00 $5,000.00 Agency Mission Statement: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 12 Ku Aloha Ola Mau (Ku Aloha) "restores meaningful, healthy lives for all Hawaii communitites through responsive and responsible action towards present and future needs in the prevention and treatment of addiction." The agency is strength based and committed to Hawaii's people and cultural preservation. Though difficult to translate into English, Ku Aloha Ola mau means "to give with compassion, from the deepest part of ourselves, life forever. " Program Mission The mission of Ku Aloha's program, Hui Ho'ola 0 Na Nahulu 0 Hawai'i, (Hui) for which this application is being written, is "to create a healing community, grounded in the spirit and culture of Hawai'i that reaches out to all ethnicities suffering from the disease of addiction." Author- Policy Steering Committee. Kupuna Abigail Napeahi gave the Hui it's name and its focus. The Hui's name means "We are the group that gives life back to the people of Hawai'i. We belileve "Every haumana is a precious gift that walks the face of the earth" and weknow there is skill and potential in every haumana for self- sufficiency and to become a valuable community resource. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 12 Ku Aloha Ola mau - Agency Name Hui Ho'ola 0 Na Nahulu 0 Hawai'i- Program Name Program Description: Purpose and Goals This proposal is intended to improve the quality and intensity of effective services for the Native Hawaiian and other Asian Pacific Island populations who are addicted and at high risk fo social problems and crime. It shall accomplish this through: 1) increasing the treatment capacity and accessibility for native Hawaiian and other API populations, 2) enhance the efficacy of services through restoration of family cohension, traditional values and roles, and promotion of self-sufficiency, health and wellness and community responsibility. Hui Ho'ola 0 Na Nahulu 0 Hawai'i (Hui) is a program under Ku Aloha Ola Mau. It is specifically geared to rural settings and is a community designed healing center located in Puna. The Hui provides substance abuse treatment that is spiritually and culturally based on the Hawaiian culture, and serves people of all ethnicities on the island of Hawai'i. Integrated Approach This will be accomplished through a unique and innovative spproach which integrates cultural traditions, values, ceremovies and healing practices into the evidenced based practices of Intensive Outpatient Treatment Cognitive Behavioral Training and Enhancing Motivation for Change. In this approach, cultural modalities do not run parallel or are adjunct services to Western practices, but are blended within the structure, activities, and interventions of the models to provide a seamless, effective and empowering approach. In addition, the Hui provides transportation as many have none and would not access treatment without it. Case management and crisis intervention are also provided. "Ice" and addictive substances create chaos in many lives. However, it is also an opportunity for individuals and their loved ones to be highly motivated to change. Provision of these modalities provides stabilization and connection to other viral community services. The program offers Intensive Outpatient (IOP), and Outpatient (OP) and Continuing care modalities. Services include Screening and Assessment, Individual Treatment Planning and Evaluation, Transition and Discharge Planning, overnight retreats. Target Population These are compromised of adults aged 18 and over (and their families) who meet State Alcohol and Drug Abuse Division definitions for addiction (DSMIV-TR, NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 12 American Society of Addiction Medicine (ASAM) Patient Placement Criteria for !OP or OP. The Hui's haumana population is comprised primarily of those addicted to "ice" - crystal methamphetamine, marijuana and alcohol, however those with cocaine and opiate addiction are also accepted. The program provides substance abuse assessment, referral, intensive outpatient, outpatient, continuing care. In addition, it provides services such as acupuncture and lomilomi through licensed consultants. Ho'oponopono, Hawaiian history and practitioners trained in these practices. Staff also lead the humana in ceremonies, traditions and practices. The program has been serving 16 haumana at any given time. However, even when it was serving 40+, they still had to turn people away due to lack of adequate resouces and staffing. This request is to open 2 more slots for those who are indigent and in need of these services. The program is attractive to the target population because of its cultural and spiritual activites, approach and Kupuna services. The Hui is the only outpatient culturally based substance abuse treatment program in Puna. It is located in Kea'au and has to - date treated over 930 individuals and families. It is staffed by Native Hawaiian certified substance abuse counselors (CSAC) and Native Hawaiians who were raised practicing trditional cultural ceremonies, values, chants, and practices which foster resiliency and protective factors as well as healing, recovery and relapse prevention skills and tools. Staffing Program Manager, Sarah Kelaukila Carter- respected community member and 10 years as Program Manager with Hui Ho'ola. Counselors meet State Alcohol and Drug Abuse Division requirements. Randal Kaipo Like, Clinical Supervisor, CSAC over 10 years supervision Rachel Kruse, Traditional Counselor, CSAC and BA Brian Ogawa, BA, working toward CSAC under Kaipo Like Dave Nakaooka, Driver- lives in Puna Counselors provide assessment, treatment planning, individual, group and family counseling through its outpatient, intensive outpatient and continuing care structure. In addition the Hui has assisted Rachel in receiving her CSAC and is now assisting Brian Ogawa to do the same. He is currently a volunteer. The staff open the doors of college and opportunities also to Haumana through tasks given to haumana which involve going to the local college such as to research their geneaology. The staff and Kupuna work together towards each individual and family, and regard the haumana (clients are called "students" in Hawaiian to remove stigma and provide a role) as special and important to create a sense of wellness and in connecting and giving back to the communtiy. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 12 Facilities The agency has land in Kapoho called the Kapoho Educational Cultural Center where many activities take place. There is currently a taro patch, a garden, a large open air pavillion and a handicap accessible restroon. Activites such as men's group, Hawaiian values group, hula, oli, Kihei, etc. are done to teach specific lessons and to awaken positive self- identity, learn Native practices which are useful in achieving and maintaing recovery, and realizing one's effect and thus responsibility to the land, elements, sea and to each other. Counseling and assessment are also provided at the office located in Kea'au, Puna which has three individual counseling and two group counseling private areas. Services The program helps to build self- esteem through validation of one's culture, through role modeling by the staff of appropriate family roles and interaction, learning difficult chants, understanding core vaules of the culture, the depth of meaning behind learning one's genealogy and respecting others. It also opens the door for higher learning, or job or vocation to play a positive part in the community. Through the Hawaiian culture, the staff lift up other cultures as well so participatns from all walks of life and cultures feel the aloha given to them and can identify spiritually with the staff and participants. The Hui provides occasional overnight retreats with and without families. Its activites are what one would see in a healthy community and family. Working together on the land, eating together, men and women having some separate times to process, share and support; creating together, taking classes together, sitting with Kupuna and so forth. The Hui's skilled counselors guide Haumana into processing these activites and find the deeper meaning/lesson(s) and connection in their lives. They move individuals to finding out "who they are" and "where they are going". They understand how some ceremonies, traditions, practices can help them prevent relapse and build strong families of their own. The program accepts people into its "ohana", teaches them discipline and gratitude and more. The haumana or"students" graduate with new responsibilities as alaka'i or leaders. One by one, family by family, the Hui is transforming the community from the desperation of drug and alcohol addiction to beautiful people and families with a strong sense of self, with tools, skills, knowlegde and the determination to creat a better legacy for their descendants and for the community. Several of the haumana have become staff of either the Hui or as counselors in other agencies. Evaluation Every six months, outcome data is collected in addition to Consumer Surveys upon discharge, a review of incidents reports, trends seen and a review of units of services provided, training needs, etc. These are shared with the Operations Management Team (all supervisors and managers for KAOM sites)for review and to recommend any changes as well as reconginizing accomplishements. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5of12 Total Budget and Position Count Total Program Budget 285,000 Total Program Position Count 3.25 Total Agency Budget 2,016,640 Total Agency Position Count 35 Program Objectives: 1) Provide screening to 25 individuals; intake to 20 withing the budget year. 2) Provide education and counseling to 15 families to assist them in understanding and implement what was learned in prevention education training by Hui Ho'ola staff and providers within 4 months from admission. 3) Provide counseling and education which is conducive to individuals needs to heal from addictions of alcohol and substance abuse for 15 individuals by the end of the contract year. 4) Provide teachings through Kupuna and staff on self- awareness , kuleana and other Hawaiian vules, and mookuauhau to 15 individuals during the course of treatment by the end of the contract year. 5) Provide supplies, transportation, case management, school and vocational counseling to 15 individuals prior to graduation and within the contract year. Program Highlights: (from Fiscal Year 2010-11) 1) A three day Cultural Immersion Training provided for counselors in Kapoho. Kupuna Pearl Ulu Gamon facililtated and guided the training on Hawaiian Wellness so staff could carry on her work beyond her time providing good succession planning. The Hui treatment services consistently met or exceeded their projected outcomes. 2) The Hui staff were all decreased from 3 FTE to .5 FTE each to maintain the program despite not receiving expected funding. In January, the clinical positions were increased to meet the demand. The staff nevertheless, have continued the program without losing its quality. However the number of people served have been fluctuating due to the decreased staff hours due to lack of adequate funding. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 12 Ku Aloha Ola Mau - Agency Name Hui Ho'ola 0 Na Nahulu 0 Hawai'i - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Haumana with no arrests since 50% 70% 100% discharge Haumana with no frequency of 50% 73% 50% drug/alcohol use 30 days prior to follow-up Haumana in stable living 75% 99% 100% arrangments at follow-up Employed, in school or vocational 50% 80% 50% training at follow up Haumana who did not receive 50% 50% 50% substance abuse treatment since discharge Haumana who did not miss work or 50% 50% 50% school due to drinking/drug use in past 30 days Haumana with no emergency room 50% 75% 50% visits since discharge Haumana who will not be 75% 75% 50% hospitalized for medical problems 6 months post discharge Haumana does not need substance 50% 60% 50% abuse treatment 6 months following discharge Haumana completing treatment 50% 50% 50% Haumana not experiencing 50% 50% 50% psychological stress at time of follow-up *If applicable Program Expenditures NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 12 FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages 132,925.00 138,242.00 138,242.00 Professional Fees 25,755.00 26,785.00 6,696.25 Operations 92,533.00 96,234.00 77,125.00 Equipment 3302.00 3434.00 2,747.20 Other# Total 323,127.00 336,051.00 285,000.00 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8of12 Ku Aloha Ola Mau - Agency Name Hui Ho'ola 0 Na Nahulu 0 Hawai'i - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Alcohol and Drug Abuse Division 200,000.00 200,000.00 200,000.00 County of Hawaii 100,000.00 100,000.00 10,000.00 Total 338,000.00 375,000.00 285,000.00 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? 1. The program is still working toward National Accreditation which will cost around $10,000. Policies and procedures are in the development stage and funding accreditation is being researched. Contracts with managed care agencies are awaiting this certifcation to move forward with paying for their beneficiaries for Intensive Outpatient, Outpatient and Continuing Care. We are anticipating to receive state accreditation this year. 2. At this time managed care only pays for Western approaches. Ku Aloha Ola Mau is on the leadership team of a consortium comprised of Native Hawaiian programs called 'Imi Ke Ola Mau. This group intends to spread awareness of the effectiveness of cultural approaches and need to preserve the culture as well as to support cultural approaches to be accepted by the federal government as evidenced based practices. This will bring the services closer to reimbursement by insurance. In 2008, the Alcohol and Drug Abuse Division issued RFPs which NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 12 would reiumburse cultural services to share their practices in a Clinical Director's meeting. These are important steps toward change and acceptance of the need for respect and the strengths of the culture in healing from this and other conditions. It will take up to five years before the program can be self-sustaining. 3. A Ph.D. student, Palama Lee, successfully presented his dissertation on Hui Ho'ola. It was touted by his reviewers as a "landmark" research of a Hawaiian program by a Native Hawaiian researcher and set a new level of Native Hawaiian research. 4. Hui Ho'ola has provided its first cultural training for counselors of Ku Aloha, Hale Kipa and the Coalition for a Drug Free Hawaii. 96% of the participants stated the new knowledge gained from the training increased their capacity to support youth and/or families and that since the training, they have been able to use the new knowledge/skills in the work. We intend to continue these trainings and open them to more and more people in the field. This will increase the income and diversify it as well providing a more solid foundation funding - wise and of skill and knowledge dissemination. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. None NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 12 Ku Aloha Ola Mau - Agency Name Hui Ho'ola 0 Na Nahulu 0 Hawai'i - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 12 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Signature of Board Presi._ Chair Date or Agency Director Sig Lure of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 6 68 Ku'ikahi Mediation Center Community Conflict Resolution Ku'ikahi Mediation Center- Agency Name Community Conflict Resolution - Program Name Agency Director: C. Parkinson Phone No.: 935.7844 Contact Person: C. Parkinson Phone No.: 935-7844 Mailing Address: 101 Aupuni St. Ste. 1014B2 Hilo, HI 96720 Facility/Site Address: Same as above Fax No.: 961-9727 Email Address: cheryl @kmchilo.com Name of Accountant/CPA (include name of firm if applicable): Carbonaro CPA & Assoc. Phone No.: 968-1002 Mailing Address: P.O. Box 4372, Hilo, HI 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $15,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $18,000 $15,000 $11,000 Agency Mission Statement: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 9 To provide a safe environment, an impartial process,and skilled, professionally trained personnel for the delivery of affordable dispute prevention and resolution services to the East Hawai'i Community. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 9 Ku'ikahi Mediation Center - Agency Name Community Conflict Resolution- Program Name Program Description: Ku'ikahi Mediation Center (KMC) is the only agency providing affordable conflict resolution services and training to our East Hawai'i community. In this difficult economy with high unemployment, foreclosures and debt defaults, our services are often the only option for low income people to resolve conflicts and move on with their lives. More than half of our clients have a household income of less than $20,624. For the majority of our clients, hiring lawyers and litigating their problems in court , through trial, is not an option for them. We are able to assist couples in coming to agreements regarding parenting plans, property distribution and communication methods so that they do not further stress the family with the burden of contested litigation. We mediate and facilitate work place disputes so that the workers and small business owners can go on to be productive members of the community instead of being focused on internal disputes. We have also instituted a telephone conference option for collection cases so that the debtors can actually speak directly with a representative of the collection company and work out a reasonable payment plan. The goal of our program is to assist people in resolving their disputes in a peaceful, confidential,workable way and to model the skills that they can use in the future to prevent and resolve conflicts. We have also initiated efforts to reduce school violence and bullying. Although that portion of our program is not in full swing, we have so far been able to provide 128 hours of mediation training for peer mediators and are working to increase our participant schools. Under our contract with the Judiciary, we are required to provide mediation services for court referred landlord/tenant and small claims disputes for no charge. We provide these services primarily at the courthouse in Hilo. We have a staff member at the court twice a week to review the docket and confer with the volunteer mediators as to what cases they may be handling. We have at least two volunteer mediators in the courtroom for the landlord/tenant and small claims calendars. Our mediators who perform the court house mediations are provided with special advanced training on handling such cases. We mediate domestic, civil TRO, debt collection and other types of disputes at our office in The Hilo Lagoon Center. The atmosphere at the office is professional, but comfortable, in order to foster a feeling of safety and calmness. All clients are treated with respect and are assured that their dispute is important and their information will remain confidential. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 9 Our foreclosure conflict resolution services include making sure both sides receive all of the documentation needed. In many cases the conflict resolution focuses on how the borrower can move out with some dignity and minimal upset such as negotiating more time so that the children can finish the school year at their current school. Our funding challenges have been great over the last couple of years. Our Judiciary funding is down over 20%. We are finding that a significant number of the clients who we are allowed to charge, cannot pay any of the mediation fee due to unemployment. Also, our individual contributors have been unable to meet the level of contributions they made in the past. However; despite severe cutbacks in staff, we have been able to take on 363 new cases and served over 778 clients in this last fiscal year. The good news is that even in these grim economic times, our clients are very impressed with our services. More than 93% of our clients were very satisfied or satisfied with our services. Even better, 99% of our clients would recommend mediation to others. Our volunteer mediators spent over 620 hours in mediation sessions last year and countless other hours assisting in training sessions. We trained 28 new mediators. We have a pool of over 65 mediators reflecting a diverse and dedicated group of volunteers. Total Budget and Position Count Total Program Budget $128,000 Total Program Position Count 2 Total Agency Budget $128,000 Total Agency Position Count 2 Program Objectives: 1) Reestablish a peer mediation/anti-bullying in-school program. 2) Provide more assistance to couples separating/divorcing who are unrepresented by counsel through expanded training of our mediators and outreach efforts. 3) Increase the number of cases that we receive prior to court actions being filed. Program Highlights: (from Fiscal Year 2010-11) 1) We provided 128 hours of training to peer mediators. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 9 2) Our domestic cases resulted in workable visitation plans involving over 100 children. 3) 130 of our cases were resolved by agreement avoiding litigation. 4) 99% of our clients would definitely or probably recommend our services to others. 5) We directly served 778 clients and indirectly served many more than that by providing the benefit of a conflict free home, workplace or neighboorhood. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 9 Ku'ikahi Mediation Center - Agency Name Community Conflict Resolution - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate cases served 436 575 600 peer mediation training 0 hours 150 hours 200 hours clients served 878 900 950 clients who would recommend 99% 99% 99% outreach events 6 6 8 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages $64,489.11 $66,828 $70,000 Professional Fees $3,378.77 $4,100 $5,000 Operations $50,360.23 $51,057 $53,000 Equipment 0 0 0_ Other# 0 0 0 Total $118,228.11 121 ,985 $128,000 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 9 Ku'ikahi Mediation Center - Agency Name Community Conflict Resolution - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Judiciary Contract $42,621.96 $42,331 $42,331 Fees generated $22,162 $13200 $13,200 Fundraising and Contributions $18,906 $24,200 $24,200 Hawai'i Justice foundation $4,250 $4,250 $4,250 County of Hawai'i $17,700 $11,000 $15,000 HIUW $12,000 $10,000 $10,000 Atherton Family Foundation $5,000 $5,000 $5,000 other $20,000 $20,000 Total $122,640.48 $129,981 $133,981 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? We are working to increase our commercial mediations for which we can charge fees and we are expanding our fundraising to include more events that are less costly to the agency. We are collaborating with UHH to assist us with training and event expenses. We anticipate the program will become self-sustaining in 5 years if the economy recovers soon. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Not aware of any such affiliation. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 9 Ku'ikahi Mediation Center - Agency Name Community Conflict Resolution - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 9 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. &q\j1/4) 31 o Signatu e of Board President/Chair ate or Agency Director )3 / eo Signatur' of Executive Director Cate UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 9 69 Legal Aid Society of Hawaii Removing Legal Barriers for Hawaii County's Vulnerable Populations Legal Aid Society of Hawaii County of Hawaii Nonprofit Grant Application (Copyl) • Legal Aid Society of Hawaii- Agency Name Removing Legal Barriers for Hawaii County's Vulnerable Populations- Program Name Agency Director: M. Nalani Fujimori Kaina, Executive Direcotr Phone No.: (808)527-8014 Contact Person: Joanna Sokolow, Managing Attorney Kona Office Phone No.: (808)329-3910 ext. 221 Mailing Address: 924 Bethel Street Honolulu, HI 96813 Facility/Site Address: 75-5656 Kuakini Highway Kailua-Kona, HI 96740 305 Wailuku Drive Hilo, HI 96720 Fax No.: (808)334-9650 Email Address: josokol @lashaw.org Name of Accountant/CPA (include name of firm if applicable): Wayne Keawe, Comptroller Phone No.: (808)527-8060 Mailing Address: 924 Bethel Street Honolulu, HI 96813 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$40,000.00 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $0 $0 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 13 Agency Mission Statement: The Legal Aid Society of Hawai'i (Legal Aid), a community-based, nonprofit law firm has empowered low-income and disadvantaged people throughout the state for over 60 years. Legal Aid is the only legal service provider in the state, and one of the few non-profits, with statewide coverage through ten offices on each of the islands, from Lanai to urban Honolulu. Legal Aid has two offices which provide full coverage on the island of Hawaii. The Hilo Office was original established in the 1950's by the County of Hawaii as a legal aid/public defender program. Legal Aid assumed operation and the office is now a vital part of the Hilo community providing free legal assistance to low- income individuals and families. Legal Aid opened its Kona Office in 1979 with one paralegal. The Kona office has since grown to include attorneys and a paralegal and similarly to the Hilo Office provides assistance in the areas of consumer, family, public benefits, housing, and senior law cases. For those who are most vulnerable in our society, legal advocacy from a trusted community resource can mean the difference between receiving food and shelter, being able to visit and ensure the safety of their children and be protected from fraud and predatory consumer practices. Legal Aid's services act as a safety net to ensure that those most disenfranchised have access to the legal system and help to achieve access to justice for Hawai'i's low-income individuals and families. Both the Hilo and Kona Offices continue to be guided by Legal Aid's mission - to achieve fairness and justice through legal advocacy, outreach and education for those in need. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 13 Legal Aid Society of Hawaii- Agency Name Removing Legal Barriers for Hawaii County's Vulnerable Populations- Program Name Program Description: Legal Aid requests $40,000 in funding to provide critical civil legal services in the Hilo and Kona offices ($20,000 allocated to each office). As the demand for Legal Aid's services increases, the organization faces a dramatic reduction in funds from major funding sources including Legal Services Corporation, Legal Aid's largest funder, and the State of Hawaii. Now more than ever Legal Aid needs support to continue to provide access and justice for Hawaii's low to moderate income individuals and families in the County of Hawaii. Legal Aid will provide free legal services to low-income individuals with household incomes less than 125% of the poverty level. According to the 2010 American Community Survey, more than 13.92% of our state's population lives below 125% of the federal poverty guidelines and is eligible for Legal Aid's services based on their income. The Census Bureau's Small Area Income and Poverty Estimates (SAIPE) Program estimates the number of people living in poverty in Hawaii County as 33,285, or 17.98% of Hawaii County's total population. These statistics confirm that there is an even greater need for free civil legal services for Hawaii County's low-income individuals and families. The Preamble of the United States Constitution states, 'We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America." The Constitution establishes Justice as a citizen's fundamental right to secure prosperity, however low income and working poor citizens are often unable to access the legal system. Author Deborah L. Rhode says, "No issue presents a more dispiriting distance between America's core principles and actual practices than access to justice. We embrace equal justice as a social ideal, but fail to make even minimal access a social priority."1 The effects of increased poverty are widespread throughout Hawaii: more people are losing their homes to foreclosure with Hawaii ranking 10th in the nation for foreclosures2, there is an increase in homelessness with 14,000 people utilizing shelter services or accessing homeless outreach programs3, and in 2010 1 Rhode,Deborah,L.Access to Justice. New York;Oxford University Press,2004.Print. 2 August 2010 RealtyTrac figures:http://www.bizjournals.com/pacific/stories/2010/09/13/dai1v32.html 3 Homeless Survey Utilization Report 2010), NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 13 more than 133,043 people in the state of Hawai'i received supplemental nutritional assistance program (food stamp) benefits4. In a 2007 report, Achieving Access to Justice for Hawai'i's People: The 2007 Assessment of Civil Legal Needs and Barriers of Low and Moderate-Income People in Hawari,5 key findings discovered that: • Only 1 in 5 low and moderate-income Hawaii residents have their legal needs met. Legal service providers are able to help only 1 in 3 of those who contact them for assistance. • The areas with the greatest unmet civil legal needs are housing (24%), family (23%), domestic violence (8%), and consumer (7%). • Significant barriers to obtaining legal assistance in addition to inability to afford an attorney includes language and cultural barriers, lack of knowledge of one's legal rights, lack of knowledge of available legal services, and difficulty in accessing legal services programs. • There is one legal service attorney for every 2,291 persons living below 125% of the federal poverty guideline. • There is one legal service attorney for every 4,402 persons living below 200% of the federal poverty guideline. • There is one private attorney for every 361 persons in the general population. Since this report, the total number of people living below 200% of the federal poverty guidelines has increased by 8.52%. In 2011, responding to the demand for services, Legal Aid's attorneys and paralegals in Hawaii County closed 1,330 cases affecting the lives of over 2,500 children, adults and seniors. Through this grant Legal Aid will provide critically needed legal services to Hawaii County's residents to: • Maintain or secure affordable housing • Help families become safe and stable with family law services, including protection from domestic violence, child custody and support • Protect families and individuals from consumer problems such as mortgage "rescue" scams or illegal debt collection practices • Obtain public benefits such as disability benefits from the Social Security Administration or Medicaid • Eliminate illegal barriers to housing • Secure appropriate placement and services for abused and neglected children • Provide critical legal services to assist immigrants who are the victims of violence or trafficking • Ensure language access for non-English speakers. 4 http://hawaii.gov/dhs/self-sufficiency/benefit/FNS 5 http://www.legalaidhawaii.org/HUI_Accessto Justice.pdf. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 13 • Our intent is to provide the widest breadth of civil legal services possible to meet the needs of Hawaii County. By assisting residents with their critical civil legal issues, Legal Aid can help them resolve their problems to meet their basic necessities like maintaining housing, stabilizing their families, avoid unfair acts and deceptive consumer practices, gain access to public assistance when they are unable to work, secure placement for abused and neglected children, and provide assistance to immigrants and those who are vulnerable because English is their second language. By removing these barriers, Legal Aid's services can greatly assist individuals and families in Hawaii County to thrive and improve their lives. This grant would enable Legal Aid to provide a wide array of legal services not funded by any other specific grants, to ensure assistance to Hawaii County residents especially in times of decreased funding from federal and state resources. Total Budget and Position Count Total Program Budget $40,000.00 Total Program Position Count 10 Total Agency Budget $5,524,755.00 Total Agency Position Count 88.5 Program Objectives: Under this grant, in FY13 Legal Aid will provide screening, intake, counsel and advice, brief services and/or full representation in 75 cases. The following services will be provided free to low-income individuals and families whose incomes are less than 125% of the poverty level. 1. Provide support for families (26 cases): Assist clients with child custody, child support, domestic violence, visitation, paternity and divorce. A domestic violence victim may require assistance in obtaining a temporary restraining order or establishing temporary custody, visitation, and support. Paternity cases are accepted to determine custody, visitation, and child support rights and obligations. 2. Keeping children safe and secure (3 cases): Assist with guardianships and adoptions; and advise family members and others about their rights and responsibilities in caring for abused and neglected children. 3. Preserving the home (10 cases): Assist clients with private landlord eviction defense or negotiation; foreclosure assistance; mortgage predatory lending practices, public housing applications, evictions, grievances, rent issues, security deposits; and, habitability, repairs, illegal lockouts, or illegal utility shutoff. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 13 4. Maintaining economic stability (16): Provide assistance with denials, appeals and terminations of General Assistance, Temporary Assistance for Needy Families (TANF), SNAP (fka Food Stamps) and other public benefit programs. Unemployment and Veteran's benefits are also areas in which assistance is provided. Public benefits may be the only source of income for an individual or family. 5. Protecting consumers (8): Assist clients with consumer issues including predatory lending, debt collection, bankruptcy, consumer credit matters, repossession, and unfair or deceptive practices. 6. Promoting safety, stability and health (12): Provide assistance with program denials of services or eligibility as well as terminations from the health insurance programs, district court restraining orders, individual rights, immigration, powers of attorney and advance health care directives. An applicant will be screened for services through the intake hotline which determines if the applicant is income and asset qualified for services, ensures there are no conflicts of interest, ensures the applicant is a citizen of the United States, legal resident alien or immigrant victim of crime and finally determines if Legal Aid can assist with their legal issue. If an applicant is not qualified for services, the intake worker attempts to find an appropriate referral to an organization or agency that can help the applicant further. Applicants who are qualified for services receive basic counsel and advice at the time of intake and their case is forwarded to the Hilo or Kona office for further assistance. The Hilo or Kona office will then assess the case and determine whether there are merits to the case and if staff is available to assist the client. Through the support of this grant, Legal Aid intends to provide critically-needed legal services to 75 individuals and families in Hawaii County. The proposed objectives reflect an average cost of $533 per case which can involve hours of assistance in a contested custody case, foreclosure defense, help in getting access to public assistance, assisting a victim to get a temporary restraining order, or getting a temporary power of attorney to care for a relative's child. Assistance will be provided by either an attorney or paralegal, depending on the nature of assistance needed. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 13 • Program Highlights: (from Fiscal Year 2010-11) In FY2011, Legal Aid's Hilo and Kona offices assisted more than 1,330 low- income individuals and families on the island of Hawai'i in the following priority areas: Hilo Kona Total Support for Families 217 246 463 Keeping Children Safe and Secure 19 17 36 Preserving the Home 41 43 84 Foreclosure Prevention 0 2 2 Maintaining Economic Security 333 137 470 Protecting Consumers 35 15 50 Promoting Safety, Stability and Health 179 42 221 Miscellaneous 3 1 4 Total 827 503 1330 To enable clients to maintain economic security, Hilo and Kona staff assisted 217 disabled individuals with their denials, appeals or terminations of their SSI benefits. Over 409 individuals and families were assisted with family law issues including custody, visitation and child support to provide support for families. Often without the assistance of Legal Aid, many of these individuals would not receive assistance which could result in homelessness, abuse of a child or domestic violence victim, or financial instability. The impact of Legal Aid's services upon the community is best exemplified by client testimonies: Hilo: - I appreciate so much the work Legal Aid does and it's so important - Nothing but the highest praises for Mr. Donald Thomas. Thank you for helping me get Social Security Disability. Kona: - They helped me with my divorce papers up until the end and they were very courteous. - The Legal Aid attorney made us understand all issues and concerns. If other people would ask me, I would recommend Legal Aid if they qualify. The Hilo and Kona Offices of Legal Aid have also received feedback from State Agencies and other community advocates. In September 2011, Legal Aid's Hawaii County offices were audited by County of Hawai'i's Office of Aging. They found, "Based on the review, Legal Aid is doing an outstanding job in the Senior Citizen Program (SCP). Mr. Hite and Ms. Barr appear very passionate about helping the kupuna on the Hawaii Island and both of them present Legal Aid with the utmost efficiency and professionalism." NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 13 In October 2011, staff members conducted 166 interviews with stakeholders throughout Hawaii including clients, government officials, social service providers and private attorneys. One stakeholder from Hawaii County said that Legal Aid is "very helpful; without [Legal Aid] services clients would get lost in the system." Another stakeholder shared, "Legal Aid serves as many people as possible who are low income or wouldn't get services otherwise. Legal Aid is dedicated to the community, takes initiative, and looks for better ways to serve the community." Legal Aid remains dedicated to providing high quality legal services to low- income individuals and families on the island of Hawaii. Given the natural isolation barriers presented to an island community, maintaining two offices to meet the needs of Hawaii County is the only way to effectively address this client population's needs and support from this grant will continue to assist Legal Aid to do so. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 13 Legal Aid Society of Hawaii- Agency Name Removing Legal Barriers for Hawaii County's Vulnerable Populations- Program Name Performance Measures: Legal Aid will provide counsel and advice, brief service or full representation to qualified low-income individuals in the following areas: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Assistance with family law issues including custody/visitation, divorce, guardianships, domestic abuse, 26 child support, etc. to Provide Support for Families Assistance with adoptions, power of attorneys regarding child custody, and minor guardian/conservatorship 3 cases, etc. to Keep Children Safe and Secure Assistance with housing issues including homeownership, landlord/tenant issues, public housing, housing discrimination and 10 mortgage foreclosures, etc. to Preserve the Home Assistance with issues to help an individual Maintain Economic Stability like applying for TAN F, 16 General Assistance benefits, and food stamps, etc. Assistance to Protect Consumers through bankruptcy assistance, collection and predatory lending 8 cases, and other consumer/finance issues. Assistance with immigration and human tracking, TRO's in District Court, Advanced Health Care Directives, Power of Attorneys and 12 others issues related to Promoting Safety, Stability and Health. Total 75 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 13 Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 35,500 Professional Fees 0 ' Operations 4,500 Equipment 0 Other" 0 Total 40,000 *If applicable "Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 13 Legal Aid Society of Hawaii- Agency Name Removing Legal Barriers for Hawaii County's Vulnerable Populations- Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate County Grant-In-Aid 40,000 LSC 427,214 Total 467,214 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Legal Aid continues to apply for federal, state and other grants in the hopes of continuing to provide needed services to low-income individuals and families in need on the island of Hawaii. In 2011, the Governor signed into law an increase in the Indigent Legal Assistance surcharge, a fee which is added when a case is filed, however full benefit from this increase will not be seen until 2016. Funding through this County Nonprofit Grant will assist Legal Aid in bridging the gap in funding until which time the benefit of this increase is achieved. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Staff in the Hilo and Kona Legal Aid Offices do not have any affiliations with the County of Hawaii. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 13 Legal Aid Society of Hawaii - Agency Name - Program Name, / I / r .v r. -arc d- -t, 6 `�-oAr I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a qrant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page bof 1j Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. PF6-.117\ Signature of Board President/C31'<(air Date or Agency Director lll� Signat, re o - ecutive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page0of !; 70 Lyman Museum Education and Public Programs Lyman Museum- Agency Name Education and Public Programs- Program Name Agency Director: Richard Henderson Phone No.: 935- 5021 Contact Person: Barbara Moir Phone No.: 935-5021 Mailing Address: 276 Haili Street Hilo, HI 96720 Facility/Site Address: 276 Haili Street Hilo, HI 96720 Fax No.: 969-7685 Email Address: bmoir @lymanmuseum.org Name of Accountant/CPA (include name of firm if applicable): Alex Smith, CPA Phone No.: 808-737-7761 Mailing Address: 1403 Frank Street, Honolulu, HI 96816 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $40,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $20,000 $20,000 $10,000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 11 Agency Mission Statement: "To tell the story of Hawai'i, its islands and its people." The Museum exists to: Collect, preserve, and exhibit artifacts, artwork, and memorabilia relating to the culture, art, and historical heritage of Hawai'i; Educate and encourage awareness in these areas through visually exciting and interpretive exhibitions, informative tours, special programs, and activities; Serve as a learning resource center for those seeking information, entertainment, and knowledge; Fully extend itself to the public in order to instill community pride and support; Maintain a high standard of excellence and professionalism, seeking to improve, progress, and realize its full potential as a museum. The Lyman Mission House and Museum, founded in 1931, consists of the Lyman family home, first built in 1839, and a modern museum building constructed in 1973. The restored Lyman Mission House is furnished to depict missionary life in Hilo in the period 1840 to 1880. It is a reminder of a devoted band of men and women who dedicated their lives to bringing their Christian faith to the people of these islands and whose presence here exerted a profound influence on the development of these island communities. The adjacent modern Museum houses exhibits and presents programs and activities, including school tours and other group tours, designed to interpret the physical environment and ecology of the islands as well as the rich and varied ethnic heritage of our island people, that there may be a deeper understanding and appreciation of the human and ecological processes ongoing in the fiftieth state, in the heart of the Pacific Basin. The Museum's historical, cultural, contemporary, and environmental exhibits illuminate the following: 1. Hawaiian life prior and subsequent to European discovery 2. The Missionary period of 1840--1880 3. The traditional lifestyles of Hawaii's major immigrant groups 4. The natural history of Hawai'i, including its volcanos, flora, and fauna 5. Other aspects of ocean and earth science, such as Pacific shells and worldwide minerals NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 11 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 11 Lyman Museum - Agency Name Education and Public Programs- Program Name Program Description: Education and Public Programs at the Lyman Museum both reaches out to the community and draws it into the Museum, to "tell the story of Hawai'i, its islands and its people" through programs, events, and activities that educate and encourage involvement by the public. Such efforts include focused educational tours and other learning activities for students; docent training for school and public tours; dissemination of information to teachers about Museum school- related programs, as well as planning assistance; an annual agenda of lectures, demonstrations, performances, workshops, and other presentations for the community; and public programming specifically linked to traveling and special exhibits at the Museum. Total Budget and Position Count Total Program Budget 96,295 Total Program Position Count 2 Total Agency Budget 590,690 Total Agency Position Count 12 Program Objectives: 1) Conduct curriculum-appropriate school tours and other learning activities at the Lyman Museum for student groups of any grade level. 