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COM 0095.001 2018-2020
• Harry Kim Deanna S. Sako Mayor :� ::'t. Director • \ , ft r�oc•N►.N= County of Hawaii Finance Department 25 Aupuni Street,Suite 2103 • Hilo,Hawai`i 96720 (808)961-8234 • Fax(808)961-8569 E3: cp February 11, 2019 Aaron Chung, Council Chair and c) Members of the Hawai`i County Council 77. rti Hawai`i County Council 25 Aupuni Street Hilo, Hawai`i 96720 Re: Nonprofit Grant Applications In compliance with Chapter 2, Article 25 of the Hawai`i County Code, I am submitting the applications from eligible nonprofit organizations for your review and appropriation of funds for the FY 2019 -20 nonprofit grant program. The applications are submitted as received from the applicants except that we removed staples and paper clips for easy scanning, and thus may contain blank or extra pages. 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. Deanna S. Sako Director of Finance Enc. Applications for Nonprofit Grant Funds List of Nonprofit Grant Applicants Comm. No. : ,!J• Ref.To: 1C Ref. Date_ FEB .i i 2019 Hawai'i County is an Equal Opportunity Employer and Provider NONPROFIT GRANT APPLICANTS FOR FY2019-20 Sort order matches separation sheet numbers(hard copies). Note that the disqualified applicants sort order are AFTER qualified applicants. Numerical Sort . Order Order ORGANIZATION NAME PROGRAM NAME REQUESTED 30 1 After-School All-Stars Hawaii After-School at Ka'u High&Pahala Elementary 8,000 29 2 After-School All-Stars Hawaii After-School at Kea'au Middle School 10,000 28 3 After-School All-Stars Hawai'i After-School at Pahoa High and Intermediate School 10,000 89 4 Aloha Ilio Rescue Tlio Mobile 11,950 25 5 Aloha Independent Living Hawaii Independent Living Program 10,000 45 6 Aloha Performing Arts Company dba Aloha Theatre Theatre Education Program 20,000 17 7 American National Red Cross Disaster Preparedness&Response in Hawaii County 50,000 11 8 Arc of Hilo,The Marketing Initiative&Capacity Building 15,350 15 9 Arc of Kona Inclusion and Community Education 39,700 75 10 Arts&Sciences Center ASC Community Education Services 93,800 119 11 Basic Image Teach at the Beach 40,000 65 12 Basic Image,Inc. Hui Hooleimaluo 42,000 117 13 Bay Clinic Inc. Diabetes Self-Management and Education 20,568 115 14 Bay Clinic Inc. Health Information Technology 26,292 118 15 Bay Clinic Inc. Pediatric Dental 60,432 116 16 Bay Clinic Inc. Substance Use Disorder and Mental Health 83,756 46 17 Big Brothers Big Sisters of Hawai'i Island . One-to-One Mentoring 10,000 24 18 Big Island Mediation,Inc.dba West Hawai'i Mediation Center Community Mediation 15,000 23 19 Big Island Mediation,Inc.dba West Hawai'i Mediation Center Peer Mediation and Youth Conflict Resolution 15,000 76 20 Big Island Resource Conservation&Development Council Beyond Organic Consulting 10,000 78 21 Big Island Resource Conservation&Development Council Big Island Invasive Species Committee Invasive Plant Program 64,930 77 22 Big Island Resource Conservation&Development Council UHH College of Agriculture,Forestry&Natural Resource Management 10,000 134 23 Big Island Substance Abuse Council (Mahi'ai Ola)Wellness Garden 37,000 137 24 Big Island Substance Abuse Council Community Outreach 10,000 132 25 Big Island Substance Abuse Council East Hawai'i Substance Abuse Treatment Services 106,953 136 26 Big Island Substance Abuse Council Hawaii Island Health and Wellness Center-Hilo 50,000 139 27 Big Island Substance Abuse Council Hawai'i Island Health and Wellness Center-Kea'au 50,000 138 28 Big Island Substance Abuse Council Hawaii Island Health and Wellness Center-Provider Training 50,000 135 29 Big Island Substance Abuse Council Po'okela Vocational Training Program 38,000 140 30 Big Island Substance Abuse Council Therapeutic Living&Clean and Sober Program 48,445 131 31 Big Island Substance Abuse Council West Hawai'i Dual Diagnosis Program 45,000 133 32 Big Island Substance Abuse Council Youth Services Skill Building Activities 50,000 152 33 Boy Scouts of America Scoutreach 65,623 106 34 Boys&Girls Club of the Big Island Daily Nutritional Security to Support Income Challenged Youth 45,000 103 35 Boys&Girls Club of the Big Island Daily Transport Services for Income-Challenged Youth 45,000 104 36 Boys&Girls Club of the Big Island,Hilo Club Literacy,Homework&Tutoring Support for Income Challenged 45,000 102 37 Boys&Girls Club of the Big Island,Kea'au Club Literacy,Homework&Tutoring Support for Income Challenged 45,000 105 38 Boys&Girls Club of the Big Island,Kealakehe Club Literacy,Homework&Tutoring Support for Income Challenged 45,000 100 39 Boys&Girls Club of the Big Island,Pahala Club Literacy,Homework&Tutoring Support for Income Challenged 45,000 101 40 Boys&Girls Club of the Big Island,Pahoa Club Literacy,Homework&Tutoring Support for Income Challenged 45,000 90 41 Brantley Center Inc. Job Skills Development Program 40,000 110 42 Bridge House,Inc. Clean&Sober Living Program 35,000 NONPROFIT GRANT APPLICANTS FOR FY2019-20 Numerical Sort _ Order- " Order : _- . - ;ORGANIZATION NAME -._ - PROGRAM NAME - - REQUESTED 111 43 Bridge House,Inc. Vocational Skills Building Program 18,000 82 44 Child&Family Service Alternatives to Violence 73,000 80 45 Child&Family Service East Hawaii Domestic Abuse Shelter 40,000 81 46 Child&Family Service Hale Kahua Pa'a Transitional Housing Program 30,000 83 47 Child&Family Service West Hawaii Domestic Abuse Shelter 60,000 107 48 Children's Law Project of Hawai'i,The Abolishing Barriers to Learning&Education("ABLE")Program 20,000 108 49 Children's Law Project of Hawaii,The Project Permanence:Guardianships/Adoptions for At-Risk Kids 20,000 48 50 Easter Seals Hawaii Adult Day Health 38,055 49 51 Easter Seals Hawaii Support Services 40,533 18 52 Family Support Hawaii Healthy Keiki24,000 27 53 Family Support Services of West Hawaii Pathways School Mentoring 30,000 26 54 Family Support Services of West Hawaii West Hawai'i Fatherhood Initiative 45,000 145 55 Five Mountains dba Kipuka o ke Ola Health Services for Underserved Populations 15,500 146 56 Five Mountains dba Kipuka o ke Ola Ulu Laukahi Project-Native Hawaiian Health and Well-Being 15,500 113 57 Food Basket Inc.,The Emergency Food Program 50,000 35 58 Friends of the Children's Justice Center of East Hawaii Special Needs,Enhancement,Support,Education&Training 20,000 42 59 Friends of the Palace Theater Fall Musical 19,000 43 60 Friends of the Palace Theater Hawaiian Roots Festival of Talent 17,700 41 61 Friends of the Palace Theater Youth Theater Program 13,500 95 62 Full Life Adult Day Health Community Learning and Transportation 10,000 96 63 Full Life Associated Costs for Self-Determined Living 6,000 97 64 Full Life Empowering Creativity-Pua Na Pua and Abled Hawaii Artists 7,000 13 65 Girl Scouts of Hawaii Hawai'i Island Girl Scout Leadership Experience(GSLE) 40,000 71b 66 Going Home Hawai'i Hawai'i Island Going Home Consortium 42,125 71a 67 Going Home Hawai'i Pu'uhonua Wellness Center(Wahine) 22,700 94 68 Goodwill Industries of Hawai'i,Inc. Job Connections 30,000 93 69 Goodwill Industries of Hawaii,Inc. Work Experience Program 45,000 39 70 Grassroots Community Development Group Hawaii Youth Business Center: Media Literacy 8,000 38 71 Grassroots Community Development Group Hawaii Youth Business Center: Ola'a(Kurtistown)Skatepark 22,000 74 72 Green Will Conservancy Inc.,The Hui Mana'o 17,500 44 73 Habitat for Humanity Hawai'i Island Together We Build 50,000 31 76 Hamakua Harvest,Inc Program Support 20,000 22 77 Hamakua Youth Foundation,Inc. Hamakua Teen Center 15,000 20 78 Hamakua Youth Foundation,Inc. Hamakua Youth Center 40,000 21 79 Hamakua Youth Foundation,Inc. Multicultural Awareness Prog 10,000 84 81 Hawaii Institute of Pacific Agriculture K-20 Agricultural Resiliency&Nutrition Educational Pipeline 25,000 34 82 Hawaii Island Adult Care,Inc. Adult Day Care Center 50,000 112 83 Hawaii Island Busidess Plan Competition(Hlplan) Hiplan Business Plan Competition 45,000 127 84 Hawaii Island HIV/AIDS Foundation Client Transportation 20,000 128 85 Hawai'i Island HIV/AIDS Foundation Sexually Transmitted Disease Education and Testing 25,000 85e 86 Hawaii Island Home for Recovery,Inc. HIHR Food Pantry Outreach 12,000 85a 87 Hawai'i Island Home for Recovery,Inc. HIHR Permanent Supportive Housing Program#1 39,000 85b 88 Hawaii Island Home for Recovery,Inc. HIHR Permanent Supportive Housing Program#2 12,000 85c 89 Hawaii Island Home for Recovery,Inc. HIHR Permanent Supportive Housing Program#3 18,000 NONPROFIT GRANT APPLICANTS FOR FY2019-20 Numerical Sort - Order Order ORGANIZATION NAME_ PROGRAM NAME REQUESTED 85d 90 Hawaii Island Home for Recovery,Inc. HIHR Transitional Housing Program 39,000 16 91 Hawaii Wildfire Management Organization Hawaii Island Wildfire Prevention 44,000 19 92 Heart Ranch Heart Ranch 15,000 141 95 HOPE Services Hawaii,Inc. West Hawaii Emergency Housing 15,000 36 96 Hope Services Hawai'i,Inc. Representative Payee Services Program 20,000 91 97 Hui Kahu Malama(HKM) UH Internal Medicine Residency Program Rural Health Elective 26,000 123 98 Hui Malama Ola Na'Oiwi Community Relations Program-Ladies Night Out&Kane 2019 10,000 125 99 Hui Malama Ola Na'Oiwi Diabetes Program-Education,Keiki&Adult Support Groups 23,505 124 100 Hui Malama Ola Na'Oiwi Fitness Program-Makahiki Games Expansion • 28,332 126 101 Hui Malama Ola Na'Oiwi Transportation Program-KOkua Hali Specialty ParaTransit 55,000 79 102 Hui Pono Holoholona . Low Cost Spay/Neuter Clinics 76,500 12 103 Innovations Public Charter School Foundation Na Kalai Ola-Life Navigators-Wellness Program 10,000 98 104 Island of Hawai'i YMCA,The Family Visitation Center(FVC) 53,000 92 105 Ka'u Rural Health Community Association,Inc. Ka'u Community"Healthy Hearts'.Pilot program 25,000 4 106 Keaukaha One Youth Development HOkualaka'i Restoration Project 25,000 5 107 Keaukaha One Youth Development Ho'Ola Hou-Hawaiian Warriorship Program 25,000 6 108 Keaukaha One Youth Development PISCES-VEX ID Robotics Program 25,000 2 109 Keaukaha One Youth Development Rise 21st Century After School Program 25,000 3 110 Keaukaha One Youth Development Youth Paddling Program 25,000 10 111 Kohala Animal Relocation and Education Service(KARES) Canine Spay and Neuter Program for Community Pets 43,150 148 112 Kohala Institute 'Aina-based Learning in the'lole Ahupua a 16,500 147 113 Kohala Institute GRACE Leadership Journey 15,000 9 114 Kona Adult Day Center,Inc. Adult Day Care 15,000 r 154 115 Kona Historical Society Experiencing Kona's Traditions 17,300 153 116 Kona Historical Society Kona Akau to Kona Hema:KHS Community Outreach Program 16,000 ' 150 117 Ku'ikahi Mediation Center Community Conflict Prevention&Resolution Services 15,000 149 118 Ku'ikahi Mediation Center Youth Peer Mediation Program 10,000 72 119 Legal Aid Society of Hawaii Hawai'i Island Medical-Legal Partnership 10,000 73 120 Legal Aid Society of Hawaii Providing Civil Legal Access to Rural Communities 25,000 56 121 Lokahi Treatment Centers,Inc. Adolescent Substance Abuse Treatment Programs 28,000 57 122 Lokahi Treatment Centers,Inc. Adultt Substance Abuse Treatment Programs 40,000 54 123 Lokahi Treatment Centers,Inc. Anger Management Treatment Programs 20,000 55 124 Lokahi Treatment Centers,Inc. Domestic Violence Intervention Treatment Programs 28,000 8 125 Mental Health Kokua Residental Rehabilitation Services 10,000 99 126 Na Kalai Wa'a Hoea Moku 43,697 37 127 Neighborhood Place of Puna Family Strengthening,Support,and Outreach Program 25,000 47a 128 North Kohala Community Resource Center Ho'Ola Honey Bee Relocation 8,700 47b 129 North Kohala Community Resource Center Kohala Radio 9,000 68 130 '0 Ka'u Kakou Family Fun Fest 7,000 69 131 '0 Ka'u Kakou Ka'u Coffee Trail Run 9,000 66 132 '0 Ka'u Kakou Ka'u Sanitation Program 4,000 70 133 '0 Ka'u Kakou Ka'u Veterans'Day Celebration 3,000 67 134 '0 Ka'u Kakou Punalu'u Annual Fishing Tournament 7,000 64 135 Pacific Tsunami Museum Tsunami Sites: Signage(Phase 2) 22,037 NONPROFIT GRANT APPLICANTS FOR FY2019-20 Numerical Sort v, ` Order Order '' ORGANIZATION NAME 3 PROGRAM NAME REQUESTED 122 136 Paddling for Hope Breast Cancer Education and Survivor Support 13,000 87 137 Project Vision Hawaii Better Vision for Keiki-Hawai'i Island 25,000 86 138 Project Vision Hawaii HiEHiE Hospitality Project 50,000 88 139 Project Vision Hawaii WE...A Hui for Health-Hawai'i Island 25,000 121 140 Rainbow Friends Animal Sanctuary Community and Pet Spay/Neuter Program 32,775 58 141 Salvation Army-Family Intervention Services,The Cultural Program 10,000 59 142 Salvation Army-Family Intervention Services,The Hawaiian Cultural Program 10,000 60 143 Salvation Army-Family Intervention Services,The Independent Living Skills Program 10,000 61 144 Salvation Army-Family Intervention Services,The Kea'au Prevention and Outreach Programs 10,000 62 145 Salvation Army-Family Intervention Services,The Pahoa Prevention and Outreach Programs 10,000 63 146 Salvation Army-Family Intervention Services,The Project TLP Hilo 10,000 50b 147 Society for Kona's Education&Art(SKEA) Art Camps for Children&Teens 14,000 50a 148 Society for Kona's Education&Art(SKEA) South Kona Workshops and Events 7,000 40 149 Special Olympics Hawai'i Special Olympics Hawaii-East Hawai'i 22,000 7 150 Special Olympics Hawaii-West Hawai'i General Fund 92,099 144 151 Teach For America Hawaii Ho'imi Pono Initiative(Teacher Recruitment) 10,000 143 152 Teach For America Hawaii Ho'opulapula Program(1st and 2nd Year Teacher Program 10,000 142 153 Teach For America Hawaii Pathways Program 10,000 14 154 Three Ring Ranch Interns,Externs,Afterschool Mentors 10,000 1 155 Volunteer Legal Services Hawaii Hawaii County Pop-Up Legal Clinics 15,000 • 129 157 West Hawaii Community Health Center,Inc. Adult Dental Program for Under-Served 20,000 130 158 West Hawaii Community Health Center,Inc. WHCHC Community Outreach to Vulnerable Populations 20,000 32 159 YWCA of Hawaii Island Sexual Assault Support Services 30,000 33 160 , YWCA of Hawai'i Island YWCA Developmental Preschool 15,000 Total 4,322,507 Note: The following applicants did not meet one or,more application requirements(disqualified)' 155 74 Hale Pule Ke Ola Hou Camp Agape Big Island 20,000 156 75 Hale Pule Ke Ola Hou Feed the People Food Ministry 75,000 114 80 Hawai'i Football Club Hawaii 8 College Athletic Club 20,000 151A 93 Holualoa Fndtn for Arts&Culture dba Donkey Mill Art Center Donkey Mill Exhibition Program 75,000 151B 94 Holualoa Fndtn for Arts&Culture dba Donkey Mill Art Center Donkey Mill Youth Program 115,000 120 156 Waikoloa Dry Forest Initiative Future Foresters Summer Camp 9,800 51 w/138 Project Vision Hawai'i HiEHiE Hospitality Project 50,000 52 w/139 Project Vision Hawai'i WE...A Hui for Health-Hawai'i Island 25,000 53 w/137 Project Vision Hawaii Better Vision for Keiki-Hawai'i Island 25,000 Total 414,800 i After-School All-Stars Hawaii After-School at Ka'u High & Pahala Elementary 1 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Kau High & Pahala Elementary Agency Director: Kimi Takazawa, CEP Phone No.: (808) 734 — 1314 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: 4747 Kilauea Avenue, Suite 210 Address: City,ST,Zip Honolulu, HI 96816 Facility Address: Address: Program operates at Kau High&Pahala Elementary Address: City,ST,Zip Email Address: ktakazawa@asashawaii.org Fax No.: (808 ) 356 — 0232 Accountant/CPA: Lester Hee Phone No.: (808 ) 532 — 7323 Firm (if applicable): Hee&Ching CPAs LLC Mailing Address: Address: 201 Merchant Street, Suite 1830 Address: City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $8,000 Geographical Areas To Be Served: (One or more can be checked) n Puna ❑ Hamakua ❑ North Kona n South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑South Kohala 0 Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns n Youth n Victims of Crimes ❑✓ Culture and the arts ❑Aged n Victims of Health or Social Crises [' Needs of the poor ❑ Physical/Emotional Disabilities [' Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Kau High & Pahala Elementary 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0 $0 $5,925-for all 3 schools 2. Agency Mission Statement: After-School All-Stars Hawai'i(ASAS Hawai'i)makes the most of the extended learning time available every day after the school bell rings. Public schools are essential to children's intellectual development; however, students spend less than 20%of their waking hours in school.After-school programs present tremendous opportunities to enhance learning,stimulate exploration,and cultivate each child's potential. The mission of ASAS Hawai'i is to provide out-of-school programs that keep children safe and help them achieve in school and in life.We partner with eight schools on Oahu and three schools on Hawai'i Island, serving 1,820 students last year.The organization was founded in Hawai'i in 2009 and is governed by a volunteer board of directors. ASAS Hawai'i works exclusively in Title I schools,which is the federal designation for schools in which 40%or more of students participate in the free and reduced lunch program.The percentage of free and reduced lunch participants is relevant because academic success is more elusive for children of low-income families. Education has traditionally been the great equalizer, offering a road out of poverty for hard working kids, but these days academic success is more likely to correlate with socio-economic status.This is known as the achievement gap:when low-income students fall below their affluent peers in terms of educational attainment. 3. Program Description: This project will provide a free, structured after-school program, including transportation,at Kau High and Pahala Elementary. ASAS Hawaii partners with some of the lowest performing middle schools to help close the achievement gap for low-income students. Our approach is to bring after-school learning that is experiential,with education largely occurring outside the classroom. Every day after-school, participants have structured homework hours and may access tutoring as needed. Students go on field trips, learn from guest speakers, engage in experiential/hands-on activities, plan community service projects, and participate in sports and arts enrichment activities.The school-based, school-linked approach enables more supervision, extended learning time,and opens up opportunities that are otherwise out of reach for low-income families. These resources are needed to ensure students do not fall behind or fall through the cracks. Considering the 2017-18 Smarter Balanced Assessment, Kau High&Pahala Elementary performed below the state average on assessments in English/Language Arts, Math and Science.This school has high percentages of students enrolled in special education (13%) and chronic absenteeism(40%-state average is 15%). Only 38%of eight graders read at or near grade level and 69%of students graduate on time. (Strive HI School Performance Reports,2018. HIDOE.) ASAS Hawaii is well-situated to prepare students for college and careers.We build relationships while students participate for up to three consecutive years of middle school. 4. Total Budget & Position Count: Total Program Budget: $83,000 Total Program Position Count: 50 Total Agency Budget: $2,028,975 Total Agency Position Count: 2,000 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii • Program Name: After-School at Kau High & Pahala Elementary 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate 21st Century Community Learning Grant(ASAS Hawaii is subgrantee) 75,000 TOTAL: 75,000 Attach additionales P 9 a ifneeded. 