2) Provide teachers on the Island of Hawai'i with information about available Lyman Museum educational, school-related programs and how to access them; provide one-to-one assistance to these teachers and schools in planning, organizing, and customizing their Museum experience to best meet the curricular needs of their students. 3) Train docents to lead school and public tours appropriate to different age groups. 4) Publicize and carry out an annual public program for adult members of the community, with semi-monthly lectures, performances, workshops, demonstrations, and other presentations. 5) Develop, publicize, and present special programming for each traveling or special exhibit at the Museum. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 11 Program Highlights: (from Fiscal Year 2010-11) 1) Serviced more than 1900 students with docent-led school tours and hands-on learning workshops (this number would have been higher were it not for Furlough Fridays, reduced instructional days, and the general economic downturn). 2) Trained 5 docents for Lyman Museum school tours. 3) Disseminated Lyman Museum educational program information, and provided one-to-one planning assistance, to 238 school teachers. 4) Presented 14 educational workshops and East Hawai'i community tours to 177 members of the public. 5) Presented 28 public programs relating to special exhibits and other Hawai'i-relevant topics, to more than 1200 members of the community. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 11 Lyman Museum - Agency Name Education and Public Programs - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Service students with school tours 1913 2200 2300 & workshops Train new docents for school tours 5 4 4 Provide public programs 28 34 43 Service community members with 1228 1350 1500 public programs Disseminate Lyman Museum 238 275 300 education to teachers Conduct educational workshops for 6 14 16 students Conduct special exhibit-related 2 10 6 programs Disseminate Lyman Museum public 600+ 750+ 850+ program information to community members (*actual recipient counts will be much higher, w/info sent electronically & by broadcast as well as print & social media, to exponentially larger audiences) *If applicable NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 11 Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 70,070 70,070 70,070 Professional Fees 3,150 3,525 4,225 Operations 22,000 22,000 22,000 Equipment 0 400 0 Other# 0 0 0 Total 95,220 95,995 96,295 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 11 Lyman Museum - Agency Name Education and Public Programs - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Private donation for public 5,000 5,000 5,000 programming Friends of Hawaii Charities grant 0 5,000 0 County Nonprofit Grant funds 20,000 10,000 40,000 Lyman Museum Operations funds 67,070 74,820 51,295 (earned income, donations, endowment allotment) Total 92,070 94,820 96,295 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? By offering a regular calendar of public programs scheduled and prominently publicized in advance, the Museum anticipates being able to increase paid memberships which allow free or reduced-cost admission to such programs. Educational services, on the other hand, are never self-sustaining in that they are offered as a public service. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 11 Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Mr. Warren Lee, a (volunteer) member of our Board of Trustees, is also Director of the County's Department of Public Works. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 11 Lyman Museum - Agency Name Education and Public Programs - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 11 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. C/-3 6 Signature of Board President/Chair Date or Agency Director I , Cs( - c3o_. 2c( 2- Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 11 71 Malama 0 Puna Jr. Live Saving MALAMA 0 PUNA- Agency Name Jr. Life Saving- Program Name Agency Director: Rene Siracusa Phone No.: 965- 2000 Contact Person: Rene Siracusa Phone No.: 965- 2000 Mailing Address: POB 1520. Pahoa, HI 96778 Facility/Site Address: 15-2929 Pahoa Village Rd., Pahoa, Hi 96778 Fax No.: none Email Address: matamaopuna @yahoo.corn Name of Accountant/CPA (include name of firm if applicable): none Phone No.: Mailing Address: You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$2,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $1,000 $ $ NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 9 MALAMA 0 PUNA - Agency Name Jr-. Life Saving- Program Name Program Description: This program is designed for at-risk youth 8 to 18 years of age. Enrolment is for about 30 students per session. The County P&R's Jr. Lifeguard Program takes place in the summer, so our program has sessions in fall, winter and spring. Each session consists of 3 consecutive weekends, Saturday and Sunday. First, the program assesses each student's swimming skills to determine if the student is eligible (this is not a swimming class-the students must already be good swimmers). Each class takes place at a different East Hawaii location so that the students become familiar with different pool and ocean conditions. Students are taught basic life saving skills, use of life saving equipment, first aid, CPR, Heimlich Maneuver, artificial resuscitation, use of available water transport (kayaks, canoes, surfboards, etc.)to reach a drowning victim quickly. They are also taught how to keep their bodies strong and healthy by fostering healthy eating and discouraging use of cigarettes and drugs. There is a strong civic responsibility component to the program. We have run this program since 2003 and many of our'graduates' now work as life guards, EMTs and firemen with the County. The costs of the program include mileage, as we carpool the students to and from various coastal areas; also healthy snacks before each class to prevent hypothermia, and nutritious lunches. We also teach Hawaiian values that encourage them to value the ocean and the coastal environment. Total Budget and Position Count Total Program Budget $2,000 Total Program Position Count 12 Total Agency Budget $5,000 Total Agency Position Count , 2 Program Objectives: 1) We are an island, so a critical survival skill is knowing how to swim well and help those who find themselves in distress in the water. The younger we start training young people, the more ingrained the skills and the kokua mindset. Students who choose to take the class are already interested in helping others and enjoy the ocean. These are interests that should be encouraged and enhanced by proper training and mentoring under the oversight of positive role models, not only to prevent antisocial behavior from developing, but keeping the future needs of our community in mind. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 9 MALAMA 0 PUNA - Agency Name Jr. Life Saving - Program Name Performance Measures: FY 2014-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate healthy snacks, lunch, serving items 339.69 525.00 750.00 copying costs and outreach 28.64 45.00 60.00 rental fees (canoes, sailboats, etc.) 160.00 240.00 300.00 volunteer&mentor mileage 480.11 720.00 885.00 postage .39 5.00 5.00 Note: FY 2010-11 was only for 2 sessions, so costs were lower. Prices for food &gas have gone up since last year. 1 1,008.83 1,535.00 2,000 *If applicable Prcaram Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages Professional Fees Operations 1,008.83 1,535.00 2,000.00 Equipment Other* Total 1,008.83 1.535.00 2,000.00 *if applicable *Please explain in detail on separate sheet • NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 9 kids to different East Hawaii locations to give them experience with different ocean conditions, so mileage is an important overhead for the program. If we find a grant to help fund the program, we will certainly apply for it. However, I have been a grantseeker for many years and have not yet found one for this sort of program, so I cannot envision the program becoming self-sustaining. However, ex-Fire Chief Darryl! Oliveira was very supportive of our program because he knew that many of his staff had taken part when they were younger, so the program helps to provide our future emergency responders. Please disclose(list here)any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. I was formerly a vice-chair of the Planning Commission and chair of the 2011 Redistricting Commission. I am currently starting a 4-year term on the Puna Community Development Plan's Action Committee. AU are volunteer positions. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 9 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Signature of Board President/Chair Date or Agency Director /Vt/ Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 9 MALAlMA 0 PUNA Jr. Life Saving PROGRAM EXPENDITURE NAR ATIVE In 2009 we only ran two sessions, in March and October, so our program costs were less. That was a Council Contingency grant that was run through the Fire Dept. In the past we also received funding from the Healing Our Island grants program, which has since been discontinued. We want to do three sessions this time,so that returning students do not forget what they learned previously or lose their muscular development and coordination. And of course prices have soared since then,so this accounts for our request to increase the funding to $2,000. Our mileage is to defray the administrative mileage costs during the planning stages,as well as to help our volunteers and mentors who will be driving the kids to various locations in East Hawaii. The kids have to experience various ocean conditions,such as sea cliffs,sandy beaches, bays,tide pools,mud flats, etc.),so they will know how to enter the water properly and what to look for.Although many of our volunteers and mentors are professionals who can command much higher reimbursement rates,they will receive a flat per diem. The outreach includes copying costs of press releases, posters and flyers announcing the program, reports to the county,curriculum materials, parental consent forms and waivers of liability forms, photos for our final report, etc. Much of this will be done in-house at the Malama 0 Puna office, and so includes the cost of paper and ink-jet cartridges. The rental fees include the fee charged by Parks&Rec for the use of the Pahoa pool, rental of the Hawaiian canoe from the canoe club (although the mentors who give the talk on Hawaiian "ah; a 4 ,=3lthit e s)and the ;:tai of the Sunfish sailboats from the Hilo Yacht Club(also wt!.Y. c .,olt:ntee-:^ troctc We r^:y also rent a TV so that we can show American Red Cross and Civil Defense videos-we already own the CDs. In the past we have sometimes exceeded our budget,and Malama 0 Puna has picked up the difference. We do not plan on purchasing any equipment,with the possible exception of a first aid kit,which is not budgeted. If we come in under-budget elsewhere we would like to reserve the right to shift those funds to the purchase of a first aid kit. Malama 0 Puna does not have an Executive Director. 1 have therefore deleted that title on the signature page. If you have any questions about the program or budget, please contact me at 965-2000. mahalo and aloha, Rene Siracusa, President 72 Malama 0 Punaj Puna Panthers Malama 0 Punaj- Agency Name Puna Panthers- Program Name Agency Director: Ren'e Siracusa Phone No.: 965- 2000 Contact Person: R. Kaipo Like Phone No.: 345-8428 Mailing Address: POB 1520 Pahoa, HI 96778 Facility/Site Address: 15-2929 Pahoa Village Rd., Unit 1 Pahoa, HI 96778 Fax No.: Email Address: malamaopuna @yahoo.com, rkruse @hawaii.edu Name of Accountant/CPA (include name of firm if applicable): none Phone No.: Mailing Address: You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $20,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $0 $0 Agency Mission Statement: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 9 The mission of the Puna Panthers is to enable young people to benefit from participation in team sports and physical activities in a safe and structured environment. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 9 Malama 0 Puna - Agency Name Puna Panthers- Program Name Program Description: This program was first started through monthly Big Island Pop Warner Football Conference meeting on November 10, 2009 where a submitted letter of intent to all association presidents asking for permission to field a team in Pahoa for the up coming (2010) football season. It was unanimously voted in and the initial struggle was the realization that we needed to purchase equipment and uniforms for 70 youth athletes which was estimated at $40,000.00. The following March of 2010 kicked off the inaugural flag season and had roughly 80 youth participants ages 5-13. In August we started the tackle season fielding a Mitey Mite and PeeWee division teams ages 7-9 and 9-12 respectively. March 1, 2011 the Puna Panthers kicked off the 2nd year of flag, this time enrollment was 120 youth athletes fielding 6 teams total. 2 teams in each division from ages 5-13. On August 1, 2011 we kicked off the 2nd year of tackle football and had an enrollment of 51 athletes. The Mitey mite and PeeWee division teams had very successful seasons. The largest obstacle is maintaining enough finances to carry through a full season. This could also be taken as an accomplishment in that the start up cost over the last 2 years has been in the area of$65.000.00 to $70.000.00 which was successfully raised. These finances are mainly to purchase equipment and uniforms for 70 youth participants as well as paying yearly dues to the Big Island Pop Warner Football Conference and referee fees which is approximately $8500.00 per year. The plan is to expand the organization to include a midget division ages 12-15 which would increase the amount of finances needed. This obstacle is going to cost an additional $22.000.00 to purchase equipment as well as uniforms for another 35 youth participants. This division is the oldest division Pop Warner offers and is aimed to transitions these athletes into a high school program. The ultimate goal of the Puna Panthers Pop Warner organization is to feed the Pahoa high school football program which should be up and running by 2014. Insurance for the Puna Panthers is not covered by the fiscal agent, but by the Pop Warner organization. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 9 Total Budget and Position Count Total Program Budget 22,000 Total Program Position Count 0 Total Agency Budget 5,000 Total Agency Position Count 2 Program Objectives: 1) To provide fun athletic learning opportunities for youths, while emphasizing the importance of academic success.. 2) To ensure a safe and positive playing environment for all participants. 3) To promote pro-social skill development and instill life-long values of teamwork and dedication. Program Highlights: (from Fiscal Year 2010-11) 1) The PeeWee division team was crowned the 2010 east Hawaii champs in 1st season of play. Outstanding accomplishment for being a brand new team 2) The 2010 season ended with the Puna Panthers participating in the annual Pahoa Christmas Parade with Mayor Billy Kenoi riding along with the players. 3) The Mitey Mites finished 1st place in the 2011 East Hawaii conference and the Peewees were crowned 2011 Big Island champs and represented the Island of Hawaii in the regional playoff game. Finishing the 2011 season as Big Island Champs and 2nd place in the State of Hawaii. 4) The 2011 season ended with the Puna Panthers participating in the annual Pahoa Christmas Parade and winning 1st place for their float as State Champions. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 9 Malama 0 Puna - Agency Name Puna Panthers - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * _ Budget* Estimate 80 Youth develop procial skills and 0 0 90% leadership 90 Youth to participate in a safe 0 0 95% environment that promotes dedication. *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 0 _ 0 _ 0 Professional Fees 0 0 0 Operations 0 0 15000 Equipment 0 0 3000 Other# 0 0 2000 Total 0 0 20,000 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 9 Malama 0 Puna - Agency Name Puna Panthers - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Program Registration 9500 10200 10000 Fundraising 7000 5700 7000 Donations 17000 9000 5000 Total 33500 24900 20000 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The goal is to become self-sustaining by 2014 The program plans to increase revenue through: 1) Fundraising 2) Soliciting community resources, through collaborations. 3) 2Grant writing Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawai`i. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 9 The president of the fiscal agent, Ren'e Siracusa, was formerly vice-chair of the Hawaii County Planning Commission and served as chair of the 2011 Redistricting Commission. She is currently serving a 4-year term on the Puna Community Plan's Action Committee. During the Yamashiro administration she served on the Mayor's Puna Parks Advisory Committee. All are voluntary positions. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 9 Malama 0 Puna - Agency Name Puna Panthers - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 9 Any funds unused by June 30, 2013 must be returned to the County of Hawari within 30 days (July 30, 2013). Failure to return these fynds.in a timely manner will itrpact the evaluation of our asenc 's future fundin reeuest and ma result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Signature of Board President Date cf2,,SL-1 • (A)e.4 47ay Signature of Exe utive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NON PROFIT GRAN I' APPLICATION FISCAL YEAR 2012-13 Page 9 of') 73 Malamalama Waldorf School Culture and Arts Specialty Program Malamalama Waldorf School- Agency Name Culture & Arts Specialty Program- Program Name Agency Director: Kehaulani Costa Phone No.: 808- 982-7701 Contact Person: Kehaulani Costa Phone No.: 808- 982-7701 Mailing Address: HC 3 Box 13068 Kea'au, HI 96749 Facility/Site Address: 15-1834 Maku`u Dr. Kea`au, HI 96749 Fax No.: 808-982-7806 Email Address: admin @hawaiiwaldorf.com Name of Accountant/CPA (include name of firm if applicable): ChrisHannigan, Midnight Oil, Inc. Phone No.: 808-930-4024 Mailing Address: 1416 Kuulei St. Hilo, HI 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$25,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $--00-- $--00-- $--00-- NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 9 Agency Mission Statement: The mission of Malamalama Waldorf School is to improve the quality of the educational experience by providing Waldorf Education in East Hawaii. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 9 Malamalama Waldorf School - Agency Name Culture & Arts Specialty Program- Program Name Program Description: Malamalama Waldorf School offers a range of culture and arts specialty classes to students in Kindergarden through Grade 8. These classes include Hawaiian Studies, Spanish Language, Ukulele, Violin, Chorus, Handwork, Drama , Art Instuction, and Movement Education. Specialists in each of the content areas provide students with supplemental lessons which enhance the school's curriculum as well as increasing the students' exposure to arts and culture. Specialty classes enrich the overall educational experience. A sampling of specialty classes a described here; although MWS will also offer classes based on the availabilty of local specialist and artists. Handwork, which encompasses skills such as knitting, crocheting, sewing and weaving, involves cross body movement which studies have shown to help connect right and left brain cognitive development. Students work with color, shape, patterns and textile variation to create beautiful and functional products. In addition to strong neural connections, handwork helps students develop fine motor skills as well as an appreciate for aestheics. Students are proud of their completed work which are placed on display during school Open House as well as community art programs such as Young at Art at the East Hawaii Cultural Center. Violin and Ukulele typically begin in the fourth grade. Student are introduced to musical concepts and can learn to read written music. Students gain understanding of harmony and timing and learn to play intricate parts for various songs from modern to classical genres. Second language introduction, both Spanish and Hawaiian, is taught from Kindergaten through the 8th Grade. Classes the first few years are oral; incorporating games, rhymes and songs. Written work and grammar begin in 4th grade, progressing to some literature-based work in the middle school years. Learning a second language allows children to become open and curious about cultures other than their own. Learning the Hawaiian language allows children to identify with our local culture and to develop as sense of place in our students. Movement Education such as sports and games allow the students to develop a healthy sense of self and space and to move with intention. The early grades offer social and rhythmic games, circle games, hand-clapping games, bean bag activities, and jump ropes. The emphasis of games in the early grades is on working together as a group, and the games become increasingly more NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 9 individualized in the middle school years. The 5th grade learns the events of the Greek pentathlon: javelin, discus, long jump, wrestling, and running. In May, they join other Waldorf schools in a Pentathlon event held at the Haleakala Waldorf School in Maui. Sixth grade brings a focus on medieval games, with a similar contest of area Waldorf schools held at Camp Mokuleia on O`ahu.. Malamalama Waldorf School (MWS) is a non-sectarian, non-denominational school established in 1978 and incorporated in Hawaii in 1979. It is the only independent school, pre-school through eighth grade, on the island of Hawaii which offers the internationally recognized Waldorf curriculum preschool through the eighth grade. The goal of a Waldorf education is "to produce individuals who are able, in and of themselves, to impart meaning to their lives." The mission of Malamalama Waldorf School is to improve the quality of the educational experience by providing Waldorf Education in East Hawaii. Malamalama Waldorf School is located in the Puna District of Hawaii County which, according to Hawai`i State statistics, has the highest level of children living in poverty in the state. Approximately 85% of Hawaii County's Section 8 low- income rental housing certificate holders are Puna residents. The school's campus is located in Hawaiian Paradise Park; a subdivision, with primarily unpaved roads, lacks sidewalks and lighting, and does not meet many current Hawaii County design standards. The subdivision does not have a centralized sewer system and most residents, including the school, rely on catchment systems for their water needs, needing to haul in drinkable water. For over 30 years MWS has put forward a tremendous effort to lovingly meet the educational needs of this rural and underserved population. The school meets this aim by incorporating the arts and hands-on learning activities in conjunction with academics while focusing on educating the whole child, head, heart, and hands. Total Budget and Position Count Total Program Budget 27,741 Total Program Position Count 6 Total Agency Budget 558,539 Total Agency Position Count 27 Program Objectives: 1) To achieve academic excellence while building a good foundation for the love of learning. 2) To nurture decision making skills and the ability to assume responsibility. 3) To encourage awareness and consideration of others. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 9 4) To develop the child's capacity to think creatively. 5) To help each child achieve a positive and healthy self-concept. 6) To develop the child's sense of community and an appreciation of democratic cooperation. 7) To cultivate the qualities of wonder, reverence, and gratitude. 8) To structure learning experiences so that the child learns enthusiatically. Program Highlights: (from Fiscal Year 2010-11) 1) Violin performance for Namaste's birthday at the Panaewa Zoo. 2) Student artwork showcased at East Hawaii Cultural Center, Young at Art. 3) Fifth graders participation at Haleakala Waldorf School annual Pentahlon 4) Sixth graders participation at Honolulu Waldorf School annual Medieval Games. 5) Public violin performances at Wailoa Art Center, Prince Kuhio Plaza. 6) Fourth and Fifth Grade performance of the Homer's The Odyssey. 7) Fifth and Sixth Grade performace of Shakespear's Much Ado About Nothing at East Hawaii Cultural Center. 8) Beauty Through the Eye of Our Children Museum of Art Children's Exhibition participation. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 9 Malamalama Waldorf School - Agency Name Culture & Arts Specialty Program - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Students will participate in 45- minute classes 2 x per week: Handwork 100% 100% 100% Spanish Language 100% 100% 100% Movement Education 100% 100% 100% Violin 100% 100% 100% Music 100% 100% 100% Students will participate in 45- minute classes lx per week: Hawaiian Language & Culture 0% 100% 100% Ukulele 0% 100% 100% Students will participate in one unit 0% of study (4-week focus) Art Instruction 0% 0% 100% Drama 100% 100% 100% *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 22,307 27,741 29,201 Professional Fees 1000 1000 1000 Operations Equipment 2150 2250 2375 Other# Total 25,457 30,991 32,576 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 9 Malamalama Waldorf School - Agency Name Culture & Arts Program - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Tuition and Fees 19,347 18,554 3,342 Donations 1,527 1,859 1,954 Fundraisers 1,783 2,169 2,280 Grants 2,800 8,409 25,000 Total 25,457 30,991 32,576 *If applicable Explain what plans your agency andlor program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Malamalama Waldorf school will continue to seek grant opportunities to increase revenue to this program. Student tuition and fees help to support this program. As enrollment increases the program will become self-sustaining. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. No know affiliations at this time. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 9 Malamalama Waldorf School - Agency Name Culture & Arts Specialty Program - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai`i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 9 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. 7/ / / ? Signature of Boa d President/Chair Date or Agency Direc or 'v'442,14M , G�t�rr 1-3) - Zo I Z U Of� S gnature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 9 74 Mental Health KOkua Residential Rehabilitation Service Mental Health Kokua Residential Rehabilitation Services Agency Director: Greg Payton Phone No.: 737-2523 Contact Person: Gary Michell Phone No.: 331-1468 Mailing Address: 1221 Kapiolani Blvd., Ste 345, Honolulu, HI 96814 Facility/Site Address: 75-5752 & 75-5750 Alanoe PI., Kailua-Kona, HI 96740 140 Wainaku Avenue, Hilo, HI 96720 139 Amau Road, Hilo, HI 96720 Fax No.: 331-1378 Email Address: gmichell(a�mhkhawaii.orq Name of Accountant/CPA (include name of firm if applicable): Summer B. Such, CPA Phone No.: (808) 737-2523 ext 1107 Mailing Address: Mental Health Kokua 1221 Kapiolani Ave, Suite 345 Honolulu, Hawaii 96814 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $5,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $18,000 $10,000 $5,000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 7 Mental Health Kokua Residential Rehabilitation Services Agency Mission Statement: We believe that all citizens should have an opportunity to live and participate in and contribute to their communities. Through specially designed services, Mental Health Kokua helps those in Hawaii who are in mental distress, emotional crisis or recovering from serious mental illness achieve their optimum level of recovery and ability to function in the community. Program Description: Funding is requested for our transitional residential services, including PATCH (Psychosocial and Transitional Community Housing) Place and Hale Amau in Hilo, and Hale Alanoe and Kealahou in Kailua-Kona. Mental Health Kokua will offer 28 beds in Hilo and 14 beds in Kailua-Kona, a total of 42 beds from which recovery in the community can occur. Mental Health Kokua staff provide daily on-site supervision and rehabilitation services with the goal to enable clients to move on to more independent housing. While in placement, clients are assisted in acquiring personal and social survival skills necessary for sustained community living. Staff provide training and support in daily living skills and medication management while facilitating social, educational and recreational activities in the community. Clients are also assisted in making connections to community resources including mental health centers, vocational training programs, and community housing agencies, as well as assistance with long-term community placement. These projects provide cost effective, humane, community based alternatives to institutional care and/or homelessness. Transitional bed day costs for FY 2011 are estimated at $94. Comparative bed day costs in a psychiatric hospital are estimated at $800 to $1000 a day. Total Budget and Position Count Total Program Budget 1,067,026 Total Program Position Count 23 Total Agency Budget _ 7,885,598 Total Agency Position Count 219 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 7 Mental Health Kokua Residential Rehabilitation Services Program Objectives: 1) Provide residential and social rehabilitation services to 125 unduplicated persons with serious mental illness. 2) Show completion of identified treatment plan goals upon discharge by at least 80% of clients served. 3) Reduce the number of consumers requiring psychiatric hospitalization to less than 10% 4) Ensure 100% compliance of Commission on Accreditation of Rehabilitation Facilities (CARF) and other monitoring recommendations. 5) Show evidence of satisfaction with services received at least 95% of consumers served 6) Show improvement in daily living skill scores upon discharge in at least 90% of consumers served. 7) Place at least 90% of consumers served in more independent living settings following planned discharge Program Highlights: (from Fiscal Year 2010-11) 1) Provided transitional residential rehabilitation services in FY 2011 to eighty-seven (87) unduplicated clients at PATCH Place and Hale Amau in Hilo and twenty-six (26) unduplicated clients at Hale Alanoe and Kealahou in Kailua-Kona. 2) Discharged 74% of clients to more independent living in the community. All clients showed improvement in daily living skills. 3) Provided a total of 13,526 bed days and 27,052 meals in our transitional residential programs during FY 2011. 4) Successful in increasing community awareness of the residential rehabilitation services we provide on the Big Island through several activities/events. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 7 Mental Health Kokua Residential Rehabilitation Services Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Number of unduplicated consumers 113 118 125 served Percentage of consumers served 74% 75% 80% who were discharged to more independent living settings Number of consumers served 9 5 3 requiring hospitalization Percentage of consumer satisfied 95% 96% 98% with services *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 1,161,679 1,196,529 1,232,425 Professional Fees 27,801 27,801 27,801 Operations 381,375 381,375 381,375 Equipment Other# Total 1,570,855 1,605,705 1,641,601 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 7 Mental Health Kokua Residential Rehabilitation Services Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate County of Hawaii 10,000 5,000 5,000 State of Hawaii — DOH 1,214,276 1,214,276 1,214,276 United Way 20,371 20,371 20,371 Program Service Fees 163,826 163,826 163,826 Donation/Other 33,247 33,247 33,247 MHK Support 129,135 168,985 204,881 Total 1,570,855 1,605,705 1,641,601 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? During the more than 30 years of providing services to people with mental illness in Hawaii,Mental Health Kokua has been successful in building strong relationships with many foundations and trusts, which have become pivotal in providing funding for new properties and major renovations to existing properties. Grant funding to help support the general maintenance of our projects in Hilo and Kona has been received from G.N. Wilcox Trust, Bank of Hawaii Charitable Foundation, Hawaiian Tug & Barge/Young Brothers, Ltd., and Visitor Industry Charity Walk. Mental Health Kokua has demonstrated notable ability and success in obtaining funding from private sources such as trusts and foundations and special events and will continue to explore ways to become fully self-sustaining. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. None NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 7 Mental Health Kokua Residential Rehabilitation Services I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 7 Any funds unused by June 30, 2013 must be returned to the County of Hawai'i within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Signature of Board President/Chair Date or Agency Director ,r—)6-i4\ 1/0/( -1_ Signature Execu ve Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 7 75 Neighborhood Place of Puna Family and Community Strengthening ©® tFY Neighborhood Place of Puna- Agency Name Family and Community Strengthening- Program Name Agency Director: Paul Normann Phone No.: 965-5550 Contact Person: Paul Normann Phone No.: 965-5550 Mailing Address: PO Box 2020 Pahoa, Hawaii 96778 Facility/Site Address: 15-3039 Pahoa Village Rd Pahao, Hawaii 96778 Fax No.: 965-5109 Email Address: info @neighborhoodplaceofpuna.org Name of Accountant/CPA (include name of firm if applicable): Alex Smith Phone No.: (877) 257-6484 Mailing Address: 1403 Frank Street Honolulu, HI 96816 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $30,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $10,000 $20,000 $21,000 Agency Mission Statement: The goal of the Neighborhood Place of Pun is to prevent child abuse and neglect. The vision: "To Nurture, strenghten and Celebrate "ohana". The mission: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 11 "Empowering families and communities in Puna by building strong faoundations through healthy relationships that value each person's uniqueness. "E malama pono kakou". NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 11 Neighobrhood Place of Puna - Agency Name Family and Community Strenghtening- Program Name Program Description: Neighborhood Place of Puna (NPP) is the only child abuse and neglect prevention program headquartered in Puna and dedicated to serving Puna families. Often, NPP is the only program that Puna families can turn to when things begin to get out of control and they recognize they need help as parents and as a family NPP outreach workers meet weekly with families, in their homes, over a period of several months, connecting the family to available resources, providing encouragement and support, and helping the parents understand their children's developmental stages. Most importantly, NPP provides the help that Puna families need in order to raise healthy safe children and remain out of the Child Protective Services system. Often our outreach workers must teach and model fundamental life skills that the parents never learned as children and young adults, simple things like: basic hygiene, money management and budgeting, effective communication, age appropriate discipline, and the importance of a structured family life. This process of regular home visits and the building of trust and relationships with "at risk" families has been documented as an effective approach in the prevention of child abuse and neglect. The relationships forged between NPP outreach workers and parents can often break through loneliness and isolation and serve as the first step in linking families to their communities. NPP is also committed to strengthening and developing caring communities as a way preventing child abuse and neglect. Vibrant and strong communities reduce isolation, a contributing factor to child maltreatment, and tend to produce healthy families. Healthy families raise healthy and safe children. In order to help promote the idea and reality of vibrant, strong, caring communities, NPP continues to bring together key players in the community: Business owners, service providers, concerned citizens, to identify community needs, form coalitions to address needs, share and promote resources, and develop family centered activities so that families will have opportunities to participate and connect with their communities. The statistics in Puna are grim. 25% of Puna residents live below the poverty level. For families with related children under 18 the number is closer to 30% NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 11 living below the poverty line. (2010 Census) Given the high level of poverty in Puna it is no surprise that 31.5% of specified and confirmed child abuse and neglect cases in Hawaii County were in the Puna district. (CWS -2010 statistics) 2011 saw headlines alleging that several members of the Penn State staff, ranging from the University President down to a graduate assistant, covered up football coach Jerry Sandusky's alleged sexual assaults on Children, some of which may have occurred on the Penn State Campus. Unfortunately, the majority of Hawaii County residents have misperceptions about what happens if they do report abuse. As a consequence, though 74% of Hawaii County residents would talk to someone else if they suspected child abuse and neglect, the majority of these individuals would talk to friends, coworkers, or family. Only 5% would talk to CWS. Statistics like these demand that we ask, how many children could be saved from child abuse or neglect, if only the people who are witnessing the abuse would report it to CWS? These tough economic times have seen safety nets for families slashed along with funding for prevention. The only other child abuse prevention program in East Hawaii is Healthy Start, which is limited of helping families with children 0-3. Neighborhood Place of Puna provides prevention and family strengthening to any family in Puna with children from 0 - 18. We are the safety net for Puna families! Total Budget and Position Count Total Program Budget $190,000 Total Program Position Count 3 Total Agency Budget $549,286 Total Agency Position Count 8 Program Objectives: 1) Help families foster optimal growth in their children by on-going home visits that include education around child development and safe home practices. Forty (40) families will receive intensive home visiting services. Forty (40) families a year will learn parenting skills and child development milestones through culturally competent, weekly home visits. Project outputs include weekly home visits until the family's service plan is completed, assessments for child abuse and neglect, assessments for safe homes, assessments for developmental milestones and individualized service plans that address protective factors and family needs. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 11 2) Provide information, referral and advocacy to Fifty (50) families to help them identify services and teach them how to navigate systems to access what they need including entitlement programs, legal help, counseling, financial assistance, medical care, activities for their children, educational services, housing, etc. 3) Convene direct service providers and other key players involved with child abuse and neglect. Set up regular meetings to generate resource sharing and communication (through emails, newsletters, meeting transcripts, calendar of events, etc.). Work with service providers to develop public awareness campaigns around abuse and neglect prevention. 4) Coordinate, plan and implement community strengthening activities to help reduce isolation, build social connections , and prevent child abuse and neglect, these may include family fun days and seasonal celebrations, or trainings for parents, grandparents and community professionals. Program Highlights: (from Fiscal Year 2010-11) 1) Ninety (90) families received intensive home visiting services during the grant period. Sixty four (64) families were assessed for child abuse and neglect risks including previous child abuse reports, domestic violence, substance abuse, adequate resources, parental depression etc. A culturally appropriate and individualized service plan was developed with each family. 2) Five hundred and sixty one (561) families received information and referrals through telephone or walk in services. 3) Ninety (90) families received advocacy and support in an effort to help them access needed services including housing, medical care, food stamps, legal services, transportation, etc. Advocacy and support for such services as WIC, Legal Aid, Section 8 Housing, Office of Social Ministries, Alu Like, Catholic Charities, Salvation Army Family Intervention Systems, Disability Rights, Department of Human Services, etc. was provided. Outreach workers provided transportation to meetings and sat in on IEP meetings, benefit meetings etc. with parents in order to help them get the services they needed for themselves or for their children. 4) The Neighborhood Place of Puna's resource directory was expanded to include resources available in upper Puna. Thanks to a Kapili Oihana Intern, we were able to update our resource directory and include the resources NPP "mapped" in upper Puna. Each family that we worked with this year was given a copy of the resource directory along with instructions on how to use it 5) Neighborhood Place of Puna offered the Hawaiian Values based Kamalama parenting classes at both our Pahoa and Mt. View offices. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 11 6) Neighborhood Place of Puna participated in the November Homeless Awareness Community Fair in which we had 136 volunteers and provided keiki ID, free clothes, free hair cuts, a Thanksgiving dinner, and music to 400 people. 7) Neighborhood Place of Puna participated in organizing a 2 dayWrestling and Take Down Clinic in Pahoa. Families and wrestlers came from all over the big island to work with coaches and trainers from the Olympic team. 8) Neighborhood Place of Puna once again offered a "Family Christmas". At this event, Parents came and selected toys for their children, approximately 130 children total. Parents were also able to select a wrapped "surprise" package for themselves from under the Christmas tree and get food to take home. Tables of donated items, including dishes, clothes, house wares, linens etc., were also available for families to take. 9) 10) Neighborhood Place of Puna was also actively involved in organizing the East Hawaii AHA conference to address 5 major concerns in upper Puna: Absenteeism in elementary schools, the lead paint at Mt. View Gym, Clean Safe water for Puna, Parent support, Kupuna respite. 