6. Explain what plans your agency or program has to increase revenues to support this program: The 21st Century Community Learning Center program is a significant resource, but these grants do not pay for the complete cost of program operations.Additionally,these grants fluctuate greatly from year to year and are unreliable. For FY2020,only eight out of eleven ASAS sites have 21st Century grants.Additionally,we were recently informed that HIDOE will not release an RFP for 21st Century grants for FY2020.Thus,ASAS Hawaii is reaching out to public and private funders to fill this gap in revenue. The plan for sustaining ASAS Hawai'i programs requires diverse revenue sources to ensure programs operate uninterrupted despite fluctuations in public funding. Government grants comprise 82%of revenue. In addition to government grants,about 9% of revenue is comprised of foundation grants from sources including Aloha United Way, Mclnerny Foundation and Kamehameha Schools. Our annual fundraiser,the ASAS Hawai'i Gala contributes 7%of income, and the remaining 2%comes from individual and corporate donations. Also contributing to sustainability, each school provides in-kind office space, classroom space,field and cafeteria space for activities,staffing support of teachers, registrars and administration and general support for our programs,the estimated value of which is$115,000 to$150,000 per year for each school. 7. Program Objectives Using County Nonprofit Grant Program Funds: For the 2019-20 school year,the following objectives will be achieved at Kau High &Pahala Elementary: 1. Increase access to extended learning time,as evidenced by 50 students participating in After-School All-Stars Hawaii,with after-school transportation provided. 2. Increase family involvement, as evidenced by four parent and family events offered at this school. 3. Expose students to college and career opportunities,as evidenced by one guest speaker visiting the program. 4. Increase opportunities for students to participate in athletics, as evidenced by two Sports Showdownevents provided for Kau Keaau Pahoa Complex Area. 5.ASAS Hawaii students perform better than the general school population on indicators of attendance,academics, and behavior. 6.20 students attend CampUs,a summer camp focused on successful transitions to high school, provided in partnership wit University of Hawaii at Hilo. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Kau High & Pahala Elementary 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of participants in the 2019-20 school year 50 Number of parent and family events offered to increase family involvement 4 Number of guest speakers visiting the program to engage students in college/careers 1 Number of Sports Showdown events provided for the complex area 2 ASAS Hawaii participants perform better on attendance than general school population achieved ASAS Hawaii participants perform better on academics than the general school population achieved Number of KKP students who attend Campus at UH Manoa 20 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 5,925 72,000 5,500 Professional Foes_ _ 3,000 Operations Supplies 7,500 2,500 Equipment Other: Staff Training 500 Other: Other: Other: Other: TOTAL 83,000 8,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Kau High & Pahala Elementary 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director n The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. ' cr,r) Ptli/ Signature of Au • ed Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Kau High & Pahala Elementary 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Kau High & Pahala Elementary 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. i/ l7 Signature of A zed Person (see checklist, 2nd item) Date Kimi Takazawa, Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Kau High & Pahala Elementary 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of participants in the 2019-20 school year 50 Number of parent and family events offered to increase family involvement 4 Number of guest speakers visiting the program to engage students in college/careers 1 Number of Sports Showdown events provided for the complex area 2 ASAS Hawaii participants perform better on attendance than general school population achieved ASAS Hawaii participants perform better on academics than the general school population achieved Number of KKP students who attend CampUs at UH Manoa 20 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 5,500 Professional Fees Operations Supplies 2,500 Equipment Other: Staff Training Other: Other: Other: Other: TOTAL 8,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 After-School All-Stars Hawai'i After-School at Kea'au Middle School 2 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Keaau Middle School Agency Director: Kimi Takazawa, CEP Phone No.: (808) 734 — 1314 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: 4747 Kilauea Avenue,Suite 210 Address: City,ST,Zip Honolulu, HI 96816 Facility Address: Address: Program operates at Keaau Middle School- Address: City,ST,Zip Email Address: ktakazawa@asashawaii.org Fax No.: (808 ) 356 — 0232 Accountant/CPA: Lester Hee Phone No.: (808) 532 — 7323 Firm (if applicable): Hee&Ching CPAs LLC Mailing Address: Address: 201 Merchant Street,Suite 1830 Address: City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ✓❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Kali Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Keaau Middle School JIV- 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0 $0 $5,925-for all 3 schools 2. Agency Mission Statement: After-School All-Stars Hawaii (ASAS Hawaii)makes the most of the extended learning time available every day after the school bell rings. Public schools are essential to children's intellectual development; however,students spend less than 20%of their waking hours in school.After-school programs present tremendous opportunities to enhance learning,stimulate exploration, and cultivate each child's potential. The mission of ASAS Hawai'i is to provide out-of-school programs that keep children safe and help them achieve in school and in life.We partner with eight schools on Oahu and three schools on Hawai'i Island,serving 1,820 students last year.The organization was founded in Hawai'i in 2009 and is governed by a volunteer board of directors. ASAS Hawai'i works exclusively in Title I schools,which is the federal designation for schools in which 40%or more of students participate in the free and reduced lunch program.The percentage of free and reduced lunch participants is relevant because academic success is more elusive for children of low-income families. Education has traditionally been the great equalizer, offering a road out of poverty for hard working kids, but these days academic success is more likely to correlate with socio-economic status.This is known as the achievement gap:when low-income students fall below their affluent peers in terms of educational attainment. 3. Program Description: This project will provide a free,structured after-school program, including transportation,at Keaau Middle School. ASAS Hawaii partners with some of the lowest performing middle schools to help close the achievement gap for low-income students. Our approach is to bring after-school learning that is experiential,with education largely occurring outside the classroom. Every day after-school, participants have structured homework hours and may access tutoring as needed. Students go on field trips, learn from guest speakers, engage in experiential/hands-on activities, plan community service projects, and participate in sports and arts enrichment activities.The school-based,school-linked approach enables more supervision, extended learning time,and opens up opportunities that are otherwise out of reach for low-income families. These resources are needed to ensure students do not fall behind or fall through the cracks. Considering the 2017-18 Smarter Balanced Assessment, Keaau Middle School performed below the state average on assessments in English/Language Arts, Math and Science.This school has high percentages of students who qualify for free or reduced lunch (96%), are enrolled in special education (14%)and chronic absenteeism(26%-state average is 15%). Only 63%of eight graders read at or near grade level. (Strive HI School Performance Reports,2018. HIDOE.) ASAS Hawaii is well-situated to prepare students for college and careers.We build relationships while students participate for up to three consecutive years of middle school. 4.Total Budget& Position Count: Total Program Budget: $135,000 Total Program Position Count: 315 Total Agency Budget: $2,028,975 Total Agency Position Count: 2,000 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Keaau Middle School 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate 21st Century Community Learning Grant(ASAS Hawaii is subgrantee) 125,000 TOTAL: 125,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The 21st Century Community Learning Center program is a significant resource, but these grants do not pay for the complete cost of program operations.Additionally,these grants fluctuate greatly from year to year and are unreliable. For FY2020,only eight out of eleven ASAS sites have 21st Century grants.Additionally,we were recently informed that HIDOE will not release an RFP for 21st Century grants for FY2020.Thus,ASAS Hawaii is reaching out to public and private funders to fill this gap in revenue. The plan for sustaining ASAS Hawai'i programs requires diverse revenue sources to ensure programs operate uninterrupted despite fluctuations in public funding. Government grants comprise 82%of revenue. In addition to government grants, about 9% of revenue is comprised of foundation grants from sources including Aloha United Way, Mclnerny Foundation and Kamehameha Schools.Our annual fundraiser,the ASAS Hawaii Gala contributes 7%of income, and the remaining 2%comes from individual and corporate donations. Also contributing to sustainability, each school provides in-kind office space, classroom space,field and cafeteria space for activities,staffing support of teachers, registrars and administration and general support for our programs,the estimated value of which is$115,000 to$150,000 per year for each school. 7. Program Objectives Using County Nonprofit Grant Program Funds: For the 2019-20 school year,the following objectives will be achieved at Keaau Middle School: 1. Increase access to extended learning time,as evidenced by 315 students participating in After-School All-Stars Hawaii,with after-school transportation provided. 2. Increase family involvement,as evidenced by four parent and family events offered at this school. 3. Expose students to college and career opportunities, as evidenced by one guest speaker visiting the program. 4. Increase opportunities for students to participate in athletics, as evidenced by two Sports Showdown events provided for Kau Keaau Pahoa Complex Area. 5.ASAS Hawaii students perform better than the general school population on indicators of attendance,academics,and behavior. 6.20 students attend CampUs,a summer camp focused on successful transitions to high school, provided in partnership wit University of Hawaii at Hilo. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Keaau Middle School 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of participants in the 2019-20 school year 315 Number of parent and family events offered to increase family involvement 4 Number of guest speakers visiting the program to engage students in college/careers 1 Number of Sports Showdown events provided for the complex area 2 ASAS Hawaii participants perform better on attendance than general school population achieved ASAS Hawaii participants perform better on academics than the general school population achieved Number of KKP students who attend CampUs at UH Manoa 20 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Reg_ Salary and Wages 5,925 116,858 7,000 Professional Fees 3,000 Operations Supplies 11,100 3,000 Equipment Other: Staff Training 1,000 Other: Miscellaneous 3,042 Other: Other: Other: TOTAL 135,000 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Keaau Middle School 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council The Mayor n The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. ( ita) //2S1/? Signature Signature c f 1 ►thorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Keaau Middle School 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Keaau Middle School 11. Certification of Understanding (Page 2 oft) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead nof costs. Any funds unused by June 30, 2019 must be returned to the County Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 7 ` 5 Signature of a u l • ized Person (see checklist, 2nd item) Date Kimi Takazawa, Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Keaau Middle School 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of participants in the 2019-20 school year 315 Number of parent and family events offered to increase family involvement 4 Number of guest speakers visiting the program to engage students in college/careers Number of Sports Showdown events provided for the complex area 2 ASAS Hawaii participants perform better on attendance than general school population achieved ASAS Hawaii participants perform better on academics than the general school population achieved Number of KKP students who attend CampUs at UH Manoa 20 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 7,000 Professional Fees Operations Supplies 0 3,000 Equipment Other: Staff Training Other: Miscellaneous Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 After-School All-Stars Hawaii After-School at Pahoa High and Intermediate School 3 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Pahoa High & Intermediate School Agency Director: Kimi Takazawa, CEP Phone No.: (808) 734 — 1314 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: 4747 Kilauea Avenue,Suite 210 Address: City,ST,Zip Honolulu, HI 96816 Facility Address: Address: Program operates at Pahoa High&Intermediate School Address: City,ST,Zip Email Address: ktakazawa@asashawaii.org Fax No.: (808 ) 356 — 0232 Accountant/CPA: Lester Hee Phone No.: (808 ) 532 — 7323 Firm (if applicable): Hee&Ching CPAs LLC Mailing Address: Address: 201 Merchant Street,Suite 1830 Address: City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ✓❑Youth ❑Victims of Crimes ❑✓ Culture and the arts ['Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Pahoa High & Intermediate School 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0 $0 $5,925-for all 3 schools 2.Agency Mission Statement: After-School All-Stars Hawai'i(ASAS Hawaii)makes the most of the extended learning time available every day after the school bell rings. Public schools are essential to children's intellectual development;however,students spend less than 20%of their waking hours in school.After-school programs present tremendous opportunities to enhance learning,stimulate exploration,and cultivate each child's potential. The mission of ASAS Hawaii is to provide out-of-school programs that keep children safe and help them achieve in school and in life.We partner with eight schools on O`ahu and three schools on Hawaii Island,serving 1,820 students last year.The organization was founded in Hawai'i in 2009 and is governed by a volunteer board of directors. ASAS Hawaii works exclusively in Title I schools,which is the federal designation for schools in which 40%or more of students participate in the free and reduced lunch program.The percentage of free and reduced lunch participants is relevant because academic success is more elusive for children of low-income families. Education has traditionally been the great equalizer, offering a road out of poverty for hard working kids, but these days academic success is more likely to correlate with socio-economic status.This is known as the achievement gap:when low-income students fall below their affluent peers in terms of educational attainment. 3. Program Description: This project will provide a free,structured after-school program,including transportation,at Pahoa High&Intermediate School. ASAS Hawaii partners with some of the lowest performing middle schools to help close the achievement gap for low-income students.Our approach is to bring after-school learning that is experiential,with education largely occurring outside the classroom. Every day after-school,participants have structured homework hours and may access tutoring as needed.Students go on field trips, learn from guest speakers,engage in experiential/hands-on activities,plan community service projects,and participate in sports and arts enrichment activities.The school-based,school-linked approach enables more supervision, extended learning time,and opens up opportunities that are otherwise out of reach for low-income families. These resources are needed to ensure students do not fall behind or fall through the cracks.Considering the 2017-18 Smarter Balanced Assessment, Pahoa High&Intermediate School performed below the state average on assessments in English/Language Arts, Math and Science.This school has high percentages of students enrolled in special education(19%) and chronic absenteeism(35%-state average is 15%).Only 70%of eight graders read at or near grade level and 77%of students graduate on time. (Strive HI School Performance Reports,2018. HIDOE.) ASAS Hawaii is well-situated to prepare students for college and careers.We build relationships while students participate for up to three consecutive years of middle school. • 4.Total Budget& Position Count: Total Program Budget: $120,000 Total Program Position Count: 6 Total Agency Budget: $2,028,975 Total Agency Position Count: 70 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Pahoa High & Intermediate School 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate 21st Century Community Learning Grant(ASAS Hawaii is subgrantee) 110,000 TOTAL: 110,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The 21st Century Community Learning Center program is a significant resource,but these grants do not pay for the complete cost of program operations.Additionally,these grants fluctuate greatly from year to year and are unreliable. For FY2020,only eight out of eleven ASAS sites have 21st Century grants.Additionally,we were recently informed that HIDOE will not release an RFP for 21st Century grants for FY2020.Thus,ASAS Hawaii is reaching out to public and private funders to fill this gap in revenue. The plan for sustaining ASAS Hawaii programs requires diverse revenue sources to ensure programs operate uninterrupted despite fluctuations in public funding.Government grants comprise 82%of revenue. In addition to government grants,about 9% of revenue is comprised of foundation grants from sources including Aloha United Way, Mclnerny Foundation and Kamehameha Schools.Our annual fundraiser,the ASAS Hawai'i Gala contributes 7%of income,and the remaining 2%comes from individual and corporate donations. Also contributing to sustainability,each school provides in-kind office space,classroom space,field and cafeteria space for activities,staffing support of teachers,registrars and administration and general support for our programs,the estimated value of which is$115,000 to$150,000 per year for each school. 7. Program Objectives Using County Nonprofit Grant Program Funds: For the 2019-20 school year,the following objectives will be achieved at Pahoa High&Intermediate School: 1. Increase access to extended learning time,as evidenced by 120 students participating in After-School All-Stars Hawaii,with after-school transportation provided. 2. Increase family involvement,as evidenced by four parent and family events offered at this school. 3. Expose students to college and career opportunities,as evidenced by one guest speaker visiting the program. 4. Increase opportunities for students to participate in athletics,as evidenced by two Sports Showdown events provided for Kau Keaau Pahoa Complex Area. 5.ASAS Hawaii students perform better than the general school population on indicators of attendance,academics,and behavior. 6.20 students attend CampUs,a summer camp focused on successful transitions to high school,provided in partnership wit University of Hawaii at Hilo. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Pahoa High & Intermediate School 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of participants in the 2019-20 school year 120 Number of parent and family events offered to increase family involvement 4 Number of guest speakers visiting the program to engage students in college/careers 1 Number of Sports Showdown events provided for the complex area 2 ASAS Hawaii participants perform better on attendance than general school population achieved ASAS Hawaii participants perform better on academics than the general school population achieved Number of KKP students who attend CampUs at UH Manoa 20 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 5,925 106,229 7,000 Professional Fees 3,000 Operations Supplies 8,000 3,000 Equipment Other: Staff Training 1,000 Other: Miscellaneous 1,771 Other: Other: Other: • TOTAL 120,000 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Pahoa High & Intermediate School 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below person per formwith a conflict is needed. If no conflicts exist,to be disclosed. One one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. ' c KI (q Signature of A ill orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Pahoa High & Intermediate School 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Pahoa High & Intermediate School 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. /X1( 1 Signature of Auth•riz-Oerson (see checklist, 2nd item) Date Kimi Takazawa, Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: After-School All-Stars Hawaii Program Name: After-School at Pahoa High & Intermediate School 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of participants in the 2019-20 school year 120 Number of parent and family events offered to increase family involvement 4 Number of guest speakers visiting the program to engage students in college/careers 1 Number of Sports Showdown events provided for the complex area 2 ASAS Hawaii participants perform better on attendance than general school population achieved ASAS Hawaii participants perform better on academics than the general school population achieved Number of KKP students who attend CampUs at UH Manoa 20 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 7,000 Professional Fees Operations Supplies 3,000 Equipment Other: Staff Training Other: Miscellaneous Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Aloha Ilio Rescue Ilio Mobile 4 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Aloha Ilio Rescue Program Name: Ilio Mobile Agency Director: Daylynn Kyles Phone No.: (808) 936 — 7955 Contact Person: Michelle Lee Phone No.: (808) 345 — 3263 Mailing Address: Address: P.O. Box 4923649 Address: City,ST,Zip Keaau, Hawaii 96749 Facility Address: Address: none Address: City,ST,Zip Email Address: dogs@alohailiorescue.com Fax No.: ( ) — Accountant/CPA: Daylynn Kyles, Director Phone No.: (808) 936 — 7955 Firm (if applicable): Mailing Address: Address: P.O. Box 4923649 Address: City,ST,Zip Keaau, Hawaii 96749 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40000 (I,'l 5 Geographical Areas To Be Served: (One or more can be checked) Q Puna ❑✓ Hamakua ❑✓ North Kona Q South Hilo 0 North Kohala Q South Kona ✓❑ North Hilo 0 South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns. ❑Youth ❑Victims of Crimes ❑Culture and the arts 0 Aged ❑✓ Victims of Health or Social Crises ❑Needs of the poor ❑Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Aloha Ilio Rescue Program Name: Ilio Mobile 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 0 0 2.Agency Mission Statement: Aloha Ilio Rescue's goals are to reduce the overpopulation and euthanasia of unwanted dogs on the Big Island. We are working to rehabilitate,foster and find forever homes for stray and abandoned dogs. We do not have a facility and our dogs are in foster homes to help them experience love and learn good behaviors. We offer adoption services to match new owners with their forever companion. 3. Program Description: Ilio Mobile is a van that was needed to rescue stray,abandoned,and surrendered dogs from our devastating volcano eruption. This vehicle was necessary to travel in our rural community. The van is leased by Aloha Ilio Rescue. For Ilio Mobile to continue to provide transportation for our dogs,we need funds for our lease amount,gas,maintenance and insurance costs.The Ilio Mobile also provides transportation for our dogs to be at adoption events. We partner with Petco and Aloha Pawz on Saturdays to match dogs with their forever home. Aloha Ilio Rescue has placed 600 dogs or more a year. Adoption fees are waived for the elderly,needy,and disabled. Ilio Mobile is also used to do community outreach to recruit new foster homes. Aloha Ilio needs to recruit more citizens to be foster homes for our dogs.Since our devastating volcano eruption,the need for more dog foster homes has increased. 4.Total Budget&Position Count: Total Program Budget: $11,950 Total Program Position Count: 0 Total Agency Budget: $51,000 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Aloha Ilio Rescue Program Name: Ilio Mobile 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Donations(online and from community businesses, cash, etc.) $2,000 Fundraiser $1,500 TOTAL: $3,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The 2018 volcanic eruption brought worldwide attention to Aloha Ilio's goal of rescuing dogs in danger of harm or death. The cable 1V show AMANDA TO THE RESCUE spotlighted our agency's endeavors to save those dogs left homeless or in jeopardy from certain death from the lava flows.With Ilio Mobile,we can continue to be visible in the community and be the recipients of positive publicity around the world. Since AMANDA TO THE RESCUE was aired,donations online have increased. 7. Program Objectives Using County Nonprofit Grant Program Funds: *Aloha Ilio Rescue is able to increase its community outreach rescue *Aloha Ilio Rescue can respond quicker to rescues *Aloha Ilio Rescue can increase our efforts to help the homeless,and needy EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2O19-20 Agency Name: Aloha Ilio Rescue Program Name: Ilio Mobile 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Increase the number of dogs rescued 700 or more a year Increase the number of dogs adopted 700 or more a year Increase the number of foster homes in the community 15 or more Attach additional pages as necessary. 9.TABLE ll: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees 0 0 0 Operations 0 0 0 Supplies 0 0 0 Equipment 0 0 0 Other: Lease 6,000 Other: Gas 2,000 Other: maintenance 2,000 Other: insurance 1,950 Other: TOTAL 0 0 11,950 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Aloha Ilio Rescue Program Name: Ilio Mobile 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director 7 The Director of Finance 7 The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: If no conflicts exist, check here. 0 )07/1, e0,----, 1 ift # /7Z(M Signature of Authoriz d P rson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Aloha Ilio Rescue Program Name: Ilio Mobile 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect anyfacility, equipment, property,or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Aloha Ilio Rescue Program Name: Ilio Mobile 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.nawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report.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. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. �t� / /:, , 06//7 Signature of Authori1erson (see checklist, 2nd item) Date aiedgic Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Aloha llio Rescue Program Name: Ilio Mobile 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result 700 or more a year 700 or more a year 15 or more TABLE H: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 0 Professional Fees 0 Operations 0 Supplies 0 Equipment 0 Other: Lease 6,000 Other: Gas 2,000 Other: maintenance 2,000 Other: insurance 1,950 Other: TOTAL 11,950 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Aloha Independent Living Hawaii Independent Living Program 5 County of a.wai`i Nonprofit Grant Appli s ati®n. 7)(2019-20 Agency Name: 1,I®It a Independent Living Hawaii Program Name: I! dependent Living Program Agency Director::,.:. Roxaoxa I a U. Bolden Phone N o.: (808) 497 — 7996 Contact Person: Roxa a Ll. Bolden Phone No.: (808) 497 — 7996 Mailing Address: ddress: P.O.Box 283 ddess: Ci,,,ST{Zip Pearl City, HI 96782 Facility Address: ddress: 1055 Kino'ole Street Unit 202 ddr�ess: Cir ,ST Zip Hilo, HI 96720 Email Address: rubolden(?alofailhawaii.org Fax No.: (800 ) 385 — 2454 Darrell) im _._--- - Phone NO: (808) 522 8833 Accountant CPA: II Firm (if applicable): Dar 4I Lim and Comany, Inc. Mailing Address: ^ddress: 81 South Hotel Street#300 ddress: Cit(,Si,,Zip Honolulu, HI 96813 If+IrUARE ESP* V xrZa_E T*, ..� a 1 111)4' Hillla,, k11AliON€ QUA RE ?AND TO P';'OMPTLY NOTI Y THE F!;-A cE DEPAi`ti Td ME- T AND U/\+CBL OF A;'°+Y CHANGES Amount of Request for 0.unt Nonprofit Grant Y p Program Funds: $10,000 Gew graphical Areas To Be Served: (One or more c:n be checked) 0 Puna Q Hamakua d North Kona 0 South Hilo 0 North Kohala V South Kona © North Hilo E]South Kohala V Ka`u rvices or Activities To Be Provided: (One or m«+re can be checked) ❑ Educational co cerns ®Youth $ Victims of Crimes ❑Culture and the arts 0 Aged . R Victims of Health or Social Crises ® Needs of the p'l.r ® Physical/Emotional Disabilities ❑ Public Health a d Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLI TION FY 2019-2020 Page 1 of 8 County of Nonprofit Grant Ai,pplication FY2019 2O Agency Name: .a Ioha Independent Living Hawaii Program Name: I! dependent Living Program 1. Prior Year Award of I.u ty Nonprofit Grant Program Funds: FY 16-17 I FY 17-19 FY 18-19 875 I $8,125 $5, 175 2.Agency Mission Stet:. rent: To provide independent livin• programs and services to persons with disabilities living in Hawaii. 3.Program Description: The concept behind indepen..•nt Hying is the empowerment of persons with disabilit'es to make choices in their lives that will enhance their dignity and self espect and provide full integration into the community as equal citizens with all the privileges and responsibilities available to the m.We have two goals which is to address their rights and responsibilities and to facilitate their accomplishments 4.Total Budget& Positii Count: Total Program .t udget: 746,719 Total Program Position Count: 13 Total ency udget: 746,719 Total Agency Position Count: 15 EXHIBIT A NONPROFIT GRANT APPLICr TION FY 2019-2020 Page 2 of 8 County of , 1,1 [waii No [profit Grant Application FY2019-20 Agency Name: doha independent Living Hawaii I_ Program Name: dependent Living Program I� depende 5. Program Funding S rce (identify ail sources of funding applied to this program): FY29-20 Revenue Sourer Estimate Title VII Part C Independe I Living Services Funded by DHS under ACL 426,151 Title VII Part B Independe , Living Services Funded by DHS under DVR 280,393 County of Hawaii 5,175 Foundation Grants 25,000 Contributions 10,000 ToTAL: 746,719 Attach additional pages,if n:-ded. S. Explain what plans y. r agency or program has to increase rever ues to support this program: AILH will continue to apply f. grants to help support both operational and programmatic costs. This is in addition to continually working on developing new, Iureative resource opportunities,including: Federally funded grants an:1 contracts State-funded grants and coil tracts -Local government grants a ' contracts 7. Program Objectives a_ink;County Nonprofit Grant Program (Funds: 1.To provide one-on-one ind: endent living skills training to carry out their everyday living activities. 2.Provide information and ref-rrals. 3. Provide training in landlord.enar t rights. 4. Provide attendant referrals �. acquire personal assistance services 5. Provide assistance in locati g affordable and accessible housing 6. Provide assistance in learni g daily life skills to further independence EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of IL i'i Nonprofit Grant Application FY2O19 20 Agency Name: . loha Independent Living Hawaii Program Name: I, dependent Living Program 8.TA:LEI: What are the intended easurable outputs or outcomes that would be achieved with this funding? PROGR kM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served, orkslrops or events held,volunteer hours,etc.Describe,be specific.) Training in landlord/tenant righ s j 35 How to complete housing app .tion 35 How to locate and maintain hgdsing 35 Training in independent living :lcillsi 30 Training in legal rights and self-advocacy 80 Provide attendant referrals to acquire personal assistance services 15 ' I Attach additional pages as n cessary. 9.TABLE II: PR GRAM EXPENDITURES FY 1849 FY 19-20 FY 19-20 Actual` Total Budget Grant Reg Salary and Wages 27,939 27,939 10,000 Professional Fees Operations Supplies 600 600 J4ti men Other: Training 400 400 Other: Other: Other: Other: TOTAL 28,939 28,939 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of c ,Id wiai'i Nonprofit Grant AppYicati®n FY20 19-2® Agency Name: ' loha independent Living Hawaii Program Name: �nd6pendent Living Program la ®I GANE .T ON' CONFLICT DISCLOSURE FO S Please disclose any con'lictS or potential conflicts of interest that any board member, officer, director, or administrator of you 1 or4anization may have with the County of Hawaii. Only those listed below need to be disclosed. 0 e form per person with a conflict is needed, If no conflicts exist, one form for the organization,with t' e ",No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disci,se. 11All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or 1.tential conflict of interest, including any familial relationship, with any of the following(check all tha I apply): ❑ Member .r members of the Council n Staff app inted by a member of the Council ❑ The May ll r ❑ The Man.,ging Director ii The DireiI or bf Finance E The Corp 'ration Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is define, as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the indi fual?as opposed to benefits accruing in genera!to an industry. Please specify any and a1 mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exi. check here. r ,% " 4 2, / / .ee 01/25/ •1 9 iS'ignature of Authorized ,Berson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLI a A TION FY 2019-2020 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Alo a Independent Living Hawaii Program Mame: Ind pendent Living Programa ii. Certification of Understanding (Page 1 of 2) I (we) have read and uncerstood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, a d iscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii C unty Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the Cointy(the Legislative Auditor,the Department of Finance, designated Council representative, r eipending/oversight agency)full,free, and unrestricted access and authority to examine and inspect-ny acility, equipment, property,or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify tha information supplied herein, including all supporting documents, is correct and that I (we) have the uthority and ability to fully administer the program(s) pursuant to law. I (we) understand that in ormation supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes I (we) understand that a plications will not be reviewed by County personnel receiving our County Nonprofit Grant submittI, and that we have full responsibility to ensure that all documents are complete and accurate ionto submittal. I (we) understand that a documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned doc ments will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from . e County of Hawaii, I (we)understand and will comply with the requirement to enroll wi h H'awai`i Compliance Express,and be compliant prior to receiving payment(s). To register, o to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual regis ration fee online using a credit card. 1 If awarded a grant from a County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end re rt to the County Council within 60 days after June 30 of the contractual year for which the :rant was aided.The report, using the template provided,shah include an explanation of the publi v benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), complete accounting of all expenditures supported by County of Hawaii grant funds,and a listinE of other funding sources and amounts obtained during the award period. Failure to submit a timel complete, and accurate year-end report, using the template provided, will impact the evaluation of our program's or agency's future funding requests. I 1 EXHIBIT A NONPROFIT GRANT APPLI TION FY 2019-2020 Page 6 of 8 G.uwgam-ti�rbseaww ru-S'4;rxw�.r a r'.a3wuw.od A.r. :.le.m..,.. .faP...➢ .. r. rm ,... ....... . ....... �... ' . County a;�all Non of ' A li,i ation 7Y2019-20 Nonprofit Grant PP Agency Name: ." Iola Independent Living Hawaii Program Name: : dependent Living Program ii i. Certification of Understindoi (Page 2 of 2) If awarded a grant fro1 the County of Hawai'i, I (we) understand th .t a current Certificate of Liability ($1,000,000 general Iialilit 1, $50,000 each occurrence) must be pro ided to the County of Hawaii Finance Department, ich'specifically and explicitly indicates that he County of Hawaii is an additional insured prio o receiving any payment(s). I (we) understand that °.Hurl e to submit the final report within 60 d-ys of June 30th shall result in loss of all grant funds recei^.� d during the grant peri•d (must be refunJed to County)and exclusion from future grant participati o n for a minimum of one year or until a wri ten rep!