11) Neighborhood Place of Puna in collaboration with the East Hawaii Coalition to prevent Child Abuse and Neglect held its annual Celebrate your family event in Sangha Hall in Hilo. This is an event filled with activities for families and children that also allows families to get information about services available in the community. 12) Neighborhood Place of Puna spearheaded the East Hawaii participation in "Blue Sunday". Blue Sunday is an annual event to provide churches an opportunity to educate their congregations about preventing Child Abuse and Neglect. 13) Neighborhood Place of Puna helped organize the 2 day Puna Basketball Clinic for Families with guest basketball coaches. 14) Once again Neighborhood Place of Puna put on "The Ready to Learn Free School Supplies Distribution" which was held at two locations in Puna, Maku'u Farmer's Market and St Theresa's Parish Hall. With the help of over 100 volunteers, NPP was able to put basic school supplies into the hands of 1800 children in a three hour period. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 11 Neighobrhood Place of Puna - Agency Name Family and Community Strenghtening - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Home Visits to 45 Families at risk 90 40 45 Child abuse/safety assessments 64 40 45 and service plans Information, referral and advocacy 561 50 50 Convenne service providers and 24 24 24 key players in child abuse and neglect prevention Co-ordinate family strenghtening 25 25 20 activities, events and trianings families will be safe and will stay out 90% 90% 90% of the Child Protective Service system. *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 154,000 124,000 124,000 Professional Fees 6,000 6,000 6,000 Operations 64,720 60,000 60,000 Equipment Other# Total 224,720 190,000 190,000 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 11 Neighobrhood Place of Puna - Agency Name Family and Community Strenghtening - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Blueprint for Change 128,000 100,000 120,000 County of Hawaii 20,000 25,000 30,000 Hawaii Island United Way 20,000 25,000 25,000 Hawaii Children's Trust Fund 56,720 40,000 0 Depatment of Human Services 0 0 15,000 Total 224,720 190,000 190,000 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Neighborhood Place of Puna offers all of its child abuse and neglect preventions services to Puna families: free of charge and on a voluntary basis. Neighborhood Place of Puna works very hard to help Puna families develop the skills and find the resources they need, so that they do not end up in the very costly, Child Welfare Services and Judicial systems. Neighborhood Place of Puna provides a service to the Puna community that will never be completely self-sustaining but is vital to the health and well being of the community. However, recognizing the perilous economic landscape, Neighborhood Place of Puna has been aggressively seeking funding from a variety sources, private and public, as well as ramping up our fundraising program. We have once again been awarded an OHA grant to offer parenting classes in Puna, we are also working NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 11 with several private foundations to develop a long term funding relationship. Additionally will be holding a fundraising event at the Civic Center in May and another event in the early fall. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. None NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 11 Neighobrhood Place of Puna - Agency Name Family and Community Strenghtening - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page l0 of 11 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Signatu e of Board resident/Chair Date or Agency Director / cklik Sign/'ure of Exe . ' _ -- : Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 11 76 • Neighborh000d Place of Puna Ready to Learn © oY Neighborhood Place of Puna- Agency Name Ready to Learn - Program Name Agency Director: Paul Normann Phone No.: 965-5550 Contact Person: Paul Normann Phone No.: 965-5550 Mailing Address: PO Box 2020 Pahoa, Hawaii 96778 Facility/Site Address: 15-3039 Pahoa Village Rd Pahao, Hawaii 96778 Fax No.: 965-5109 Email Address: info @neighborhoodplaceofpuna.org Name of Accountant/CPA (include name of firm if applicable): Alex Smith Phone No.: (877) 257-6484 Mailing Address: 1403 Frank Street Honolulu, HI 96816 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $5,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: The award amounts below are for a different program. 09-10 10-11 11-12 $10,000 $20,000 $21,000 Agency Mission Statement: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 9 The goal of the Neighborhood Place of Pun is to prevent child abuse and neglect. The vision: "To Nurture, strenghten and Celebrate "ohana". The mission: "Empowering families and communities in Puna by building strong faoundations through healthy relationships that value each person's uniqueness. "E malama pono kakou". NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 9 Neighobrhood Place of Puna - Agency Name Ready to Learn- Program Name Program Description: Since 2004, Neighborhood Place of Puna in collaboration with community police officers, community associations, service clubs, government agencies, churches, foundations, businesses and individuals have worked together to purchase and distribute school supplies to children and youth in East Hawaii. On July 9, 2011, 1814 children lined up with their parents/grandparents or guardians to receive school supplies. Over 100 volunteers helped with this project. Parents accompanied their keiki as they put their new supplies into recycled shopping bags. Families came from all over East Hawaii and some from as far as Waimea. Forty-eight (48) different schools and thirty-five (35) subdivisions were represented. Sixty-six percent (66%) of the children self identified as Hawaiian. One hundred and Eighty-two (182) children were orphans or half orphans. Three hundred and forty-eight (348) children were not living with their biological parents. Donations from twenty-one (21) businesses, churches, service clubs, government agencies, schools, foundations, non-profits and individuals helped purchase over $16,000 in pencils, paper, crayons, scissors, composition books, glue, binders, portfolios, colored markers and colored pencils. Pens, rulers, binders and portfolios were also donated. The Ready to Learn School Supply Project' is a simple project with a big goal - to provide Hawaii's needy children with basic school supplies to give them a "jumpstart" at learning. It is an effort to build self-confidence in children and help them reach for their dreams. No child should have to go to school without the basic supplies that would make their educational experience worthwhile and enjoyable. It is the goal of this project that every child start school "Ready to Learn". The "Ready to Learn" project is a family affair. Children and their parents/guardians walk down the line of tables and select supplies. Once the child has selected his or her supplies, families are encouraged to have their keiki ID pictures taken and help themselves to the donated juice and cookies. A table of resource information for parents to take home is also available. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 9 Total Budget and Position Count Total Program Budget 20,000 Total Program Position Count 0 Total Agency Budget $549,286 Total Agency Position Count 8 Program Objectives: 1) The Ready to Learn School Supply Project' is a simple project with a big goal - to provide Hawaii's needy children with basic school supplies to give them a "jumpstart" at learning. It is an effort to build self-confidence in children and help them reach for their dreams. No child should have to go to school without the basic supplies that would make their educational experience worthwhile and enjoyable. It is the goal of this project that every child starts school "Ready to Learn". 2) Given the current economic situation, we expect to distribute free school supplies to 2,000 school age children in July of 2012. Program Highlights: (from Fiscal Year 2010-11) In July of 2010 the "Ready to Learn" program distributed free school supplies to 1683 school age children. Over 100 volunteers helped with this project. Additionally Neighborhood Place of Puna donated 100% of its employees' time over the course of the planning year. Parents accompanied their keiki as they put their new supplies into recycled shopping bags. Families came from all over East Hawaii and some from as far as Waimea. Forty-eight (43) different schools and thirty-five (33) subdivisions were represented. Sixty-six percent (64%) of the children self identified as Hawaiian. Thirty-two percent (32%) of the children were not living with their biological parents. One hundred and fifty nine (159) of the children were orphans or half orphans. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 9 Neighobrhood Place of Puna - Agency Name Ready to Learn - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Distribute Free School Supplies to 1683 1814 2000 School Age Children *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages Professional Fees Operations — School 15,587 $16,320 $18,500 Supplies & Incidentals Equipment Other# Total $15,587 $16,320 $18,500 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 9 Neighobrhood Place of Puna - Agency Name Ready to Learn - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Carry-Over Funds 3920 5668 377 Blueprint for Change 5000 0 0 Friends of Hawaii Charities 2000 2500 5000 Individual Donations 3685 1900 1500 In-Kind Donations 6000 6629 7000 County of Hawaii 0 0 5000 Trimble Foundation 950 Total 21,225 16,697 18,877 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? In 2004, after six years of chairing the "Ready to Learn" school supply project, Senator Daniel Inouye and his wife Maggie stepped down. Neighborhood Place of Puna stepped into the breach and have been coordinating the "Ready to Learn" school supply program ever since. Neighborhood Place of Puna has always donated all of its staff time and resources towards the "Ready to Learn" program. The Ready to Learn committee actively seeks donations from the community. However, economic times are tough. In July 2011 funding was very insecure and we were only able to purchase supplies because of a carry-over surplus from previous years' donations and the very generous in-kind support of two groups, which purchases supplies we would not have been able to purchase. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 9 NPP does not see this program becoming self sustainable. With out support from funders and the county, the amount of school supplies distributed will decrease. This will mean that more students show up in school unprepared to learn and succeed. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. None NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 9 Neighobrhood Place of Puna - Agency Name Ready to Learn - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 9 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. A O'/31/12 Signature of Board y-sident/Chair Date or Agency Director , / _ - ±:Ti Ig, Sig Pure o xecutive Director ate UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 9 77 0 Ka'u Kakou Punalu'u Annual Fishing Tournament 0 Ka'u Kakou- Agency Name Punalu'u Annual Fishing Tournament- Program Name Agency Director: WS Kawachi Phone No.: 937-4337 Contact Person: Nadine Ebert Phone No.: 928-0027 Mailing Address: PO Box 365, Pahala, HI. 96777 Facility/Site Address: Aspen Center Pahala, HI. 96777 Fax No.: 808-928-8961 Email Address: ebertn004 @hawaii.rr.con Name of Accountant/CPA (include name of firm if applicable): Ronald G. Hawkes Phone No.: 939-7392 Mailing Address: PO Box 2030, Kealakekua, HI. 96750-2030 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$7,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $00 $6,000 $6,000 Agency Mission Statement: To Foster Health and Prosperity for all of Ka'u NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 6 0 Ka'u Kakou - Agency Name Punalu'u Annual Keiki Fishing Tournament- Program Name Program Description: To have an annual fishing tournament for keiki ages 1 yr. to 14 yrs. old Total Budget and Position Count Total Program Budget $7,000 Total Program Position Count $00 Total Agency Budget $60,000 Total Agency Position Count $00 Program Objectives: 1) To promote a healthy love for the art of shore-line fishing, by providing an opprotunity for family participation in a suporvised fishing tournament. Each child up to the age of 14 must be accompnied by a parent or guardian in this catch and release tournament. Program Highlights: (from Fiscal Year 2010-11) 1) The 3rd Annual Keiki Fishing Tourament was held January 22, 2011. There were 246 Keiki participants (everyone winning a prize) and approximately 500 lunches were served. Special prizes were awarded for various fish catagories. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 6 0 Ka'u Kakou - Agency Name Punalu'u Annual Keiki Fishing Tournament - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Keiki Fishing Tournament $8,715 $6,500 $7,000 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages $00 $00 $00 Professional Fees $00 $00 $00 Operations $5,215 $5,000 $5,500 Equipment $3,500 $1,500 $1,500 Others Total $8,715 $6,500 $7,000 *If applicable Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 6 O Ka'u Kakou - Agency Name Punalu'u Annual Fishing Tournament - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate County Grant $5,668 $5,000 $7,000 Donations* $3,047 $1,500 Total $8,715 $6,500 $7,000 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? We plan to reuse our equipment from previous years. We continue to seek donations and while the community continues to support the efforts of 0 Ka'u Kakou we have used these donations to continue the programs for which we are not asking the county's help to maintain. Of course we will continue to seek a sponsor for the fishing toumamen. We continue to look for new venues for fund raising and community donations to become self-sustaining. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 6 *We have, in the past, always applied for a grant to cover all of our programs. Because of this our bookkeeping has always listed the donations, but not to a specific program. We are in the process of changing this, but are unable to specify donations to a specific program at this time. 0 Ka'u Kakou - Agency Name Punalu'u Annual Fishing Tournament - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135—2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.uslforms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 6 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. 0,491c&dadk' / /3/ //).--- Signature of Board President/Chair Date or Agency Director -1,t431k - '1.-t/c. t / ) ,/ j / ) / (9- Signat re of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 6 78 Palakena Kai Ocean Safety, LLC Ocean Safety Program Palekana Kai Ocean Safety, LLC. - Agency Name Ocean Safety Program- Program Name Agency Director: Harlen Fragas Phone No.: 9379805 Contact Person: Harlen Fragas Phone No.: 9379805 Mailing Address: 980 Railroad Avenue Hilo, Hawaii 96720 Facility/Site Address: 980 Railroad Avenue Hilo, Hawaii 96720 Fax No.: Email Address: Palekanakai @yahoo.com Name of Accountant/CPA (include name of firm if applicable): Phone No.: Mailing Address: Amount of Request for County Funds: $30,000.00 Prior Year(s) Funding: 09-10 10-11 11-12 $20,000 $15,000 $20,000 Agency Mission Statement: To educate community youth about ocean water safety while providing opportunities and alternative activities that build these young adults confidence, self-esteem, motivation, and a lifelong respect for the ocean and the skills needed to enjoy the ocean safely. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 Palekana Kai Ocean Safety, LLC. - Agency Name Ocean Safety Education- Program Name Program Description: Palekana Kai Ocean Safety, LLC. is a non-profit 501(C)3 Organization that provides ocean awareness, ocean safety and ocean rescue training along with lifeguard, First Aid/CPR/AED training free-of-charge for community and at-risk youth between the ages of eleven and eighteen. Additionally the team conducts First Aid/CPR and AED training for staff of various community organizations island-wide. Palekana Kai also provides rescue services at numerous ocean water sports events, such as outrigger canoe regatta, The Business Man Race, Richardson Rough Water Swim, Long Distance Races for the Big Island Racing Association, Paddle Board Races, High School Race, The Lili'uokalani Long Distance Race in Kailua-Kona and the One Man Canoe Races. Palekana Kai's main objective is to educate and promote public safety and awareness through their water safety programs that include: ocean water safety, First Aid/CPR/AED (automated external defibrillation) and Lifeguard Training at various Public Schools and Youth Agencies. The Team's experienced lifeguards conduct ocean safety classes voluntarily at four public schools located in the Hilo and Puna Districts of Hawai'i County. We are expanding to schools island-wide as needed. Activities are scheduled throughout the year. Youth between the ages of eleven and fifteen complete basic skills courses and earn certificates of completion that recognize their readiness for the next levels of training. The next levels of training include First Aid/CPR/AED, Ocean Awareness/Safety and Ocean Rescue. After completing the additional training levels youth between the ages of sixteen and eighteen will have the opportunity to complete a basic Lifeguard Training course and earn a Lifeguard Certification Card. This Certificate is recognized by the County of Hawai'i as evidence of meeting the primary requirements for an entry level paid Lifeguard 1 position. Total Budget and Position Count Total Program Budget 30,000.00 Total Program Position Count 7 Total Agency Budget 30,000.00 Total Agency Position Count 7 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 11 Program Objectives: 1) Obtain equipment needed to expand the current training program and on- site activities enabling our Certified Instructors and staff to continue educating community youth and at-risk youth effectively in the areas of Ocean Awareness/Safety, First Aid/CPR/AED (automated external defibrillation), Oxygen Administration and Bloodborne Pathogens. 2) Conduct informational classes for community youth and at-risk youth in the areas of Ocean Awareness/Safety, First Aid/CPR/AED ( automated external defibrillation). It will enable youth to be prepared to respond to an emergency situation should one occur. 3) Conduct informational classes in the areas of Ocean Awareness/Safety, First Aid/CPR/AED (automated external defibrillation) for various agencies, organizations and residents of Hawaii County Island-wide to enable them to be prepared to respond to an emergency situation. 4) Conduct informational classes in Lifeguarding skills, Oxygen Administration and Bloodborne Pathogens for community youth, at-risk youth, various agencies and organizations. These skills will increase the number of Hawaii County residents to assist in an emergency situation at recreational water sites, our local pools, rivers and beaches. It will enhance youth's self-esteem and confidence, opening a large door of opportunities to prepare them for future employment. 5) Decrease the number of injuries, accidents and fatalities. Decrease the possibility of drowning and death following an emergency situation. 6) Acquire or build a 2,000 square foot facility that will serve as a classroom to conduct informational classes and hands-on activities. Also serve as a storage area for program and training equipment. Program Highlights: (from Fiscal Year 2010-11) 1) (12) Water Awareness Classes were conducted - 110 youth participated 2) Youth mentorship programs were conducted once a month - 25 youth participated 3) (10) First Aid/CPR/AED classes were conducted - 92 youth participated 4) (5) Lifeguard Classes for youth were conducted - 34 youth participated 5) (12) First Aid/CPR/AED, Oxygen Administration, Bloodborne Pathogens and Sinai Management Classes were conducted - 116 adults participated 6) (5) Lifeguard for the Professional Rescuer conducted - 29 adults participated 7) (12) Youth who participated in these informational classes were able to use their certificates of completion as experience on their resumes - 4 are currently employed NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 11 8) Palekana Kai Ocean Rescue Team provided services for school events - 432 participants 9) Palekana Kai Ocean Rescue Team provided services for various races/swims - 2500+ participants 10) NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 11 Palekana Kai Ocean Safety, LLC. - Agency Name Ocean Safety Education - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Water Awareness Classes - Youth 112 80 100 Youth Mentorship Program 25 25 30 First Aid/CPR/AED - Youth 92 75 80 Lifeguard Classes - Youth 34 40 45 First Aid/CPR/AED -Adults 116 85 90 Lifeguard Training -Adults 54 55 60 Youth found employment as a result 11 10 15 of participating program Youth who participated in program 12 10 15 were able to assist victims in trouble at our local beaches, etc. Youth who participated in program 4 6 8 were able to help save a life Provide Rescue at various canoe 2800 3000 3500 races: business man, one-man, paddle board, rough water swim, high school races, Lili'uokalani Long Distance Race- participants served *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 0 0 0 Professional Fees 0 0 0 Operations 9817.30 8145.72 15,000.00 Equipment 5182.70 4684.26 15,000.00 Other# Total 15,000.00 12,829.98 30,000.00 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 11 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7ofll Palekana Kai Ocean Safety, LLC. - Agency Name Ocean Safety Education - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate County of Hawai'i 15,000.00 20,000.00 30,000.00 Healing Our Islands - mini grant 2,000.00 Total 17,000.00 20,000.00 30,000.00 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Currently fundraising events such as car washes, bake and garage sales, donations and sponsors continue to cover the basic program expenses such as licensing and registration fees as well as annual First Aid/CPR and AED Certification fees. The County of Hawai'i Non-profit Grants Committee has generously awarded Palekana Kai Ocean Safety, LLC. with a 20,000.00 grant in July of 2011. This Grant was used to purchase training equipment, training site and office supplies and equipment. Also covered our General Liability Insurace and covered operation expenses. All of these items are very much needed in order to provide a consistent level of program delivery in order to teach our youth and those of our Community effectively. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 11 Through its community capacity building program, the County of Hawaii'i Departmentof Research and Develoment continues to recognize the services that Palekana Kai provides and is providing technical assistance related to non- profit board development, reporting fundraising strategies. The value of this consultation is valued at $2000.00. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 11 Palekana Kai Ocean Safety, LLC. - Agency Name Ocean Safety Education - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 11 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. r : ii Signatu of and President/Chair ate or Agency Di ector cikici.„, V.3/92__— Signature of Executive Director ate UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 11 79 Pantry, The Mama's Hale Clean & Sober Housing The Pantry — Agency Name Mama's Hale Clean & Sober Housing — Program Name Agency Director: Beth Mehau Phone No.: 808-887-2289 Contact Person: Beth Mehau Phone No.: 808-887-2289 Mailing Address: P.O. Box 2401 Kamuela, Hawaii 96743 Facility/Site Address: 64-1013 Mamalahoa Hwy Bldg. #3 Kamuela, Hawaii 96743 Fax No.: 808-443-0182 Email: bethmehauqmail.com Name of Accountant/CPA (include name of firm if applicable): Charles Seitz, All About Taxes PC. Phone No.: 541-686-9223 / Fax No.: 866-523-3606 Mailing Address: 311 W. 13th Ave. Eugene, OR. 97401 Email: charlie(c�allabouttaxespc.com You are responsible to keep the above information current Amount of Request for County Grant-in-Aid funds: $32,000 Prior Year Award of County nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $0 $0 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 9 The Pantry — Agency Name Mama's Hale Clean & Sober Housing — Program Name Program Description: Agency Mission Statement: The Pantry's mission is to develop economic opportunities that strengthen North Hawaii families through sustainability and cultural competence. The Pantry is a North Hawaii community initiative focused on long-term behavior changes associated with drug and alcohol addiction, specifically the reduction or outright elimination of relapse and recidivism. The Pantry strives to provide returning offenders in recovery from substance addiction with tools and resources necessary to reintegrate into society thus reducing relapse, homelessness and/or imprisonment. North Hawaii offers little or no transitional services for offenders reintegrating into society. Specifically, substance abuse recovery support is inadequate to meet the demands even though it is a key factor to reducing recidivism for this population. Nearly three quarters of inmates have a history of substance abuse while half were under the influence at the time of their offence. In fact, inmates who met diagnostic criteria for current substance abuse are doubly likely to have three or more convictions. These figures suggest that support for substance abuse recovery should be a top priority for this population. On Feb 1st, 2011 The Pantry opened Mama's Hale #1 (a six bed facility for men). The Hale is one of only two clean and sober houses for men in North Hawaii. There are no homes available for women at this time. Mama's Hale #1 Men's Clean and Sober Housing provides safe, affordable housing and support for recovering addicts and offenders who are reintegrating into society. The design of the program allows residents to build levels of independent living while still adhering to strict guidelines of probation and out patient treatment. The homes are democratically run allowing residents to learn communication skills, problem solving and conflict resolution. By partnering with other agencies and Pantry programs Mama's Hale #1 offers support systems for offenders with the goal of successful reintegration into our community. These supports include: (a) access to safe and sober housing;(b) liaison with parole, probation and drug court officers to ensure compliance; (c) no cost routine substance abuse counseling; (d) personal financial training; (e) volunteer and work force opportunities; (f) resume development assistance, career and employment counseling; and (g) mentorship from local churches and 12 step recovery groups. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 9 The Pantry — Agency Name Mama's Hale Clean & Sober Housing — Program Name The Pantry's clean and sober housing program's primary goal is to reduce the rate of relapse and recidivism in recovering addicts through full wrap around services that help these individuals build the confidence and support needed to reintegrate into society. Total Budget and Position Count Total Program Budget $157,085 Total Program Position Count 3 Total Agency Budget $386,238 Total Agency Position Count 12 Program Objectives: 1. Open, by 08/12, Mama's Hale #2 Women's House in Waimea 2. Start, by 08/12, women's no cost support/outpatient treatment group 3. Increase, by 03/01/13, volunteer and community participation of: (a) faith based community partners by 3 organizations (b) employment opportunity partners in North Hawaii by 5 businesses (c) active committee members and advisory committee members to include 6 new participants. 4. Delegate committee members and Mama's Hale residents as representatives at the Going Home task force and H.O.P.E. committee 5. Utilize, by 10/01/12, National Recovery Month to educate and advocate for continued support of clean and sober housing in North Hawaii through: (a) article in the West Hawaii Today (b) event at Mama's House Thrift Store (c) youth group annual sign waving 6. Send Director, house manager, and one committee member to Oahu for site visit and mentorship training by 06/13 7. Host strategic planning with all sectors of the community to develop a second men's house and a women and children's home in 2013/2014 (by 04/01/13) Program Highlights: (from Fiscal Year 2010-11) 1. Opened Mama's Hale Men's Clean and Sober House on 02/01/11. Home was at capacity with wait list by 06/01/11. 2. Developed a committee to revise house rules, contract, policies and procedures. 3. Trained and appointed house members to governing positions within the house and gave residents the power to be democratically run. 4. Secured private and grant funding to assist with costs. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 9 The Pantry — Agency Name Mama's Hale Clean & Sober Housing — Program Name 5. Compiled the following statistics: Out of 16 applicants: • 10 were accepted • 2 were rejected due to criminal record of sex offenses • 2 were rejected because they showed no signs of working a 12 step program and continued to drink during the interview process • 2 had mental health issues too great to be able to function within the guidelines of the house. Housemates were concerned for possible aggravation and assault. Out of the 10 who were accepted: • 4 were in homeless status (1 had been homeless for more than 20 years) • 6 were in homeless status transitioning from an inpatient therapeutic treatment program • 3 have relapsed, 1 of which moved into a half way house in Hilo, one is seeking help through adult behavior mental health and 1 voluntarily admitted himself to San Island for further treatment • 1 transferred probation to Kauai to reintegrate with his family and is still in recovery • 6 remain sober, in probation compliance and are living in the house • 0 participants have been reincarcerated thus far NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 9 The Pantry - Agency Name Mama's Hale Clean & Sober Housing - Program Name Performance Measures: The Pantry will be able to quantify indicators of public and client benefits from the Mama's Hale Clean & Sober House program by meeting the goals and deadlines of the program objectives. Program objectives are clearly outlined with dates and number of participants to allow for proper evaluation. Client benefits will be tracked by staff through accurate records of data collected from participants in regards to; number of relapses, number of discharges due to noncompliance, number of 12 step meetings attended, number of offenders served, number of clients able to pay rent (stabilized) and number of offenders who meet compliance with sobriety and probation. Agency Budget FY2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate * Income Retail Sales from Thrift Store 72,854 200,899 284,000 Individual Contributions 8,740 70,000 35,000 Payroll Reimbursement State Program 17,493 10,000 0 Loans (Liability) 17,400 0 0 Rent Collected for Clean & Sober 4,550 23,050 31,950 Housing Grants 0 21,000 36,000 Total Income 121,037 324,949 386,950 Expense Salaries &Wages 27,492 145,000 170,000 Profeesional Fees 9,741 5,000 2,000 Operations 44,838 86,838 93,238 Equipment 2,119 1,200 1,000 Other 45,046 82,000 120,000 Total Expense 136,841 320,038 386,238 *If applicable NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 9 The Pantry — Agency Name Mama's Hale Clean & Sober Housing — Program Name Program Expenditure: FY2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate * Salaries and Wages 0 45,275 45,275 Professional Fees 0 7,200 7,200 Operations 11,000 33,000 52,800 Equipment 1,550 1,200 0 Other# 0 51,810 51,810 Total 12,550 138,485 157,085 *If applicable #Please explain in detail on separatesheet Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate * Rental Fees Collected from Residents 4,550 26,200 30,000 Individual Contributions 2,000 2,000 2,000 Retail Sales from Thrift Store 6,000 86,285 75,735 Grants 0 24,000 17,500 Nonprofit Grants-In-Aide 0 0 32,000 Total *If applicable NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 9 The Pantry — Agency Name Mama's Hale Clean & Sober Housing — Program Name Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? More than two thirds of The Pantry's income comes from the operation of Mama's House Thrift Shop which was established February 13th, 2010. In our second year of operation the store more than doubled it's income. As we continue to expand and improve upon the retail business we expect our income to continue to increase. Our goal is to have programs that can operate at bare minimal expense without exceeding the revenues generated by the retail business. This will ensure that The Pantry's programs are not dependant on grant and private funding but rather are enriched and are able to expand their services when these funds are made available. The Mama's Hale Clean and Sober Housing program is designed in such a way that when residents enter the home they are charged rent at a sliding scale based on their ability to pay. Rent is not to exceed $350 a month per person and includes all utilities, services, cleaning supplies, hygiene products and some food. For offenders, finding employment is often difficult and can take months. By first breaking the cycle of homelessness we are able to gradually aid the residents in seeking job training and /or employment. Many of the residents start by volunteering at the thrift store and then transition into paid employees. As they regain confidence and skills they move onto higher paying jobs and become able to pay their full rent. When all house members are able to pay full rent the house becomes self-sustainable leaving only administrative personnel costs and supplies and materials costs. Eventually over time The Pantry will be able to cover these remaining costs through the revenues generated from the Mama's House Thrift Store. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawai'i. None Known NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 9 The Pantry — Agency Name Mama's Hale Clean & Sober Housing — Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawai'I County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'l Revised Statues. I (we) understand that applications will not vbe viewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibilty to ensure that all documents are complete and accurate prior to submittal. I (we) understan that all documents require a signature must the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after june 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of allexpenditure supported by County of Hawai'i grant funds, and alisting of other funding sources and amounts abtained during the award period. Failure to submit a timely, complete and accurate year-end report will impact the evaluation of your program's or agency's future fundings requests. I (we) understand there is no provisions for further notification to submit the final report. No late or incomplete reprots will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 9 Any funds unused by June 30, 2013 must be returned to the County of Hawai'i. Within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Signature of Board President/Chair Date or Agency Director . l Sig - : xecutive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 10 80 Paradise Ponies, Inc. High-School Shop Cooperative Paradise Ponies, Inc. A 501(c)(3) Tax Exempt Private Foundation- Agency Name High-School Shop Cooperative Project- Program Name Agency Director: Juanette Baysa Phone No.: 808- 333-6097 Contact Person: Katherine Patton Phone No.: 808- 315-1093 Mailing Address: P. O. Box 1030 Kurtistown, HI 96760-1030 Facility/Site Address: 16-1334 Uhiniana Rd Mountain View, HI 96771 Fax No.: 808-968-7305 Email Address: CarouselOfAloha@gmail.com or katheri ne.patton @m e.corn Name of Accountant/CPA (include name of firm if applicable): Nancy J Kramer, CPA Phone No.: (808) 965-2729 Mailing Address: 15-2984 Pahoa Village Road, Pahoa, HI 96778 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $10,000.00 Prior Year Award of County Nonprofit Grants-in-Aid funds: NONPROFIT GRANT APPLICATION FISCAL YEAR 201 2-13 Parrn 1 of 09-10 10-11 11-12 $0.00 $0.00 $0.00 Agency Mission Statement: Paradise Ponies, Inc., a nonprofit corporation, intends to construct and operate a unique Hawai'i-themed carousel along the Volcano Heritage Corridor on Hawai'i, The Big Island. The Carousel of Aloha Pavilion & Park, containing the Carousel of Aloha, features hand-carved menagerie figures, seating benches, rounding boards, scenic panels, mirrors and other carousel amenities carved and painted by volunteer artisans. An expansive pavilion houses the carousel and music system, special events room with commercial kitchen, restoration workshop, gift shop, café, offices, conference room, and ballroom. Targeted fundraising begins the second half of 2011. The dedication date of the carousel pavilion is projected to be December 2015. Combined revenues from carousel rides, special events, and gift shop sales can make the project self-sustaining within the second year of operation. This project benefits local communities and brings the neighbor islands together in a statewide art project. The Carousel of Aloha Pavilion & Park will generate numerous benefits for the youth, families, residents and visitors of the East Side of Hawaii Island. • It will provide a focal point for youth and family-oriented recreational and cultural activities along the Volcano Heritage Corridor. • It will enhance the attraction of other nearby facilities such as the Pana'ewa Rainforest Zoo & Gardens, Hilo Coffee Mill, 2400° Fahrenheit, Akatsuka Orchids, the artist community of Volcano Village, and Hawai'i Volcanoes National Park. • Hawaii's tropical climate will enable the carousel to operate year-round, serving our citizens, as well as our visitors from around the world. • Free Ride Days will be offered on holidays of special significance to Hawai'i, such as King Kamehameha Day. Special discount fares or free passes will be offered on other designated days to seniors or those with special needs. • Hale Makana, our gift shop, provides a venue for locally produced carousel-related arts, crafts, books and souvenirs. • Carving and restoration activities in the glass-enclosed restoration workshop will entertain and educate residents and visitors alike. • Community organizations i.e. clubs, schools, etc., can utilize the facility for showcasing events and fundraising activities that celebrate and promote Hawaii's diverse cultural heritage. • The ballroom will host fundraising activities for other nonprofits, organized club functions, school groups, as well as private family events such as birthdays, reunions and receptions. Paradise Ponies, Inc. and The Carousel of Aloha Pavilion & Park will offer both full-time and part- time employment opportunities. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Pan,. ) nfQ Paradise Ponies, Inc. A 501 (c)(3) Tax Exempt Private Foundation - Agency Name High-School Shop Cooperative Project- Program Name Program Description: General scope of the activities for Paradise Ponies High School Cooperative Shop Project is to 1) assist in the training of High School shop teachers to carve figures of indigenous and culturally appropriate animals and rounding boards for the carousel, who will, in turn, 2) train their students to assist in the creation of carved carousel figures and other artworks for the Carousel of Aloha being developed by Paradise Ponies, Inc. 3) teaching children, adults and visitors about the culture, fauna and flora of the individual islands that make up our state. 4) skills learned can be transferred to other artistic endeavors; design, engineering and construction principles and Total Budget and Position Count Total Program Budget 29,400.00 Total Program Position Count 0 Total Agency Budget 4,000,000.00 Total Agency Position Count 0 Program Objectives: 1) recruit carvers from all of the Hawaiian Islands to develop the unique figures that represent their own islands. 2) enlist the services of a professional carousel carver from successful non- profit carousel projects that have been established in other states. 3) present a series of 3 training workshops beginning in February and extending into the summer. 4) establish a head carver for each county within the State of Hawaii who will be responsible for directing the community volunteer project on their respective islands in the creation of the figures which represent the indigenous culture and biological diversity of their island(s). 5) provide tuition fees to the HS teachers from the Island of Hawaii so that they may attend the training courses gratis, and pass on their knowledge to their students. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Paw : of1(1 Program Highlights: (from Fiscal Year 2010-11) 1) Not applicable NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Pacrs.d of Q Paradise Ponies, Inc. A 501 (c)(3) Tax Exempt Private Foundation - Agency Name High-School Shop Cooperative Project - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Teachers attend classes 4 teachers attend Teachers include skills in class School curriculum curriculum includes carousel figure making Teachers & students carve carousel Carousel pieces pieces constructed Finished pieces ready to assemble Carousel figures delivered Schools participate in the overall Ongoing construction of Carousel of Aloha class curriculum and Volunteer Log *If applicable Program Expenditures NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Pn(VP Snf1U FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 0.00 Professional Fees 13,000.00 Operations 3,700.00 Equipment 12,700.00 Other# Total 29,400.00 * If applicable Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 PaoP 1 M 1 fl Paradise Ponies, Inc. A 5O1 (c)(3) Tax Exempt Private Foundation - Agency Name High-School Shop Cooperative Project - Program Name Program Funding Sources: Identify all funding sources (specific to this program only Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Class fees charged non-teachers 2,700.00 Donated labor and services (in kind) 19,500.00 County grant 10,000.00 Fundraising cash donations 500.00 Total 32,700 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The High-School Shop Training Project will be able to support the effort as soon as the teachers are trained and able to assist the development of the carousel. Paradise Ponies has initiated separate efforts to raise funds (coloring book, bake sales, banquets, etc.) and submit grant proposals for the construction of the carousel. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Pang 7 of 1(1 Paradise Ponies, Inc. A 501(c)(3) Tax Exempt Private Foundation - Agency Name High-School Shop Cooperative Project - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a •rant from the Count of Hawaii I we understand and will corn•i with the re•uirement to submit a ear-end re•ort to the Count Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a time/ complete and accurate ear-end re.•rt will im• ct the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Parer Q .,�0 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. A c1-49 Signa ure of Board President/Chair Date or Agency Director A/4 Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Pane Q of 0 81 Parents and Children Together Economic Development Center Parents And Children Together- Agency Name Economic Development Center- Program Name Agency Director: Ruthann Quitiquit Phone No.: 808- 847-3285 Contact Person: Ruthann Quitiquit Phone No.: 808- 847-3285 Mailing Address: 1485 Linapuni Street Honolulu, HI 96819 Facility/Site Address: 1485 Linapuni Street Honolulu, HI 96819 Fax No.: 808-841-1485 Email Address: adminrquitiquit @pacthawaii.org Name of Accountant/CPA (include name of firm if applicable): NA Phone No.: NA Mailing Address: NA You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$100,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $000.00 $000.00 $000.00 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 15 Agency Mission Statement: The mission of Parents And Children Together is to promote and support healthy individuals, families, and communities by creating opportunities for them to identify and address their own strengths, needs, and concerns and successfully realize their potential. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 15 Parents And Children Together - Agency Name West Hawaii Microenterprise Project- Program Name Program Description: The Economic Development Center (EDC) of Parents And Children Together (PACT) proposes to provide microenterprise (a small business of 5 or less employees and less than $250,000 in revenue) creation services to low-income individuals at a cost of$100,000 per year to start 10 businesses per year. EDC's objective is to help poverty-level individuals become business owners and achieve "self-reliance." PACT EDC will provide the direct services needed for clients to become small business owners. The projected cost per business start- up is $10,000. Parents And Children Together (PACT) has served low-income populations with multiple social and economic challenges since 1968. PACT's Economic Development Center (EDC) has successfully transitioned unemployed residents into jobs, self-owned micro-enterprises, home childcare, and franchise ownership since 1991. PACT EDC proposes to provide training and support services throughout West Hawaii, specifically Honaunau to Waikoloa, using a client-centered approach that has proven successful with residents of public housing and low-income communities throughout Oahu, West Hawaii, and Kauai. EDC has developed a successful track record in helping TANF recipients start their own businesses and "graduate" from TANF support. EDC has also helped other "hard-to-reach" clients, who have a hard time conforming to a regular work schedule, by starting commercial cleaning franchises, home childcare, and other self-employment. PACT partners with the First To Work program provider in West Hawaii to obtain referrals of individuals who could benefit from the proposed the program. EDC can provide a seamless continuum of services by working closely with the First To Work program providers to obtain referrals of those in need of training to become self-reliant. In addition, the proposed micro-enterprise start-up project complements PACT EDC's job readiness training and placement contract in Kona, funded by the Department of Labor's Office of Community Services. Clients participating in the job readiness training and placement program will be assessed for whether they are better suited for job placement or business start- up. PACT's Economic Development Center (EDC) is well-networked with service providers throughout West Hawaii, to refer clients to them should they encounter NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 15 obstacles that interfere with their ability to start up or maintain their micro- enterprises. Facilities: EDC's Kona Office is located at 75-240 Nani Kailua Drive, Suite #11, Kailua-Kona, HI 96740, which is located five minutes from Kailua-Kona town. The facility is leased through Pines Plaza, LLC and is ADA compliant. The office is located on the second floor accessible by elevator and has an ADA accessible restroom. Staffing: The Microenterprise Project will be delivered using a team approach allowing staff members to contribute their areas of expertise to help all clients while also assigning clients to specific staff for casework/case coordination purposes. The Program Director (.15 FTE) will supervise the Senior Program Specialist (.75 FTE) and will be responsible for the overall planning, implementation, and coordination. The Senior Program Specialist will provide full business start-up and follow-up services. Client to staff ratio will be approximately 20:1. The Administrative Assistant II (.40 FTE) will perform data entry and operate our electronic client records database to prepare reports regularly. Description of Microenterprise Project services: The Microenterprise Project consists of eight components, each carefully designed to support clients who will, over the life of the grant, receive the training and job experience needed to become licensed business owners. 1. Outreach and Recruitment: The project will begin with an intensive outreach campaign in West Hawaii, specifically Honaunau to Waikoloa, to potential clients and providers who work with the target population and can make referrals. The opportunity to participate in the project, with the goal of self- employment, will be actively promoted using press releases, flyers, posters, job fairs, and other forms of advertising. Information will be presented at community meetings, resident association meetings and events, staff meetings, and gatherings. 2. Intake and Assessment are critical to clients' overall success as these procedures determine the direction for each client's plan. EDC will take the time needed to understand the client's situation, background, motivation, skills, resources, and needs. The Intake process initiates a relationship and rapport with the client. The interaction between program specialist and client provides insight into relevant factors such as his/her overall economic well-being, attitude, education and skill level, family support and responsibilities, job readiness, ability to set goals, and existing barriers. Eligibility is determined by: •TANF qualified or income equal to or less than 150% of the Federal Poverty Guidelines; •Client goals — and how these match with what the program offers; •Transportation —verify to ensure ability to attend training; and NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 15 'Whether applicants are suitable for entrepreneurship. EDC will assign to each client a Program Specialist (sometimes referred to as Coach) to assess the client's level of assistance needed and to help create a plan to achieve economic goals. Personalized one-on-one intake and assessment is scheduled for one to two hours. At this stage it is important to: 'Assess strengths and needs, with the Program Specialist coaching clients on how to plan and set goals; 'Help clients understand the nature of entrepreneurship and running a business so they can make an informed choice about whether this is something they want and can realistically pursue; -Evaluate which work activities need to be planned, and whether the client is: Ready to re-enter the labor market and needs help with business ownership; Needs general guidance and encouragement; Needs to update skills or arrange for childcare and transportation; Needs basic remedial training (workplace habits, presentability, English language competence, financial literacy, communication skills, basic computer familiarity); or Needs significant personal interventions (e.g. substance abuse counseling); • Link clients to resources (including referrals for "wrap-around" services, e.g. childcare, English as a Second Language) and coordinate follow-through; and • Strategize how to reduce or eliminate barriers. Intake Session review and discussion with clients: • Overview of project— allowing for questions and answers • Rules and Responsibilities for both clients and staff: expectations, commitment, attendance and performance requirements, etc. • Consent forms — e.g. Consent to Receive Services, Consent for Transportation, and Medical Consent • Client Rights — e.g., confidentiality, non discrimination, etc. • Client Complaint Procedures and Appeal processes • Notice of Privacy Practices [HIPAA compliance] • EDC Forms—e.g. for information on demographics, residence, income • Education, employment history, experience and marketable skills • Resources and barriers to employment. EDC also uses assessment tools such as: Myers Briggs personality type inventory; Personality Mosaic; Verification of Reading Level. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 15 Service Planning: After assessment, the Program Specialist and client will develop a written Individual Service Plan and Barriers Reduction Plan together. This plan includes proposed business concept, action steps, and ultimate economic goals. The Program Specialist and client will discuss barriers and strategize how they can be overcome, accessing help from other providers by referrals if needed. 3. Technical Assistance: Training: Clients will be expected to complete the entire "Core Training" which covers basic information about workplace values and expectations. Low-income clients often come from backgrounds where they have not been exposed to these basics. All training will be held at designated sites throughout West Hawaii, to accommodate the demand from the different geographical areas and make training accessible. The following subjects are included in the core training: a) Values (3 hours): Values training helps clients understand and identify their own personal, family, and community values, which effect their employability and ability to retain employment or run a business. The class helps close gaps between clients' values and workforce values. Areas of instruction include identification of values, self-evaluation, decision-making, identifying objectives, and overcoming barriers to success. b) Life Skills (3 hours): Life Skills training helps clients break through self- imposed limitations by helping them discover how to manage their daily actions through time management, attitudes, interactions with others, coping skills, and most importantly decision making. c) Financial Literacy (9 hours): This training is designed to help clients build personal financial management skills. It develops competency in creating a household budget and a savings plan so the client can learn to live within his/her means. Clients are also educated about the Asset Accumulation Program and Individual Development Accounts (IDAs): EDC's Asset Accumulation Program is based on the understanding that economic well-being is not the result of income alone, but also of asset accumulation through savings and investment. Asset accumulation encourages long-term development, which in turn generates positive psychological, social, and economic effects. Across the nation and in Hawaii in particular, Individual Development Accounts or IDAs have been recognized as an effective way for low-income persons to accumulate assets. The project will offer IDAs to clients, as funding is available, to enable them to accumulate savings for their employment needs. Personal attention will be given to each client to assess and identify life goals, establish savings objectives, and open and maintain an IDA with EDC's partner bank, American Savings Bank. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 15 The clients must save a minimum amount of earned income per month. Throughout the program, regular meetings will be held with clients to review progress. Upon the successful completion of the program, deposits will be matched 2:1 and use of funds for identified goals will be verified. e) Business Literacy: (30 hours) The Business Basics course teaches how to start and manage a business, including accounting, filing taxes, marketing, writing a business plan, accessing capital, and obtaining licensing. With guidance, clients research and write their own business plans. EDC's experience shows that typically those who attempt self-owned businesses are not aware that there are business regulations, safety requirements, business taxes and employment laws; nor are they familiar with such matters as market identification, marketing, sales, customer relations and contracts. This year EDC has added two additional components to the Core Training: 1) Career Kokua and 2) Test of Adult Basic Education. Career Kokua, the Hawaii Career Information Delivery System, is a computerized system of localized, current career and related educational information for career decision making. Career Kokua provides a start in planning your life's work. Assessments require signing up as a subscriber. After using Career Kokua a person should have a better sense of themself, their career goals, and the decisions affecting the achievement of these goals. The Test of Adult Basic Education (T.A.B.E) is designed to assess reading, mathematics, language, and spelling skills. It also includes a version in Spanish and Independent tests that assess basic skills in work-related contexts. Both the T.A.B.E and Career Kokua will be administered at the end of the training to identify the client's educational level and career goals. These tools will help the Program Specialist and client create an employment plan tailored to the client's likes, dislikes, and aptitude. A post-training assessment, conducted by personal interviews and questionnaires, helps determine who is ready to move forward. Those who are not ready will, in any case, have improved their employability, and have new knowledge in financial literacy and workplace values, and valuable life and business skills. They will receive counseling and assistance to find other employment. Those who do not qualify to move forward in the program, but who still show motivation and potential, may repeat the training or receive remedial help. Business Development— Clients, who have consistent attendance and class performance, pass a post-training assessment and demonstrate entrepreneurial aptitude and capabilities will be eligible for the next steps. 4. Business Start-Up: EDC will work one-on-one with the client to ensure their individual business plan is complete, start-up equipment is purchased, NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 15 licensing is in order, and the business meets industry standards. Weekly meetings will keep the client on track and on target. 5. Business Support: Once the business is started, the Economic Development Center will continue to provide technical assistance every two weeks, which is "best practice" to help sustain the business. The Program Specialist and client will meet to develop action steps to further implement the overall plan, and review what the client must complete by the next session. In coaching sessions, the Program Specialist will build on the client's strengths and will help motivate him/her to achieve the identified goals. Together they will review progress, and address challenges. Plans will be documented and used as a tool to acknowledge achievements and to track progress. The meetings build effective working relationships, which will enhance the rate of success. 6. Business Retention: The Program Specialist will seek to maximize retention in the business by continuing to coach the client. The Program Specialist will meet/communicate with the client no less than twice a month. Meetings with the client will consist of continued reinforcement of(1) how to plan; (2) setting goals and objectives; (3) carrying out action tasks; (4) budgeting; and (5) understanding the business. These meetings will also be a means for clients to share any new barriers that may have arisen or to follow-up on any old barriers. A client whose business is earning at least $1,500 a month will have achieved the objectives of this project to bring their income to the Department of Human Services' definition of self-sufficiency. 7. Feasibility: EDC's track record with micro-enterprise development over the past seven years shows that its process is highly successful in identifying and working with novice entrepreneurs. Of 131 businesses started up, 54 are in business today, resulting in a 41% business success rate, which is exceptionally good for this inexperienced and high-risk population starting with minimum resources. Of 38 businesses started up 2009-2010, seven are no longer in business today, resulting in an 81% business success rate, which is outstanding for this population. 8. Sustainability: EDC's trainings will meet the special needs of this target population by providing individualized support for clients. The Program Specialist will serve as a personal coach and facilitate the development of individual plans tailored to each client. Learning how to plan, set goals and objectives, and carry out action tasks are important life and business skills which are sustainable gains. Other knowledge imparted in the training provides long-term skills for continuing success. Only clients who maintain regular, punctual attendance and who understand the concepts presented will be eligible for business development and start-up. A post-training assessment, conducted by personal interviews and questionnaires, will help determine which clients are ready to move to the next step. For those NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 15 not appropriately meeting goals and completing the program, the Program Specialist will discuss with EDC staff whether he/she needs to be given remedial assistance or be referred to another agency. Total Budget and Position Count Total Program Budget $100,000 Total Program Position Count 1.3 Total Agency Budget $18,600,000 Total Agency Position Count 408 Program Objectives: Clients who successfully complete EDC's five-month training program are projected to earn between $1,500 and $2,000/month (depending on their capacity level), which is more than they would earn at minimum wage level and meets the $8.67/hour or $1,500/month self-reliance milestone recommended by the Department of Human Services. Clients will own and operate their own home businesses and will be able to stay home with their young children, allowing them to save on childcare costs. Although each client may not reach full microenterprise capacity in the first year, EDC anticipates that at least 25% of the new small business owners will be grossing at least $2,000/month, no longer needing government aid (depending on their family size), and thus be self-reliant by the end of the funding period. Recruitment will be conducted in low-income communities from West Hawaii— specifically Honaunau to Waikoloa that have the highest TANF population— identifying families that live at or below 150% of the Federal Poverty guidelines who have the potential for running a microenterprise. Most project clients will be past, present, or potential Temporary Assistance for Needy Families (TANF) recipients, and/or come from families with multiple social and economic challenges. Because some clients tend not to complete the program, the following projections reflect our experience of what will be feasible. The project output and outcome goals are: Outputs: Outreach and Recruitment, Intake, Assessment, and Service Planning EDC will deliver monthly recruitment presentations; attend at least four community events; and distribute approximately 200 flyers. Business Training Training scheduled monthly: -Values •Life Skills 'Financial Literacy NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 15 •Business Literacy •TABE testing •Career Kokua •Computer training-optional Business Support EDC will continue to provide technical assistance to clients and meet with them to develop action steps to further implement overall plan. One-on-One Coaching Program Specialist continues to meet with clients every two weeks, and continue to work on barrier reduction plan. Business Retention Maximize business retention by continuing to provide technical assistance to clients. One-on-One Coaching: Program Specialist meets no less than twice a month with clients, and continue to work on barrier reduction plan. Business Sustainability Maximize sustainability by continuing to provide technical services. One-on-One Coaching: Program Specialist meets no less than once a month with clients. Continue to work on barrier reduction plan. Outcomes: Approximately 100 clients are recruited into the program. At least 35 intake, assessments, and individualized service plans created At least 35 clients will enroll in training modules which are intended to strengthen their entrepreneurship. At least 15 clients will obtain GET lisence At least 15 clients will register their trade name At least 10 clients will complete a business plan At least 10 clients will complete training At least 10 business owners will receive technical support. At least 10 clients will start up home businesses. At least 10 businesses will earn $500/month. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 15 At least 5 businesses will earn $1000/month. At least 3 businesses will earn $1500/month Program Highlights: (from Fiscal Year 2010-11) 2008-2011 EDC was awarded a three-year contract $375,000 from the Housing and Urban Development to expand employment services to the residents of Kuhio Park Terrace, Kuhio Homes, Kalihi Valley Homes and Mayor Wright Housing. The Ready To Work Ill project goal was to improve residents' employability, increase job placements, and home ownership. EDC exceeded its employment training and placement goals and due to the economic down turn was unable to meet the home ownership goal. 2010-2011 PACT EDC was awarded $1.5 million, a First to Work contract for parts of Oahu, Kauai, and Hawaii (Ka`u to Laupahoehoe) to provide case managaement and support services to clients receiving TANF financial benefits. EDC met all goals and objectives. 2010-2011 EDC was awarded $270,600 biennium contract from the State of Hawaii Office of Community Services to provide: 1) intake and assessment, job readiness training; 3) job placement; 4) and one-on-one coaching to 66 low- moderate income individuals by June 2011. EDC exceeded all milestones. 1) NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 15 Parents And Children Together - Agency Name Economic Development Center - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Recruit n/a n/a 100 Intake and assessment n/a n/a 35 Obtain GET n/a n/a 15 Register trade name n/a n/a 15 Complete business plan n/a n/a 10 Complete training n/a n/a 10 Receive technical support n/a n/a 10 Start up a home business n/a n/a 10 Business earns $500/month n/a n/a 10 Business earns $1000/month n/a n/a 5 Business earn $1500/month n/a n/a 3 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages $65,556 Professional Fees Operations $27,544 Equipment Other# $6,900 Total $100,000 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 12 of 15 Economic Development Center - Agency Name - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate County of Hawaii Nonprofit Grants- $100,000 in-Aid Program Total $100,000 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? PACT EDC's services are provided free of charge to low-moderate income participants and is solely funded by grants and private donations. The goal is to increase revenue within the client's family, which will lead to self-reliance. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Not to our knowledge. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 13of15 Parents And Children Together - Agency Name Economic Development Center - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 14 of 15 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirementm Th■ 7 / January 27, 2012 Sig ure of Am-7/c_Board President/Chair Date or Agency Director January 27, 2012 Signatu - of PietlAWIDTKEIMIE Date Chief Operating Officer UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 15 of 15 0 , . Program PAO- Expenditure ndl PARENTS AND CHILMEN RGETHER 24 II-4,.151.50 Jpit * Explanation ... idisS, F • i Year 2012- 13 ..,...., .,, ).. , . • . 4 /401 - i ...... , ... A . :„„ ...4 , ,,.-- , . s . ;. — - ..• , Ne . ----- l'oP * Vil#+. "-- •'''' ' ' , .is , .. . - . - Attachment to Nonprofit Grant Application — Fiscal Year 2012-13 Parents And Children Together—Agency Name Economic Development Center— Program Name Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate * Salaries and Wages $65,556 Professional Fees Operations $26,104 Equipment Other# $8,340 Total $100,000 *If applicable #Please explain in detail on separate sheet Salaries and Wages include wages, payroll taxes and assessments, and fringe benefits for the following staff: • 15% of one full-time Economic Development Center Program Director • 75% of one full-time Senior Program Specialist • 40% of one full-time Administrative Assistance Operations include: • Audit services • General liability insurance for staff, clients and program services • Lease/rental of copier equipment and space • Utilities (telecom services and electricity) • Supplies (including office and training supplies, as well as postage and printing) • Administrative costs # Other costs include: • Local Travel — Mileage reimbursement for staff travel to meetings with clients at their micro-business site if needed and to network with community partners. $120 per month x 12 months = $1,440. • Inter-Island Travel —Airfare for Program Director from Honolulu to Kona for on-site quality reviews of program services, and supervision and training of Kona staff. $200 per round-trip x 6 round-trip = $1,200. • Business startup funds provided to client after completion of business plan for purchase of small business equipment. $500 per client x 10 clients = $5,000 • Business registration and General Excise Tax (GET) application fees. $70 per client x 10 clients = $700. ATTACHMENT To NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 2 Program Funding Sources: ID all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate * County of Hawaii Nonprofit Grants- $100,000 in-Aid Program Reynolds Recycling $10,000 Total $110,000 PACT will supplement the $100,000 County of Hawaii funding request with up to $10,000 of funds secured from Reynolds Recycling, a private donor that has been supporting the Economic Development Center for over five years. These monies will be used for Individual Development Accounts, which provide clients with matching funds to help grow their businesses. ATTACHMENT To NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 2 82 Pulama is Kona Heritage Preservation Council Mamalahoa Kona Heritage Corridor Pulama is Kona Heritage Preservation Council- Agency Name Mamalahoa Kona Heritage Corridor- Program Name Agency Director: Scott Seymour Phone No.: 808- 329-5777 Contact Person: Tomoe Nimori Phone No.: 808- 329-3058 Mailing Address: PO Box 398 Captain Cook, HI 96704 Facility/Site Address: 75-662 Hua Ai St. Kailua Kona, HI 96740 Fax No.: 808-329-5777 Email Address: jnimori @hawaii.rr.com Name of Accountant/CPA (include name of firm if applicable): Bookkeeper--Jennifer Ching Phone No.: 808-322-3880 or 808-987-9447 Mailing Address: PO Box 594 Holualoa, HI 96725 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$17,178 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 D., .0 1 ..f' Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $0 $0 Agency Mission Statement: Th mission of Pulama is Kona Heritage Preservation Council is to preserve, protect and enhance the special qualities of Kona. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 D,.07 ^r(1 Pulama is Kona Heritage Preservation Council - Agency Name Mamalahoa Kona Heritage Corridor- Program Name Program Description: Signage for the Mamalahoa Kona Heritage Corridor is an important part of this program. The ten mile segment of Mamalahoa Highway is between Palani Junction and Honalo Junction. Signage approved by the Hawaii State Department of Transportation will be placed at Palani Junction, intersection of Queen Ka'ahumanu and Hualalai Road, and Honalo Junction. The need was demonstrated by a visiting guest who asked, "If I were not your guest, how would I have found this place?". Pulama is Kona Heritage Preservation Council (Pulama), sponsor of this State Scenic Byway and its Local Byway Committee composed of representatives of organizations and agencies strongly believe that signage is of foremost importance. Each sign is composed of two parts. The upper sign will state " State Scenic Byway". Another sign attached to this will name the scenic byway and serve as a directional sign. Each sign will be placed along both sides of the highway to ensure visibility for persons traveling north as well as south. Along the Mamalahoa Kona Heritage Corridor, signs to identify this scenic byway by name will be installed. Three signs on the northbound and three signs on the southbound sides of the highway will be placed at three mile intervals. Total Budget and Position Count Total Program Budget $17,178 Total Program Position Count 1 Total Agency Budget $23,500 Total Agency Position Count 0 Program Objectives: 1) Design a sign that is consistent with federal and state guidelines and approved by the Hawaii Dept. of Transportation by August 30, 2012. 2) Contract with a sign production company capable of creating signs that are uv-protected, weatherproof and mounted on stakes approved by the Hawaii State Dept. of Transportation by September 30, 2012. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 D, 'o Z ,.Fn 3) Accept completed signs and posts by January 30, 2013. 4) Install signs at State Hughway 190 and County Highway 180 (Palani Junction), State Highway 11 and Hualalai Rd. intersection and State Highway 11 and County Highway 180 (Honalo Junction) by March 30, 2013. 5) Install byway name signs at three mile intervals along Mamalahoa Kona Heritage Corridor by March 30, 2013. 6) Bring renewed interest and economic vitality to the area by increasing the number of visitors and sales to businesses along this State Scenic Byway by June 30, 2013. • Program Highlights: (from Fiscal Year 2010-11) 1) Funded by a $29,140 grant from the Federal Highways Administration, a team of consultants composed of a cartographer, geographer, ethno- botanist, historian, photographer and civil engineer, analyzed intrinsic qualities and safety along the Scenic Byway. 2) Pulama's planning committee, trained and advised by the Hawaii State Scenic Byways Coordinator, initiated the process of developing a corridor management plan based on reports prepared by the consultants. 3) Pulama developed a strategic plan to implement the corridor management plan. The most important strategy identified is to install signs that direct travelers to this Scenic Byway and identify the Mamalahoa Kona Heritage Corridor. 4) Pulama met with the Hawaii County Director of Planning and Director of Public Works to determine how the corridor management plan would fit into the scope of their responsibilities. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 n....e A n Pulama is Kona Heritage Preservation Council - Agency Name Mamalahoa Kona Heritage Corridor - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate 50 % increase in travelers to the 1,000 Scenic By Way in 2013 Completion of Design of signage $5,000 Fabrication and Installation of signs $12,178 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 0 Professional Fees $5,000 Operations Equipment Other# $12,178 Total $17,178 * If applicable Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Other Costs Fabrication:6 signs at$350/sign $2,100.00 Fabrication:12 byway name signs at$50/sign $600.00 Posts @2/sign for 12 signs and Hardware at$250/sign $3,000.00 Installation:12 signs at$500/sign { $6,000.00 Shipping $250.00 Tax : .04 X$5700 $228.00 Total $12,178.00 Pulama is Kona Heritage Preservation Council - Agency Name Mamalahoa Kona Heritage Corridor - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Federal Highways Administration $29,140 $29,140 0 Membership Dues $2180 $2000 $3000 County of Hawaii Non-Profit Grant $17,178 Total *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? To support this program, Pulama will research state and national grant funding sources including the County sponsored E Civis program. Pulama will conduct a membership campaign that will reach businesses along the Scenic Byway. The program will become self sustaining when increases in revenues for businesses due to signage develop a willingness to partner with Pulama on the scenic byway committee, as members, or as contributors to other Pulama fund drives. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 CI Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. 1. Volunteers of Pulama affiliated with the County of Hawai'i are: Marni Herkes--Member of the Action Committee of the Kona Community Development Plan. Bob Ward--Member of the Action Committee and Chairman of the Transportation Committee of the Kona Community Development Plan. 2. Volunteers of Pulama have established a working relationship with the County of Hawai'i in the following ways: Ben Ishii, Department of Public Works serves as a member of the Local Byway Committee of the Scenic Byway. Bobby Command, Executive Assistant to the Mayor serves as a member of the Local Byway Committee of the Scenic Byway. Warren Lee, Director, Department of Public Works has been informed of the Corridor Management Plan of the Scenic Byway and has agreed to write a letter of endorsement of the plan. Bobby Jean Leitthead-Todd Director, Department of Planning has been informed of the Corridor Management Plan of the Scenic Byway and has agreed to write a letter of endorsement of the plan. Margaret Masunaga, Deputy Director of Planning has been informed of the Corridor Management Plan of the Scenic Byway. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Pulama is Kona Heritage Preservation Council - Agency Name Mamalahoa Kona Heritage Corridor - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 D,.oQ .�(1 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. • . tg0/01 Signature of Boar:'re."dent/Chair Date or Agency Director t &Olinset , /404a/a Signature of Executive Director Date VV • UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 D....eAnr0 83 Puna Community Medical Center Uninsured/Underinsured Fund PUNA COMMUNITY MEDICAL CENTER- Agency Name Uninsured/Underinsured Fund- Program Name Agency Director: Daniel DiDomizio Phone No.: 930- 6001 Contact Person: Rene Siracusa Phone No.: 965- 2000 Mailing Address: 15-2662 Pahoa Village Rd., Ste. 306, PMB 8741 Pahoa, HI 96778 Facility/Site Address: 15-2662 Pahoa Village Rd., Ste. 303 Pahoa, HI 96778 Fax No.: (808) 930-6007 Email Address: dand @punahealth.org Name of Accountant/CPA (include name of firm if applicable): Nancy Kramer Phone No.: 965-2729 Mailing Address: P.O.Box 1519, Pahoa, HI 96778 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$120,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $50,000 $59,500 $115,000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 10 Agency Mission Statement: To provide walk-in, accessible, competent and compassionate health care to the residents of and visitors to the Puna District, 7 days/week including holidays, without regard to insurance coverage or ability to pay. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 10 PUNA COMMUNITY MEDICAL CENTER - Agency Name Uninsured/Underinsured Fund- Program Name Program Description: Since the 2000 Census the Puna District population has grown 24% and now comprises two Council Districts, an increase from 31,335 to 45,000+. Yet despite our efforts, Puna still has a federal designation as a Health Professional Shortage Area (HPSA), a Medically Underserved Area/Population (MUA/MUP), and a Primary Care/Mental Health/Dental Professional Shortage Area (HPSA), because access to health care has not kept pace with growth. Thus, although the State DOH 2009 Primary Care Needs Data Book lists Puna as having 15.9% of adults without health insurance (2"d only to liana), in our clinic we are now seeing between 18-22% uninsured/underinsured. Our patient visits in 2011 increased from 391 to 522 per month and have exceeded the 500 benchmark consistently since October. Since opening on 2/1/09 we have treated 7,500 patients in more than 14,400 encounters. Puna has some of the worst economic indicators in the State. Many residents can't even afford to pay the minimum sliding scale fee we charge ($25), or pay for their prescriptions. We see them anyway and give them vouchers for the pharmacy. This is paid out of our Uninsured/Underinsured Program, which the County has generously helped to fund. We wish to continue the program so that we can provide the needed care and still pay our overhead. Total Budget and Position Count Total Program Budget $120,000 Total Program Position Count 3 , Total Agency Budget , $ 580,620 Total Agency Position Count , 6 Program Objectives: 1) To provide acute care for common medical problems, such as infectious diseases of the Respiratory System (eg. colds, bronchitis and asthma); of the Digestive System (enteritis, constipation); of the Genito-Urinary System (bladder infections, STDs); the Skin, etc. and for common surgical problems (cuts and abrasions, sprains and strains, contusions, etc.). These services will be provided on a walk-in basis, with no appointment needed. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 10 2) To perform Physical Exams (school, athletic, Pop Warner, PUC, etc.) which are needed immediately and cannot be scheduled in a timely way with the client's primary care provider, if any. 3) To provide short-course refills of medications for chronic illness (Hypertension, Diabetes, etc.) should the client run out of these medications. Clinical Laboratories and Puna Pharmacy are also located in the Pahoa Marketplace, which makes this process easier and faster. 4) To have ready access to 911 services (ambulance, fire, police) located across Hwy. 130, should the need arise to transfer clients to HMC's ER. 5) To provide'seasonal flu/H1NI vaccinations on request and Tetanus on an as needed basis. 6) To continue our various fundraising efforts to generate a positive cash flow based upon fees for services and other methods (grants, Rural Health Clinic (RHC) designation, etc.), sufficient to sustain operations indefinitely. We are partway through the approval process for RHC certification, which includes enhanced reimbursement rates for providing Medicaid and Medicare services in a rural area. Once we achieve this designation, we expect our fiscal operations to be more robust. We will also be able to provide the same services that are required of a community health center. 7) To enter into partnerships and/or collaborative agreements with other entities (non-profit corporations, agencies, practitioners) for the purpose of creating a larger, more comprehensive health center for Puna makai. We already have agreements with Malama 0 Puna and Kokua Pahoa (formerly Pahoa Weed and Seed). 8) To continue our Uninsured/Underinsured Program (previously called indigent Care Program) to provide all the above listed services to clients who would otherwise go untreated. This includes discounted or free medication. 9) In our FY2009-10 HSEDC application we listed an objective of increasing our staff to 9 employees. We have done this. However, once we get our RHC designation and start providing other services, such as visiting nurse services to the homebound, we will have to add at least one more employee, an RN. 10) We now keep the clinic open 7 days a week, including 1/2 days on holidays. We would like to be able to increase our hours. 11) To provide emergent health services for 500 clients/month, including the indigent. 12) To continue working with our 'Friends of PCMC' group to do outreach events, such as the annual Puna Health Fair, and fundraising through benefits, events and seeking charitable donations. 13) To acquire a parcel of land on which to begin the process of creating a comprehensive medical center. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 10 Program Highlights: (from Fiscal Year 2010-11) 1) We hired a bookkeeper to free up other staff for medical coding and billing, to prepare us for the now-completed audit, to help us increase our reimbursements and to fine tune our fiscal operation. She is a Puna resident. 2) We passed our audit and incorporated its recommendations. 3) We hired another RN (also a Puna resident). 4) We applied for a RHC designation, and have already passed most of the programmatic hurdles. We went through an initial site visit in January 2012. 5) We increased our hours to 7 days per week and were open on all major (and all minor) holidays. 6) We have now managed over 14,400 client visits and are consistently treating more than 500 per month. 7) Our Clinical Operations Director and Physician's Assistant, Daniel DiDomizio, returned to his North Carolina alma mater and was officially recertified. 8) We have been seeking a parcel of land on which to eventually construct , in affordable increments, our comprehensive medical center, as envisioned in the Puna Community Development Plan. We are in negotiations with both State and County regarding land and permitting requirements. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5of10 PUNA COMMUNITY MEDICAL CENTER - Agency Name Uninsured/Underinsured Fund - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate patient visits/mo 345-484 391-521 500-550 patients covered under program 110 178+ 245+ *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages Professional Fees Operations Equipment Other* 59,500 115,000 120,000 Total 59.500 115,000 120,000 *If applicable *Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 10 PUNA COMMUNITY MEDICAL CENTER - Agency Name Uninsured/Underinsured Fund - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate HSEDC 59,500 115,000 120,000 Other grants to be applied for unknown Benefits and fundraisers unknown Total 59,500 115,000 120,000+? *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Unlike regular clinic operations this program, by definition, will bring in no income. Thus, by its very nature there is no way that the program can become self-sustaining, because it pays for health care services to people who are not covered, cannot pay, and therefore would go untreated. Any such patients with contagious diseases would otherwise spread their contagion throughout the community. With the population growth of more than 24%, and an increase in unemployment, we are now treating 18-22% patients who are eligible under this fund. This figure is expected to increase. In August we passed our 500 patient/month benchmark and have consistently treated more than that number per month, with an all time high of 522 in December. Our plans to become a Rural Health Clinic will, if achieved, bring us higher reimbursements for Medicare/Medicaid patients, but will not effect those clients who have neither form of coverage. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page'7 of10 Our fundraising does not bring in anything even close to the amount we need to sustain this program, and with the economy as it is, will not do so in the foreseeable future. We will continue to seek grant funding, if available, from federal, state and private sources, but private foundations are besieged with more applicants than ever, so the competition for these grants is fierce and therefore undependable. l Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Our Board President, Rene Siracusa, has served as vice-chair of the Hawaii County Planning Commission, and as chair of the Hawaii County Redistricting Commission in 2011. She is currently serving a 4-year term on the Puna Community Development Plan Action Committee and is vice-chair. All these are volunteer positions. Because PCMC was created in response to the PCDP and its goal of becoming a comprehensive medical center is one of the goals/objectives of the plan, she is well-positioned to bring this goal to fruition. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 10 PUNA COMMUNITY MEDICAL CENTER - Agency Name Uninsured/Underinsured Program - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135—2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 10 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. z z .cz ,co,i,- -' / - J -t o Signature of Board President/9181r- Date or-Ag r Signat o • ector ,1 Date e pit�c al go e-f fi0 UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 10 84 Puna Men's Chorus - Agency Name - Program Name Agency Director: ELYSE MORISHITA,PRES Phone No.: 808-990-8433 Contact Person: DAVID ELLIS,VICE-PRES Phone No.: 808-965-0505 Mailing Address: POST OFFICE 1881,PAHOA,HI 96778 Facility/Site Address: 12-7124 KALAPANA KAHOHO RD,PAHOA 96778 Fax No.: 808-965-0505 Email Address: davidmcellis @gamil.com Name of Accountant/CPA (include name of firm if applicable): NANCY J KRAMER CPA Phone No.: 808-965-2729 Mailing Address: PO BOX 1519,PAHOA,HI 96778 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$ 8,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $ 0 $ 7,000 $ 1,000 Agency Mission Statement: THE PUNA MEN'S CHORUS IS A DIVERSE OHANA WHICH SHARES THE POWER OF MUSIC WITH OUR COMMUNITY. GROUNDED IN PUNA,OUR VOICES REACH OUT TO INSPIRE, EDUCATE AND TRANSFORM OURSELVES AND OUR WORLD. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 6 - Agency Name - Program Name Program Description: SEE PROGRAM DESCRIPTION ATTACHED Total Budget and Position Count Total Program Budget 36,500 Total Program Position Count 3 Total Agency Budget 36,500 Total Agency Position Count 3 Program Objectives: SEE PROGRAM OBJECTIVES ATTACHED 1) Program Highlights: (from Fiscal Year 2010-11) 1) SEE PROGRAM HIGHLIGHTS ATTACHED NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 6 - Agency Name - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate MEMBERSHIP 23 30 30 PUBLIC APPEARANCES 13 25 25 ATTENDANCE 2,100 2,500 2,500 VOLUNTEERS 32 40 40 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 0 0 0 Professional Fees 19,420 17,700 19,500 Operations 11,823 9,596 11,000 Equipment 3.254 0 1,000 Other# 5,098 5,169 5,000 Total 39,595 32,465 36,500 * If applicable - #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 6 - Agency Name - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate TICKET SALES 14,323 11,309 12,000 MEMBER PARTICIPATION FEES 2,118 2.122 2,000 CONTRIBUTIONS 6,557 3,603 2,500 GRANTS 7,500 2,000 8,000 IN-KIND 5,090 5,076 5,000 SPONSORS 1,650 1,150 1,000 SPECIAL EVENTS 4,746 7,205 6,000 Total 41,985 32,465 36,500 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? 1.Hold 5 concerts throughout the Island in late summer/early fall 2012,generating increased ticket sales. 2.Generate mailng for donation solicitation;developed brochure. 3.Expand seb-site donations and ticket sales 4.Silent auctions for all performances. 5.Sale of CD's and DVD's. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawai`i. No employee or volunteer with PMC has any affliation or position with Hawaii County except one singer,Kevin Reardon,who works in the planning department. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 6 - Agency Name - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135— 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 6 Any funds unused by June 30, 2013 must be returned to the County of Hawai'i within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. 1/Pi 2,.i 4-- (11/I ( Signatu of :o!IT - nt/Chair Date - director 6) Signature of C suti4e-Dire for Date 'Pis Je---/- UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 6 ATTACHMENT TO PUNA MEN'S CHORUS HAWAII COUNTY GRANT APPLICATION * Program Description * Program Objectives * Program Highlights * Planned Uses for County Grant Funds Program Description 1. Concert Series In 2012, PMC started the year with the Aloha Broadway concert series, playing five venues in Puna and Hilo (Palace with the Vaudeville show, East Hawaii Culture Center, HPP, Palace, and Kalani Honua in February). As this series is completed, the singers will begin rehearsals and preparation for the next concert series, planned for late summer/early fall -- a 5th Anniversary program, incorporating the best from the past and new favorites for the future. We plan to take this program to at least five venues, including a return to the Palace and Kalani Honua, as well as different local venues (the Akebono in Pahoa, Wailoa Pavilion in Hilo, and a new venue in West Hawaii/Kona so that we can include more of Hawaii Island in our mission). 2. Outreach performances In 2012, PMC will continue our community outreach performances, with plans to repeat past outreach (including Goodwill, Lion's Club, lmiloa, County Holiday Festival, ARC of Hilo, parades for Pahoa Christmas and Merrie Monarch), and to add new outreach such as Merrie Monarch Wednesday night, Roller Derby, and Kamehameha School. We are also targeting joint performances and workshops with schools and other local singing groups -- including specifically HAAS in Pahoa (Hawaii Academy for Arts & Sciences). Of the $8000 grant requested, we would allocate $1000 to developing a joint program with HAAS and include students in both voice coaching and other PMC activities and performances. Program Objectives 1. Present to the local community (including a new audience in West Hawaii/Kona) a new concert series that will recognize PMC's five year anniversary and further our mission of using the power of music to celebrate the diversity of Hawaii Island's citizens, and to inspire, educate and transform ourselves and the world. 2. Educate our singers and other performers in choral and musical arts, including a focus on voice coaching. 3. Seek out and perform outreach opportunities in the community, bringing our music to schools and community organizations and events. 4. Reach out to others in the community, to inspire and educate them to join our chorus or other performing arts. 5. Help establish the economic viability of Puna, Men's Chorus so that we can become self-sustaining. Program Highlights Following is a summary of shows and activities from the past couple of years: # CONCERT SERIES: "Waiter, There's a Singer in my Soup" featuring Broadway show tunes -- Oct 17, 2009 at Akebono in Pahoa; Oct 23, 2009 at HPP in Kea'au; Oct 30, 2009 at Wailoa Pavilion in Hilo; Nov 7, 2009 at Seaview Performing Arts Center in Kalapana. # OUTREACH: Black & White Night in Hilo, Nov 6, 2009 at the Palace; Christmas caroling, Dec 20, 2009 in Puna Beach Palisades; annual Community Holiday Music Event, Dec 27, 2009 in Kapoho; "Celebration of Life" with Hospice of Hilo, May 8, 2010 at Wailoa Pavilion in Hilo. # CONCERT SERIES: "ExtrABBAganza" featuring music from ABBA-- June 25, 2010 at HPP; July 3, 2010 at People's Theater in Honoka'a; July 16, 2010 at the Palace in Hilo; July 4, 2010 at Kalani Honua in Puna Makai; Sept 19,2010 at the County Fair in Hilo (excerpts). # OUTREACH: Open Arms Metropolitan Community Church Nov 13, 2010 at HPP; Annual Community Holiday Music Event, Dec 28, 2010 in Kapoho; Rotary Club, Dec 21, 2010 in Hilo. # CONCERT SERIES: "HoIiDAZED!" featuring traditional holiday tunes in a very non- traditional setting -- Dec 3, 2010 at the Palace in Hilo; Dec 4, 2010 at HPP; Dec 10, 2010 at Kilauea Military Camp Theater in Volcano; Dec 20, 2010 at Kalani Honua. # OUTREACH: Merrie Monarch Parade in Hilo Apr 30, 2011; Volcano Art Center May 1, 2011; Puna Music Festival at Kalani Honua May 1, 2011 ; Anuenue Festival at Kalani Honua July 3, 2011. # CONCERT SERIES: "Keepin' It Country" featuring Western and cowboy favorites -- July 16, 2011 at HPP; July 23, 2011 at the Palace in Hilo; July 30, 2011 at People's Theater in Honoka'a. # OUTREACH: Halloween Benefit for HIHAF and PMC Oct 29, 2011 in Puna Beach Palisades; Puna Lion's Club annual Fund dinner Nov 5, 2011 ; Pahoa Christmas parade Dec 3, 2011 ; lmiloa membership Appreciation Night Dec 16, 2011; Christmas at the Cliff Dec 23, 2011 at Kalapana. # CONCERT SERIES: "Aloha Broadway" featuring medleys of Broadway show tunes -- Jan 12, 2012 at the Vaudeville fundraiser for the Palace Theater, S.P.A.C.E., and PMC, held at the Palace; Jan 20, 2012 at East Hawaii Culture Center in Hilo; Jan 21, 2012 at HPP; Jan 28 at the Palace in Hilo; Feb 4, 2012 [planned] at Kalani Honua. # OUTREACH: Apr 11, 2012 [planned] Hi'ike performance at Merrie Monarch. Proposed Use of $8000 in County Grant Funds 1. $2000 for voice coaching and lessons for PMC singers. Our formally trained Artistic Director (Amy Yamasaki) will leave at the conclusion of the current Aloha Broadway series; and she will be followed by our new Choral Director (Ken Reinhardt). We will need some outside professional help with voice coaching to achieve and maintain the excellence that has marked our performances in the past. 2. $3000 for arranging -- creating the sound for a men's chorus (tenor, tenor, baritone, bass). 3. $1000 for capital equipment (spotlight, and stage microphones) 4. $1000 for advertising to reach out for a paying audience. 5, $1000 for coordinating with and including students from Hawaii Academy of Arts & Sciences in PMC performances and other activities. We are working with Gail Clarke at HAAS 85 Recycle Hawaii Less Waste Means More Fun Recycle Hawaii- Agency Name Less Waste Means More Fun- Program Name Agency Director: Paul J. Buklarewicz Phone No.: 969- 2012 Contact Person: Kristine Kubat Phone No.: 969- 2012 Mailing Address: P.O. Box 4847 Hilo, Hawaii 97620 Facility/Site Address: 165 Keawe Street Suite#108 Hilo, Hawaii 96720 Fax No.: 969-2014 Email Address: kristinekubat @hawaii.rr.corn Name of Accountant/CPA (include name of firm if applicable): Alex J. Smith Phone No.: 877-257-6484 Mailing Address: 1403 Frank Street, Honolulu, Hawai'i 96816 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$19,400.00 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $0 $0 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 9 Agency Mission Statement: Recycle Hawai'i is a 501(c) 3 educational organization incorporated in 1992 and active as a grassroots effort since 1989. Our mission is to promote resource management and recycling throughout the state by educating and informing the people of Hawai'i about environmentally sound resource management and recycling opportunities. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 9 Recycle Hawai'i - Agency Name Less Waste Means More Fun- Program Name Program Description: Over the past 20 years, promoting recycling in the school environment has been an integral part of Recycle Hawai'i's public service legacy. Moving forward, we are determined to increase our impact on the next generation by doing less talking about the "Three R's" and doing more to create new recycling opportunities. Throughout the U.S. the commitment to stage large zero waste events includes organizers at college campuses and even major sporting franchises like the NFL. Our program builds on this trend to inspire Hawai'i Island students to plan for and then manage the waste stream of community events. A successful pilot program, dubbed "Less Waste Means More Fun" has proven that local organizers within the public and private sector are willing to stage zero waste events. In fact we found more interest than we were able serve given our current budget, which restricted manhours and travel time and resulted in a lower level of service to the Ka'u, Kona and Kohala Coast communities. This funding request supports expansion of the program to include increased service to schools in particular and West Hawai'i in general. For the past 20 years Recycle Hawai'i has made presentations at schools throughout the island, allowing us to establish a network of educators that collaborate with us to promote environmental stewardship. We have also earned a reputation as the island's leading recycling organization and one of the foremost advocates for resource management and sustainability state-wide. Our goal under the expanded "Less Waste Means More Fun" program is to leverage these existing relationships and build capacity for the staging of zero waste events within the greater community by focusing on the schools. A zero waste guide tailored to our local demographic will provide general instructions; hands on support will come in the form of assisted planning. Managing the waste stream during the event and processing the discards will be the responsibility of the students and community volunteers who will also have • learned how to document diversion rates. We are further committed to developing a Zero Waste School Challenge for students who want to compete for the highest diversion rates. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 9 Total Budget and Position Count Total Program Budget $38,200.00 Total Program Position Count 1 Total Agency Budget $612,000.00 Total Agency Position Count 11 Program Objectives: 1) Reduce the amount of waste that goes to the landfill. 2) Increase the number of local events staged as zero waste. 3) Promote environmental stewardship among island youth. 4) Increase recycling educational services to the underserved West Hawai'i community. 5) Alleviate frustration among island youth who are clearly troubled by environmental problems but at a loss to create solutions. Program Highlights: (from Fiscal Year 2010-11) 1) In 2011, Recycle Hawai'i began looking for ways to promote the concept of zero waste among local event organizers. Throughout the Spring, we worked with the Hilo Orchid Society to stage their opening gala as a zero waste event. As a result, volunteers were able to divert an estimated 99% of the waste generated by participants. At the end of the 4-hour affair, which was attended by over 200 people on August 4, one gallon of disposables remained, with the bulk of this trash coming from outside sources in the form of discarded Starbucks' and MacDonald's cups. Greatly encouraged by this experience, we looked for other opportunities and while we found strong interest islandwide, budget cuts did not allow us to assist groups in West Hawaii, which were largely left to organize and manage on their own. 2) In late August, Recycle Hawai'i received an award of$10,000 from Waste Management, Inc. through their"Think Green" initiative to fund our"Less Waste Means More Fun" program. The bulk of this grant was dedicated to a fund that local event organizers drew on to pay the cost differential between disposable and compostable dinnerware. Making the switch away from disposables is the primary method for achieving high diversion rates. Since this program began, we have paid out$4,700 in support of the following events: Mealani Taste of the Hawaiian Range, World Peace Day Festival, The Kohala Country Fair, HPA Pumpkin Patch, Pahoa High and Intermediate School Ho'olaulea and the ongoing Mercy NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 9 Program/Feed the Homeless as well as fundraisers for the lmiloa Astronomy Center, SurfRider Foundation, Friends of Hawai'i Volcano National Park, Youth Horizons and Breakthrough Adventures at UH-Hilo. Of the events listed above, Recycle Hawai'i was only able to assist with the waste stream and diversion of compostables for those on the Hilo side of the island. 3) Our next important achievement came in collaboration with the Pahoa High and Intermediate School's Green Club. Recycle Hawai'i helped manage the waste stream for the community's biggest event, the annual ho'olaulea held each year at the school. With the help of students and faculty, we diverted an estimated 85% of the discards generated over a 6- hour period. Event organizers estimated 2,000 attendees. The extent to which the community accepted the waste diversion scheme and the amount of pride the students took in their accomplishment convinced us that introducing this approach throughout the school system would have great benefit. 4) Also throughout the year, our zero waste event program has brought us into contact with recycling promoters in the sporting industry, including organizations as influential as the NFL. Through these contacts we have come to realize the time is right to get local sports programs onboard through outreach to island youth and faculty. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 9 Recycle Hawaii - Agency Name Less Waste Means More Fun - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Number of schools contacted 3 50 Number of school-sponsored zero 2 3 waste events staged/East Hawai'i Number of school-sponsored zero 0 6 waste events staged/West Hawai'i Average diversion rate for school- 85% 85% sponsored zero waste events Volume of waste diverted for Pending TBD** program ** this is really difficult to estimate but we will measure and report on it *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages N/A 15,200 33,800 Professional Fees N/A 1,500 -0- Operations N/A 8,800 5,000 Equipment N/A 800 -0- Other# N/A -0- -0- Total N/A 26,300 38,800 *If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 9 Recycle Hawai'i - Agency Name Less Waste Means More Fun - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Waste Management, Inc. N/A 10,000 10,000 Grousbeck Foundation N/A 5,000 5,000 County of Hawaii GIA N/A -0- 19,400 Recycle Hawai'i N/A 11,300 4,400 Total 26,300 38,800 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Our goal is to work to introduce the concept and assist in the first year. After this, we believe the schools can manage to organize and stage these zero waste events on their own. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. N/A NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 9 Recycle Hawai'i - Agency Name Less Waste Means More Fun - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135—2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 9 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. __- / a7-.242( z Signat ":o?,rd President/Chair Date or Agency Director IIII inill:- / (30 I i'. .-_ Signatu ! - ive Direc .1 Date Imi jo UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 9 86 Salvation Army Family Intervention Services, The Independent Living Skills The Salvation Army Family Intervention Services Independent Living Skills Program — West Hawaii Agency Director: Pauline Pavao Phone No.: 959-5855 ext 28 Contact Person: Denise Pacheco Phone No.: 959-5855 ext. 14 Mailing Address: P.O. Box 5085 Hilo, HI 96720 Facility/Site Address: 1786 Kinoole St. Hilo, HI 96720 Fax No.: 959-2301 Email Address: Pauline.Pavao @usw.salvationarmy.org Name of Accountant/CPA (include name of firm if applicable): Name: Donna Lum (DHQ Director of Finance)/Cary Ebesugawa, CSE Consulting Phone: (808) 988-2136/ (808) 981-2775 Mailing: P.O. Box 620 Honolulu, HI 96809/1542 Maunakai St. Hilo, Hi 96720 Amount of Request for County funds: $36,962.00 Prior Year(S) Funding: 09_010 10-11 11-12 $15,000 $15,000 $15,000 Agency Mission Statement: To provide youth with skills for a healthy life, and instill purpose, hope, and vision to youth and their families. Our agency's goals are to provide youth with a safe, caring, and nurturing environment. We recognize that all youth are "Youth of Promise," and have the potential to become self-directed, goal oriented and contributing members of our community. Program Description: For children and youth in the foster care system, life's ordinary challenges and opportunities frequently become extraordinary (NCWD, youth.) Age 18 is the age of majority and past this age the individual is expected to make "adult decisions." However, there is an increasing awareness that a "transition cliff' occurs and few young people are able to go at it alone without strong supports (NCWD, youth.) Foster youth need connectedness, and a sense of belongs, whether it is to a community, program, peers, or a support system. As indicated by Jim Casey Youth Opportunities data, since 1999, more than 230,000 young people have aged out of foster care. In fiscal year 2008 they reported more than 29,000 teenagers aged out NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of foster care. Not surprisingly, these young adults are particularly vulnerable to drugs, crime, mental health issues, early pregnancy, poverty, homelessness, lack of education, health insurance, and employment (Casey Family Services.) The Salvation Army- Family Intervention Services—Independent Living Skills Program is designed to help foster youth and emancipated foster youth ages 12-21 prepare for and manage the transition to productive, self-sufficient adulthood with a base of independent living skills. The goal of the Independent Living Skills Program is to: 1) Provide a comprehensive life skills based curriculum 2) Provide opportunities for foster youth to pursue higher education, vocational training, and/or employment, 3) Provide linkages and resources to services in the community including: housing, health insurance, and other vital needs. The curriculum emphasizes career, education and job-skills development, utilizing a school-based skills format as a framework for implementing an array of independent living/transition curriculums that can be tailored to fit the respective participants relative to age, level of education and psychosocial developmental levels. The focus of this training is to draw a connection between academic success,jobs skills and positive social skills development in order to attain a higher quality of life in the high need areas of Health, Housing, and Economic Self-Sufficiency. The curriculum is divided by components or themes that highlight sessions connected to self- sufficiency. In following with the school year, each component represents a month. These components include: • Orientation/Personal Development (Sept) • Educational Success & Planning (Oct) • Social and Community Awareness (Nov) • Vocational/Job Skills Training (Dec) • Post-High Options/ Financial Aide (Jan) • Career Preparation &Work-Based Learning Experiences(Feb) • Life Planning & Money Management (Mar) • Self Care & Positive Relationship Building (Apr) • Daily Living & Community Involvement (May) • Evaluation, Youth Recognition (June) • Community Service Learning Projects/Team Building Activities- Leadership (July, August) Group sessions are held at Konawaena High School on Wednesdays and individual focus sessions on Mondays and Tuesdays. Each foster youth is required to attend one 2-hour session per week as well as individual sessions. In addition, we stress a youth driven approach when developing their transition plan. Community service projects, Family Strengthening and extra- curricular activities are designed to further expand their knowledge of their community and the abundance of resources available to them. They include: College Fairs, Job Fairs, Housing Fairs, World of Work Tours sponsored by the Hawaii Community College, West Hawaii Community College, University of Hawaii at Hilo, Hawaii National Park Service, National Energy Laboratory Hawaii Authority, Sheraton Keauhou Beach Resort and Spa, Work Force Development Division-West Hawaii and many others. We strongly encourage our participants to engage in civic connectedness and giving back to ones community. The Department of Human Services currently funds our Independent Living Skills Program. Our area of coverage is West Hawaii which includes: Kohala, Waimea, Waikoloa, Kealakehe, Konawaena and the Kau District. This contract supports only a 1.00 FTE Youth Development Specialist IV, which is not enough to cover this vast district. Funding received through the NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 County would help support .50 FTE Youth Development Specialist IV position to increase staff coverage and services to the West Hawaii District. Total Budget and Position Count Total Program Budget $91,038 Total Program Position Count .5 FTE Total Agency Budget $3,446,551 Total Agency Position Count 59 Program Objectives: The objective of the program is to accomplish the following for 30 foster youth in West Hawaii each year: • Of the 30 foster youth, ages 12-15 participating in the program, 75% will demonstrate increased independent living skills, as identified in their IL plan. • Of the 30 foster youth, ages 16 plus participating in the program, 75% will successfully complete their Independent Living Skills Program and attain at least a "fair prognosis" of achieving goals of independence upon exiting the program. • Of the foster youth, ages 18 plus, participating in the program, 80% will participate in Higher education, Vocational Training, Employment and/or Military • 75% of youth will avoid non-marital childbirth, incarceration and homelessness during program participation. Program Highlights: FY 2010-11 In our 2010-2011 fiscal years, The Independent Living Skills Program in West Hawaii provided over 1,641 direct service hours to foster youth and obtained the following performance measures: • 95% of foster youth age 12-15 demonstrated an increase in Independent Living Skills, as identified in their IL plan • 80%of foster youth age 16 plus completed their Independent Living Skills Program and attained at least a fair prognosis of achieving goals, as identified in their IL plan • 85%of foster youth 18 plus, participated in Higher Education, Vocational Training Employment and/or Military • 100% avoided non-marital childbirth, incarceration and homelessness during program participation We believe that networking and building partnerships are key elements in providing direct and indirect services to youth and families. Since 1999, TSA-FIS has worked cooperatively with organizations and communities on behalf of foster youth. When appropriate, TSA-FIS makes referrals and/or linkages of participants to the following: inter-Agency, Foster Care Alumni Support Program, Transitional Living Program-HYSN, Independent Living Transition Home- OYS, Street Outreach Program, Emergency Shelter Service, Group Home, Youth Development Program, and Community Based Outreach Services. Community, Alu Like, Catholic Charities, Hawaii Community College-Career Center, Office of continuing education, West Hawaii Community College, Hawaii Foster Youth Coalition, Bay Clinic, Big Island Substance Abuse Clinic, Big Island Work Force Development-West Hawaii, Office of Social Ministry-Care-A-Van. DOE, All High Schools in East and West Hawaii, Alternative Learning Centers, Charter Schools, and Community School for Adults. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Completion of ILSP 46 30 30 Participates in IL Activities 66 30 30 Participates in IL Plan 66 30 30 Follow up and Monitoring 66 30 30 Program Expenditures FY 2010-11 FY 2011-12 FY2012-13 Actual * Budget* Estimate Salaries and Wages 73,141.35 61,264.20 82,764.20 Professional Fees Operations 45.071.34 44,773.80 45,235.80 Equipment Other* Total 118,212.69 106,038.00 128,000.00 Program Funding Sources Revenue Source FY 2010-11 FY 2011-12 FY 2011-12 Actual * Budget* Estimate State of Hawaii 91,038.00 91,038.00 91,038.00 County of Hawaii 15,000.00 15,000.00 36,962.00 Total 106,038.00 106,038.00 128,000.00 Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self- sustaining? The Salvation Army-Family Intervention Services, while part of The Salvation Army, is required to seek its own funding for program services. As such, TSA-FIS relies primarily on funding from government at the federal, state and county levels to continue our outreach programs to assist at-risk youth and their families. Such funding is primarily through the purchase of service system, which we are required to submit proposals through a competitive process. Very limited funding is available through grants from trusts and foundations. We continuously explore avenues of funding to continue these programs. However, in view of the nature of our mission in developing healthy lifestyles for youths and their families, we do rely heavily on funding from all levels of government. As such, we do not anticipate being self-sufficient in providing Outreach services to the youth and families residing in Hawaii County. Please disclose (List Here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii As an agency, the only affiliation with the County of Hawaii is in regards to grants received: SPF-SIG Underage Drinking Grant, and Independent Living Skills Program- West Hawaii and Prevention Programs-Pahoa. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 The Salvation Army Family Intervention Services Independent Living Skills Program-West Hawaii I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135—2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the Legislative auditor within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report may impact the evaluation of your program's or agency's future funding requests. Sign; e of Board President/Chair Date /3-4 20 ! i.• Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 87 Salvation Army Family Intervention Services, The Prevention Programs - Kea'au The Salvation Army Family Intervention Services Prevention Programs-Keaau Agency Director: Pauline Pavao Phone No.: 959-5855 x 28 Contact Person: Denise Pacheco Phone No.: 959-5855 x 14 Mailing Address: P.O. Box 5085 Hilo, HI 96720 Facility/Site Address: 1786 Kinoole St. Hilo, HI 96720 Fax No.: 959-2301 Email Address: pauline.pavao©usw.salvationarmy.org Name of Accountant/CPA (include name of firm if applicable): Name: Donna Lum (DHQ Director of Finance)/Cary Ebesugawa, CSE Consulting Phone: (808) 988-2136/ (808) 981-2775 Mailing: P.O. Box 620 Honolulu, HI 96809/1542 Maunakai St. Hilo, HI 96720 Amount of Request for County funds:$ 35,000.00 Prior Year Funding: 09-10 10-11 11-12 $0.00 $0.00 $0.00 New funding request for Prevention Services- Keaau District Agency Mission Statement: "To provide youth with skills for a healthy life, and instill purpose, hope, and vision to youth and their families." Our agency's goals are to provide youth with a safe, caring, and nurturing environment; and provide opportunities for youth to challenge their life styles through development of appropriate social skills, academic success, and personal resiliency. Program Description: The Salvation Army Family Intervention Services-Prevention Programs provides a safe and nurturing environment along with access to opportunities, experiences, and services to support positive youth development. We utilize a prevention approach to decrease the use and abuse of alcohol, tobacco, and other illicit drugs (ICE, ecstacy, and etc.), involvement in gangs and violence, delinquent behaviors, early sexual behaviors, and to improve academic performance and school attendance. This will be accomplished by implementing Community-Based Outreach Services and Positive Alternative Activities to youth ages 7-18 years old and their families, residing in the Keaau district. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 Services consist of: ➢ The Botvin Life Skills Training Curriculum which is an evidence based program designed to strengthen student skills in: Personal Self-Management, General Social Skills and Drug Resistant Skills. Curriculum consists of 10 sessions -45 minutes each session. ➢ Leadership Development Program -The L.E.A.D. Team (Learning Experience in Assisting and Directing) provides development of leadership skills and training in areas of personal and social skills, teamwork, decision making, goal setting, and action planning to conduct community service and learning projects. ➢ TSA-FIS has developed a program called "Project Family"to build relationships between agency, youth, parents, and community. Project Family Activities provide parent support and family strengthening activities to promote family cohesion and positive relationships within diverse family structures. Youth and their families along with agency staff participate in regularly scheduled "Family Days"which are activity-based and fun. ➢ Positive Alternative Activities consist of: Recreational, Educational, Cultural, and Youth Leadership Activities. Other prevention activities consist of Community Service and Learning Projects, Drug-free dances, and Excursions. All services will be part of a compilation of Prevention Programs currently funded by the Office of Youth Services. Program services will be provided at Keaau School Districts, Neighborhood Place of Puna- Mountain View and Charter schools. We propose to implement program services during in-school, after-school, and occasionally weekend hours. The proposed funding would support a 0.5 FTE Youth Development Specialist IV. Supplemental funding from the Office of Youth Services- Positive Youth Development Program will help support and establish a 1.00 FTE Youth Development Specialist IV to provide outreach services to the Puna Community. Total Budget and Position Count Total Program Budget 74,063.00 Total Program Position Count .50 Total Agency Budget 3,446,551 Total Agency Position Count 59 Program Objectives: 1) Of the 40 youth targeted to participate in the Prevention Program, at least 80% will register for Outreach Services (L.E.A.D. Team, Project Family, Positive Alternative Activities) and maintain participation with the program to completion or for 6 months beyond the registration date. 2) Of the 40 youth participating in the prevention activities throughout the year, at least 80% will participate in Positive Alternative Activities (Community Service and Learning Projects, Recreation, Tutoring, Community Events, and Family Days), demonstrate an increase in competencies (social well-being, knowledge, and social responsibility) for the first 3 months, and continue that gain for an additional 6 months or completion of the program. Program Highlights: FY 2010-11 In fiscal year 2010-2011, The Prevention Program in Keaau achieved the following Program objectives: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 • Participated in the Annual School Supply Distribution in district of Keaau at St. Theresa's Church in Mt. View. Provided youth with school supplies, and family strengthening activities. • Facilitated the Botvin Life Skills Curriculum training to Keaau Elementary and High School students twice a week, reinforcing Decision Making, Social Skills, Respect, Emotions, Communication and Tobacco and Alcohol Prevention • Facilitated Botvin Life Skills at Mt. View Elementary School, focusing on Respect, Anger Management, Alcohol and Tobacco and other Drugs Prevention • Facilitated "Girls Group"throughout the school year with young women ages 12-15. Utilized the Swim with Your Current curriculum. • Coordinated with other programs to be part of the National "Kick Butts Day" This community service project saw our participants picking up more than 3,000 cigarette butts from our streets • Facilitated a Violence Prevention Program at Keaau Elementary and Mt. View Elementary school focusing on differences between anger and violence, self-talk, assertiveness, communications, and how to manage anger before it turns into violence Community Collaborations: Linkages with Other Agencies: Referrals to the prevention programs are currently coordinated through the In-School Services at Keaau Elementary, Intermediate and High Schools, Mountain View Elementary and Na Wai Ola-Waters of Life Charter School. TSA-FIS has also worked cooperatively in coordinating services for youth and families with the following programs: Big Island Substance Abuse Council; Workforce Investment Youth Employment Services; Hawaii County Community Policing Officers; Bay Clinic; Queen Liliuokalani Children's Center; Neighborhood Place of Puna; Pahoa Parks and Recreation; Boys and Girls Club of the Big Island; Alulike Inc; Specific Collaborations include: • Neighborhood Place of Puna allows us the use of their conference room free of charge to hold afterschool classes and classes for youth expelled from school • Hawaii County Parks and Recreation allows us use of their facilities for groups and special events, and community meetings • The Hawaii County Community Police Officers and the School Resource Officer collaborate with us on student referrals, community events and presentations. • The Queen Liliuokalani Children's Center is a strong collaborator in community events, student groups and community service learning projects. • Puna Community Action Team (PCAT) Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Completion of L.E.A.D. Team 48 60 40 Participates in Pos. Alter. Activities 50 60 40 Participates in Project Family 41 60 40 Follow up and Monitoring 45 60 40 Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 43,973.68 50,954.26 73,454.26 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Professional Fees 0 0 0 Operations 24,479.19 23,108/4 36,545.74 Equipment 0 0 0 Other* 0 0 0 Total 68,452.88 74,063.00 110,000.00 Program Funding Sources Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate State of HI-Office of Youth 67,470.75 74,063.00 75,000 Services* County of Hawaii 0.00 0.00 35,000 Total 67,470.75 89,063.00 110,000.00 *Positive Youth Development services funded under Office of Youth Services. Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self- sustaining? The Salvation Army-Family Intervention Services, while part of The Salvation Army, is required to seek its own funding for program services. As such, TSA-FIS relies primarily on funding from government at the federal, state and county levels to continue our prevention and outreach programs to assist at-risk youth and their families. Such funding is primarily through the purchase of service system, which we are required to submit proposals through a competitive process. Very limited funding is available through grants from trusts and foundations. We continuously explore avenues of funding to continue these programs. However, in view of the nature of our mission in developing healthy lifestyles for youths and their families, we do rely heavily on funding from all levels of government. As such, we do not anticipate being self-sufficient in providing prevention services to the youth and families residing in Hawaii County. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. As an agency, the only affiliation with the County of Hawaii is in regards to grants received: SPF-SIG Underage Drinking Grant, and Independent Living Skills Program- West Hawaii and Prevention Programs-Pahoa. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 The Salvation Army Family Intervention Services Prevention Programs-Pahoa I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135—2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the Legislative auditor within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report may impact the evaluation of your program's or agency's future funding requests. A/.1 Ili 713/-Ze Siggfo a - r esident/Chair Date ._..: . or I , 1/4///2.- ignature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 88 Salvation Army Family Intervention Services, The Prevention Programs - Pahoa The Salvation Army Family Intervention Services Prevention Programs-Pahoa Agency Director: Pauline Pavao Phone No.: 959-5855 x 28 Contact Person: Denise Pacheco Phone No.: 959-5855 x 14 Mailing Address: P.O. Box 5085 Hilo, HI 96720 Facility/Site Address: 1786 Kinoole St. Hilo, HI 96720 Fax No.: 959-2301 Email Address: pauline.pavao @usw.salvationarmy.org Name of Accountant/CPA (include name of firm if applicable): Name: Donna Lum (DHQ Director of Finance)lCary Ebesugawa, CSE Consulting Phone: (808) 988-2136/ (808) 981-2775 Mailing: P.O. Box 620 Honolulu, HI 96809/1542 Maunakai St. Hilo, HI 96720 Amount of Request for County funds:$ 35,000.00 Prior Year Funding: 09-10 10-11 11-12 $15,000 $15,000 $15,000 Agency Mission Statement: "To provide youth with skills for a healthy life, and instill purpose, hope, and vision to youth and their families." Our agency's goals are to provide youth with a safe, caring, and nurturing environment; and provide opportunities for youth to challenge their life styles through development of appropriate social skills, academic success, and personal resiliency. Program Description: The Salvation Army Family Intervention Services-Prevention Programs provides a safe and nurturing environment along with access to opportunities, experiences, and services to support positive youth development. We utilize a prevention approach to decrease the use and abuse of alcohol, tobacco, and other illicit drugs (ICE, ecstacy, and etc.), involvement in gangs and violence, delinquent behaviors, early sexual behaviors, and to improve academic performance and school attendance. This will be accomplished by implementing Community-Based Outreach Services and Positive Alternative Activities to youth ages 7-18 years old and their families, residing in the Pahoa district. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 Services consist of: ➢ The Botvin Life Skills Training Curriculum which is an evidence based program designed to strengthen student skills in: Personal Self-Management, General Social Skills and Drug Resistant Skills. Curriculum consists of 10 sessions -45 minutes each session. ➢ Leadership Development Program -The L.E.A.D. Team (Learning Experience in Assisting and Directing) provides development of leadership skills and training in areas of personal and social skills, teamwork, decision making, goal setting, and action planning to conduct community service and learning projects. ➢ TSA-FIS has developed a program called "Project Family" to build relationships between agency, youth, parents, and community. Project Family Activities provide parent support and family strengthening activities to promote family cohesion and positive relationships within diverse family structures. Youth and their families along with agency staff participate in regularly scheduled "Family Days"which are activity-based and fun. ➢ Positive Alternative Activities consist of: Recreational, Educational, Cultural, and Youth Leadership Activities. Other prevention activities consist of Community Service and Learning Projects, Drug-free dances, and Excursions. All services will be part of a compilation of Prevention Programs currently funded by the Office of Youth Services and Department of Health -ADAD. Program services will be provided at Pahoa School Districts, Neighborhood Place of Puna and at the Nanawale Community Center. We propose to implement program services during in-school, after-school, and occasionally weekend hours. The proposed funding would support a 0.5 FTE Youth Development Specialist IV. Supplemental funding from the ADAD Substance Abuse Prevention Program will help support and establish a 1.00 FTE Youth Development Specialist IV to provide outreach services to the Puna Community. Total Budget and Position Count Total Program Budget 117,492.80 Total Program Position Count .50 Total Agency Budget 3,446,551 Total Agency Position Count 59 Program Objectives: 1) Of the 40 youth targeted to participate in the Prevention Program, at least 80% will register for Outreach Services (L.E.A.D. Team, Project Family, Positive Alternative Activities) and maintain participation with the program to completion or for 6 months beyond the registration date. 2) Of the 40 youth participating in the prevention activities throughout the year, at least 80% will participate in Positive Alternative Activities (Community Service and Learning Projects, Recreation, Tutoring, Community Events, and Family Days), demonstrate an increase in competencies (social well-being, knowledge, and social responsibility) for the first 3 months, and continue that gain for an additional 6 months or completion of the program. Program Highlights: FY 2010-11 In fiscal year 2010-2011, The Prevention Program in Pahoa achieved the following Program objectives: NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 • Participated in the Annual School Supply Distribution in district of Puna at the Maku'u Farmers Market. Provided well over 400 families including over 1300 youth with school supplies • Facilitated the Botvin Life Skills Curriculum training to Pahoa Elementary students twice a week, reinforcing Decision Making, Social Skills, Respect, Emotions, Communication and Tobacco and Alcohol Prevention • Facilitated Botvin Life Skills at Pahoa Middle School, focusing on Respect, Anger Management, Alcohol and Tobacco and other Drugs Prevention • Facilitated "Girls Group"throughout the school year with young women ages 12-15. Utilized the Swim with Your Current curriculum. • Coordinated with other programs to be part of the National "Kick Butts Day" This community service project saw our participants picking up more than 3,000 cigarette butts from our streets • Facilitated a Violence Prevention Program at Pahoa High School focusing on differences between anger and violence, self-talk, assertiveness, communications, and how to manage anger before it turns into violence • The Neighborhood Place of Puna sponsored a "Celebrate Your Family Day" and we participated by having a activity booth and engaging with the families of Pahoa • TSA-FIS sponsored a dance at Pahoa Middle School and encouraged participants to abstain from alcohol, tobacco and other drugs. This drug free event was a big hit, serving over 120 middle school youth. Community Collaborations: Linkages with Other Agencies: Referrals to the prevention programs are currently coordinated through the In-School Services at Pahoa Elementary, Intermediate and High Schools, HAAS (Hawaii Academy of Arts and Sciences), Ku O'Kala, Keonepoko Elementary, and Mountain View Elementary. TSA-FIS has also worked cooperatively in coordinating services for youth and families with the following programs: Big Island Substance Abuse Council; Workforce Investment Youth Employment Services; Hawaii County Community Policing Officers; Bay Clinic; Queen Liliuokalani Children's Center; Neighborhood Place of Puna; Pahoa Parks and Recreation; Boys and Girls Club of the Big Island; Alulike Inc; Pahoa Weed and Seed, and Nanawale Community Center. Specific Collaborations include: • Neighborhood Place of Puna allows us the use of their conference room free of charge to hold afterschool classes and classes for youth expelled from school • Hawaii County Parks and Recreation allows us use of their facilities for groups and special events, and community meetings • The Hawaii County Community Police Officers and the School Resource Officer collaborate with us on student referrals, community events and presentations. • The Queen Liliuokalani Children's Center is a strong collaborator in community events, student groups and community service learning projects. • Pahoa Weed and Seed is a community focused strategy and we work with them to inform community members through the families on what is going on in the community Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Completion of L.E.A.D. Team 53 60 40 Participates in Pos. Alter. Activities 53 60 j 40 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 Participates in Project Family 42 60 40 Follow up and Monitoring 45 60 40 Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 43,865.36 74,448.32 84,963.45 Professional Fees 0 0 0 Operations 40,462.49 43,044.48 40,036.55 Equipment 0 0 0 Other* 0 0 0 Total 84,327.85 117,492.80 125,000.00 Program Funding Sources Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate State of HI-Office of Youth 68,169.70 17,813.00 0.00 Services* Dept. of Health, Substance Abuse 0.00 84,679.80 90,000.00 Prevention* County of Hawaii 15,000.00 15,000.00 35,000.00 Total 83,452.87 117,492.80 125,000.00 *Positive Youth Development services funded under Office of Youth Services. *Substance Abuse Prevention services funded under Department of Health-ADAD. Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self- sustaining? The Salvation Army-Family Intervention Services, while part of The Salvation Army, is required to seek its own funding for program services. As such, TSA-FIS relies primarily on funding from government at the federal, state and county levels to continue our prevention and outreach programs to assist at-risk youth and their families. Such funding is primarily through the purchase of service system, which we are required to submit proposals through a competitive process. Very limited funding is available through grants from trusts and foundations. We continuously explore avenues of funding to continue these programs. However, in view of the nature of our mission in developing healthy lifestyles for youths and their families, we do rely heavily on funding from all levels of government. As such, we do not anticipate being self-sufficient in providing prevention services to the youth and families residing in Hawaii County. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. As an agency, the only affiliation with the County of Hawaii is in regards to grants received: SPF-SIG Underage Drinking Grant, and Independent Living Skills Program- West Hawaii and Prevention Programs-Pahoa. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 The Salvation Army Family Intervention Services Prevention Programs-Pahoa I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the Legislative auditor within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report may impact the evaluation of your program's or agency's future funding requests. a of Bo_rd President/Chair Da efr • vs.,/, '2__ Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 89 Special Olympics Hawaii Special Olympics Hawaii - East Hawaii Area COPY Special Olympics Hawaii- Agency Name Special Olympics Hawaii - East Hawaii Area- Program Name Agency Director: Nancy Bottelo Phone No.: 808- 695-3522 Contact Person: Carey Uchida Phone No.: 808- 990-5751 Mailing Address: P.O. Box 7265 Hilo, HI 96720 Facility/Site Address: 230 Kekuanaoa Hilo, HI 96720 Fax No.: 808-935-/qa Email Address: careyuchida©hotmail.com Name of Accountant/CPA(include name bf firm if applicable): Akamine, Oyadoinari & Kosaki Phone No.: 808 941-0500 Mailing Address: 1440 Kapiolani at#900 Honolulu, HI 96814 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$25,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11 -12 $10,000 $12,000 $15 000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of i 1 , I I i Agency Mission Statement: The mission of Special Olympics is to provi a year round sports training and athletic competition in a variety of Olympic- ype sports for children and adults with intellectual disabilities, giving them continuing opportunities to develop physical fitness, demonstrate courage, exp rience joy and participate in the sharing of gifts, skills and friendship with th it families, other Special Olympics athletes and the community. NONPROFIT GRANT APPLICATION FISCAL YEAR 012-13 Page 2 of 1 i 1 Special Olympics Hawaii - Agency Name Special Olympics Hawaii-East Hawaii Area- Program Name Program Description: Special Olympics is a national award-winning nonprofit organization created by Eunice Kennedy Shriver in 1968 to address the neglect and disregard of individuals with intellectual disabilities. Our special Olympics program is open to everyone with intellectual disabilities in Hawai'i, regardless of the extent of their disability. People who are isolated from life experience by a disability have little chance for the developmental growth and acquisition of important skills that they will need to gain employment, maintain relationships and function within the community. Special Olympics believes that all people, regardless of their disability deserve to lead full, active lives, a 'riched with social and recreational opportunities that most of us take for grante . Unfortunately, appropriate physical education programs in the public schools a d social service programs that realistically address the special needs of thi population are virtually non- existent. An impact study done in 2004 stat s that 52% of the adult Special Olympics athletes in the United States are a ployed, over half of those are in competitive employment. The general disc led population only has 10% employed. This is a significant impact withi the communities that we are involved with. 1 Special Olympics East Hawaii Unified Sport Program continues to grow. The interaction between non-handicapped peers and our Special Olympics athletes on a weekly basis has shown significant cha ges within school programs, especially when we are talking about accept nce of everyone within their school community. This can only impact these non- andicapped students as they grow into adulthood and become parents themsel es and employers of our East Hawaii businesses. Unified Sports is a prog am that combines equal numbers of athletes with intellectual disabilities and spe ial partners without disabilities. All participants are of similar age and athletic a ility. Special Olympics East Hawaii would like to expand to 2 unified softball tea s, 12 unified bowling teams and 24 unified bocce teams that will participant in o r Unified Sports Program. They all train and compete together here in East Ha aii and they travel to Maui and Oahu for regional and state competitions. The benefits for our athletes continue to be: mproved physical fitness and motor skills, greater self-confidence, a more postitie self-image, friendships, and increased family support. We encounter the benefits in their daily lives at home, in the classroom, on the job, and in th community. Our program could not happen without the help from our community volunteers. Through our program ■ NONPROFIT GRANT.APPLICATION FISCAL YEAR$012-13 Page 3 of 111 I . I over 500 community volunteers interact with individuals with special needs without our community. Our program is free of cost to all our athlete , special partners, and coaches. All of the money raised for the East Hawaii pro ram stays here to support our program. Those funds will pay for all aspect of the Special Olympics program, which includes, equipment, uniforms, transportation costs, training of the coaching staff, family activities and our Athlete Leadership Program (ALPS). ALPS athletes are trained to become coaches, public speakers, members of the Board of Directors, and officials. Special Olympics East Hawaii believes that our athletes are the Voice of our program. As always, Special Olympics East Hawaii's largest expense for 2012-13 will be transportation. It is an essential part of our program that Special Olympics athletes are provided an opportunity to interact and compete against people of smiliar athletic ability. Unfortunately our area program is too small to be able to provide quality competition, therefore our athletes must travel to other islands to achieve that goal. The state competitions tat are held on Oahu 3 times per year provide many activities that our athletes never have a chance to experience. They include; dances, Opening and Closing Ceremonies, entertainment and games, and being exposed to a Healthy Ath ete Program. This program provides a free dental screening, vision screening, aring screening, Fun Fitness (flexibility& strength) screening, nutrition s reening and podiatric screening for our athletes. As you know, these services a e sometimes not available to individuals with disabilities due to financial d fficulty or lack of professionals who are trained to treat people with disabilities. =ach athlete who participated in the vision screening at the 2011 Summer Game. and who required glasses, were given free glasses that were mailed to each :thiete. Because of the economic difficulty here in Hawaii and around the Unit. • States, Special Olympics East Hawaii has begun to utilize a quota system f•r athletes traveling off island. No longer will ALL athletes be able to travel to s •to games, but we would like to still provide that service to as many athletes as e possibly can and with the help of the County of Hawaii we will be able to conti ue to provide that services as well as help to fund the on-going expenses we e ounter every year. Special Olympics Hawaii-East Hawaii Area is asking for$25,000 from the County of Hawaii to help fund our Special Olympics Ea.t Hawaii program activities. 1 Total Budget and Position Count Total Program Budget 118,230 otal Program Position Count 1 Total Agency Budget _ 1,606,290 _ otal Agency Position Count 15 Program Objectives: NONPROFIT GRANT PPLICATION FISCAL YEAR 012-13 Page 4 of 11 1) To provide quality sports training and Olympic type competitions in our area program to 190 Athletes and 70 Unified Partners by June 2013. 2) To provide sports specific coaches training or recertifications for 5 coaches in various Olympic type sports and various ability levels so that they may provide appropriate trainin to the athletes within their delegations by June 2013. 3) To provide our families, coaches, volunteers and athletes with 3 family activities throughout the year, which will be conducted by our family (Ohana Task Force) committee by June 2013. 4) To provide transportation to 150 athletes, coaches & special partners three times a year, so that they may compete at each State Competition with athletes of the same ability level lby June 2013. 5) To increase business participation by 2 new businesses in our Mile of Quarters campaign in order to raise more funds to cover our annual budget by June 2013. 6) To develop and conduct 1 new fundraising event called the East Hawaii Bowl-a-thon to help raise additional finds to cover our annual budget by December 2012. 7) To provide an opportunity to 500 community volunteers to interact with our Special Olympic athletes throughout the year, providing them with the chance to make a difference in their Community by June 2013. 8) To continue to reach out to any individual with special needs in our East Hawaii community to provide them these unique experiences. 9) Provide Global Messenger Training (iublic speaking) to 2 Special Olympics athletes and 2 athlete ment, rs by December 2012. 1 1 Program Highlights: (from Fiscal Year 260-11) 1 1) We conducted 7 area athletic competitions for our athletes and Special Partners between June 2010 and July 2011 . We began our year with our Bocce Competition where 11 doubles teams competed and 15 community volunteers assisted. We also held a Unified Bocce Competition were 20 teams competed and 25 community v lunteers assisted. Our newest program Golf also held their competiti n with 13 athletes attending along with 12 community volunteers. Our a ea singles bowling competition with 74 athletes and 70 community volunt ers attended this competition. We conducted our area unified (special) rtners bowling competition with 21 athletes, 21 unified partners, and 30 mmunity volunteers in attendance. We hosted the Weinberg Regional B ketball competition at UH Hilo Gynmasium, due to financial contra throughout the state only Big Island teams participate, but with a re ord number of teams at 7. 25 community volunteers helped to cond ict this event. Our area track & field NONPROFIT GRANT PPLICATION FISCAL YEAR 012-13 Page 5 of 11 I 1 competition was held at Keaau High chool track with 87 athletes participating in the days events. Also in attendance at the areaTrack & Field competition along with 125 co munity volunteers. 2) Our Ohana Task Force committee p ovided our families, coaches, volunteers and athletes with 3 family events where they enjoyed music, food and fellowship. 3) Special Olympics East Hawaii provided quality sports training and Olympic type competitions for 251 athletes and special partners in swimming, track and field, powerlifting, softball, golf, bocce, soccer, bowling, and basketball. East Hawaii is very proud of the fact that we provide more sports than any other program for Special Olympics Hawaii. 4) Athletes, coaches, volunteers and families conducted 4 fundraisers this year selling bentos, chili, Cop on Top, Fueling Dreams and Tip a Cop to support the area's annual budget needs. 5) ' We continue to offer 9 sports throughout the year for our athletes which are: track& field, swimming, power lifting, softball, bocce, soccer, golf, basketball & bowling. 6) We continued to provide coaches traipings throughout the year and now require each coach to be a certified coach through our sports training program. 7) Our Area Global Messengers continue to emcee our sporting event as the "voice" of our program. 8) 1 athlete represented Special Olympics East Hawaii at the 2011 World Summer Games in Athens Greece is Track and Field. Louie returned to us with 3 gold medals and a lifetime Of memories. NONPROFIT GRANT 4PPLICATION FISCAL YEAR 012-13 Page 6 of 11 Special Olympics Hawaii - Agency Name Special Olympics Hawaii-East Hawaii Area - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Athlete and Special Partners 260 251 260 Volunteers from the community 440 495 500 Family Members 115 121 125 Coaching Staff 27 30 Community Service Projects 1 1 1 State Competitions attended 3 3 3 Area/regional competitions attended 8 4 4 Delegations within the program 9 8 10 Number of family events provided '3 3 3 Number of volunteer hours provided 10,850 10,875 10,900 by volunteer from the East Hawaii community as coaches/day of volunteers Note: these figures are not dollar amounts, rather in the number of people, events, hours *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages 2140 2140 6,140 Professional Fees 0 _ Operations 93,406.32_ _ 104,460 110,190 _Equipment 364.34 5,650 1,900 Other" Total 95,910.66 __ 112,250 _ 118,230 _ * If applicable r Please explain in detail on separate sheet I I I NONPROFIT GRANT i PLICATION FISCAL YEAR 012-13 Page7of 1 i Special Olympics Hawaii - Agency Name Special Olympics Hawaii-East Hawaii Area - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 10-11 FY 2011-12 FY 2012-13 Ac ual * Budget * Estimate County of Hawaii 12,000 12,000 25,000 Foundations 7,000 5,000 9,000 Individual contributions 71,719.30 12,500 12,000 Corporation contributions 1 ,527.47 4,500 4,500 Special Events 2 1,981.14 35,500 29,680 SOHI Co-op monies 0 3,700 2,800 Merchandise Sales 31,467.82 38,450 35,050 Service Clubs ! 1050 100 100 Interest 1 461.48 500 100 1 1 1 1 1 Total 981,207.21 112,250 118,230 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? 1 2011-2012 plans to increase revenues to support our programs: 1) We are planning to expand our Mile of Qi4arters fundraising campaign to 2 more businesses. 1 2) We are planning to add a a Bowl-A-Thon chat will help us to generate between $4,000 to $5,000 more. 1 3) We will be applying for 1 more grants for East Hawaii Non-Profits. 1 Special Olympics East Hawaii is very divers in how we raise money to support the athletes, families &volunteers. However as we continue to meet our mission of continuing to outreach to new athletes, fa illy members and volunteers within our community, and with increased costs, o r budget continues to grow, so even NONPROFIT GRANT PLICATION FISCAL YEAR 2012-13 Page 8 of 1 f 1 I as we get better at raising money, it contin es to be difficult to reach our budget without the support of the County of Hawaii Because so much of our program is developed around bowling fees and airfare, which are costs that occur and increase each year, our budget continues t grow. I Please disclose (list here) any affiliation that any employee or volunteer of your organization may have with the Co my of Hawaii. None that we are aware of. We do utilize some Park and Rec facilities for our training and competitions. : i i I I I NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of i i . Special Olympics Hawaii - Agency Name Special Olympics Hawaii-East Hawaii Area - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records,Ireporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135—2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have thle authority and ability to fully administer the program(s) pursuant to law. , I (we) understand that information supplied I'ierein shall be made public according to Chapter 92F, Hawaii Revised Statutes. 1 1 I (we) understand that applications will not b reviewed by County personnel accepting our County Nonprofit Grant submi al, and that we have full responsibility to ensure that all documents a e complete and accurate prior to submittal. I (we) understand that all documents require g a signature must be the ORIGINAL, SIGNED document. Unsigned ocuments will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii. I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtaine during the award period. Failure to submit a timely, complete, and accurate yea -end report will impact the evaluation of your program's or agency's fu re funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT ,APPLICATION FISCAL YEAR 012-13 Page 10 of 1 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. / / 7/2_ Signa of Board Presi ent/Chair Date or Agency Director ' ?C 1 C I Le f ,t•1/ , 1 - f c__ I I J I l—.- Signature of E4cutive Director Date sf UNSIGNED PROPOSAL WILL NOT BE ACCEPTED! NONPROFIT G ANT APPLICATION FISCAL AR 2012-13 PagO 11 of 11 90 Special Olympics West Hawaii SOWH General Funding Special Olympics West Hawaii- Agency Name SOWH General Funding- Program Name Agency Director: Nancy Bottelo Phone No.: 943-8808x22 Contact Person: David Ross Phone No.: 345-1344 Mailing Address: P.O. Box#390358, Keauhou, HI 96739 Facility/Site Address: 77-296 Kalani Way#2 Kailua-Kona, HI 96740 Fax No.: 808-943-8814 Email Address: sowhdave @yahoo.com Name of Accountant/CPA (include name of firm if applicable): Akamine, Oyadomari,and Kosaki CPA's, Inc. Phone No.: 808-941-0500 Mailing Address: 440 Kapiolani Blvd.Suite#900,Honolulu, HI 96814 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$12,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $12,000 $7,000 $12,000 Agency Mission Statement: The mission of Special Olympics is to provide year-round sports training and athletic competition in a variety of Olympic-type sports for all children and adults with NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 11 intellectual disabilities, giving them continuing opportunities to develop physical fitness, demonstrate courage, experience joy and participate in a sharing of gifts, skills and friendship with their families, other Special Olympics athletes and the community. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 11 Special Olympics West Hawaii - Agency Name SOWH General Funding- Program Name Program Description: Special Olympics believes that people who are isolated from life experience by a disability have little chance for the development growth and acquisition of important skills that they will need to gain employment, maintain relationships and function independently as adults. Special Olympics helps to give individuals with a intellectual disability the necessary skills to achieve that independence. We believe that all people regardless of their disability deserve to lead full, active lives, enriched with social and recreational opportunities that most of us take for granted. Unfortunately, appropriate physical education programs in the public schools and social service programs that realistically address the special needs of this population are virtually non- existent. Special Olympics West Hawaii fulfills that need and provides the necessary skills for people to continue good health throughout their lives within our community. Thanks to the Hawaii County grant, Special Olympics West Hawaii is able to continue to provide many opportunities for the special needs individuals in our community. The benefits that all the athletes receive from their participation in Special Olympics include: improved physical fitness and motor skills, greater self- confidence, a more positive self-image, friendships, and increased family support. Special Olympics athletes carry these benefits with them into their daily lives at home, in the classroom, on the job, and in the community. Families who participate become stronger as they learn a greater appreciation for their childs' talents. We have found that many of our strongest supporters and best volunteers are the family members of our Special Olympics athletes. We provide a "safe haven" for families where they know that their child is not judged and is accepted for who they are and for what they can do. Community volunteers find out what good friends the athletes can be and make long lasting bonds that continue off of the sports field. Everyone learns more about the capabilities of people with intellectual disabilities, and a huge majority of our volunteers continue with the program year after year. These active volunteers are often a source of new volunteers to the program as they share their stories with friends, neighbors and co-workers. Special Olympics West Hawaii Unified Sports Program is a vital program where these special needs individuals interact with their non-handicapped peers. Unified Sports is a program that combines equal numbers of athletes with intellectual disabilities and special partners without disabilities. This program dramatically increases inclusion of our athletes into the community by helping break down barriers that have historically kept people with and without disabilities apart. Special Olympics West Hawaii will have unified softball, bocce ball and bowling teams in FY 2011-12, and we hope to expand to have our first unified soccer team in the Summer. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 11 The need for the Special Olympics West Hawaii program to continue here on this island is extremely high. There is no other program in our Area to provide these services to our athletes. Special training is provided for our athletes and the coaching staff throughout the year. The training is essential due to the unique services that we provide. Our founder, Eunice Kennedy Shriver, believed sports training and competition opportunities should be available for all who qualify rather than all who could afford to participate. Therefore, our program is free of cost to all of our athletes, Unified Partners, and coaches. We receive no money from the Kennedy Foundation or the Federal Government. Due to this aspect of our program , a volunteer committee under the leadership of our Area Director must raise all the funds needed for our West Hawaii area program. Those funds will pay for all aspects of the Special Olympics program. Our goals for 2012-2013 are 1. Develop our new Kohala delegation complete with staff, coaches, uniforms, equipment, advertising and promotional materials and 2. Host a neighbor island softball /t-ball tournament, a neighbor island Powerlifting Tournament, and Soccer, Bocce Ball, and two Bowling tournaments. As always our largest yearly cost is airfare to get our athletes to their competitions where they compete against their peers from around the state of Hawaii. Hosting five competition days here on the West side of the Island are a lot of work but help us out financially by not having to buy as many flights to off island competitions. It is an essential part of our program that Special Olympics athletes are provided an opportunity to interact and compete against people of similar athletic ability. We find as many teams in the community as we can to practice and play against, but we still must travel to Oahu three times a year to compete against similar Special Olympics competition at the State Games. The state competitions that are held on Oahu 3 times per year provide many activities that our athletes never have a chance to experience. They include; dances, Opening and Closing Ceremonies, entertainment and games, and free health exams through the Healthy Athlete Program. This Healthy Athlete program provides free dental, vision, hearing, podiatry, flexibility & nutrition screening and education for our athletes. As you know, these services are sometimes not available to individuals with disabilities due to financial difficulty or lack of professionals who are trained to treat people with disabilities. Special Olympics West Hawaii wishes to continue to provide these opportunities to all the athletes that are currently involved and be able to reach out to new special needs individuals throughout our communities. In order to do this, we will need funds to maintain our services and to purchase new uniforms and equipment, host local competitions as well as provide transportation for athletes to get to competitions. Special Olympics Hawaii-West Hawaii Area is asking for $12,000.00 from the County of Hawaii to help fund our Special Olympics West Hawaii program activities. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 11 Total Budget and Position Count Total Program Budget 60,000 Total Program Position Count 1 Total Agency Budget 1,606,290 Total Agency Position Count 15 Program Objectives: Expand our new Kohala delegation to provide services to North Hawaii. Add Unified Soccer to our Summer season to raise the caliber of competition and community involvement. Train a new Head of Delegation for Kohala and a management team to run an efficient program. Train more coaches and volunteers to continue to provide the highest skilled training to our athletes. Expand out outreach to local school student organizations to educate the youth about our program and the many achievements of people with special needs. Provide athletes with additional opportunities to learn,work opportunities, and move towards self-sufficiency through our partnerships with The Arc of Kona, Full Life Hawaii, and the Kona Paradise Club. Continue to add community service events to give back to the community that is so supportive of us. Expand our management team to have additional input from local community members and businesses. Train a basketball team to represent the State of Hawaii at the National Games. Expand the role that athletes have in planning our social and community service events. Strengthen our fmancial contacts and expand our local fund raising opportunities. Revitalize our Cop-on-Top fund raiser which has begun a partnership with Wal-Mart. Expand our outreach to younger sthletes in the community to enhance the development of our keiki. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 11 Program Highlights: (from Fiscal Year 2010-11) 1) Our West Hawaii United soccer team won the gold medal at the State Games for the first time in several years. Trained and participated in 8 official Special Olympic sports. Partnered with the P.A.T.H. organization to clear brush on local walking trails. Expanded our relationship witht the West Hawaii Today who featured several stories about SOWH. Expanded the "Fueling Dreams" fund raiser to 2 days to increase it's revenue and effectiveness. Continued to post pictures and articles spotlighting our athletes and program accomplishments @ sowh.org. West Hawaii has contiued our push to make the public aware of our events and that they are open to the public. Expanded our volunteer screening and training practices to keep our program safe and expand the quality of interactions with athletes. Continued to build our relationship with the County of Hawaii division of Parks and Recreation, an essential link to our success. Trained 3 new coaches to raise the quality of instruction our athletes receive. We volunteered at manned two aid stations for the Kona Marathon and the Charity Walk. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 11 Special Olympics West Hawaii - Agency Name SOWH General Funding - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Number of Athletes in SOWH 42 44 46 Area/Regional Competitions 10 10 10 Competitions Held in West Hawaii 5 5 5 Number of Unified Teams 12 16 14 Community Service Project Days 9 9 10 Families Participating in SOWH 30 32 34 State Competitions on Oahu 3 3 3 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 10500 11000 11000 Professional Fees 2200 2500 2700 Operations 10372.40 11000 13000 Equipment 2100 1500 500 Other# 32,800 34000 32700 Total 57,972.40 60,000 60,000 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 11 Other Estimated Program Expenditures Special Olympics West Hawaii FY 2012 - 2013 Estimated$32,700 Airline Tickets (est. $170 /per) $22,100 Ground Transportation of Big Island Competitions $2,500 Train expenses for new coaches and Head of Delegation Training $2,000 Promotional Material (handouts, shirts, awards, ect.) $ 3,100 Events for Families and Athletes (bbq's, bowling nights, movies ect.) $3,000 Total $ 32,700 Special Olympics West Hawaii - Agency Name SOWH General Funding - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate County of Hawaii Non-Profit Grant 7000 12000 12000 Private Donations 7000 6000 6000 Cop-on-Top 13000 18000 18000 Corporate Contributions 5000 5000 4200 Underpants Run 5000 5000 4500 Fueling Dreams 4500 4500 5000 Project Compassion 2000 0 0 Visitor Industry Charity Walk 10000 10000 3300 SOHI Co-Op Money/Weinberg 2000 0 0 Interest, In-Kind,Merchandise 600 500 500 Robert S. McLean Estate 0 0 1500 Fire-Truck Pull 0 0 2000 Golf Tournament 0 0 2500 Total 56100 60000 60000 *If applicable NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 11 Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? 1) We are planning to increasing our donations for our Cop on Top event in 2012 by partnering with Wal-Mart. 2) We will plan to expand our Fueling Dreams event with the Law Enforcement personnel in Kona in partnership with Tesoro. 3) We will work with the Air National Guard to hopefully receive the free airlift from Kona to Oahu for our State Games in December, saving us thousands of dollars. 4) We will continue to make our events more open to the public in order to spread the knowledge of our program and hopefully increase our donation base. 5) We are planning a new fund raiser"Fire Truck Pull" event which will hopefully raise a few thousand dollars. 6) We plan to put on a charity golf tournament to raise funds and awareness. However as we continue to meet our mission of continuing to outreach to new athletes, family members and volunteers within our community, our budget continues to grow, so even as we get better at raising money, it continues to be difficult to reach our budget without the support of the County of Hawaii. Becoming self sufficient is the ultimate goal of our program, however we do know that if any of our events/grants fail to raise the expected amount of money, our program would change drastically. We would have to cut back on some services that we currently provide and/or we would have to cut back on our outreach goals. Cutting any services would be tragic since in many areas we are the only services of our kind to the community. We have streamlined our opperations but as we continue to expand, since our services are in high demand and successful, our budget increases and we need your continued support. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. N/A NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 11 Special Olympics West Hawaii - Agency Name SOWH General Funding - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our.County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due._ NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 11 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. _.mss." Signs ure of Board 'resident/Chair Date or Agency Director 60410 ( e I Z..,- Sign ture of ¶ftecutive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 11 91 Sure Foundation Yeshua Outreach Center Sure Foundation, Inc.- Agency Name Yeshua Outreach Center- Program Name Agency Director: Pastor Keith Jackson Phone No.: 966-6489 Contact Person: Andrea Miday Phone No.: 966-6489 Mailing Address: P.O. Box 1598 Kea'au, HI 96749 Facility/Site Address: 16-1592 Pohaku Circle Kea'au, HI 96749 Fax No.: 966-6712 Email Address: andrea@surefoundation.ty Name of Accountant/CPA (include name of firm if applicable): Carolee Fernandez, Strategy By Numbers, Inc. Phone No.: 808-982-3900 Mailing Address: PO Box 4130 Hilo, HI 96720 Amount of Request for County Funds: $70,000 Prior Year(s) Funding: 09-10 10-11 11-12 $65,000 $50,000 $50,000 Agency Mission Statement: Sure Foundation's mission is to build bridges and connect people to Christ. Our vision for the Yeshua Outreach Center is to impact lives, families and our community through Yeshua,which is Hebrew for healing,wholeness and victory. Our mission is to turn lives around through quality Christ-centered mentoring,fitness and support programs. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 7 Sure Foundation, Inc. - Agency Name Yeshua Outreach Center- Program Name Program Description: The Yeshua Outreach Center (YOC) at Sure Foundation in Puna, Hawaii provides an alternative outlet for whole families in the community to focus their energy and set personal goals for their future. We hope that by providing a nurturing environment, which focuses on three athletic programs, boxing, weightlifting, and martial arts, we can give families in our community a positive environment in which to develop. In addition to these athletic programs, we offer counseling and community service programs in drug and alcohol abuse, nutrition, and outreach to youth. We hope that in the process of pursuing personal fitness goals, we can offer members of our community some guidance and mentoring that will help prevent them from the distractions of drugs, alcohol and crime. This model for drug and crime prevention has been proven in many cities and communities throughout our country. By combining efforts with local law enforcement and justice department officials, we hope to mainstream our efforts to the broader community. Sure Foundation church has offered their large recreational gymnasium as a site for our center, and all of our volunteer staff are members of either the Hilo or Puna branches of the church. In addition to providing a home for the YOC and helping fund some of its expenses, Sure Foundation has devoted some of its paid employee resources to help coordinate volunteers of the Yeshua programs. Total Budget and Position Count Total Program Budget $221,000 Total Program Position Count 1.8 FTE Total Agency Budget $650,000 Total Agency Position Count 6.5 FTE Program Objectives: 1) To hold regular boxing exhibitions and Kempo Karate events to promote the athletic programs offered by the Yeshua Center (3-4 boxing events per year and one Kempo event,the first boxing event will be held September 15th, 2012) 2) To enhance membership by 10% though increased enrollment of our boxing, weightlifting, martial arts and Synergy Youth programs (ongoing enrollment throughout the year) 3) To construct a new weightlifting facility to support the growth of the boxing, weightlifting and Kempo Karate programs (funding applications 2nd and 3rd quarters,2012,with construction to begin in early 2013) 4) To track attendance and monitor effectiveness of intersession and after school programs, by ensuring faithful membership and better recording of enrollment (currently ongoing) 5) To involve local private businesses and organizations, such as other Hawaii USA Boxing clubs, Rotary, County government, local Fire and Police Departments, University of Hawai'i Hilo, YMCA, AG Churches, Teen Challenge Hawaii, and HIANG/HIARNG, in our Yeshua programs, to further assist our community families and focus on long-term sustainability (3rd and 4th quarters, 2012, efforts by recently rejoining member Gary Thomas) NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 7 Sure Foundation, Inc. - Agency Name Yeshua Outreach Center - Program Name Program Highlights: (from Fiscal Year 2010-11) Boxing Program • Yeshua Center Boxing program held 3 USA Boxing-sanctioned amateur events during for the fiscal year 2010-11. These events are highlighted as follows: 1. July 23rd&24th, 2010, 55 amateur bouts, over 500 people each day 2. December 4th, 2010, featured 17 bouts,attended by more than 700 people 3. February 19th,2011, featured 12 bouts, attended by 300-350 people • Each of these boxing special events were heavily publicized in local media, and well attended by local and state representatives, such as Council Representatives Jerry Chang,Dominic Yagong and Fred Blas. • Currently the boxing program has 64 boxers regularly attending the program, with as many as 135 different boxers having enrolled for some months of 2010-11. Universal Kempo Karate • Universal Kempo Karate (UKK) members hosted their first local sparring competition at YOC on September 24, 2011, featuring 67 competitors from all over the Big Island, including 21 from YOC,with 18 divisions from 6 year olds to adults. • The UKK program had 44 karate students enrolled at the end of June, 2011, with as many as 28 new students enrolling for at least part of the year. • During the past year, UKK has had regular testing and rank promotions twice a year for each of the 40-45 students enrolled. • The UKK program has been actively involved in community outreach through a clothing drive (August, 2011), a food drive (October, 2011) and a rummage sale (November 2011). Synergy Youth Outreach • Synergy Youth Program holds regular Friday night meetings for youth between 6th and 12 grades with free dinner and sports, break-dancing and other activities run by volunteers from Sure Foundation. • The Synergy Youth program continues to be popular having up to 140-180 youth attending every Friday night(this is an increase of 15%from 2011). • Our real challenge for this program has been transportation on Friday nights for youth who wish to attend,but have no ride to and from the events. Weightlifting Program • Weightlifting has had 72 members sign up for at least part of the fiscal year 2010-11, with a total enrollment of 26, as of June,2011. • We recognize that the limiting factor to significantly increasing our enrollment and maintain numbers in weightlifting is a dedicated facility for weight training and exercise equipment, and we intend to construct this facility in the next fiscal year. • Strengthening our weight training program will have a systemic effect on our other physical activity programs by promoting overall health and fitness. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 7 Sure Foundation, Inc. - Agency Name Yeshua Outreach Center - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Boxing enrollment (>10% increase 64 72 80 yearly) Karate enrollment (>10% increase 44 49 54 yearly) Weightlifting enrollment (>10% 26 35 45 increase yearly) Friday Night Youth attendance 140 160 180 (>10% increase yearly) Total enrollment in Yeshua(>10% 274 316 359 increase yearly) Attendance rate of members 50-85% >80% >80% *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages $54,000 $55,200 $55,200 Professional Fees $10,710 $7,150 $10,000 Operations $69,069 $81,875 $80,850 Equipment $50,073 $76,775 $75,750 Other# $0 $0 $0 Total $183,852 $221,000 $221,800 * If applicable Please explain in detail on separate sheet *** See attached spreadsheet for breakdown of estimated expenses for each program NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 7 Sure Foundation, Inc. - Agency Name Yeshua Outreach Center - Program Name i): ,08 i (W ,.."..4 � 6r 1 '6 (11. M F 1 c C e4 4G el «. O r © o - Q; 0 0 fV Z tr. O tr, rl O C,- O 5 •- in c-• tr, N ,r v'■ ." 0 C b'3 V' (a, i1 i,9 f+9 64) y it W b 0 0 r, to ,C * U. * rJ a�i CI m G '` tr. O O L8 v, v:, v, • Lr cr., .: 69 69 69 iA O • O 6/3 O ao i Ft /3.. r.. IS it, G v u O is W ° o ow° cam. o � •° 4' - ricncs3ct3r' „f 0 0 9) 5 I••••• O • P V. ice: . W v a i 01, y "0 4' L. 1.. a. K �` a ci a E 8 x 0 v '" N bl, V a .5 5 aP kr, ti .4 v 0 O 0 0 0 'r, r O G r 04, .. r v II: v — O, D L . a O O O J" O p .D ,� W ^ G1, Ar W, t ,. to Yy r O, 'O = .� * * NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 7 ■ I s 1 Sure Foundation, Inc. - Agency Name Yeshua Outreach Center - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate County Grant $50,000 $50,000 $70,000 Tuition from membership $ 6,354 $20,800 $22,000 Net Income from special events $4,859 $7,000 $7,000 Cash Donations $2,406 $2,500 $2,600 Admission Fees $5,731 $4,500 $5,000 Registration Fee $75 $0 $0 Sure Foundation will cover all $54,000 $55,200 $55,200 salaries of permanent staff Sure Foundation will donate its $60,000 $60,000 $60,000 recreational facility for Yeshua ($5000/month in-kind) Total $183,425 $201,000 $221,800 *If applicable Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The goal of YOC during the 2012-13 fiscal year is to formalize the weightlifting facility. It is our intention to use the weight training facility to dramatically increase the revenue generated to help fund the YOC programs. In the meantime,we will continue to work on a limited budget comprised of a few paid church employees working part of their time running YOC, a volunteer work force made up of Sure Foundation church members to run the programs, and a recreational facility donated by Sure Foundation. Our long-term goal is to support the operating costs of YOC from a combination of revenue sources, including, but not limited to: membership dues from increased enrollment especially in weightlifting, monies derived from special boxing events held at YOC, including sales of goods and entrance and admission fees, as well as business partnerships with local companies interested in sponsoring our efforts. Recently, Col. Gary Thomas rejoined our YOC administration and is renewing efforts to coordinate with local businesses and the judiciary. Our goal is to make YOC self-sustaining within two years. At that point, we hope to have at least 400 hundred members enrolled in tuition based athletic programs, including the new weightlifting facility (approximately $120,000 revenue per year), increased revenue from special events sponsored by YOC, multiple businesses donating equipment and supplies for the fitness programs, funds donated through the church allocated for an endowment, and a good track record established with local judges and correctional facilities. By having Sure Foundation lend its support throughout our growth, we hope to gain momentum for this important community program over the next year and quickly develop our own independence, as our own 501(c)3 organization. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 7 Sure Foundation, Inc. - Agency Name Yeshua Outreach Center - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135—2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the Legislative auditor within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. / _ a2_ _ ( Signature of Board President/Chair Date 1.4 I �. _ /— 26 - / 2 Signature of`3recutive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 7 92 Volcano Art Center HINA Project Volcano Art Center- Agency Name HINA Project- Program Name Agency Director: Tanya Aynessazian Phone No.: 808- 967-8222 Contact Person: Tanya Aynessazian Phone No.: 808- 967-8222 Mailing Address: PO Box 129 Volcano, HI 96785 Facility/Site Address: 19-4074 Old Volcano Road Volcano, HI 96785 Fax No.: none Email Address: director@volcanoartcenter.org Name of Accountant/CPA (include name of firm if applicable): Carbonaro CPA & Associates, Inc. Phone No.: 808-968-1002 Mailing Address: PO Box 4372, Hilo, HI 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: $25,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $0 $0 $0 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 16 Agency Mission Statement: To develop, promote and perpetuate the artistic, cultural and environmental heritage of Hawaii's people through the arts and education. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 16 Volcano Art Center - Agency Name HINA Project- Program Name Program Description: Hawaii Island Network of Artists (HINA) Report and Website As a leader in arts administration, including sales, education and promotion, VAC is in a particularly strong position to promote, perpetuate, and document Hawaii's community of artists throughout Hawaii County. Located in Hawaii Volcanoes National Park, Volcano Art Center Gallery welcomes the highest number of visitors in the State and we continually receive requests for a catalog of local artists. Our dedication to selling only locally made work has earned us the respect of the artists who sell their art through our gallery. The HINA Report and Website Project presents the opportunity to document Hawaii Island's creative workforce. The National Endowment for the Arts states in their 2006 report, "Artists in the Workforce" that the State of Hawaii ranks #3 per capita of the 50 states with fine artists and craftspeople. According to their report, nearly 15 of every 10,000 residents is an artist. Given our involvement with this community, we are certain Hawaii Island has far more than 270 visual and fine artists. Our research will provide the County and State with the documentation they need to promote Hawaii as an arts destination. Our web site and subsequent catalog will directly benefit local artists and will help educate the public about the rich diversity of artists who call the Island of Inspiration their home—further inspiring others to purchase works of art and support our local economy. "To gauge the contributions to and potential impact of arts and culture on a state's economy, it is important for each state to first measure its creative economy. Maine offers one example of how states can do this. In the mid-1990s, the Maine Arts Commission began its effort to measure the size and impact of the state's creative economy with the creation of its Discovery Research Program. The Discovery Research Program is an ongoing, statewide inventory of cultural resources within communities around the state. The program provides funds and expert assistance for Maine communities to survey local events, artists, traditions, and tradition-bearers as well as cultural organizations that promote or support the performing, visual, craft, or literary arts. Once collected, the information is used to formulate local economic development strategies and tourism initiatives as well as coordinate local and state economic, workforce, and cultural development efforts. The program has indexed cultural assets in more than 70 percent of the state's communities. Some states have focused on mapping their assets in specific sub-clusters of the arts industry. For example, NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 16 the Arizona Humanities Council (AHC), the Arizona Community Foundation, Arizona Office of Tourism, and the Museum Association of Arizona (MAA) documented the state of cultural heritage tourism in Arizona and the potential for an improved economy through cultural heritage tourism." (Arts and Economic Impact Report, 2000) VAC would like to partner with Hawaii County in measuring our creative economy and the impact of arts and culture on our state's economy, starting with this HINA Project and surveying the visual and fine artists of Hawaii Island. The HINA Project can encourage and support a greater awareness of Hawaii Island as an arts destination, the individual artists who create this beautiful community, and the economic impact of our creative workforce. VAC has over 36 years experience in arts administration and in working with artists, and our organization is honored to provide the opportunity for visitors and residents to relate personally with Hawaii's artists and their work. The arts are an integral way to engage others in all that we see, feel, taste, touch and are when in Hawaii. This project has a low-waste and low-carbon impact and helps support traditional and contemporary artists in sharing the Aloha Spirit. To achieve these goals, Hawaii Island Network of Artists (HINA) Report & Website will take a triune approach to ongoing research and development: • (1) Monthly HINA Meetings—Data collection and visiting artists where they reside. Each month, HINA project manager, Tiffany Shafto, and VAC CEO, Tanya Aynessazian, will visit one of the nine districts of the Island to meet with the working artists living there. The meetings will be announced through the VAC newsletter, social media sites, public announcements on the radio, newspaper, and through partnerships with other island arts organizations including Donkey Mill, South Kona Education for the Arts, Arts of Kona, Hamakua Artisans' Guild, Hawaii Wood Guild, Big Island Woodturners, West Hawaii Woodturners, Waimea Arts Council, and the East Hawaii Cultural Center. The artists will be asked to complete a survey (see draft, attached) and provide professional images of their work. The HINA Survey is designed to collect data relevant to our research. Our goal is to understanding the economic impact, connectedness to local, national, and international organizations, and the sources of inspiration for Hawaii Island artists. With this research we can create a comprehensive report that shows artist density by district, the economic impact they have cumulatively, the level of connectedness beyond our shores, and the sources of artistic inspiration found on Hawaii Island. (2) Compilation of Information and Website—Counting our resources for locally made works of art. As the information is collected from each artist and their images are submitted, the extensivity and details of the report and website will begin to take form. Artists in each district will be added to the website as their NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 16 information is submitted and monthly press releases will keep the community at large informed of our findings. These press releases will also inspire additional working artists who were unable to attend our meeting to submit their information for inclusion in our comprehensive directory. (3) HINA Report— Celebrating the Aloha Spirit of Hawaii Island through the works of Contemporary & Traditional Artists. Following the completion of the nine monthly meetings, the report, and web site, the Hawaii Island Network of Artists Economic Impact Report will be produced and published. HINA project manager, Tiffany Shafto, and VAC CEO, Tanya Aynessazian will write the report and publish a minimum of 20 printed copies, and offer the completed report online. The report, including an executive summary, will be distributed to all nine County Council Members, the Mayor of Hawaii County, the Governor of Hawaii and various legislators, arts administrators and arts and cultural centers. After years of requests for an artists' catalog from VAC gallery visitors, VAC will also gauge interest in creating a printed catalog of visual and fine artists. Knowing that this catalog will help artists make a living doing what they love, we are eager to create a physical book that will showcase the wide array of talent found on this Island. However, since the total number of artists is currently unknown, this portion of the project is not part of the currently requested funding. However, it is pertinent that no such comprehensive catalog has been created since the mid-to-late nineties. PLANNED PROMOTIONAL AND ADVERTISING ACTIVITIES As the HINA website is launched, we will advertise it through press releases to local and statewide newspapers, local and national arts related magazines, and through our website and social media sites. VAC will dedicate a portion of our hosted site to the HINA Project. We have a strong, long-standing relationship with our island community media outlets and a new, robust website that is frequented by many visitors to the Volcano area and anticipate that artists will likely want to participate and spread the word. Our website, www.volcanoartcenter.org has averaged 2,963 unique hits over the last three months and our Facebook page receives over 3,000 views per month (with Dec. 17-Jan15, 2012 hitting a high of 5,737 for the month). Our Board of Directors oversees and participates in our Social Media Strategy, and is the driving force behind our popular website, Facebook page and Twitter account. We have also recently redesigned our website to incorporate an informative page and calendar of events covering hula programs within HVNP at www.volcanohula.com. Statistics are not yet available from Google Analytics, but will be for the 2012 calendar year. Planned advertising includes: • Press releases, PSAs and flyers NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 16 • Design and maintenance of volcanoartcenter.org/HINA web pages • Targeted Facebook advertising • Development of an ongoing radio ad campaign • Post-report advertising is planned to promote the results of the analyses performed and includes articles written for local papers (West Hawaii Today), magazines (Ke Ola) and blogs WORK PLAN AND TIMELINE Work on this project will not begin until funding is secured and we are working on additional funding opportunities. Once funding is provided, our schedule is as follows: 2012 HINA District Meetings: Aug. 15, Sept. 12, Oct. 17, Nov. 14, Jan. 16, Feb. 20, March 20, April 17, May 16 Web site updates are scheduled as follows: 1. Aug. 13—District X 2. Sept. 10– District X 3. Oct. 15 – District X 4. Nov. 12– District X 5. Jan. 14– District X 6. Feb. 18 – District X 7. March 18 – District X 8. April 15– District X 9. May 14- District X Research Report: The report will be a detailed census of Hawaii Island artists and the economic impact of this creative workforce. This information will be used to accurately market Hawaii Island for what it truly is, the Island of Inspiration. The HINA Economic Impact report will outline the number of artists, type(s) of visual and fine artists, demographics and accomplishments of our island artists by district. The HINA report will be written by HINA project manager, Tiffany Shafto, and VAC CEO, Tanya Aynessazian, and edited by Tom Peek, a writer, editor and resident of Volcano. Upon receiving COH Nonprofit funding, work can start on a radio ad to inform residents of our meeting dates, locations, and times. COMMUNITY SUPPORT AND INVOLVEMENT Hawaii Island is rich with resident artists, something our research will prove. Island residents are also very aware of the buy local campaign and through our web site, we can share the importance of buying from local artists and makers. When you purchase something made locally, you are directly touching lives in NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 16 your community. As the public is becoming more and more aware and has a growing desire to purchase things that have meaning and a story. Artists and makers provide those products. Our web site will allow for an ongoing network of connectivity between artists, makers, and the public. IMPACT The benefits of having a fairly accurate count of Hawaii Island artists who make their living from their creative work are remarkable. This Island draws creative people to it with its sheer magnitude and beauty, yet Hawaii is overlooked as an arts destination. We are home to communities like Volcano, Holualoa, and Kapaau—rich with artists entrepreneurs—but these small business owners are overlooked for the economic impact they provide and are without the tools to grow their businesses during these unprecedented economic times. The outcome of our research and web site will be an Island that is much more connected and aware of its creative economic engine. Artists businesses will grow due to the increased sales through the marketing efforts provided by our report and web site. In turn, they return more money to the community through their daily lives. Measuring Impact While our report will provide the statistics and synopsis of our findings, our web site and catalog sales will give us addition measures on the success of our project. Quantitative success is measured by the following: • Comparing actual artist figures against the NEA report number of approx. 270 • Comparing meeting attendance figures with marketing and promotional efforts • Determining success of various marketing strategies: radio, social media, print Qualitative success is measured by: • Written evaluations of participants • Written evaluations of staff, project manager, other arts organizations, editor and volunteer members • Written evaluations by web site visitors • Verbal evaluations by HTA, County employees and departments, County Councilmembers, HVCB and • Identifying how the HINA Report and its data is utilized ORGANIZATIONAL PROFILE "Where People, Art and Nature Meet" Volcano Art Center (VAC) was founded in 1974 by a group of visionary artists who saw that the region of Kilauea, with its dynamic volcano, environment, and beauty, is a place for creative people of all ages and experience to gather, NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 16 become inspired by and connected to our natural environment and to make powerful works of art. Originally, VAC was housed in the 1877 Volcano House Hotel, located within Hawai'i Volcanoes National Park (HVNP) along the rim of Kilauea Crater. Today, the 1877 building is home to our VAC Gallery, which represents over 300 artists who draw inspiration from this dynamic setting. VAC has fifteen full- or part-time staff who are passionate about the role of arts and culture as integral to a healthy island community. VAC's staff and board are dedicated to developing, promoting and perpetuating the artistic, cultural and environmental heritage of Hawaii's people through the arts and education. VAC's administrative offices are located in Volcano Village at our Niaulani Campus facilities. Niaulani is a 7.4 acre parcel of land leased from DLNR and includes a 4-acre old-growth rain forest and loop trail open to the public, an administrative facility and our 3-classroom Learning Center, Hale Ho'omana. Hale Ho'omana opened in the fall of 2010, and provides multi-purpose and classroom space for arts, education, environmental and community programs and events. It is intended to provide a venue, nestled within the nurturing canopies of Niaulani, to draw established and emerging artists and students from throughout Hawaii and beyond, who come to study and leave with newly discovered talents and skills, as well as a deeper appreciation for the cultural and creative force of our unique environment. In congruence with caretaking Niaulani, VAC has been recycling cans, bottles, paper and plastic, composting staff food waste, using biodegradable products where possible, encouraging carpooling, and conserving water and energy wherever possible and minimizing waste in day-to-day activities for years. VAC's Board of Directors is now drafting a formal organizational environmental policy. Our new policy will provide the organizational structure we need to prioritize and increase these efforts in event planning, program implementation and in buying locally even when financial costs are increased. With the hiring of a new CEO in May 2010, VAC continues to revitalize and reengage itself as a leading arts and culture organization. Our challenging economy requires us to continuously re-evaluate our efficiencies, capabilities, strengths and opportunities and take timely action. Recognizing the importance of our member artists and the economic impact they have on our organization, along with the need to grow beyond the confines of our location, is the impetus for creating the Hawaii Island Network of Artists. VAC has a long history of "think local, buy local" - selling locally made artwork in the Park since 1976. Volcano Art Center Gallery is well-loved by the Volcano community, as well as the arts community throughout the Island and visitors to the Kilauea region. Creating the Hawaii Island Network of Artists (NINA) embodies our organizational tagline, "Where People, Art and Nature Meet." Qualifications and Expertise NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 16 VAC's core strengths continue to lie within its people and our relationships internally and externally with the public and community stakeholders in what we do. Our staff's ability, passion and dedication to increase the awareness of the importance of art and culture in healthy communities and to meet the current need for arts and education programming are tempered only by the challenging economy and our ability to adapt to the challenging, unprecedented financial, emotional and business conditions. Thankfully, board and staff alike are inspired and dedicated, and deeply moved to perform and lead to meet our mission and goals through these changing times. We see an opportunity to support the creative workforce of Hawaii Island artists by documenting the economic impact they have on the Island, generating a report that can be used to market our Island, creating a web site to promote our artists, and creating a printed catalog in year two. Tiffany DeEtte Shafto, HINA Project Manager, Producer, and Publisher Tiffany is the owner of Contemporary Publications and an active member of Hawai'i's arts community. In 2009 she co-authored, produced, and published the award-winning coffee table book, Contemporary Hawaii Woodworkers; the Wood, the Art, the Aloha. She is currently the volunteer president of the Hawaii Wood Guild, and a director for the national Craft Organization Development Association. She is also past president of Hawaii Craftsmen, a statewide nonprofit for all fine craft media. Tiffany graduated with a degree in Interior Design from California State University of Sacramento and work as a project manager and designer for high-end residential construction. Prior to starting Contemporary Publications, Tiffany worked as a woodworker with her husband, Tim. Her past experience and her passion for Hawai'i's artists make her the ideal person to bring about the Hawaii Island Network of Artists catalog and web site. Tanya Aynessazian, Chief Executive Officer, joined VAC in May 2010. Tanya graduated with a degree in Communications from the University of Iowa, where she studied linguistics, cultural anthropology and interpersonal, group and mass communication. Her work and project management experience has been focused on marketing and marketing research, including the use of information technology, and business development and consulting. Prior to coming to VAC, Tanya was the Marketing Director for The Arc of Hilo and worked on several projects in collaboration with non- and for-profit local and mainland businesses, UH-Hilo, and HCC, and local, state and federal government agencies and departments. Tanya has proven board leadership abilities and was effective in rebuilding the board of Bay Clinic, Inc. as Board Chair from June 2001-2010. She currently sits on the boards of Bay Clinic, Inc., is Treasurer of the Arts and Sciences Center in Pahoa, and works with the Hawaii Primary Care Association in training community health center board members state wide in understanding their critical roles as leaders, community strengtheners, and health care advocates. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 16 Total Budget and Position Count Total Program Budget $44,555 Total Program Position Count 4 Total Agency Budget $1.3M Total Agency Position Count _ 14 Program Objectives: 1) To create and deliver a comprehensive Economic Impact report documenting the rich diversity of Hawaii Island visual and fine artists and the economic impact of this creative workforce. The arts are a strongly supported by tourism, yet Hawaii is overlooked as an arts destination. By showing the strength of our community, we can increase awareness for the economic impact of this creative workforce as well as generate the vital statistics that Hawaii Tourism Authority and HVCB need to focus the marketing efforts on the arts. Visitors are seeking meaningful experiences and are interested in buying locally made products—our local artists create both of those things. 2) To create a web site that showcases the people who make a living creating—artists who drive an overlooked sector of our economy—so that they can continue to earn their living through the power of their own creativity during these trying times. By shining a spotlight on this creative power and supporting our community, we will share the inspiration and imagination that is inspired by the Aloha spirit. 3) To educate the public about the value and significance of artists and makers, both traditional and contemporary, working in the mediums of clay, fiber (including kapa and lauhala), glass, metal, mixed media, wood, painting, and photography. 4) To help preserve the art of making by documenting those who are making their living following their creative passions. The economic impact report and web site will serve as inspiration for generations to come. The arts are how cultures are remembered and by documenting today's artists, we will create a resource for the historians of tomorrow. 5) To assist in marketing Hawaii Island as a place of creative inspiration where we can re-awaken our innate connection to earth and land—the very things that inspire so many of our talented artists. Program Highlights: (from Fiscal Year 2010-11) 1) None; this is a new project/program. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 16 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 16 Volcano Art Center - Agency Name HINA Project - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate # Visual/Fine Artists surveyed 0 0 700 *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate Salaries and Wages 0 0 $40,140 Professional Fees 0 0 0 Operations 0 0 2,265 Equipment 0 0 0 Other" 0 0 2,150 Total 0 0 $44,555 * If applicable u Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 12 of 16 - Agency Name - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget * Estimate County of Hawaii 0 0 $25,000 Volcano Art Center 0 0 11,665 In-kind donations of time or facility 0 0 7,890 additional sources are being identified; no state or federal opportunities have been identified at this time Total $44.555 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? This is a one-time, thorough community research project to identify, assess and analyze the number of Hawaii Island artists and their economic impact on the island's economy. This program can likely become sustainable if maintained regularly through online means. The initial investment will provide financial resources to start up the project, the website and to fund an initial economic impact report. Artists fees will likely fund this project in the future, if outcomes and impact is seen as helpful to artists. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 13 of 16 Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. None that we are aware of; we work closely with HTA through the CPEP and Kukula Ola and Natural Resources grant application process. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 14 of 16 Volcano Art Center - Agency Name HINA Project - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we)iJnderstand that information supplied herein shall be,rnade,pubJi€, according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 15 of 16 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. Signature of Board President/Chair Date or Agency Director Signature of Executiv Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 16 of 16 ` li� �'�rrr \ VOLCANO Artist's Survey & Participation Confirmation for � �_� ART CENTER Hawai'i Island Network of Artists // � ART•MAN• EARTH ��(�� • Economic Impact Report & Web Site Name: GET#: Address: Business City & Zip: Name: E-mail: ears in -mail: Business: Website: Years in Hawaii: Phone: What is your age? What ethnicity are you? What is your current household ❑ 25 or under ❑ Asian/Pacific Islander income in U.S. dollars? ❑ 26-40 ❑ Black ❑ Under $10,000 ❑ 41-55 ❑ Caucasian/White ❑ $10,000 - $19,999 ❑ 56 or older ❑ Hispanic ❑ $20,000 - $29,999 ❑ Hawaiian ❑ $30,000 - $39,999 What is your gender? ❑ Filipino ❑ $40,000 - $49,999 ❑ Female ❑ Other $50,000 - $74,999 ❑ Male ❑ $75,000 - $99,999 What is ,, rre marital status? ❑ $100,000 - $150,000 What is the highest level of education ❑ • • .. ❑ Over $150,000 you have completed? ed ❑ Grammar school ❑ g Which of the following best describes ❑ High school or equivalent , II dowed the area you live in? ❑ Vocational/tech school ❑ Suburban ❑ Some college Where were you born? ❑ Rural ❑ Bachelor's degree ❑ Ranch or Farm ❑ Master's degree ❑ Doctoral degree Do you own or rent? Do you have health insurance? ❑ Other ❑ Own ❑ Yes ❑ Rent ❑ No What media do you work in? Wholesale price range? Do you have social media sites? Addresses: Have you taught art? Are you interested in teaching? Volcano Art Center develops,promotes, and perpetuates Hawaii's artistic, cultural and environmental heritage through the arts and education. PO Box 129 • Volcano, Hawai'i 96785 • www.volcanoartcenter.org Office (808) 967-8222 • Fax (808) 967-8512 • Gallery (808) 967-7565 Are you represented by local galleries? Mainland galleries? On Etsy? What local arts organizations are you a member of? National arts organizations? International arts organizations? What service would you most like to have from VAC? Please include 100 words about what inspires you to create . (This will be reviewed, edited, and posted on the NINA web site.): Thank you for your participation in the Hawat`' ` d ork of Artists Economic Impact Report& Web Site. Please provide the following for three im, .'s o irk & mail this form with a CD of your images to the address below: • Images sized at 4"h x 6"w and 300• abe , a ,2 lows: LastName.Title.jpeg(hi-res .tif files are also accepted). • reproduction license/s from the phc • I raph:T s to use their image of your work in our web site and in print (attached). They will receive photo cre• Title Dimensions Medium Photo credit By signing,you agree that Volcano Art Center has unrestricted and irrevocable license to use the images of your work in Signature: Hawai`i Island Network of Artists Research Report and Web Site and in any subsequent print media including PR.. Print: * If you need assistance with photography or images, please let us know- we are happy to help you. Date: Volcano Art Center develops,promotes, and perpetuates Hawaii's artistic, cultural and environmental heritage through the arts and education. PO Box 129 • Volcano, Hawai'i 96785 • www.volcanoartcenter.org Office (808) 967-8222 • Fax (808) 967-8512 • Gallery (808) 967-7565 2 of 2 Hawaii Island Network of Artists(HINA) Report and Website Budget Narrative Operating Expenses Operating expenses are minimal, and estimated at$1,815 in cash expenses and $450 in in-kind donations.These expenses include website hosting for the first two years,general office supplies, printing of artist surveys and the printing of final reports. In addition, and estimated $450 is budgeted in in-kind donations for meeting space use.Total operating expenses of$2,265 make up 5.15%of the total project expenses. Marketing Marketing expenses include time for a graphic designer to design marketing pieces and the initial website. For advertising and PSAs, $1,050 is budgeted, specifically for post-report marketing of the outcomes. $500 in social media advertising is budgeted to spread the word about the report and identify as many artists on island as possible. A total of$2,150 is budgeted for marketing, which makes up 4.8%of the total project expenses. Administrative Administrative costs make up the majority of the expenses for the HINA Project.The full amount of funding requested, $25,000, is budgeted for the project management, data analysis and writing of the HINA Report.We estimated twenty hours per district at$25 per hour for nine districts for the planning, implementation and seeking of artists and information in Part 1 of this project for a total estimated cost of$4,000. In addition, the majority of time will be spent on the survey creation,data analysis, website creation and maintenance and project management. We have estimated hours at 40 hours per district at$65 per hour—with a $5k in kind donation of time at this rate from the Project Manager. Writing the report is estimated at forty hours at$65 per hour.Total funds requested are$5,000 and make up 23.1% of the total project costs.VAC estimates spending$7,700 in salaries or contract labor allocated to this program, including a professional editor.Additional, in-kind time spent on this project by CEO and volunteers are estimated at$2,440. Overall The HINA Project Budget is projected at$44,555; 25,000 is being requested from the County of Hawaii. VAC expects to pay out a minimum of$11,665, or 26.2%of total project funds in cash; and to date we have in-kind donations for time dedicated to this project at and estimated $7,890. ATTACHMENT B. Itemized Budget Form HINA Economic Impact Report and Website County of Hawaii VAC & TOTAL EXPENSES IN-KIND PROJECT CASH Request Other BUDGET Please list specific project expenses and group expense items by category as appropriate(i.e.,Administration,Operations,Marketing) Operating Website hosting- Years 1-2 125 _ 125 Office Supplies 100 100 Survey Printing 90 90 Printing- HINA Reports(20) 1,500 1,500 Meeting Spaces 450 450 Subtotal - 1,815 450 2,265 Marketing Graphic/Web Design 600 600 Advertising-PSAs 1,050 - 1,050 Web/Social Media/Word of Mouth _ 500 500 Subtotal - 2,150 - 2,150 Administrative Monthly Meetings 4,000 500 4,500 Research/Folllow up/Project Manager 18,400 5,000 23,400 Economic Report Writing 2,600 2,600 Volunteers(2 regular, ongoing) 1,440 1,440 VAC CEO staff time 4,900 1,000 5,900 Bookkeeper staff hours/benefits 300 300 Editor 2,000 2,000 Subtotal 25,000 7,700 7,440 40,140 ITOTAL EXPENSES I 25,000 I 11,665 I 7,890 I 44,555 (a) (b) (c) (d) County of Hawaii VAC & TOTAL INCOME IN-KIND PROJECT CASH Request Other BUDGET County of Hawaii Funding Request 25,000 25,000 Organization's Contribution 11,665 11,665 Other Sponsors/Sources - 7,890 7,890 e _ tit:r - TOTAL INCOME 25,000 11,665 7,890 44,555 (a) (b) (c) (d) 93 West Hawaii Community Health Center Adult Emergency Dental Services West Hawaii Community Health Center Adult Emergency Dental Services Agency Director: Richard Taaffe Phone No.: 808-326-3878 Contact Person: Donna Altshul,RDH Phone No.: 808-323-8005 Mailing Address: 75-5751 Kuakini Hwy., Suite 203 Kailua Kona, HI 96740 Facility/Site Address: 74-5599 Alapa St(Old Industrial Area) Kailua Kona,HI 96740 Fax No.: 808-327-1939 Email Address: dalthsul(&westhawaiichc.org Name of Accountant/CPA(include name of firm if applicable): Nishihama& Kishida, CPAs, INC. Phone No.: 808-524-2255 Mailing Address: American Savings Bank Tower 1001 Bishop Street., Suite 1700 Honolulu, HI 96813-3696 Amount of Request for County Funds: $10,000 Prior Year(s) Funding: 09-10 10-11 11-12 $10,000 $ 10,000 $ 10,000 Agency Mission Statement: The mission of the West Hawaii Community Health Center(WHCHC) is to make quality, comprehensive and integrated health services accessible to all regardless of income. These services will be culturally sensitive and will promote community well-being through the practice of"malama pono". Program Description: The Need for Emergency Adult Emergency Dental Services in West Hawaii A report prepared by the Hawaii Primary Care Association in 2005 still holds true in 2012. It stated that, "On the whole, the neighbor islands have greater need and fewer available dentists than Oahu. Many areas have an acute shortage of dentists willing to serve Medicaid and uninsured patients. Not surprisingly, these same areas have the highest rates of poverty, uninsured and Medicaid participation. For example, 58% of the population of Moloka'i and 55% of the population on the Big Island are either uninsured or covered by Medicaid, compared to 34% on Oahu." NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 1 West Hawaii Community Health Center Adult Emergency Dental Services For Hawaii County low-income adults, the problem of access to dental care is extreme because of the very limited number of private practice dentists that accept Medicaid AND because State Medicaid pays only for emergency care and has limited payments to a $500 annual cap. The participation of our state's dentists in public insurance plans is so low that according to a 2004 report, Hawaii "ranked almost last—46th out of 47 states with available data, for the proportion of dentists (30%) who offer services to publicly-insured individuals." An example of this on the Island of Hawaii is that in a 2006 telephone survey of private dentists, only one dentist accepted new Medicaid patients. Dentists say that they do not accept Medicaid primarily because of the low reimbursement rates, leaving adults who have severe and immediate dental problems without options for even an extraction to alleviate pain and infection. Today, given the downturn in the economy, increased layoffs with resulting loss of health coverage, AND the State's elimination of adult dental benefits for Medicaid recipients in 2010, the demand for adult dental services is acute for adults living in West Hawaii and in need of emergency care having nowhere to turn but to WHCHC's dental van. Although many van patients are Medicaid-eligible, Medicaid reimbursements alone do not support these emergency services in Kona. WHCHC's Solution—Adult Emergency Dental Services (dental van) WHCHC's dental van is the only solution today for Kona's uninsured and low income adults experiencing dental emergencies. WHCHC has been operating the van two days a week since October 2009 at Hope Services Hawaii (formerly called The Friendly Place) located in Kona. Total 2012-13 Budget and Position Count Projection: Total Program Budget $145,200 Total Program Position Count 1.45 FTE Total Agency Budget $7,859,124 Total Agency Position Count 75 FTE Program Objective: Provide quality emergency dental care to approximately 800 adults who are either uninsured or covered by Medicaid. Program Highlights: WHCHC started seeing patients at the dental van in October 2009. At the end of December 2011 (26 months of providing service), a total of 1,641 adult patients have been provided emergency dental services at the van. The County has been supporting the van since July 1, 2010 (FY 2010-2011). County funding has been vital to keeping the van open and serving uninsured adults who have a dental emergency. Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget Estimate Number of uninsured or Medicaid adults seen for 696 750 800 emergency dental services NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 2 West Hawaii Community Health Center Adult Emergency Dental Services Program Expenditures: FY 2010-11 FY 2011-12 FY 2012-13 Actual Budget Estimate Salaries and Wages $98,655 $105,000 $104,700 Professional Fees 0 $250 $800 Operations $31,270 $27,800 $3 1,050 Equipment & Supplies $23,032 $9,000 $7,600 Other $2,438 $1,200 $1,050 TOTAL $155,395 $143,250 $145,200 Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 Actual FY 2011-12 Budget FY 2012-13 Estimate Patient Generated (self- $92,542 $85,000 $92,000 pay[uninsured], Medicaid) George P & Ida Tenney $53,250 $50,000 -0- Castle Trust County of HI $10,000 $10,000 $10,000 WHCHC Operating Funds ** $43,200** TOTAL $155,792 $145,000 $145,200 ** any shortfall in funding sources will be absorbed by WHCHC Explain what plans, if any, your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? In 2012 and beyond, WHCHC will seek funding from a variety of additional sources, both public and private, in order to continue meeting the community's emergency adult dental health needs since the $50,000 from George P & Ida Tenney Castle Trust (a 3 year grant) ended 12/31/2011. The Hawaii Department of Health may make limited funding available in FY 2012-13 to help augment dental care to uninsured adults. If so, WHCHC will apply, however the dental van has never been self-sustaining even when owned and operated by the Office of Social Ministries/Catholic Social Services. WHCHC will continue to maximize patient revenue while it searches for other funding sources. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 3 West Hawaii Community Health Center Adult Emergency Dental Services FY 2012-13—Operations Budget Detail ATTACHMENT A EXPENSES: Salaries and Wages Dentist ( .40FTE) $ 52,000 Dental Assistant/Van Ops Coordinator( .50FTE) $ 17,160 Receptionist/Assistant (.50FTE) $ 16,640 Subtotal: $ 85,800 Fringe @ 22% $ 18,900 TOTAL $104,700 Professional Fees $ 800 (licensing& other associated fees) Operations Rent &Utilities $ 2,750 Telephone/Internet/Support ($800/mo) $ 9,600 Van fuel/repair/maintenance $ 3,500 Dental equipment repair/maintenance $ 1,200 Van insurance $ 500 Contract Dentist (Locum Tenem 18 days @ $500) $ 9,000 Contract Dentist travel from Oahu @ $250 x 18 trips $ 4,500 TOTAL $ 31,050 Equipment & Supplies Dental supplies (based on $8.75 x 800 patient visit) $ 7,000 Office supplies $ 600 TOTAL $ 7,600 Other Staff interisland travel (conferences & meetings) $ 750 On-island mileage (600 mi x $.50) $ 300 TOTAL $ 1,050 GRAND TOTAL $145,200 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 4 West Hawaii Community Health Center - Agency Name Adult Emergency Dental Services - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 6 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. /+' 4;1144_ i/.2 026/ Sign re of Board President/Chair ate or Agency Director LLSignature of xec(7----', iv Dire 'r Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 6 94 West Hawaii County Band Friends Volunteer Musician and Uniform Fund West Hawaii County Band Friends - Agency Name Volunteer Musician and Uniform Fund - Program Name Agency Director: Libby Keison Fulcher Phone No.: 808) 322-3322 Contact Person: Libby Keison Fulcher Phone No.: 808) 322-3322 Mailing Address: PO Box 4965 Kailua Kona, HI 96745 Facility/Site Address: Kealakehe Intermediate School Band Room, Kailua Kona 96740 Fax No..: 808) 327-3445 Email Address: weddingsalaheart@hawaii.rr.com Name of Accountant/CPA (include name of firm if applicable): AO J4. 19-RLE Phone No.: g'OP - °I - Mailing Address: )1 - (, y 7 .5,EAvi5vlp CieCC'E kft-ICAM'ki NA- ) 9 (,7 yo You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$ 23,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $ 0 $ 0 $ 0 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 7 Agency Mission Statement: The primary and specific purpose for the West Hawaii County Band Friends shall be to support morally and financially, promote, assist and enance the County Band in West Hawaii. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page2of7 West Hawaii County Band Friends - Agency Name Volunteer Musician and Uniform Fund - Program Name Program Description: The Program covers expenses that volunteer musicians incur, such as gas costs for travel to music sessions. Currently, only 9 musician positions of a total of 19 county budgeted personnel are filled and the Band requires extra players to fulfill the instrumental requirements of the musical pieces, for a total of a 29 musicians band. Also, the Program will cover the costs of new uniform shirts for the 19 personnel plus 11 extra shirts to promote the professional appearance of the Band. Additionally, to fulfill the Band's commitment to full instrumental performance at parades, the Program will fund the purchase of a new Sousaphone, a necessary instrument. Total Budget and Position Count Total Program Budget 23000 Total Program Position Count 20 Total Agency Budget 24000 Total Agency Position Count 8 Program Objectives: 1) To fund "honoriums" of 20 musicians at$1,000 per instrument per year. To fund the cost of uniform shirts for 30 musicians for a total of $1000. To fund the purchase of a Sousaphone at$2000. Program Highlights: (from Fiscal Year 2010-11) 1) The Program funded honorariums of 17 musicians to partially fulfill the . instrumental requirements of the Band's concert commitments. The Band was met with sincere gratitude from its audiences and the extra volunteer musicians provided greater instrumental coverage for the compositions and a fuller sound. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 7 West Hawaii County Band Friends - Agency Name Volunteer Musician and Uniform Fund - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Honorarium for 20 musicians 2100 2200 20,000 Purchase of uniform shirts 0 0 1000 Purchase of Sousaphone 0 0 2000 *lf applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 0 0 0 Professional Fees 0 0 0 Operations 2400 2400 20000 Equipment 0 0 3000 Other Total 2400 2400 23000 *If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 7 West Hawaii County Band Friends — Agency Name Volunteer Musician and Uniform Fund — Program Name For Program Expenditures, FY 2010-11 Actual: Other* is listed as expense specifically set aside by a special donation from the Billfish Tournament for meal costs between sessions played by musicians on the same day. For example, the parade for the Tournament participants is 2 hours before the more formal concert and the musicians who play both sessions are encouraged to remain and take a break in town. This special donation is divided equally by the musicians and does not fit the category of honorariums. West Hawaii County Band Friends - Agency Name Volunteer Musician and Uniform Fund - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Donations 2600 2600 1000 HI County Non-profit grant 0 0 23000 Total 2600 2600 24000 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? The WHCB Friends plans to do more vigorous fund raising which will include more grant writing and direct fund raising efforts. The Friends anticipates the Program will be self-sustaining by FY 2013—2014. Please disclose(list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Some of the directors of the WHCB Friends are also county employees of the West Hawaii County Band. One of the musician volunteers also works for the County in another department. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 7 West Hawaii County Band Friends - Agency Name Volunteer Musician and Uniform Fund - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due._ NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6of7 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result_ in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these re:uirements. � 1 lip %�- • - • Qf • :ture . : •. d •resi tiChair Da or -genc ►,irector • aatAt (446 /2_0 Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 201243 Page 7 of 7 95 West Hawaii Mediation Center Mediation Services West Hawaii Mediation Center Mediation Services Agency Director: Janie Chandler-Edmondson Phone No.: 885-5525 Contact Person: Janie Chandler-Edmondson Phone No.: 885-5525 Mailing Address: PO Box 7020, Kamuela, HI 96743 Facility/Site Address: 65-1279 Kawaihae Rd., Ste. 213, Kamuela, HI 96743 Fax No.: 887-0525 Email Address: ED @WHMediationCenter.org Name of Accountant/CPA: John Carbonaro Carbonaro CPA's Phone No.: 808-242-5002 Mailing Address: 1885 Main Street, Suite 408, Wailuku, HI 96793 Amount of Request for County Funds: $13,000.00 Prior Year(s)Funding: 09-10 10-11 11-12 15,000.00 10,000.00 8,000.00 Agency Mission Statement: West Hawaii Mediation Center exists to improve the way people deal with conflict by providing mediation, facilitation, youth conflict resolution education and training services. Program Description: The funds are requested to support West Hawaii Mediation Center(WHMC)which serves the districts of Hamakua, North &South Kohala, North&South Kona, and Ka'u. WHMC provides community-based mediation for both self-referred and court/legal system referred clients. These services are provided in an accessible and affordable manner to ensure any and all disputes in West Hawaii can be resolved in a safe, fair and appropriate way without the expense(time and money)of litigation. WHMC utilizes trained community volunteers to deliver this vital service to their fellow community members. WHMC also provides conflict resolution education and training to adults, and to youth through peer mediation. We have dedicated next year to expanding peer mediation in order to allow more schools to participate and to focusing education on bullying and social media education. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 Total Budget and Position Count Total Program Budget 113,000.00 Total Program Position Count 2 Total Agency Budget 113,150.00 Total Agency Position Count 2 West Hawaii Mediation Center Mediation Services Program Objectives: 1) Offer mediation services for a wide array of dispute issues including, divorce(property division, finances, custody), landlord-tenant, small debt, foreclosure, small claims, neighbor-neighbor, condominium, civil rights, special education, victim-offender, and community issues. 2) Recruit, train and retain high quality volunteer community mediators. 3) Provide continuing education opportunities for volunteer mediators as well as specialty trainings, i.e., condominium, special education, civil rights, and divorce/custody mediation. 4) Provide mediation services in an affordable and accessible manner for disputes arising both in and out of the court/legal system. 5) Educate youth in peaceful conflict resolution skills and provide peer mediation 6) Provide adequate case management services to adequately serve all referred cases. 7) Provide information and referral services to individuals who need services instead of, or in addition to, the mediation services offered at WHMC. 8) Provide community outreach and education around constructive conflict resolution practices for adults. Program Highlights: 1) Delivered 1760 hours of case intake services. 2) Served 328 cases(79% referred by County court, Family court or police and 21% self referred)with 665 clients served. 3) Served an increase of 37% in divorce/custody and 15% in small debt cases over the past two years. 4) Serving an increase of 80% in foreclosure cases 5) Utilized volunteer mediators in mediation sessions for a total of 649 hours of mediation. 6) Reached full agreement in 52%of cases mediated. 7) 207 mediation sessions held. 8) Achieved a 94%service satisfaction rating by respondents(post-mediation satisfaction survey). 9) Achieved a 98% rating by respondents indicating that they would recommend mediation to others in the future. 10) Provided 50%of total services to low income clients(annual income under$20,625). 11) Provided conflict resolution education and/or peer mediation training to over 500 elementary students in West Hawaii and at community events. (Learning Disabilities Association, Kona Family Fun Day, Waimea Keiki Fest) NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 Performance Measures: FY 2010-2011 FY 2011-12 FY 2012-13 Actual* Budget* Estimate* Case Management Hours 1760 1760 1800 Mediation Cases Served 328 338 348 Mediation Sessions Conducted 207 220 230 Agreements reached in mediation 52% 62% 62% Client's satisfied with service _ 94% 94% 95% Client's willing to recommend service to 96% 96% 96% others Skills enhancement trainings offered for 8 8 8 volunteers Affordable or free service to low income 48% 50% 55% (%of clients considered low income) Number of schools provided conflict 4 5 6 resolution and peer mediation education Conflict Resolution Education events for 6 6 6 adults and youth. West Hawaii Mediation Center Mediation Services Program Expenditures: FY 2010-11 FY 2011-12 FY 2012-13 Actual* Budget* Estimate Salaries and Wages 70,000.00 72,000.00 77,500.00 Professional Fees 500.00 500.00 500.00 Operations 33,812.00 35,700.00 36,700.00 Equipment 300.00 Other* Total 104,312.00 108,500.00 114,700.00 *If Applicable #Please explain in detail on separate sheet Program Funding Sources: Revenue Source FY 2010-2011 FY 2011-2012 FY 2012-13 Actual* Budget* Estimate County of Hawaii 10,000.00 8,000.00 13,000.00 State of Hawaii 39,138.00 39,138.00 39,100.00 Hawaii Justice Foundation 5,000.00 4,250.00 4,250.00 Hawaii Island United Way 11,850.00 12,000.00 12,000.00 Private Foundations/Partnerships 16,000.00 22,500.00 26,550.00 Donations 7,195.00 6,500.00 2,000.00 Fundraising 6,916.00 7,000.00 8,000.00 Service/Program Fees 1,590.00 1,692.00 1,500.00 Client Private fees 9,100.00 8,920.00 8,300.00 Total 106,789.00 110,000.00 114,700.00 *If applicable NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 Future Program Support: 1. West Hawaii Mediation Center completed its first Online Auction fundraiser in 2010. In 2011 we focused our efforts on an extended matching funds drive. We are currently planning our next online auction for 2012. In addition to the auction we will continue with our annual Sponsors and Supporters Campaign. We hope to create a separately sustained peer mediation program in the next several years. West Hawaii Mediation Center continues to receive and seek support from the United Way and other private agencies. 5 new grant proposals have been submitted this fiscal year and we have received support from 2 new foundation/grantors this year. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 - Agency Name - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135—2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 6 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you e acknowledging that you have read and understand these r uirements. gnature of Board President/Chair D e or Agency Director gnatur = xecutive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED!, NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 6 96 YWCA Hawaii Island Healthy Start Plus C 0 Plf YWCA of Hawai'i Island - Agency Name Healthy Start Plus- Program Name Agency Director: Ms. Jeanine Atebara, Chief Executive Officer Phone No.: 808-935-7141 ext 102 Contact Person: Mr. Andy Kahili, CREO and Program Director Phone No.: 808-961-3877 ext. 127 Mailing Address: 1382 Kilauea Avenue Hilo, Hawaii 96720 Facility/Site Address: 1382 Kilauea Avenue Hilo, Hawaii 96720 Fax No.: 808-961-9140 Email Address: akahili @ywcahawaiiisland.org Name of Accountant/CPA (include name of firm if applicable): Mr. Del Del Los Santos, Chief Financial Officer Phone No.: 808-935-7141 ext. 103 Mailing Address: 1382 Kilauea Avenue, Hilo, Hawaii 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds: The YWCA of Hawai'i Island is applying for $75,000 funding for its Healthy Start Plus home visiting program, which is a voluntary home visiting program that support families and promotes positive child relationships. Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $75,000 $60,000 $75,000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 10 Agency Mission Statement: Our Mission: YWCA of Hawai'i Island is dedicated to eliminating racism, empowering women, and promoting peace, justice, freedom and dignity for all. The YWCA of Hawai'i Island is dedicated to providing services to meet our Hawai'i Island community needs, drawing together people with diverse experiences and relationships so that we may join together in implementing the YWCA's mission. We work to maintain the National YWCA's goals and objectives, but our primary function is to fulfill our local community's needs. The YWCA of Hawai'i Island first organized in Hilo in 1919 when a group of courageous women recognized the need for a women's organization and for programs geared primarily towards women and girls. From a very humble beginning with 14 women housed in a small cottage, the YWCA has expanded from the original residence in both activities and facilities. Throughout our history, the YWCA of Hawai'i Island has offered valuable programs and activities for the benefit of women, children and their families. The YWCA of Hawai'i Island was established as a 501(c)(3) non-profit organization in 1965 and has been a partner agency of the Hawai'i Island United Way (HIUW) since 1979. It belongs to a national organization consisting of 300 YWCA Associations across the U.S. with 2.6 million members. Employing over 78 full-time, part-time and on-call staff, the YWCA offers a variety of services to people of all ages, from newborns to senior citizens in their 90's throughout the island of Hawai'i. Last year, the YWCA of Hawai'i Island touched the lives of close to 9,000 people, almost 5 pecent of the island's population. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 10 YWCA of Hawai'i Island - Agency Name Healthy Start Plus- Program Name Program Description: The YWCA Hawai'i of Island Healthy Start Plus (YWCA HSP) is part of the Hawaii State Department of Health, Hawai'i Healthy Start Program and the State Department of Human Services, Hawaii Enhanced Healthy Start Program. The YWCA HSP is a voluntary home visiting program that supports families and promotes positive child relationships. Families are identiified via our Early Identification intake and assessment team and referrals from the East Hawaii Child Welfare Service Division. The target population served include prenatal women and families of infants under the age three (3) years may enter the program. Our home visiting program utilizes a multi-disciplinary team approach and provides culturally appropriate support services within the family's natural environment and primarily focuses on the reduction of parental/environmental stressors, which are directly related to child maltreatment. This program is voluntary until the child reaches three years of age. Children identified at-risk for parental and environmental stressors is a significant problem for Hawaii's children. These children are at increased risk for sub- optimal health, developmental delay and maltreatment. Current research indicates this problem is a serious threat to the lives of these children and will have a tremendous impact on the community in the future. The YWCA HSP program is effective and unique as it identifies and serves infants at risk from birth, before abuse can occur, which is truly a prevention program. It also addresses the need to respond and serve those families who have a confirmed case of child abuse and neglect, which are considered to be the highest risk for child maltreatment. The YWCA HSP program utilizes 10 full-time Home Visitors who are paraprofessionals and works with a team of professionals consisting of a Clinical Manager/Supervisor, Clinical/Intervention Specialist, Child Development Specialist and Registered Professional Nurse. Home visiting services include screenings/assessments for possible delays and referrals for early intervention services. In addition, the program provides child development and parenting information, problem solving skills, and links families to appropriate community resources. The program also identifies families in need of services to address substance abuse, mental health issues and domestic violence. The YWCA HSP program utilizes the Hawaii Healthy Start Nurturing Parenting curriculum, which is designed to involve the entire family. Parents and their children participate in home-based activities designed to meet the unique needs and culture of families. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 10 There are few places on earth that embody the spirit of nurturing such as Hawai'i. It is the land of Aloha, the symbolic expression of love, compassion and empathy. Families will realize that parenting doesn't have to be a war raising children, you don't have to "pick your battles" with your kids like some type of commando, nor is "parenting the most difficult and challenging job you will ever have" as some parent educators suggest. Parenting can be the ongoing "Aloha" of your life if you look for the goodness in children, treat them as you would like to be treated, have fun and enjoy the time together. Welcome to Nurturing Families of Hawai'i. YWCA HSP provides safety net services to Hawai'i's most vulnerable families and infants. As part of the State of Hawai'i Blueprint for Change Plan, UH economist David McClain conducted a cost benefit study on Healthy Start which showed a 3:1 positive cost benefit ratio. Nationally, prevention and early intervention programs have shown 7:1 cost benefit ratios. According to economist James Heckman (NYT op-ed, 7-29-08) "Big gaps in potential for educational attainment are present at age 5. Some children are bathed in an atmosphere that promotes human capital and increasingly more or not. By age five, it is depressingly possible to predict who will finish school and college and who will not" This has a real impact on development of human capital and the overall economy. The YWCA of Hawai'i Island operates the only home visiting program of its kind in East Hawai'i. The funding from the County of Hawai'i and other funding sources will allow the YWCA Healthy Start Plus Program to provide services to 225 families in fiscal year 2012 — 2013. The Healthy Start and Enhanced Healthy Start Programs have been funded through the State of Hawai'i and other private sources since 1989 and will seek funding for the continuation of these prevention and intevention home visiting programs. Total Budget and Position Count (FY 2011-12) Total Program Budget $1,102,712 Total Program Position Count 26 Total Agency Budget $3,807,558 Total Agency Position Count 78 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 10 Program Objectives: 1) Provide screening and assessments to identify prenatal and postnatal women and families at-risk for sub-optimal health, developmental delays, and child maltreatment (child abuse and neglect). 2) Develop a Family Service Plan (FSP) to address identified risk factors. 3) Utilize a cohesive team approach in providing services. The home visiting team members work with the family to develop outcomes, and break those outcomes into meaningful strategies to ensure success. 4) Monitor and review family's progress in completing their objectives/strategies. In order to support the growth in the family, the home visiting team members and the family review the family's progress towards the achievement of their outcomes. 5) Deliver home visitation services. Home visits are conducted in the family's natural environment by the home visiting team members, in accordance with the FSP, in a seamless, cohesive manner where all disciplines involved communicate with one another regarding their relationship to the family. 6) Assess and monitor children identified with developmental status and health care needs. 7) Promote positive child health development. 8) Promote positive parent child interaction. 9) Promote a health and safe home environment. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5of10 Program Highlights: (from Fiscal Year 2011-12) 1) The program provided home visiting services to 238 families and 309 children during the fiscal year. 2) 100% of live birth at the Hilo Medical Center were screened by the program's intake and assessment staff. 3) 96% of children enrolled have a medical home, which means the child has a primary care physician (PCP). When there is no PCP, the child's health and well-being are at risk. Typically, no well child checkups and immunizations are performed. Families resort to using the Emergency Department as their primary medical provider. 4) 88% of children enrolled who turned 2 years of age were fully immunized by 25 months. Immunizations protect children and others. It is important that children are fully immunized. This not only protects the child from diseases, but also helps prevent the spread of diseases to family, friends and community. 5) 100% of mothers enrolled received early prenatal care with a subsequent pregnancy. All mothers started prenatal care in their first trimester. 6) 95% of children enrolled who are eligilble for Women's Infant Children (WIC) program were referred and enrolled in the WIC Program. The Special Supplemental Nutrition Program for Women, Infants, and Children - better known as the WIC Program - serves to safeguard the health of low-income pregnant, postpartum, and breastfeeding women, infants, and children up to age 5 who are at nutritional risk by providing nutritious foods to supplement diets, information on healthy eating including breastfeeding promotion and support, and referrals to health care. 7) 100% of children enrolled in the program had no confirmed report of child abuse and neglect. Child Abuse and Neglect by Hawaii law requires parents to provide their children with a safe family home, free from child abuse and/or neglect. Child abuse and neglect is often referred to as harm or as threatened harm. Child abuse and neglect includes physical abuse or neglect, medical neglect, psychological abuse or neglect, inadequate care and supervision, sex abuse, and giving illegal drugs to a child by a family member, legal guardian, and/or a person responsible for that child's care. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 10 YWCA of Hawai'i Island - Agency Name Healthy Start Plus - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate (as of December 2011) Percentage of enrolled children with 100 98 98 no confirmed child abuse and/or neglect report Percentage of enrolled children with 90 88 88 a completed FSP within 60 days Percentage of enrolled children with 96 96 96 an identified medical home Percentage of enrolled children with 100 100 100 a confirmation developmental delay who were referred to for early intervention services Percentage of fully immunized by 88 88 88 age 2 years. Percentage of families after 12 96 95 95 months of service received and accepted family planning *If applicable Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages $664,845 $765,146 $785,146 Professional Fees 171,879 172,414 172,414 Operations 174,130 154,382 154,382 Equipment 37,620 10,500 5,770 Other# Total 1,048,474 1,102,712 1,117,712 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 10 YWCA of Hawai'i Island - Agency Name Healthy Start Plus - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate State of Hawaii — Dept of Health, $580,191 $671,000 $671,000 Maternal Child Health Branch State of Hawaii — Dept. of Human 368,284 371,712 371,712 Services County of Hawaii 75,000 60,000 75,000 Office of Hawaiian Affairs 24,999 0 0 Total $1,048,474 $1,102,712 $1,117,712 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? Since 1989 the program has been funded 100% by the State of Hawaii, Department of Health, Maternal Child Health Branch (DOH-MCHB). Currently the program is funded by DOH-MCHB, Department of Human Services and a grant with County of Hawaii. In addition the program will be submitting grant proposals to the following organizations; O'Neill Foundation Positively Mom Project, and the Hawaii Community Foundation. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Karen Teshima —YWCA of Hawaii Island Board of Directors, Volunteer NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 10 YWCA of Hawai'i Island - Agency Name Healthy Start Plus - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 10 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. < < <z Signature of Bo rd President/Chair Date or gency D" tor (1)3a4f0-- 1/3 / //,21--, Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 10 97 YWCA Hawaii Island Sexual Assault Support Services • © PY YWCA of Hawaii Island- Agency Name Sexual Assault Support Services- Program Name Agency Director: Jeanine Atebara, Chief Executive Officer Phone No.: (808) 935-6067 ext 102 Contact Person: Lorraine Davis, Chief Operating Officer Phone No.: (808) 961-3877 ext. 162 Mailing Address: 145 Ululani Street Hilo, HI 96720 Facility/Site Address: 1382 Kilauea Ave., Hilo, HI 96720 75-5706 Hanama Place, #202, Kailua Kona, HI 96740 Fax No.: (808) 934-7179 Email Address: jatebara(a)ywcahawaiiisland.orq or Idavis @ywcahawaiiisland.org Name of Accountant/CPA (include name of firm if applicable): Carbonero and Associates Phone No.: A (808) 968-1002 Mailing Address: P.O. Box 4372, Hilo, HI 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$60,000 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $20,000 $15,000 $20,000 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 12 Agency Mission Statement: YWCA Hawaii Island is dedicated to eliminating racism, empowering women, and promoting peace, justice, freedom and dignity for all. The YWCA Hawai'i Island, first organized in Hilo in 1919, has offered valuable programs and activities for the benefit of women, children and their families. The YWCA Hawai'i Island was established as a 501(c)(3) non-profit organization in 1965 and has been a partner agency of the Hawai'i Island United Way (HIUW) since 1979. It belongs to a national organization consisting of 300 YWCA Associations across the U.S. with 2.6 million members. Employing 78 full-time and part-time staff, the YWCA offers a variety of services to people of all ages, from newborns to senior citizens in their 80's. throughout the island of Hawai'i. YWCA Hawai'i Island programs include: • Healthy Start, the only home visitation family support program for all East Hawai'i new mothers and babies who are at risk for abuse; • Teen Court, available island-wide and the only way for teens and `tweens to make up for their first-time offense, give back to the community and wipe their record clean. • Sexual Assault Support Services, the only 24/7 rape crisis center of its kind for all of Hawai'i Island. • An aquatics center that offers the warmest, solar heated salt water and therapeutic pools in East Hawai'i. • A preschool that promotes kindergarten readiness by providing care at one of the only nationally accredited preschools on the island. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 12 YWCA of Hawaii Island - Agency Name Sexual Assault Support Services- Program Name Program Description: The Program's mission is to provide services for the healing and prevention of sexual violence. Sexual violence is a hard topic to talk about and it is on our island. Our victims have been as young as 6 months old and as old as 95 years old. Sexual violence is an equal opportunity crime that crosses the boundaries of age, race, religion and gender equally. Sexual violence is pervasive. Sexual violence is crippling to the victim. Victims of sexual violence want to keep their experience a secret. To let you know how pervasive this crime is, imagine yourself seated in a crouded movie theater here on the island. Based on national and local statistics, at least 2 people in every row either has been or will be a victim of sexual violence. If you attend a high school graduation in Hilo, Kona, Honolulu or somewhere on the mainland, chances are 1 in 4 girls and 1 in 6 boys will have been a victim of sexual violence already. The impact of sexual violence to a person manifests itself in many different ways and during various times in a victim's life. Studies show that sexual violence left untreated will cost more to the public than the treatment of chronic diseases like diabetes or life-threatening diseases like cancer, with respect to lost wages, mental and emotional issues, and alcohol and substance abuse. In the economic depression that the County of Hawaii has been experiencing, with an increase in financial stress and unemployment, alcohol and substance abuse increases as does sexual and domestic violence. While our funding sources are reducing their assistance to support the services to victims, the demand for the same services has increased. In a comparison of the first 6 months of the last fiscal year against the first 6 months of this fiscal year is shown in Table 1. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3 of 12 Table 1. Comparison of Number of Victims/Survivors Served Descriptor July 1, 2010 to July 1, 2011 to December 31, 2010 December 31, 2011 Number of Initial Crisis 206 265 Calls Taken Number of Secondary 164 214 Phone Contacts Number of Initial Face to 82 85 Face Served Number of Victims 87 82 Receiving Crisis Outreach Victims receiving Clinical 140 189 Services Number of Persons 1536 1804 Served through Community Activities and Presentations In the coming fiscal year, due to Federal and State mandates, the SASS program funding will be reduced by an estimated $140,000. The program has made cuts in the infrastructure and now faces cuts in direct service to victims. As shown in Table 1, the demand has increased and the program is facing a reduction in direct services. The SASS program works to reduce the incidences of sexual assault and disability to those who have been victimized. Services include the only 24/7 sexual assault crisis line on the island which includes crisis response and stabilization and opportunities to enter into the SASS program for a variety of services. The advocates who answer the crisis line also accompany a victim to the hospital for a forensic exam and, in the case of a minor, will meet the family at the children's Justice Center to stay with the family during a forensic interview. The SASS program also offers clinical services which includes counseling for the victim and immediate family. The clinician will also accompany the victim and family to court to help prevent re-traumatizing the victim and family during court proceedings. The third component of the program is to provide prevention education presentations and activities to our island youth from preschool through college. The prevention educator follows age appropriate curriculum surrounding body boundaries, good touch vs. bad touch, healthy relationships and safe dating to island children. The SASS program provides professional training to adults on how to look for signs of sexual assault, what to do when a child discloses and the effects of sexual assault on a person. All services are provided at not charge to the client or family. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 12 The SASS program functions as team members with the Hawaii County Sexual Assault Response Team (SART). Both advocates and therapists work with SART members in providing quality services to clients. SART members include police investigators, sex assault nurse examiners, prosecutors, Children's Justice Center and Child Welfare Services. The YWCA is in our third decade of helping sex assault survivors, who are men, women, girls and boys. Primary funding of the program is through the State of Hawaii, Office of the Attorney general through a subcontract with the Kapiolani Women's and Children's Medical Center Sex Abuse Treatment Center. As a result, quality assurance, program and fiscal monitoring of services are maintain at a statewide standard. The SASS program experienced budgetary cuts during the economic downturn beginning in 2008. The budgetary cuts could have resulted in the reduction of services as the demand for services increased. However, because the YWCA applied for and received Federal Appropriations, VOCA ARRA fund and State of Hawaii Rainy Day funds, the program was able to continue full service and meet the increasing needs of the community. However, Federal Appropriations are no longer available to anyone in the nation and VOCA ARRA funds provided were one-time appropriations. The State of Hawaii has opted not to extend Rainy Day funds in the next fiscal year. As a result, the program faces a reduction in providing direct services. The funding requested in this proposal is to provide assistance in continuing to meet the demands of the community rather than reduce the services are to a vital need to support victims. Total Budget and Position Count Total Program Budget 623,455 Total Program Position Count 16 Total Agency Budget 3,807,558 Total Agency Position Count 78 Program Objectives: 1) Continue to operate the 24-hour, 7 day a week Sexual Assault Crisis Hotline receiving calls island-wide from persons seeking support, information, and referral that may lead to face to face support as described in the next objective. 2) Provide a SASS Advocate to support each sexual assault victim undergoing forensic and legal examination in the period July 1, 2012 to June 30, 2013. 3) Deliver professional counseling and/or case management services to at least 100 sex assault survivors. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 12 Program Highlights: (from Fiscal Year 2010-11) 1) The most notable outcome of the year was that the program was able to maintain services for victims and meet the increased demands for services. 2) The SASS added a 0.75 FTE therapist to the mix in July 2010 and quickly moved the position to a 1.0 FTE due to demand. 3) Due to travel restrictions and costs for clients in the Kau district, the SASS program provides a therapist in Na'alehu one day a week. Due to similar obstacles in North Kohala, the SASS program is considering taking the therapist to the client's one day a week as well. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 12 YWCA of Hawaii Island - Agency Name Sexual Assault Support Services - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Fully trained personnel are 818 800 1000 available to assess and respond to Estimate callers on the Sexual Assault Crisis 958 based Phone Line. Crisis line available 24 on first 6 hours a day 7 days a week, 365 months days a year.. Crisis counseling, legal systems 161 150 175 advocacy, information and referral Estimate are provided to each sex assault 170 based victim undergoing medical-legal on first 6 examination in East and West months Hawai'i. 150-200 victims will receive service contacts Survivors of sexual assault receive 209 250 375 psychotherapy services and Estimate intensive clinical case management 378 based from masters-prepared therapists in on first 6 East and West Hawai'i. 100 victims months will receive therapeutic services. (Victims we counsel range in ages from 4 years of age to elderly. From October 2010 to December 2010, all of our face to face referals were under the age of 18, except for one 29 year old adult.) *If applicable NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 12 Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 321,213 340,380 384,781 Professional Fees 133,642 195,264 1,430 Operations 73,344 87,811 132250 Equipment 600 Other# Total 528,200 623,455 519,061 *If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 12 YWCA of Hawaii Island - Agency Name Sexual Assault Support Services - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) These funds are secured for the next fiscal year. Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate State of Hawaii Attorney General 264,860 264,860 264,860 through SATC Office of the Prosecuting Attorney 54,452 26,000 26,000 OVC Federal Appropriations 146,423 226,595 10,000 State of Hawaii Attorney General 1,619 17,500 17,500 SASP through SATC Private Donations 17,315 3,500 2,500 County of Hawaii SANE (30,000 30,000 90,000 secured, 60,000 pending) State of Hawaii Attorney General 28,531 (VAWA) County of Hawaii 15,000 20,000 60,000 State of Hawaii Attorney General 35,000 Rainy Day Funds through SATC Total 528,200 623,455 470,860 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? This program has a variety of funding streams because sexual assault is something that nobody wants to talk about much less fund. That being said, this agency is taking the following steps to keep this program funded: • Fundraising. In the past three years, the YWCA has sponsored "Walk a Mile" and "YWalk" where the program was recipient of some of the funds raised. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 12 • Continuous grant writing to foundations, agencies and response to request for proposal that would support the efforts in alignment with the program services. • Donations from the community, either in-kind or monetary to help victims of sexual assault. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Karen Teshima, YWCA of Hawaii Island Board of Directors, volunteer NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 12 YWCA of Hawaii Island - Agency Name Sexual Assault Support Services - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 — 2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 11 of 12 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand these requirements. toard tI3ot (.. _ Signature President/Chair Date r Agency I ector nu,A}co--- y3 ,Aa., Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 10 98 YWCA Hawaii Island YWCA Developmental Preschool YWCA Hawaii Island- Agency Name YWCA Developmental Preschool- Program Name Agency Director: Jeanine Atebara, Chief Executive Officer Phone No.: 808/935-6067 ext 102 Contact Person: Lissa Van Kralingen, Child Care Director Phone No.: 808/935-7141 ext 203 Mailing Address: 145 Ululani Street Hilo, Hawaii 96720 Facility/Site Address: 145 Ululani Street Hilo, Hawaii 96720 Fax No.: 808/935-5150 Email Address: Ivankralingen @ywcahawaiiisland.org Name of Accountant/CPA (include name of firm if applicable): Carbonaro CPA &Associates Phone No.: 808/968-1002 Mailing Address: P.O. Box 4372, Hilo, HI 96720 You are responsible to keep the above information current Amount of Request for County Grant-in-aid funds:$25,000.00 Prior Year Award of County Nonprofit Grants-in-Aid funds: 09-10 10-11 11-12 $ $ $ Agency Mission Statement: The YWCA is dedicated to eliminating racism, empowering women and promoting peace, justice, freedom and dignity for all. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 1 of 10 YWCA Hawaii Island - Agency Name YWCA Developmental Preschool- Program Name Program Description: YWCA Developmental Preschool focuses on the whole child...socially, cognitively, emotionally and physically. Our program is Licensed by the State of Hawai'i Department of Human Services (DHS) and accredited nationally by the National Association for the Education of Young Children (NAEYC). We focus on helping parents, many of whom are young, single mothers trying to make ends meet. We try to assist them first with short-term termporary tuition assistance and, then, help them find long-term tuition assistance so their child can remain in preschool. We know how critical a quality early childhood education is for a child's success. We know that if children can stay in preschool, their chances for success in kindergarten and in life in general are increased exponentially. We provide educational classes for our parents to attend (optional) covering a wide variety of subjects, with the most recent about healthy and nutritious meals for their family. We have a preschool parent association that meets regularly and we focus on a variety of topics that impact parents in today's world. Each meeting has set aside time for the parent to read to their child to encourage a love for reading. We, as an extension of the family, provide children with a warm, caring, safe and secure environment in which to explore and discover those things around them and within themselves. In this environment, we offer the opportunities for children to make choices that will enhance their naturally emerging skills. We encourage independent thinking, curiosity, exploration and discovery through developmentally appropriate curriculum, materials, and methods. It is through movement and discovery, rather than an immobile state, in which children grasp and learn about the world around them. Our purpose is; • To provide an environment which is safe, secure and respectful of each child. • To promote growth socially, emotionally, cognitively and physically. • To help the child build a foundation for success. • To promote creative expression through art, music, dance, story-telling, etc. • To provide a curriculum that acknowledges cultural diversity. • To continually promote positive self-esteem in each child. • To provide a curriculum that encourages a lifetime love for learning • To provide a curricululm that produces a well-rounded kindergarten-ready student when he/she graduates from our preschool at 5-years old. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 2 of 10 Total Budget and Position Count Total Program Budget 769,106 Total Program Position Count 15 Total Agency Budget 3,807,558 Total Agency Position Count 78 Program Objectives: The objectives that we have for each child entering in our preschool are listed below. 1. To give each child opportunities to develop independence, responsibility, self- control and self-confidence. 2. To give them faith in themselves to set goals and achieve them. 3. To have them look in the mirror and smile back at themselves. 4. To have each child meet or exceed the State of Hawaii Contents Standards for Kindergarten Readiness by the time they graduate from our Preschool We can further accomplish our goals and objectives by supporting the families with tuition assistance which would allow their children to be enrolled. Families apply for, and have received; short term financial assistance and we actively assist them in applying for tuition assistance through other agencies that offer financial support for early childhood education and/or child care. In the past two years, through other grants, we have been able to assist over 70 families with tuition assistance while they sought and applied for other subsidies. Most of those families have their child (ren) enrolled in our preschool. Program Highlights: (from Fiscal Year 2010-11) 1. We have taken the initiative and have successfully applied for grants that have enabled us to provide temporary tuition assistance to financially needy families. By doing this, we were able to help nearly 70 students enroll or remain in our preschool over the past two years. If not, they would not have been able to start or continue the kindergarten-readiness curriculum that is so important for their future success in school. 59% of our enrolled students come from families living at or below federal poverty guidelines for family size and income. Many are socio-economically challenged and many come from single-parent homes. 75% our enrolled students qualify and receive some type of tuition assistance from Pauahi Keiki Scholars, Arbor, First to Work or Open Doors. 2. Following an on-site visit to our campus, our application for accreditation by the National Association for the Education of Young Children (NAEYC) was approved. Our staff and our preschool curriculum met the 10 Early Childhood NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 3of10 NAEYC Program Standards and more than 400 related Accreditation Criteria. We are one of only four preschool programs on the entire Big Island that are NAEYC accredited. 3. Because of our NAEYC accreditation, our student to teacher ratio is lower than those preschools that just meet State of Hawaii standards. With lower student to teacher ratios, our students receive more individual attention. 100% of our preschool graduates pass the Hawaii Contents Standards test for kindergarten readiness. 4. Because of our NAEYC accreditation, we receive student referrals from Pauahi Keiki Scholars (Kamehameha Schools) who use NAEYC as a benchmark standard. They provide tuition assistance to qualifying students (families) who attend NAEYC accredited preschools. 5. We take whatever time is necessary to walk parents through the often-times confusing and complicated process of applying for tuition assistance from the various agencies, including Pauahi Keiki Scholars, Arbor, First To Work or Open Doors. 6. We applied for and received a grant from Target Stores that promotes literacy in families. The program is entitled "Read a book, take it home". With funds from Target, parents may choose a new book and read it to their child at our school. Each new book that they read to their child, they are entitled to keep and take home. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 4 of 10 YWCA Hawaii Island - Agency Name YWCA Developmental Preschool - Program Name Performance Measures: FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Assist families with temporary 70 41* 75 tuition assistance while they pursue and apply for other means of financial assistance. *If applicable * In FY 2010-11, the YWCA received $42,000 in funds to assist families with tuition assistance. In FY 2011-2012, the YWCA received $20,000 in funds to assist families. Program Expenditures FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Salaries and Wages 446,955 500,248 515,255 Professional Fees 110,763 128,401 131,254 Operations 78,469 138,457 139,539 Equipment 1,660 2,000 4,000 Other# Total 637,846 769,106 790,048 * If applicable #Please explain in detail on separate sheet NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 5 of 10 NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 6 of 10 YWCA Hawaii Island - Agency Name YWCA Developmental Preschool - Program Name Program Funding Sources: Identify all funding sources (specific to this program only) Revenue Source FY 2010-11 FY 2011-12 FY 2012-13 Actual * Budget* Estimate Contributions&Special Events 40,500 10,000 15,000 Gov.Contracts 31,017 3,500 H I U W 12,001 20,000 10,000 USDA 10,470 12,600 54,000 Trust& Foundation 42,455 36,250 20,000 Program Fees 523,186 704,656 706,548 Tuition Discounts -29,519 -14,400 -20,000 Other funds 473 1,000 Total 630,584 769,106 790,048 *If applicable Explain what plans your agency and/or program has to increase revenues to support this program. When do you anticipate your program to become self-sustaining? 1. We continue to look for early childhood educational grants from private or public foundations that will support our goal of providing tuition- assistance for needy families. Some grants do not allow you to re-apply every year if you successfully receive funding from them one year. So, it's a case of staggering our applications every other year to multiple funding sources. It's difficult because most grants want to see that you affect and help big numbers of recipients in the community. But, even though our short-term tuition-assistance doesn't help huge numbers of families, we feel that each child we help is one more child in our community who has a better chance of being a success in kindergarten and in life. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 7 of 10 2. We plan at least one fundraising project each year with our preschool families. Example: Last year we had a school-wide sweetbread sale partnering with KTA. 3. Being able to offer some sort of short-term tuition-assistance to needy preschool families will never be self-sustaining. We try to assist as many families as we can for about a 3-month period and only on a partial-tuition basis, usually $100 or $200 a month for up to 3-months. The goal is to help parents find long-term tuition assistance, either through Arbor, Open Doors, Pauahi Keiki Scholars, First to Work or other social service resources that may become available. We try to stretch the private foundation grants we receive as much as possible so that we can help as many students as possible. We know that the numbers of students we help doesn't represent huge numbers overall. But, we feel that each child we are able to keep in preschool is one less child who gets left at home and who may fall between the cracks when it comes to being kindergarten ready at five years-old. Please disclose (list here) any affiliations that any employee or volunteer of your organization may have with the County of Hawaii. Karen Teshima, Hawaii Island Board of Directors, Volunteer NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 8 of 10 YWCA Hawaii Island - Agency Name YWCA Developmental Preschool - Program Name I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting and fiscal accountability requirements as mandated in Article 25, Sections 2-135 —2-142.2, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) hereby certify that information supplied herein including all supporting documents is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel accepting our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant, a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report will impact the evaluation of your program's or agency's future funding requests. I (we) understand there is no provision for further notification to submit the final report. No late or incomplete reports will be accepted after the 60 day due date. Information and instructions are available at co.hawaii.hi.us/forms/grantapps.html on or about May 30 of the year the final report is due. NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 9 of 10 Any funds unused by June 30, 2013 must be returned to the County of Hawaii within 30 days (July 30, 2013). Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understand, ,,o ,these requirements. ignature •' Board Presiden�/Chair Date r Agency •erector a0 IA,hc>,_, Signature of Executive Director Date UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! NONPROFIT GRANT APPLICATION FISCAL YEAR 2012-13 Page 10 of 10