+rt is submitted to,and accepted by,the cun-,. I (we) understand thea:: is rno provisi.n for further notification to s !brnit the final report. Information and instructions are ay. lable at http://www.hawaiicounty.gov/fn-no profit-grant-forms/on or about May 30 of the year the 1nal,report is due. As part of this applicati'�n, you acknowledge that any funds awarde• will be restricted for the purposes stated in the appiicatio II, except for a maximum ten percent(10%)fir administrative and overhead ; costs. Any funds unus1l► by June 30, 2019 must be returned to t e County of Hawaii with the final report. Failure to retur these funds in a timely manner will impact e evaluation of your agency's future funding request grd may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of C•nstruction, materials, insurance or securities)on privet== properties unless otherwise authorized by law. By signing below, you a Ie acknowledging that you have read and un•erstood these requirements. 42,�� i /19 --6/en--. 01/2512019 Sdriature of Authorized person (see checklist, 2nd item) Date eYe c.,-,,St.--e 4,t.,c,Vit._ Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Eai'i Nonprofit Grant Applic.:tion FY2019-2O Agency Name: �I oh!a independent Living Hawaii Program Name: I I de•endent Living Program 12. COUNCIL .A V Af D WORKSHEET TABLE I: P,ROG, lM PERFoRMANCE MEASURESApplicant ::: ° IIProjected Results d Result ■ ■35 ■35 ■30 80 � ■15 TABLE II: IP FY 19-20 Grant CouncilOGRAM EXPENDITURES Request Award Salary and Wages 10,000 Professional Fees Operations ■. Supplies Equipment 1111 Other: Training Other: Other: ■ Other: ■ Other: ■-_ TO 10,000 Additional C.uncil •cthvs lre ard'on award: EXHIBIT B NONPROFIT GRANT APPLIC A ION FY 2019-2020 Page 8 of 8 Aloha Performing Arts Company dba Aloha Theatre Theatre Education Program 6 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Aloha Performing Arts Company dba Aloha Theatre Program Name: Theatre Education Program Agency Director: Melissa J Geiger Phone No.: (808) 322 — 9924 Contact Person: Melissa J Geiger Phone No.: (808) 322 — 9924 Mailing Address: Address: PO 794 Address: City,ST,Zip Kealakekua, HI 96750 Facility Address: Address: 79-7384 Mamalahoa Highway Address: City,ST,Zip Kealakekua, HI 96750 Email Address: admin@alohatheatre.com Fax No.: ( ) — Accountant/CPA: Patricia Schumacher Phone No.: (480 ) 584 — 4344 Firm (if applicable): Schumacher Tax&Accounting Mailing Address: Address: PO Box 395 Address: City,ST,Zip Dewey,AZ 86327 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna • ❑ Hamakua ❑✓ North Kona 0 South Hilo ❑ North Kohala p✓ South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns ❑✓ Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor 0 Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Aloha Performing Arts Company dba Aloha Theatre Program Name: Theatre Education Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $5,500 $3,750 $5,425 2.Agency Mission Statement: The mission of the Aloha Theatre is to enrich the lives of Hawaii residents and visitors by providing quality live theatre, performing arts education,and a venue for artistic expression. I � 3. Program Description: Education has long been a cornerstone of the Aloha Theatre's programming, both as a service to the community and as an investment in the future of the performing arts. The lack of resources for arts education in West Hawaii schools creates not only an opportunity,but an imperative for the theatre to lead in creative and performing arts education,as well as pursuing collaborations within the creative industry on Hawaii Island. The theatre has proven its commitment to this mission by hiring an . Education Director to lead expansion of programming. Jaquelynn Collier grew up in West Hawaii and as a participant in the theatre's programming,which led her to pursue post secondary education at The American Musical and Dance Academy in New York. Ms.Collier's passion for the arts and education has driven her substantial success in her first year,increasing the number of classes offered during a single season to 40 courses/workshops this season compared to 19 in 2017-2018. Courses in performance skills are provided for all age groups: Little Theatre Club for ages 4-7,Tuesday Troupers for ages 8-12,Aloha Teen Theatre for ages 13-18,and multiple offerings for adults. This year adult coursework has included acting skills, improvization,comedy,play writing,and'cosplay. Workshops have also been offered in audition preparation, improvization,and play writing. Workshops for youth have also expanded in number,and now include offerings for older teens. Subjects during the current season have included hip hop,self-expression through dance,social media production,and audition preparation. Ms.Collier is planning further expansion of subject matter for the coming season in all age groups. The Aloha Theatre is also working on expansion of scholarship funding so more of the areas underserved can be reached through low or no-cost programming like Aloha Teen Theatre., 4.Total Budget& Position Count: TotaLProgram_Budget: - $74,925 Total-Program_Position Count:, 1 Total Agency Budget: $645,000 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Aloha Performing Arts Company dba Aloha Theatre Program Name: Theatre Education Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii $20,000 Tuition 22,270 New Grants 16,455 Bill Healey Foundation 5,000 Hawaii Community Foundation 3,000 Hawaii State Foundation on Culture and the Arts 2,500 Donations and Ticket Sales from Aloha Teen Theatre Production 5,700 TOTAL: $74,925 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: As has been demonstrated during the current season,enrollment increases and subsequent increase in tuition receipts are beginning to cover a greater share of program costs. This trend is expected to continue,and it is hoped thateventually this will be a self-sustaining program through earned revenue. Until that milestone is reached,the Education Director will continue to seek additional funding in coordination with the Aloha Theatre's other fund development efforts. 7. Program Objectives Using County Nonprofit Grant Program Funds: Objective 1: Increase enrollment in existing courses Objective 2:Produce 2 teen-led shows(showcase in fall,full production in spring) Objective 3: Increase offerings for adults Objective 4: Research and design a program for seniors Objective 5: Maintain high level of satisfaction and sense of safe learning space among student population EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Aloha Performing Arts Company dba Aloha Theatre Program Name: Theatre Education Program 8.TABLE I: • What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops'or events held,volunteer hours,etc.Describe,be specific.) Increase number of youth served by educational programming by 15% From 114 to 132 individuals Increase number of adults served by educational programming by 22% From 78 to 100 individuals Produce 2 teen-led shows(showcase in fall,full production in spring) 4 public performances Increase number of adult courses/workshops by 33% From 9 to 12 Develop senior programming Curriculum designed and implemented High satisfaction level among students,acknowledgment of safe learning space Positive exit survey results Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $41,800 $49,000 $15,000 Professional Fees 14,074 20,600 3,500 Operations 1,450 1,575 Supplies - 1,391 1,750 500 Equipment Other: Performance Rights for Aloha Teen Theatre Production 1,660 2,000 1,000 Other: Other: Other: Other: TOTAL $60,375 $74,925 $20,000 *If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Aloha Performing Arts Company dba Aloha Theatre Program Name: Theatre Education Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as neededto fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. Manuts4 b►rec. January 28, 2019 Signature f uthorized.Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Aloha Performing Arts Company dba Aloha Theatre Program Name: Theatre Education Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fullyadminister 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Aloha Performing Arts Company dba Aloha Theatre Program Name: Theatre Education Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. • By signing below, you are acknowledging that you have read and understood these requirements. 4-11 January 28, 2019 Signature of Authorized Person (see checklist, 2nd item) Date hfre.chw Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 • • • County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Aloha PerformingArts Company dba Aloha Theatre Program Name: Theatre Education Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increase number of youth served by educational programming by From 114 to 192 indiviauais Increase number of adults served by educational programming by 22% From 78 to 100 individuals Produce 2 teen-led shows(showcase in fall,full production in spring) 4 public performances Increase number of adult courses/workshops by 33% From 9 to 12 Cunicum • Develop senior programming implemen edesigned and High satisfaction level among students,acknowledgment of safe learning space Positive exit survey results • TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $15,000 Professional Fees 3,500 Operations Supplies 500 Equipment Other: Performance Rights for Aloha Teen Theatre Production 1,000 Other: Other: Other: Other: TOTAL $20,000 Additional Council directives regarding award: • EXHIBIT B NONPROFIT.GRANT APPLICATION FY 2019-2020 Page 8 of 8 American National Red Cross Disaster Preparedness & Response in Hawaii County 7 y r County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County Agency Director: Coralie Matayoshi Phone No.: (808) 739 — 8103 Contact Person: Kerrey Gomes Phone No.: (808) 739 — 8140 Mailing Address: Address: 4155 Diamond Head Road Address: City,ST,Zip Honolulu, HI 96816 Facility Address: Address: 55 Ululani Street Address: City,ST,Zip Hilo, HI 96720 Email Address: kerrey.gomes@redcross.org Fax No.: (808 ) 735 — 8626 Accountant/CPA: KPMG LLP Phone No.: (703 ) 286 — 8000 Firm (if applicable): KPMG LLP Mailing Address: Address: 1676 International Drive Address: City,ST,Zip McLean,VA 22012 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 1 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $10,500 $17,250 $6,675 2.Agency Mission Statement: The mission of the Red Cross is to prevent and alleviate human suffering in the face of emergencies by mobilizing the power of volunteers and the generosity of donors. In Hawaii,we have assisted our community during every major local disaster since 1917,when the Hawaii Red Cross was founded. Our organization fulfills its humanitarian mission and delivers help, hope,and healing by meeting the immediate emergency needs of disaster victims;sharing vital disaster preparedness information through community disaster education outreach; providing emergency communication between military service members and their families in times of crisis;sponsoring the Human Animal Bond Program at Tripler Army Medical Center;and teaching people how to save lives through standardized training programs. The American Red Cross is the nation's premier emergency response organization and is committed to helping people through the entire disaster cycle,which includes preparedness, response,and recovery. When devastating events occur, people in need turn to the American Red Cross for immediate relief, hope to overcome staggering losses, and support as they piece their lives back together. The Red Cross serves as a safety net for victims of everyday disasters who have nowhere else to turn. Following our principle of impartiality, all Red Cross disaster services are available free of charge. 3. Program Description: Disaster relief is a vital part of our mission. The American Red Cross is the only nonprofit organization that responds to disasters 24/7,365 days a year;our services are essential and irreplaceable. The American Red Cross of Hawaii responds every four days to disasters here at home, and the immediate and compassionate services provided to those affected reduce the harsh physical and emotional distress that prevents people from meeting their own basic needs following a disaster. Disasters and emergencies happen quickly and often unexpectedly, leaving people scrambling to help or get help. The geographic remoteness of Hawaii makes community preparedness and resiliency imperative. Following a major disaster,our logistics bridge could become compromised and critical resupply of items such as food, medical supplies and fuel could be delayed for weeks. Educating the public about being prepared will enable entire communities to bounce back from disasters of all sizes. As studies demonstrate,being prepared-having the resources and plans in place to withstand disaster-is a key component to mitigating disaster risk and is essential to a community's ability to recover. Prepared communities fare better following disasters:more lives are saved, less money is required for recovery,and a community stabilizes more quickly when it is resilient (Disaster Resilience:A National Imperative, National Research Council,Washington D.C.:National Academies Press,2012). Every$1 invested in pre-disaster preparedness and mitigation activities saves$6 in post-disaster response and recovery expenses(The Natural Hazard Mitigation Saves:2017 Interim Report). 4.Total Budget& Position Count: Total Program Budget: $138,693 Total Program Position Count: 1 Total Agency Budget: $4,692,632 Total Agency Position Count: 20 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii $50,000 Hawaii Island United Way $17,000 Other contributions(direct mail, individuals, corporations,foundations) $50,000 Subsidy by American Red Cross to meet deficit $21,693 TOTAL: $138,693 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Red Cross is not a government agency and does not receive federal funding for disaster operations. All disaster training, services and financial assistance to victims are provided to the public free of charge. Each year,we rely on the generosity of foundations,corporations,and individuals to sustain critical programs that help people through the entire disaster cycle. The increasing frequency and intensity of disasters our nation faces means greater numbers of people are affected. No matter the type,disasters can strip people of their basic necessities and comfort,and leave them in despair. When disaster strikes, relief cannot wait. Those affected face unthinkable anguish and distress. They deserve the fastest and most capable response possible:a hot meal, new clothes,shelter to rest and recover. The Disaster Preparedness&Response Program address both the Red Cross humanitarian mission and its federal mandate. It takes preparation, resources and infrastructure to be able to respond everyday throughout the year. The Red Cross is able to take appropriate action at a moment's notice thanks to our year-round readiness efforts and dedicated volunteers. Response is only the tip of the spear. Volunteers need to be recruited beforehand and trained,scheduled for on-call duty,and deployed at a moment's notice when there is a disaster. Maintaining a large volunteer workforce requires resources for recruitment,screening,training, and retention. To ensure quality and consistency of service,volunteers require supervision and coordination. Support from the County will provide the Red Cross with essential resources to help us galvanize,train,and support a robust disaster volunteer force. 7. Program Objectives Using County Nonprofit Grant Program Funds: The following goals and objectives have been defined for the Disaster Preparedness&Response Program: •Meet the immediate emergency needs of victims(food,clothing,shelter,crisis counseling)following disasters by recruiting, training and coordinating volunteers to be on call 24/7, 365 days a year to provide disaster relief assistance to victims. •Create informed communities that know how to protect their own lives and property following a disaster by reaching individuals with lifesaving information through community disaster education outreach. This includes educating children in grades 3-5 about disaster preparedness via the Pillowcase Project and children in grades K-2 via the Prepare with Pedro program. •Reach vulnerable populations with disaster preparedness information to help them mitigate the loss of life and property through the Red Cross Home Fire/Sound the Alarm campaign. We install smoke alarms, replace smoke alarm batteries, provide fire safety education,and help families to create a fire escape plan. •Establish integrated community networks to ensure that response to any type of disaster is coordinated and effective in protecting people and property. We work closely with government and private partners to ensure that inclusive and robust mass care plans are developed. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of disaster responses 12 Number of individuals assisted after a disaster 24 Number of smoke alarms installed 100 Number of children reached with preparedness information 200 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $61,791 $50,000 Professional Fees $0 Operations $53,602 Supplies $400 Equipment $1,100 Other Disaster relief assistance(*NOTE: unpredictable) $20,000 Other: Travel, postage, gas, program materials $1,800 Other: Other: Other: TOTAL $138,693 $50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. 11119 Signature of Authorized Person (specify title) Date ierWil Chief Vxecvr ve, ordictr EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County g p ii. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1/a411 Signature of Authorized Person (see checklist, 2nd item) Date T-eL nO11 GInle# 1xecurhvr Kc&r. Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of disaster responses 12 Number of individuals assisted after a disaster 24 Number of smoke alarms installed 100 Number of children reached with preparedness information 200 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $50,000 Professional Fees Operations Supplies Equipment Other: Disaster relief assistance(*NOTE: unpredictable) Other: Travel, postage, gas, program materials Other: Other: Other: TOTAL $50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 • Arc of Hilo, The Marketing Initiative & Capacity Building 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Arc of Hilo Program Name: Marketing Initiative & Capacity Building Agency Director: Michelle M. Hiraishi Phone No.: (808) 935 — 8534 Contact Person: Marta Birchard Phone No.: (808 ) 935 — 8534 Mailing Address: Address: 1099 Waianuenue Ave. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1099 Waianuenue Ave. Address: City,ST,Zip Hilo, HI 96720 Email Address: mhiraishi@hiloarc.org Fax No.: (808 ) 934 — 7714 Accountant/CPA: Rozanne Connell Phone No.: (808 ) 930 — 6850 Firm (if applicable): Carbonaro CPA&Management Group Mailing Address: Address: 136 Kinoole St. Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑ South Kona ❑✓ North Hilo ❑ South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ❑✓ Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019 -2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Arc of Hilo Program Name: Marketing Initiative & Capacity Building 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0.00 $12,250 $10,125 2. Agency Mission Statement: The mission of The Arc of Hilo is to improve the quality of life for people with developmental and other disabilities who reside on Hawaii through educational,vocational, and skill training as well as employment and residential opportunities. 3. Program Description: The Arc is embarking on an organizational capacity building and marketing initiative through the development of a new web site which will function as a powerful communications tool to reflect updated information,generate greater community awareness, showcase new developments, and provide a means of obtaining financial support through donations.The Arc has had a web site for some years, but the content and overall look is out-of-date and does not meet the current ADA compliance regulations for content and viewing. Our goal is to provide a visually appealing, easy-to-use interface for people to browse the services available and take action to request a call-back, or place a reservation for their desired services.A web site which will serve as a landing-site for marketing, showcasing the Event Center, current client programs and services, and ensure underlying code meets current security standards.Another important feature, currently unavailable to us, is the ability to convert to a mobile-friendly version,which works well on devices with small screens,such as i pads and tablets. 4.Total Budget& Position Count: Total Program Budget: $22,869„,„ ,_ Total Program Position,Count: 105 Total Agency Budget: 3.2 Total Agency Position Count: 105 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Arc of Hilo Program Name: Marketing Initiative & Capacity Building 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate The Arc of Hilo (Salaries, camera/video/editing equipment) $7500 TOTAL: $7500 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Organizational capacity building is essential for structured growth and shared goals for the future.A effective web site and marketing strategy can reach and resonate with the disability service providers and families,while complementing and extending our current communication efforts. By aligning the vision with the brand and ensuring that what is communicated to the target market is accurate and meaningful is of utmost importance. Revenue streams will come in the following ways: 1. More individuals and community-based organizations will become aware of our in-house employment training and placement services in our laundry,yard and janitorial programs. Qualified job seekers will be able to connect with community employers by posting their video resumes on line,through a secure,encrypted portal on our web site. 2. Event Center revenue for conferences/party venues will increase as the web site will offer on-line booking/reservation options and showcase live video footage of events and amenities. 3.The Arc's(future)certified kitchen will provide in-house catering options as a fee for service to event customers.The culinary arts program will open the door to entry-level employment in the food and restaurant industry,which is the largest employer of individuals with disabilities. 4. By utilizing all social media integration and analytical tools from Google, Facebook, Pinterest,Twitter and Instagram we can reach a larger donor base and facilitate online donations.The best resources are the ones that leverage digital marketing strategy with proven results. 7. Program Objectives Using County Nonprofit Grant Program Funds: A new web platform is integral to our overall success in our Client Support Services and Commercial Services. Our objective is to expand employment potential by promoting The Arc through an integrated,strategic&coordinated marketing effort,which will give us optimum return on our social&financial investment.The first step to our success is to create awareness of our services with a comprehensive marketing tool, including effective web site development,outreach,social media, advertising, events and promotions. Our goal is to remove people with disabilities from public assistance, and help them in becoming tax-paying contributors to our State,thereby eventually returning every dime of government funds invested.The eventual result of this support is the creation of new jobs,quality of life enhancement, a safer community, crime statistics go down, unemployment rate goes down and finally as a tax base grows,there is less pressure on social safety net capacity.As new disability providers compete for clients in east Hawaii,we must have a strong presence in the community targeted at family members of disabled adults, employers, and low income underemployed individuals. In 2018,The Arc's focus has been on the hire of a new CEO, CFO and HR Manager. Our determination in quantifying and identifying new job markets remains strong; however as our organization grows and our programs continue to evolve,we are conscious of the importance of an on-line web presence, one which effectively promotes our mission and meets ADA standards for compliance.This web site can be fully developed in-house with.the oversight and expertise of the IT Specialist and direct input from program managers.We have already invested in video editing software which is an essential item for future social media marketing.The eventual result of this support is directly translated to being relevant in the current marketplace, increasing donations, quality of life enhancement and a stronger, more integrated community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Arc of Hilo Program Name: Marketing Initiative & Capacity Building 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Use website to explain our mission and programs to potential supporters&clients 5000+ individuals Refers people to our social media profiles and=generates followers 1200+ " Offers information to our community about upcoming events&fundraising campains 1000+ " Connect with_qualified job seekers 500+ " Strengthen social supports and outreach to employers 100+ employers Portrays our organization as a change-maker to corporate social responsibility programs 100+ individuals Creates proper platform for Crowdfunding integration and new donation revenue streams 5000+ " Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $3500 Professional Fees $10,000 $10,000 Operations Supplies Equipment Other: Video/Camera/w imaging processor/editing software $4000 Other: ADA compliance plug-ins software $350 $350 Other: Annual Social Media Analytics & Marketing software $5000 $5000 Other: Other: TOTAL $22,850 $15,350 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Arc of Hilo Program Name: Marketing Initiative & Capacity Building 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form er person with a conflict is needed. If no conflicts exist, one form for p the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council n The Mayor • The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. CA441/1;10;411144, 6theiC 6cfse/R)V6 )aa49 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Arc of Hilo Program Name: Marketing Initiative & Capacity Building 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Arc of Hilo Program Name: Marketing Initiative & Capacity Building 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving'any payment(s). J(we) understand that failure to submit the final report within 60 days of June 30th shall result in loss -of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nanprafitzgrantfarms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. CAW' /A 6 ti?a- 1/ Signature of Authorized Person (see checklist, 2nd item) Date (4 E,(E v6- OfiLC---gg-__ Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Arc of Hilo Program Name: Marketing Initiative & Capacity Building 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 5000+ individuals 1200+ " 1000+ " 500+ 100+ employers 100+ individuals 5000+ TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees $10,000 Operations Supplies Equipment Other: Video/Camera/w imaging processor/editing software Other: ADA compliance plug-ins software $350 Other: Annual Social Media Analytics & Marketing software $5000 Other: Other: TOTAL $15,350 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Arc of Kona Inclusion and Community Education 9 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Arc of Kona Program Name: Inclusion and Community Education Agency Director: Michele Ku, President/CEO Phone No.: (808) 323 — 2626 Contact Person: Michele Ku, President/CEO Phone No.: (808) 323 — 2626 Mailing Address: Address: PO Box 127 Address: City,ST,Zip Kealakekua, HI 96750 Facility Address: Address: 81-1065 Konawaena School Road Address: City,ST,Zip Kealakekua, HI 96750 Email Address: michele@arcofkona.org Fax No.: (808 ) 323 — 9444 Accountant/CPA: Ann N. Fukuhara, CPA, MBA Phone No.: (808 ) 961 — 5532 Firm (if applicable): Ann N. Fukuhara,An Accountancy Corporation Mailing Address: Address: PO Box 6691 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $39,700 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ✓❑ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑✓ Victims of Health or Social Crises ❑ Needs of the poor ✓❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 • Agency Name: Arc of Kona Program Name: Inclusion and Community Education 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $8,750.00 $10,000.00 $9,300.00 2.Agency Mission Statement: The Arc of Kona is a private nonprofit organization for persons with disabilities,their advocates, and families.We believe that people with disabilities are as individual in their needs, abilities, and gifts as any other cross section of society.We believe that all people of all abilities have the same fundamental human rights which includes participating and being included in our communities. As a result, our mission is to help persons with disabilities achieve the fullest possible independence, participation, and inclusion in our society according to their wishes. 3. Program Description: The Inclusion and Community Education program is designed to meet the individual Participant's needs and preferences for active community participation including their choice to do activities individually or in a small group based on shared interests. The program provides increased Participant access to their local community and delivers identified and measurable services 365 days per year to individuals with Intellectual and Developmental disabilities. The population we serve is vulnerable and is often the target of various types of abuse and is challenged with making good judgments and decisions due to cognitive delays. This program provides a strong mix of services and resources in the community setting focusing on building skills such as communication,social, networking, self advocacy, pre-employment, and leisure skills. Acquiring these experiences within their local communities,the Participant becomes more independent over time in the community where he or she resides and eventually requires less paid supports. This program provides a much needed educational opportunity for the public to include learning about the unique gifts and talents of this population. The presence and visibility of people with disabilities within our communities develops a deeper understanding and acceptance and results in opportunities such as volunteering,employment, and natural friendships among community peers. Transports will be provided during the program year with a staff ratio that meets the guidelines of the Department of Health, Developmental Disabilities Division,for the health and safety of each individual Participant. 4.Total Budget& Position Count: • Total Program Budget: $360,356 Total Program Position Count: 23 Total Agency Budget: $4,062,309 Total Agency Position Count: 114 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Arc of Kona Program Name: Inclusion and Community Education 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Medicaid Waiver Home and Community Based Services $295,656 Hawaii Island United Way $20,000 Annual agency fundraiser(Bazaar) $5,000 County of Hawaii $39,700 TOTAL: $360,356 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Arc of Kona is proactive and strategically seeks funding through a variety of resources to support our agency and program including: 1. Fundraising: Holding our annual signature fundraising event(Bazaar)in early December 2019. This next fiscal year will be our 23rd annual Bazaar. A portion of the proceeds will be designated to help support this program. 2. Partnerships: Partnerships with other organizations such as West Hawaii Rotary Clubs, Lions Clubs, and UH Manoa Center for Disability Studies for additional funding support and/or in-kind donations and services. 3. Grant Funding: Actively seeking both government and non-government grant funding opportunities to supplement the program budget. 4. Donor Cultivation: Maintain current donors and cultivate new donors to increase annual donations. 7. Program Objectives Using County Nonprofit Grant Program Funds: Leverage funds to: 1. Assess interest areas of each program Participant, 2. Increase Participant level of independence in community learning areas identified in their Service Plan, 3. Provide a safe, healthy, and supportive learning environment in the community, and 4. Increase community activity and event opportunities for individual Participants and small groups. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Arc of Kona Program Name: Inclusion and Community Education 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Maximize number of Participants served island wide Serve a minimum of 90 program Participants Ensure the safety of Participants while in the community Zero community related adverse events Increase Participant level of independence on applicable goals Average 25%increase overall Encourage Participant attendance at agency staffed community events for visibility Participant attendance at 75%staffed events Conduct interest inventory assessments with Participants yet to be assessed 95%completion of assessments Increase number of transports into the community 5,000 transports into the community Gauge Participant/family program satisfaction via satisfaction surveys minimum 90%satisfaction rate Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 295,962 33,000 Professional Fees 10,343 1,000 Operations 48,121 5,300 Supplies 5,930 400 Equipment Other: Other: Other: Other: Other: TOTAL 360,356 39,700 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Arc of Kona Program Name: Inclusion and Community Education 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director I The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: h i If no conflicts exist, check here. 01 /23/2019 Signature of Authorizedrson (sped ilei ) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Arc of Kona Program Name: Inclusion and Community Education 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A . NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Arc of Kona Program Name: Inclusion and Community Education 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. ,,// //, ,.ide .. 01 /23/2019 Signature of Authorized P- on (see chec r , •e 'tem Date Meek 7Le46—° Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 • Agency Name: Arc of Kona Program Name: Inclusion and Community Education . 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Serve Maximize number of program Participants served island wide Servs minimum of 90 program Participants Ensure the safety of Participants while in the community Zero community related adverse events Increase Participant level of independence on applicable goals. Average 25%increase overall Encourage Participant attendance at agency staffed community events for visibility sarfcipantattendance at75% staffed events Conduct interest inventory assessments with Participants not yet assessed 95 ecompletion of assessments 5,000 Increase number of transports into the community c mmun tspo is into the v Gauge Particpant/family program satisfaction via satisfaction surveys minimum 90%satisfaction rate TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 33,000 Professional Fees 1,000 Operations 5,300 Supplies 400 Equipment Other: Other: Other: Other: Other: TOTAL 39,700 Additional Council directives regarding award: • EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Arts & Sciences Center ASC Community Education Services 10 0 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Services Agency Director: Gail Clarke Phone No.: (808) 938 — 2933 Contact Person: same Phone No.: (808) 965 — 3730 Mailing Address: Address: PO Box 2091 Address: City,ST,Zip Pahoa, HI 96778 Facility Address: Address: 15-1397 Homestead Rd Address: no mail delivery City,ST,Zip Pahoa, HI 96778 Email Address: ascpuna@gmail.com Fax No.: (808 ) 965 — 3733 Accountant/CPA: Rozanne Connell, CPA Phone No.: (808 ) 968 — 1002 Firm (if applicable): Carbonaro CPA and Associates Mailing Address: Address: PO Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) O Puna ❑ Hamakua ❑ North Kona • ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑✓ Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 7250 8175 9750 2.Agency Mission Statement: ASC formed as a 501 c3 in 2003,to provide outstanding support and infrastructure for community-based learning rooted in Puna.ASC envisions learning and sharing opportunities to empower participants to thrive,cooperate, innovate and serve.ASC works to provide(1)access to education, (2)stewardship of diversity and cultural infusion, (3)stewardship of our environments, and(4)partnerships for positive economic impacts. Notes:ASC has been honored to serve as the fiscal umbrella for receiving contingency funds from the County of Hawaii for the Friends of the Pahoa Skate Park and Senior Class activities for HAASPCS 12th grade students.ASC also voluntarily facilitated hundreds of responses to Bob Agres' and the Counties call for input for the KERP in December 2018. 3. Program Description: ASC continues to develop partnerships and provide services for local groups to hold meetings, classes and network via Community Learning Festivals, launched in 2016. Festival participants are guests, educators,vendors, and entertainers.The Spring Tropical Living Festival is focused on culture, community,environment, and energy, and the Fall Art Is Life Festival is to create,share,celebrate and support local art. Both are attended by hundreds and surveys indicate all want them repeated and expanded. Safe, informative gatherings are of increased value in these times of recovery and rebuilding our community. ASC is offering weekly Yoga classes to staff,students(free)and community members(by suggested donation)with a Pacific Quest grant of$5000 as a stress reduction strategy in response to the recent Kilauea Eruption.The Hawaii Island School Garden Network(HISGN)plans to hold more workshops,the island-wide Spelling Bee was hosted for the 3rd year January 2019, and community groups book meeting time regularly. Community groups apply for use of facilities and fees are on a sliding scale including NO fee access for Boys2Men, Girls2Women community counseling efforts, and the HI Island All Nations Pow-wow groups. Management of facility use and an activity calendar require staff, currently limited to 5 hours per week, backed-up by volunteers. ASC's primary tenant, HAASPCS,with 673 grade k-12 students, has needs for expanded afterschool activities focused on STEAM learning that ASC strives to facilitate with staff as funding allows. Funded, programs would open to the wider Pahoa community.ASC is engaged in fact-finding for strategic planning and exploring shared-workspace models that would allow students, interns, mentors and entrepreneurs to work and learn together. An accessible kitchen to process value-added food, and shops and studios for woodworking, art, music and virtual access are needed. Staff is needed to coordinate offerings. 4.Total Budget& Position Count: Total Program Budget: 100,000 Total Program Position Count: 1.8 Total Agency Budget: 276,350 Total Agency Position Count: 1.925 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Services 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate ASC General Funds(rent,fees, contributions) 1,200 County of Hawaii Grant 93,800 Other grants-Pacific Quest-Yoga for KERP support 5,000 TOTAL: 100,000 Attach additional pages,if needed. 6. Explainwhat plans your agency or program has to increase revenues to support this program: Establish fair fees and advertise for the use of facilities including partnerships with agencies and groups such as: Hawaii Community College(HCC Running Start and other opportunities), Serve Safe food safety courses, HCEOC(HECO programs for low-income residents), HAASPCS Learning Garden, Small Business Development Center(SBDC),Aloha Hui o Puna Makai, Friends of the Pahoa Skate Park, Pacific Quest, National DISC Golf Assn., Paradise Ponies wood carvers, Hawaii Farmers Union Unified-Puna, and the Hawaii Island All Nations Pow-wow group. Fees support(1)security, (2)maintenance, (3)utilities and(4)ASC overhead that includes data tracking and analysis for reporting and planning. ASC actively seeks grant funding to facilitate individuals and groups to learn,envision, articulate, plan and implement entrepreneurial or service projects. OUR PAHOA YOUTH NEED EXPANDED OPPORTUNITIES AFTERSCHOOL AND ASC IS POISED TO STEP IN AS FUNDING ALLOWS. Community Learning Festivals include a small revenue stream from vendor booth spaces with free admission to the community. 7. Program Objectives Using County Nonprofit Grant Program Funds: A. Provide a safe and accessible place for community education, events, meetings and programs including two—four Community Learning Festivals and weekly community meetings serving up to 3000 residents. B. Support a network of mentors(community and virtual), partners and multi-generational students who collaborate and produce together, ideally via safe, afterschool and intersession programs, to strengthen our community and economy. Replicating a model such as the Hilo Makery in Pahoa for access to tools and workspaces for STEAM projects is included in developing strategic plans for ASC. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Services 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Host 2-4 Community Learning Festivals—400-600/ea 800—2400 participants Host 20-50 community meetings w sliding scale fees 200—500 participants Host afterschool STEAM and student-mentor learning 80-300 participants Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 1148 40,000 40,000 2000 2000 Professional Fees 2000 800 Operations Supplies 1239 1000 1000 Equipment Other: Note:Actual* 18-19 are for first 6 mo of grant period Other: Festival (4x ads, entertain, security) 1583 16,000 16,000 Other: Yoga 5000 Other: Afterschool program facilitator(.4 FTEx2) 34,000 34,000 Other: 100 000 TOTAL 3970 93,800 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Services 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Gail Clarke POSITION: President, EO May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council Ti The Mayor n The Managing Director n The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Q✓ If no conflicts exist, check here. PAAk JAaAkji A" . 'g,V1 /30/2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Services 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Services 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. lgviL /,� , 1 /30/2019 Signature of Authorized Person (see checklist, 2nd item) Date 4.t z,p . Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Arts & Sciences Center Program Name: ASC Community Education Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Host 2-4 Community Learning Festivals—400-600/ea 800-2400 participants Host 20-50 community meetings w sliding scale fees 200-500 participants Host afterschool STEAM and student-mentor learning 80-300 participants TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 40,000 Professional fees 2000 Operations 800 Supplies 1000 Equipment Other: Note:Actual* 18-19 are for first 6 mo of grant period Other: Festival (4x ads, entertain, security) 16,000 Other: Yoga Other: Afterschool program facilitator(.4 FTEx2) 34,000 Other: TOTAL 93,800 Additional Council directives regarding award: EXHIBIT B NO P 0 N R FIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Basic Image Teach at the Beach 11 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Basic Image Program Name: Teach at the Beach Agency Director: Keith Nehls Phone No.: (808 ) 640 — 2740 Contact Person: Pam Nehls Phone No.: (808) 365 — 2758 Mailing Address: Address: PO Box 6988 Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: Honolii Beach Park Address: 180 Kahoa Place City,ST,Zip Hilo, Hawaii 96720 Email Address: phsunshine@icloud.com Fax No.: (NA ) — Accountant/CPA: NA Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: • Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑✓ Hamakua ❑ North Kona n South Hilo n North Kohala ❑ South Kona ❑ North Hilo n South Kohala ❑ Kalil Services or Activities To Be Provided: (One or more can be checked) n Educational concerns Q Youth ❑ Victims of Crimes ❑✓ Culture and the arts ❑Aged ['Victims of Health or Social Crises ❑✓ Needs of the poor Q Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Basic Image Program Name: Teach at the Beach 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 0 0 2. Agency Mission Statement: Basic Image was established as a 501(c)3 non-profit organization in 2003 on the Big Island of Hawaii. Its mission is to establish,maintain, and implement programs for the protection, preservation, and enhancement of Hawaii's natural resources and advocate on behalf of educating residents and visitors. Basic Image's sustainability efforts focus on an enduring connection with the`aina and ocean, malama'aina malama ke kai. It includes practical solutions: education, awareness, stewardship, land use, recycling,water and energy conservation. Basic Image, Inc. is dedicated to the preservation and promotion of cultural education and recreational resources for the benefit and inspiration of present and future generations. 3. Program Description: Please see attached. 4. Total Budget & Position Count: Total Program Budget: $125,000 Total Program Position Count: 5 Total Agency Budget: $350,000 Total Agency Position Count: 12 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Basic Image Program Name: Teach at the Beach 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Hawaii Community Foundation (Private Donor) $2,000 Hawaii Island Creations Partner Donor(HIC) $5,000 Hawaii Community Foundation Grant Request $25,000 County of Hawaii NP Grant Request $40,000 Private Donations/Fundraiser $53,000 TOTAL: $125,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: To increase revenues to support and fulfill its mission, Basic Image receives financial support through tax-deductible donations, in-kind donations to include volunteer time, equipment, supplies and other resources. Basic Image also receives support through the grant process and have recently applied for grants through the Hawaii Community Foundation, Hawaii Tourism Authority and the County of Hawaii. Additionally,sources of donations through fundraising efforts and partnerships. 7. Program Objectives Using County Nonprofit Grant Program Funds: Please see attached. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2O19-20 Agency Name: Basic Image Program Name: Teach at the Beach 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Please see attached Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 75,000 12,000 Professional Fees 9,000 3,000 Operations 10,000 2,500 Supplies 14,500 12,500 Equipment 11,500 5,000 Other: Travel 3,000 3,000 Other: Professional Development 2,000 2,000 Other: Other: Other: TOTAL 125,000 40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of FIawai`i Nonprofit Grant Application FY2019-20 Agency Name: Basic Image, Inc. Program Name: Teach at the Beach so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council -❑ The Mayor ❑ The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. *-1 Ffif' Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Basic Image Program Name: Teach at the Beach 11. Certification of Understanding (Page 1 of 2) 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— 2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Basic Image, Inc. Program Name: Teach at the Beach 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any.payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about i May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance . or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. f(a.-9// Signature of Authorized Person (see checklist, 2nd item) Date 'Q55V t Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Basic Image Program Name: Teach at the Beach 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Please see attached. TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 12,000 Professional Fees 3,000 Operations 2,500 Supplies 12,500 Equipment 5,000 Other: Travel 3,000 Other: Professional Development 2,000 Other: Other: Other: TOTAL 40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Basic Image, Inc. 3. Program Description: Since its inception, Basic Image has been dedicated to the protection, preservation and enhancement of Hawaii's natural resources and advocate on behalf of educating residents, with a special focus on youth. Through stewardship, education, policy, science, fieldwork and the arts, we're applying smart solutions to protect the natural resources that we all depend on and help to build more resilient communities. We are dedicated to educating our youth and believe that when we take care of the keiki,we take care of our future. From 2006-2014 Basic Image administered the Paka/Pakalove Crew Youth Leadership Program. This program was mainly focused on youth surfers and malama 'aina efforts at our adopted spots. In 2015, we broadened our outreach by introducing our monthly Teach at the Beach initiative. The Teach at the Beach living classroom series, a three-prong initiative that offering year-round presentations on topics related to malama'aina, kuleana and leadership. It offers hands-on learning that combine cultural values, service to the community, education and experience at our adopted beach parks. It is a unique way to teach participants,surfers and non-surfers, lessons in history, environment education, sciences and arts; teach and share about the joys and wonders of the outdoors as well as potential gateway to careers in natural resources. The program, an investment in the future of the Big Island of Hawaii,through develops youth as community leaders and 'aina keepers. In 2019, Basic Image continues to partner with a variety of educational institutions, local youth groups and organizations to conduct improvement projects,share knowledge and traditional practices. We encourage the youth from diverse backgrounds to connect in a fun and friendly way to join our conservation effort and to learn from our outreach. We ensure our youth know more about their connections to the 'aina and to each other. Here are two outcomes of the program: • Participants synthesize their learning over the past month to create a short public service announcement. Participants will practice important critical thinking and literacy skills—by having them make and edit their own PSA that deal with a specific Teach at the Beach Living Classroom subject. Students create a 30-second Public Service Announcement (PSAs)to help raise awareness about an environment issue as part of the Teach at the Beach: Living Classroom Series developed by Basic Image. • Art is an interactive platform which allows everyone to engage at one's own pace, experiment with ways to increase creative self-expression, and be inspired through art making for health and well-being. Art is a key method that helps students feel the importance of helping to protect our'aina . It offers not only visual beauty but also a therapeutic sense of serenity, connects emotions through the interpretation of what one see's through exploration of their own perspectives. In coordination with the Teach at the Beach curriculum, Participants will be introduced to various mediums of art to include traditional arts such as lauhala weaving, haku lei making and print block. Participants will create art and their selected piece of work will be displayed at our annual Aloha Honua Festival. Basic Image, Inc. 7. Program Objectives Using County Nonprofit Grant Program Funds: Today,we face a combination of pressures unlike any our kupuna struggled through. Families are busy, many scattered, some without cultural connections forcing them to learn from somebody else or not. Many of Hawaii's youth are impacted by modernization and lack of traditional practices. There is a loss of awareness of the old,traditional ways and a fading recollection of customs and knowledge. Similarly, Hawaii's delicate eco-systems face threats from alien and invasive species, sources of pollution and environmental degradation. Our tropical paradise is also home to bacteria that causes staph infections. In fact, Hawaii has twice the national average, and Native Hawaiians are more prone to staph infections. The challenge is how we will reverse the trends and take personal and collective positive steps that ensure healthy natural eco-systems and a network of sustainable resilient communities. At Basic Image we support action-oriented approaches with hands-on experiences (malama,testing and analysis). We believe that with the necessary tools, our youth will have the confidence and knowledge to do something positive in their communities and make a difference. Our Teach at the Beach campaign seeks to engage our young people as active citizens who improve conditions in their ahapua'a now and in the future. It empowers them to learn more about where they live in and use their findings to create lasting solutions. Additionally, Basic Image will administer a special emphasis program that will address the high incidences of staph infections by promoting safeguard measures of prevention. By providing accurate information and increasing local awareness of risks, maintaining control and compliance of sanitary conditions, encourage the importance of good hygiene and dietary and lifestyle choices which build and maintain a strong immune system. Basic Image, Inc. 8. PROGRAM PERFORMANCE MEASURES Program Performance Measures Applicant Projected Results Council Proposed Projected Results Total#of youth 17 under 200 per grant year Total#of Native Hawaiian youth 17 and under 100 per grant year Total#of new groups 2 per grant year Total#of malama'aina days 4 quarterly work events per grant year Total#of community work days 4 quarterly work events per grant year Total#of Public Service Announcements (PSA) 9—3 minute per grant year Total #of Presentations to include art displays 2 per grant year Total community festivals 2 per grant year Total Professional Development hours participated 10 hours per member per by Team Members grant year Participant Measurements Studies have shown that service-learning benefits student retention and leadership development thus improving their academics.The outcomes show students who are actively participating versus participating connect better with the subject matter. Through pre, post and self—tests, Basic Image will measure participants in three areas: leadership, malama'aina and teamwork. We will also view report cards, conference with parents, other stakeholders and conduct survey with peers. Area Outcome Impact Measurement Leadership Ability to seek out role Ability to engage in the Coordinate visit from community models who have been community in a positive leader/representatives to speak to leaders manner youth participants about area of special interest. Malama'aina Ability to independently Ability to work with a Working with another program assess situations and team participant,contextualized learning environment activities such as a special service- learning projects in which youth apply malama'aina concepts to community and park needs. Communication Ability to create and Ability to resolve conflicts Role playing positive and adverse communicate a vision situations concerning family, and peer relationships. Basic Image, Inc. Hui Hooleimaluo 12 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Basic, Image Inc. Program Name: Hui Hooleimaluo Agency Director: Keith Nehls Phone No.: (808) 640 — 2740 Contact Person: Kamala Anthony Phone No.: (808) 430 — 2032 Mailing Address: Address: PO Box 6988 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 2306 Kalanianaole Avenue Address: City,ST,Zip Hilo, HI 96720 Email Address: kamala.anthony@huih000leimaluo.com Fax No.: ( ) — Accountant/CPA: N/A Phone No.: ( ) — Firm (if applicable): N/A Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑ South Kohala ❑ Kali Services or Activities To Be Provided: (One or more can be checked) • Educational concerns n Youth ❑Victims of Crimes ® Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Basic, Image Inc. Program Name: Hui Hooleimaluo 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 0 0 2. Agency Mission Statement: Basic Image Mission Statement: To establish, maintain, and implement programs for the protection, preservation, and enhance- ment of Hawai'i's natural resources and advocate on behalf of educating residents and visitors. • 3. Program Description: SEE PROGRAM DESCRIPTON ATTACHED 4.Total Budget& Position Count: Total Program Budget: 185,200 Total Program Position Count: 5 Total Agency Budget: 350,000 Total Agency Position Count: 12 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of FIawai`i Nonprofit Grant Application FY2019-20 Agency Name: Basic, Image Inc. Program Name: Hui Hooleimaluo 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Kamehameha Schools $90,000 Ka Umeke Kaeo $18,000 Ke Ana Laahana $5,000 Sig Zane Designs $3000 County of Hawaii $42000 Private Donations $27200 TOTAL: $185,200 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: SEE EXPLANATION ATTACHED 7. Program Objectives Using County Nonprofit Grant Program Funds: SEE OBJECTIVES ATTACHED EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Basic, Image Inc. Program Name: Hui Hooleimaluo 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Total#of groups that are returning participants 10 in grant year Total#of new groups 15 per grant year Total#of students in grades 3-12 that spend 120 hours or more at the loko i'a in a 12 mod 5o pergrant year Total#of community workdays 4 quarterly work evets per grant year Total#of participants in community work days 250 per event Total community Festivals Hosted (Waiuli Ocean Festival) 1 per grant year Total Professional Development hours participated in by Team members 40 hours per memeber per. grant year Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages: Team member wages $102,800 $120,000 $34,150 Professional Fees: consultants, facilitators, research $15,050 $18,000 $2,950 Operations (facilities, utilities, general admin) $29,200 $29,200 $0 Supplies: gardening tools, tabis, gloves, printer ink, wetsuit $6,000 $7,000 $1,000 Equipment: Ipad, YSI water quality tool, flow meter $5,300 $6,000 $700 Other: Travel: participation in statewide loko is conferences and meetings $1,800 $3,000 $1,200 Other: Professional Development $0 $2,000 $2,000 Other: Other: Other: TOTAL $160,150 $185,200 $42,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Program Name: 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council n The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: • ✓❑ If no conflicts exist, check here. / 72 ?//7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY,2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Basic, Image Inc. Program Name: Hui Hooleimaluo ii. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),'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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Program Name: 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. /.2 7/ e Signature of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Basic, Image Inc. • Program Name: Hui Hooleimaluo 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Total#of groups that are returning participants 10 in grant year Total#of new groups 15 per grant year Total#of students in grades 3-12 that spend 120 hrs or more at the lokoia in a 12 months 5o pergrant year Total#of community work days ntgYearerlyworkevetspergra Total#particpants in community work days 250 per event Total community Festivals hosted(Waiuli Ocean Festival) 1 per grant year 4Total Professional Development hours particpated in by team members. g hours per memeber per. grant year TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $34,150 Professional Fees $2,950 Operations $0 Supplies $1,000 Equipment $700 Other: Travel: participation in statewide loko is conferences and meetings $1,200 Other: Professional Development $2,000 Other: Other: Other: TOTAL $42,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Program Description: Ho'oleimaluo is a loko i'a project at Honokea Loko I`a at Waiuli in Keaukaha Hawaii (Richardson's Beach Park). Hui Ho'oleimaluo's mission is to Nourish Hawai`i`s loko i'a(fish pond) communities through placed based education, community advocacy, and place-based management of natural resources. Ho'oleimaluo provides opportunities for STEAM skill building,place-based learning, and community engagement through the rehabilitation and management of a native Hawaiian ecosystem. Our work includes restoring native plant and animal life in the loko, increasing fishpopulations of surrounding reef areas, perpetuation of Hawaiian cultural traditions and practices, and creating STEAM experiences that allow participants to build the skills needed to further pursue local STEAM studies. Since 2011,the Ho'oleimaluo team has worked with over 50 different school groups and organizations and 3000 individuals providing hands on science learning opportunities in a loko ia ecosystem. Activities have been closely tied to anthropological studies and presentations of the area, cultural protocols, and hoike. Activities include building the loko ia wall, natural recruitment of pua ama(juvenile mullet) into the loko (1200 count), and improving water quality for optimum salinity (resulting in increased fish congregation). The team has also developed curriculum in both Hawaiian language and English and presented their work at conferences around the world. Currently the team has projects and weekly site visits with students from two East Hawai`i based charter schools in grades three through twelve. During intercession months we work with Native Hawaiian students from across the state, we also host quarterly community work days at Honokea loko ia providing family engagement, and community relationship building opportunities. Attached you will find two letters of support from organizations that we have been working with for the last few years. In 2016 we entered into a MOU with the County of Hawaii Parks and Recreation for care over Honokea Loko ia and the anchialine pools at Puakahinano. This MOU has allowed us to expand our services and secure funding for our work. We are in the process of negotiating a new MOU, a draft of which is attached. Our desire is to work in partnership with the county to achieve the goals of their long-term vision for our island community. 6. Explain what plans your agency or program has to increase revenues to support this program: To increase revenues to support this program,the Ho'oleimaluo team will continue to seek grant funds from both public (Hawai`i County, State of Hawaii) and private(Hawaii Community Foundation,Kamehameha Schools, Purple Maia Foundation) organizations. We will also continue to build partnerships and relationships with local education, environmental, and cultural groups for private donations and contracts. Over the last couple of years Hui Hooleimaluo was a program under Kamaaha Education Initiative (KEI). With support from KEI we have secured grant funds and contracts in excess of$90,000 and have logged hundreds of hours in inkind services from loko ia research to legal advice. We have also received donations in the form of supplies, food, and equipment for our educational activities and community events worth more than $20,000. Our team and our board have experience managing grants funds and we will be working closely with Basic Image to ensure we are able to financially sustain our program and that all required data collection and reporting is completed on time. 7. Program Objectives Using County Nonprofit Grant Program Funds: In the 2019 to 2020 project year the team will focus on two major areas. The first will be to increase restoration and education activities by expanding the project site to include the Anchialine pools at Puakahinano, Waiuli. This expansion will include the following specific activities: removal of weeds and waste, removal of invasive species, water quality, species identification and documentation, and Anchialine pool dynamics. The second focus area will be around building curriculum for students in grades 3-12. Taking into account student surveys and data collection over the last two years we will work to better engage students by aligning learning activities across ages and grade levels and ensuring.students are getting well rounded science and cultural experiences. The team will be focusing on improving curriculum in both Hawaiian language and English. We will be collaborating with some of our school partners to help to develop curriculum. These focus areas seek to increase meaningful interactions with the loko is by learners, ohana, and regional schools and partners,provide access to high quality sites leading to a more balanced use of community sites for broader community benefit, increase interest and skills in science through STEAM learning activities, increase community collaboration to support Native Hawaiian youth in STEAM, and increase readiness for participants to engage in academic STEAM learning. Objective 1: To Increase interest and skills in science through STEAM learning activities. Obejective 2: To Increase knowledge about the local environment in Keaukaha. Objective 3: To Increase community collaboration to support youth in STEAM. Bay Clinic Inc. Diabetes Self-Management and Education 13 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Diabetes Self-Management and Education Agency Director: Harold Wallace Phone No.: (808) 930 — 0499 Contact Person: Leelen Park Phone No.: (808) 961 4088 Mailing Address: Address: 450 Kilauea Avenue Ste. 105 Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: Same as Above Address: City,ST,Zip Email Address: leelen.park@bayclinic.org Fax No.: (808 ) 961 — 5678 Accountant/CPA: Rozanne Connell Phone No.: (808) 930 — 6850 Firm (if applicable): Cabonaro CPAs&Management Group Mailing Address: Address: P.O.Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,568 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona ❑✓ South Hilo 0 North Kohala ❑South Kona ✓❑ North Hilo ❑South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ✓❑Youth ❑Victims of Crimes ❑Culture and the arts ✓❑Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Diabetes Self-Management and Education 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 $25,000 0 2.Agency Mission Statement: Mission: Bay Clinic is a community-directed healthcare organization that provides quality primary and preventive care services to the people of East Hawaii. Bay Clinic will ensure that patient-centered,culturally responsive,and affordable healthcare services are locally accessible in our communities. Founded in 1983, Bay Clinic Inc.(BCI)is a 501(c)(3)nonprofit Federally Qualified Health Center(FQHC)with a network of eight community health centers covering the Hawai'i County Districts of North and South Hilo, Puna,and Ka'u. BCI's health center locations include Hilo, Kea'au, Pahoa, and Na'alehu;with a Mobile Health Unit. This Mobile Health Unit provides school based clinical health services at the Kea'au-Ka'u-Pahoa District Complex Area Schools as well as serves the towns of Mountain View, Volcano and Ocean View. BCI works to ensure that affordable, comprehensive,patient centered health care is available to all in East Hawaii. As a FQHC,Bay Clinic provides primary medical,dental and behavioral health care on a federally approved Sliding Fee Schedule that is based on income level and family size. 3. Program Description: Since its launch in 2006, BCI's Diabetes Self-Management and Education(DSME)program has and still is the only organization on the entire island that provides Medicaid/QUEST;making it absolutely critical that we continue to expand access, provide outreach and prevention,and culturally appropriate care management and self-empowerment support for all in need. Included in BCI's DSME program are 10-week DSME classes that are led by BCI's registered dietitian(RD)and follows the American Association of Diabetes Educators(AADE)DSME class requirements. The DSME team is comprised of highly trained professionals including BCI's Chief Medical Officer,who is an medical doctor(MD)and oversees the RD,the RD,a Physician's Assistant,a Clinical Psychologist,and a number of support staff including nurses, health information systems technologists, quality improvement specialists,and clerical support personnel. Hawaii County had the highest diabetes(underlying or non-underlying)mortality rate in the entire state. For those dealing with diabetes, its complications and the high cost of care,an estimated 20-45%of sufferers also experience anxiety,depressive or distress symptoms,complicating their ability to manage the lifelong behavior modification aspects of diabetes treatment. In addition to DSME classes,the RD partners with: 1)other BCI providers and behavioral health specialists to ensure patients that are at-risk are provided nutrition counseling, mental health support as needed,and other support options with social service organizations,transportation,and other help to ensure they succeed in their efforts to live healthy and control their diabetes; and 2)local organizations and events to outreach and educate community members on the importance of living healthy,as well as provide healthy cooking demonstrations. 4.Total Budget& Position Count: Total Program Budget: $313,133 Total Program Position Count: 8 Total Agency Budget: $17,095,856 Total Agency Position Count: 178 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Diabetes Self-Management and Education 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate The Harry and Jeanette Weinberg Foundation $75,000 TOTAL: $75,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This program is sustainable as BCI is an FQHC and receive federal support for comprehensive health and preventative care to the underserved and low-income in East Hawaii. However, BCI plans to provide certified wound care treatment for diabetic patients will increase the amount of funding we receive through patient visits. Bay Clinic's DSME programs are completely self-sustained through Medicaid(QUEST)and insurance billing. BCI's approved 2019 Medicaid Federally Qualified Health Clinic PPS rate for primary medical services is$208.71. In addition to BCI's DSME classes, BCI expects to expand access to 978 of BCI's 1,631 diabetic patients offering them comprehensive treatment and education for diabetic wound care(foot, ulcers, etc.). This additional service will ultimately increase the number of visits per patient. BCI projects and increase of 3%of its 5,088 diabetic encounters will occur. With 153 new encounters multiplied by $208.71 pps will increase revenue to$31,932.63. 7. Program Objectives Using County Nonprofit Grant Program Funds: One of the major concerns for diabetic patients is the risk of slow healing wounds caused by the disease. For BCI to be more capable of handling these complications we plan on sending two of our Advanced Practice Register Nurses(APRN)to a specialty certification training program for diabetic related wound care offered by the University of Washington School of Nursing . This comprehensive, intensive program addresses a broad range of wounds(venous,arterial, neuropathic and pressure ulcers),healing problems(wound infection,failure to heal),and components of specialized nursing practice(role development,collaboration, research utilization, providing in-service education). Central concepts guiding the content and practicum experiences are prevention,assessment,diagnosis,treatment and evaluation of the healing process. This training will certify BCI's APRNs to:apply assessment techniques to wounds in different stages of healing,select therapeutic options that correct systemic alterations,select appropriate topical therapies, implement appropriate therapeutic strategies,and support healing using an evidence based approach. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Diabetes Self-Management and Education 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 1)Send APRNs to Specialized Diabetic Wound Care Training at University of Washington 2 APRNs complete wound care training 2)Expand access to comprehensive diabetic wound care to diabetic patients 978 patients gain access to wound care 3)Increase encouters of diabetic patients seeking education and wound care Increase diabetic encounters by 153 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $222,529 $228,765 $0 Professional Fees $0 $0 $0 Operations $0 $0 $0 Supplies $63,800 $63,800 $0 Equipment $0 $0 $0 Other: Training Wound Care x 2 APRNs $0 $20,568 $20,568 Other: n/a Other: n/a Other: n/a Other: n/a TOTAL $286,329 $313,133 $20,568 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Diabetes Self-Management and Education 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Bay Clinic Inc. POSITION: N/A May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, heck here. eja January 30, 2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Diabetes Self-Management and Education 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express,and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Diabetes Self-Management and Education 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. January 30, 2019 Signature of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Diabetes Self-Management and Education 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result 2 APRNs complete wound care training 978 patients gain access to wound care Increase diabetic encounters bl TABLE II: PROGRAM EXPENDITURES FY 19-20 Grant Council Request Award Salary and Wages $0 Professional Fees $0 Operations $0 Supplies $0 Equipment $0 Other: Training Wound Care x 2 APRNs $20,568 Other: n/a Other: n/a Other: n/a Other: n/a TOTAL $20,568 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Bay Clinic Inc. Health Information Technology 14 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Health Information Technology Agency Director: Harold Wallace Phone No.: (808) 930 — 0499 Contact Person: Leelen Park Phone No.: (808) 961 — 4088 Mailing Address: Address: 450 Kilauea Avenue Ste. 105 Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: Same as Above Address: City,ST,Zip Email Address: leelen.park@bayclinic.org Fax No.: (808 ) 961 — 5678 Accountant/CPA: Rozanne Connell Phone No.: (808) 930 — 6850 Firm (if applicable): Cabonaro CPAs&Management Group Mailing Address: Address: P.O.Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $26,292 Geographical Areas To Be Served: (One or more can be checked) p Puna ❑ Hamakua ❑ North Kona ✓❑South Hilo D North Kohala ❑South Kona ❑✓ North Hilo ❑South Kohala ❑✓ Kali Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ✓❑Youth ❑Victims of Crimes ❑Culture and the arts ✓❑Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Health Information Technology 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 $25,000 0 2.Agency Mission Statement: Mission: Bay Clinic is a community-directed healthcare organization that provides quality primary and preventive care services to the people of East Hawai'i. Bay Clinic will ensure that patient-centered, culturally responsive,and affordable healthcare services are locally accessible in our communities. Founded in 1983, Bay Clinic, Inc.(BCI)is a 501(c)(3)Federally Qualified Health Center(FQHC)network of eight community health centers serving the Hawaii County districts of North and South Hilo, Puna,and Ka'0, East Hawai'i. BCI's health centers are located in the towns of Hilo, Kea'au, Pahoa,and Na'alehu. For over 35 years, BCI has provided comprehensive primary medical,dental,and behavioral health care for all regardless of income level or insurance status. Clinic fees are based on a federally approved Sliding Fee Schedule and applied to all patients depending on their income level,family size, and insurance status. 3. Program Description: In 2011, BCI transitioned to an electronic medical practice via implementing an Electronic Practice Management(EPM)system and Electronic Health Records(EHR)at all of its 6 health center sites;and in 2014 added Electronic Dental Records(EDR)at its 3 dental sites.The implementation of its certified EHR/EDR was a significant component of BCI's move from the provision of episodic care to a coordinated patient-centered care model that supports a long-term clinician-patient healing relationship.The EHR/EDR system also enhanced the quality of care provided to patient via the provision of: 1)clinical decision making support, 2)performance improving tools,3)interfaced with labs, registries,and other EHRs,and 4)improved diagnostics. BCI is a National Committee on Quality Assurance recognized Level 3 Patient Centered Medical Home(PCMH),the highest level attainable by a medical practice. As a Level 3 PCMH, BCI is a fully electronic practice that uses systematic processes and Information Technology to enhance the quality of patient care. One of the major obstacles to BCI providers is the inability to review all of the patient's health information in a quick and efficient manner. This impediment is designated under the Health Information Technology(HIT)department. HIT is a major component in BCI's overall operation. The providers need to frequently switch between numerous EHR templates and scroll excessively. On average,this consumes five patient appointments worth of provider time each day. By completing this project,we expect to save the providers enough time to see up to two additional patients per day. 4.Total Budget&Position Count: Total Program Budget: $38,001 Total Program Position Count: 2 Total Agency Budget: $17,095,856 Total Agency Position Count: 178 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 Countyof Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Health Information Technology 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate TOTAL: Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: By purchasing the high-resolution monitors, BCI providers will be able view entire patient records,allow for quicker updates of those records, and allow providers to be able to see more patients each day. BCI expects to increase revenue through efficiency of these monitors that will facilitate each BCI primary medical provider to see two additional patients per day. Currently,BCI employs a total of twenty five(25)primary care and behavioral health(BH)providers.BCI's approved Medicaid Federally Qualified Health Clinic PPS rate for primary and BH medical services is$208.71. With the new upgrades to its HIT system monitors, BCI expects to generate 384 new encounters this year x 25 providers x PPS rate of$208.71 for a total of $2,003,616 in increased revenue. Providing monitors to the dental providers will also increase turnaround time and allow our nine(9)dentists to see one additional patient per day,generating 1,728 new dental encounters. BCI's approved dental PPS rate is$167.59 per encounter x 1,728 encounters for a total of$289,595.52. All expected additional revenue generated by both primary medical and dental encounters is$2,293,211.52 in the program year. 7. Program Objectives Using County Nonprofit Grant Program Funds: BCI respectfully requests$26,292 from the County of Hawai'i that will be used for the installation and purchase of high-resolution monitors needed by our care providers,thereby giving them the efficient and effective tools to update patient records. In addition,this project will allow BCI to schedule more patients daily and provide greater access to comprehensive health care to our community. Lastly,this addition will provide for enhanced patient satisfaction. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Health Information Technology 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 1)Purchase of high-resolution monitors 35 high-res monitors purchased and installed 2)Increase of encounters primary care and behavioral health 9600 new encounters 3)Increase of encounters dental care 1728 new encounters Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $0 $21,709 $10,000 Professional Fees $0 $0 $0 Operations $0 $0 $0 Supplies $0 $0 $0 Equipment $0 $16,292 $16,292 Other_ n/a Other: n/a Other: n/a Other: n/a Other: n/a TOTAL $0 $38,001 $26,292 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Health Information Technology so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Bay Clinic Inc. POSITION: N/A May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. ND January 30, 2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Health Information Technology 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Health Information Technology ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report.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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 4/t/1"-- January 30, 2019 Signature of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Health Information Technology 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 35 high-res monitors purchased and installed 9600 new encounters 1728 new encounters TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $10,000 Professional Fees $0 Operations $0 Supplies $0 Equipment $16,292 Other: n/a Other: n/a Other: n/a Other: n/a Other: n/a TOTAL $26,292 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Bay Clinic Inc. Pediatric Dental 15 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Pediatric Dental Agency Director: Harold Wallace Phone No.: (808) 930 — 0499 Contact Person: Leelen Park Phone No.: (808) 961 — 4088 Mailing Address: Address: 450 Kilauea Avenue Ste. 105 Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: Same as Above Address: City,ST,Zip Email Address: leelen.park@bayclinic.org Fax No.: (808 ) 961 — 5678 Accountant/CPA: Rozanne Connell Phone No.: (808 ) 930 — 6850 Firm (if applicable): Cabonaro CPAs&Management Group Mailing Address: Address: P.O.Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $60,432 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona ❑✓ North Hilo ❑South Kohala ❑✓ Keil Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ✓❑Youth D Victims of Crimes ❑Culture and the arts 0 Aged ❑✓ Victims of Health or Social Crises ✓❑ Needs of the poor 0 Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Pediatric Dental 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 $25,000 0 2.Agency Mission Statement: Mission: Bay Clinic is a community-directed healthcare organization that provides quality primary and preventive care services to the people of East Hawai'i. Bay Clinic will ensure that patient-centered,culturally responsive,and affordable healthcare services are locally accessible in our communities. Founded in 1983, Bay Clinic, Inc.(BCI)is a 501(c)(3)nonprofit Federally Qualified Health Center(FQHC)network of eight community health centers serving the Hawai'i County districts of North and South Hilo, Puna,and Ka'u.Bay Clinic health centers are located in the towns of Hilo, Kea'au, Pahoa,and Na'alehu;with a Mobile Health Unit providing primary medical and dental care to the towns of Ocean View, Mountain View and Volcano,as well as school-based clinic services to the DOE Kea'au-Ka'u-Pahoa District Complex schools. Bay Clinic offers a federally approved sliding fee schedule for those individuals in need of assistance. 3. Program Description: Dental problems can lead to lifelong health and socioeconomic challenges. Research shows that kids who do not receive needed dental care miss significant number of school days, use expensive emergency room services more often,and face worsened job prospects as adults compared with their peers who do receive care. To address the acute and persistent pediatric dental care disparities present in our service area community, BCI developed the Pediatric Dental Care Program(PDCP)in 2010 to: 1)expand access to comprehensive pediatric dental care,thereby reducing the burden on many low-income families of having their children referred to Oahu for dental care;2)promote workforce development and expertise in the community with the aim of growing the dental provider pool in our service region;and 3) significantly reduce the high prevalence of dental caries and other oral conditions present in our East and South Hawaii Island children. Pain and discomfort of tooth decay in children,as well as the barriers to oral health services,is largely preventable.BCI helps people struggling to understand and access the health care system.We provide care to all regardless of ability to pay,and we work to teach preventative practices to parents and children to improve lifelong oral health. 4.Total Budget& Position Count: Total Program Budget: $233,232 Total Program Position Count: 1 Total Agency Budget: $17,095,856 Total Agency Position Count: 178 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Pediatric Dental 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Ouida and Doc Hill Foundation $25,000 TOTAL: $25,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Most of Hawaii's children qualify for Med/Quest which is the state funded Medicaid plan that offers health insurance to low-income families.SCI's approved 2019 Medicaid FQHC PPS rate for primary dental service is$167.59 for each dental encounter,therefore increasing dental services will assist in long-term sustainability. We are committed to improving access to dental care for the 10,223 children who are on Medicaid in our community. If not all funding is secured as planned,we will continue to seek additional grants and funding from foundations and organizations who are dedicated to rectifying this disparity in children's dental care access.This is a high priority for our community and our organization,thus we are committed to continue to strive for its success. 7. Program Objectives Using County Nonprofit Grant Program Funds: BCI strives to ensure that comprehensive, preventative and restorative dental care services are available to all East Hawai'i Keiki. Majority of our pediatric dental visits are conducted at Kea'au Family Health and Dental Center. Every Friday, dental residents and pediatric dentist, Dr.Ohata,see children patients all day. These"Pedo-Fridays"at the Kea'au Clinic happen every week with the exception of the last Fridays of each month. However,due to the age and condition of the equipment, dentist and staff are limited to the quality and efficiency of the care provided. Most of the major equipment that is used is from the clinic's opening in 2003. Upgrades to the equipment would dramatically improve not only the quality of care but also the number of patients seen in a given day.With the continuous and rapid advancement of technology,fifteen year old equipment is lightyears behind today's standard equipment. This request for support will cover the cost of three(3)dental chairs,one(1)sterilization center,and one(1)vacuum system. Dental chairs are a crucial component of any dental visit. Having three functioning dental chairs will promote comfort and provide greater availability to its patients. Central to the safe and efficient operation of a dental practice is the sterilization center.Functioning properly, it allows dental practitioners to create an environment that minimizes the risk of cross-contamination and ensures the safety of patients and staff. Ultimately, it keeps the office running smoothly and on schedule.Vacuums allow the doctor and staff to keep the oral cavity clean to work in. Having a functioning vacuum system provides comfort to the patient because saliva and other liquids can easily be evacuated from their mouth during procedures. If the vacuum system goes down, the practice cannot function. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Pediatric Dental AL 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 1)Purchase of Dental Chairs Purchase 3 Dental Chairs 2)Purchase of sterilization center Purchase 1 Sterilization Center 3)Purchase of vacuum system Purchase 1 Vacuum System Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $22,248 $22,915 $0 Professional Fees $0 $0 $0 Operations $0 $0 $0 Supplies $0 $0 $0 Equipment $0 $210,317 $60,432 Other: n/a Other: n/a Other: n/a Other: n/a Other: n/a TOTAL $22,248 $233,232 $60,432 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Pediatric Dental 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Bay Clinic Inc. POSITION: N/A May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, ck here. Cep January 30, 2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 ` County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Pediatric Dental 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Pediatric Dental 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hewai'i with the final report.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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. January 30, 2019 Signature of Authorized Person (see checklist,2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Pediatric Dental 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Purchase 3 Dental Chairs Purchase 1 Sterilization Center Purchase 1 Vacuum System ( TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $0 Professional Fees $0 Operations $0 Supplies $0 Equipment $60,432 Other: n/a Other: n/a Other: n/a Other: n/a Other: n/a TOTAL $60,432 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Bay Clinic Inc. Substance Use Disorder and Mental Health 16 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Substance Use Disorder and Mental Health Agency Director: Harold Wallace Phone No.: (808) 930 — 0499 Contact Person: Leelen Park Phone No.: (808) 961 — 4088 Mailing Address: Address: 450 Kilauea Avenue Ste. 105 Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: Same as Above Address: City,ST,Zip Email Address: Ieelen.park@bayclinic.org Fax No.: (808 ) 961 — 5678 Accountant/CPA: Rozanne Connell Phone No.: (808) 930 — 6850 Firm (if applicable): Cabonaro CPAs&Management Group Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $83,756 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala D South Kona 0 North Hilo ['South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ✓❑ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Substance Use Disorder and Mental Health 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 $25,000 0 2.Agency Mission Statement: Mission: Bay Clinic is a community-directed healthcare organization that provides quality primary and preventive care services to the people of East Hawai'i. Bay Clinic will ensure that patient-centered,culturally responsive,and affordable healthcare services are locally accessible in our communities. Founded in 1983, Bay Clinic Inc.(BCI)is a 501(c)(3)nonprofit Federally Qualified Health Center(FQHC)covering the East and South districts of Hawaii Island. BCI's service area covers four of the nine county districts comprising of North Hilo,South Hilo, Puna,and Ka'u.Bay Clinic's seven health centers are located in towns of Hilo, Kea'au, Pahoa,and Na'alehu and a Mobile Health Unit providing service to the towns of Mountain View,Volcano,and Ocean View and also servicing students of the KKP Complex area school system. As an FQHC, Bay Clinic provides affordable,comprehensive and patient centered health care for all of East and South Hawaii. Patients are given the opportunity to participate in our sliding fee schedule which is determined by their income level and family size. 3. Program Description: BCI's Substance Use Disorder(SUD)and Mental Health(MH)program addresses the growing need for services to treat Substance Abuse and Mental Health problems plaguing our East Hawaii community. In 2018, BCI conducted a Community Needs Assessment(CNA)which showed that health services of greatest need were substance abuse support services followed by mental health services.The CNA showed that 61%of respondents to the survey knew three or more people in their community who needed help with a substance abuse problem. Interesting enough,the CNA showed that the priority substance abuse service needed in the community was for outreach workers who could help clients connect with different health and support services. BCI currently offers individual therapy for those seeking SUD and/or MH counseling. Each patient is given an initial visit for one hour to assess the patient's need and follow-up visits, if needed, lasting half an hour per session. Most of these visits are required for patients who receive assistance by the state. Once assessed and if needed, patients continue to see one of BCI's behavioral health providers on a monthly or bi-monthly basis. If more intensive treatment is required that is beyond the scope of our providers,the patient is referred to other services like ACCESS Capabilities, BISAC or Lokahi Treatment Centers. However, BCI's behavioral health department continues to monitor the patient's progress and provides care coordination support as needed. BCI is making a difference. Last year, 1,707 unduplicated patients accessed treatment for depression and other mood disorders, 1,531 unduplicated patient's accessed treatment for anxiety disorders,and 1050 unduplicated patients were aided for other mental disorders. 247 unduplicated patients were treated for substance related disorders and 204 patients were assisted for alcohol related disorders. In total, BCI treated 4,739 patients with SUD-MH problems last year alone. 4.Total Budget& Position Count: Total Program Budget: $159,601 Total Program Position Count: 1 Total Agency Budget: 1$17,095,856 Total Agency Position Count: 178 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Substance Use Disorder and Mental Health 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate TOTAL: Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BCI's plan is to expand access to SUD and MH services through personnel increases,training,and equipment purchased to address an opioid overdose rate that has doubled over the past nineteen years(National Institute on Drug Abuse)due to a number of factors,one being insufficient access to MH and SUD treatment providers in our East Hawai'i community.We project 95 patients new to our health center will access SUD and MH services with the implementation of Telehealth. BCI's SUD and MH services are completely self-sustained through Medicaid(Quest)and insurance billing. BCI's approved 2019 Medicaid FQHC PPS rate for primary medical service is$208.71. With 310 projected new encounters at$208.71,which will result in an increase of revenue totaling$64,700.10. 7. Program Objectives Using County Nonprofit Grant Program Funds: BCI's 2018 CNA showed that for a large portion of our patient population living in poverty, lack of transportation was one of the greatest barriers to accessing health care services.The establishment of Telehealth will expand access to mental health services by providing our patients the extra option of accessing mental health and SUD services from their own home.The Behavior Health(BH)staff, in collaboration with BCI's pharmacist and Chief Medical Officer,will develop a more responsive referral and treatment entry system protocol in support of MH and SUD objectives.The patient registration kiosks will provide a pre check-in option,with easy completion of forms electronically that is integrated into BCI's Electronic Health Record system.This will facilitate shorter wait times for appointments, promote the reduction of patient no-shows,and support greater patient satisfaction. BCI's Behavioral Health Program will use the Telehealth system that will be established through this supplemental to expand access to MH and SUD services by offering an alternative platform for patients,from their own home,to receive the mental health and other support services.The Telehealth option is especially critical for the 15,899(2016 Census)residents living in the most remote East Hawaii communities where there are no MH clinics or SUD services available. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Substance Use Disorder and Mental Health 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 1 Implement Telehealth system Telehealth system networked at 6 sites 2 Increase number of SUD-MH patients 2%of current 4739 patients Increase of 95 new SUD-MH patients 3 Increase amount of encounters from SUD-MH patients 2%of current 15,507 encounters Increase of 310 new encounters Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages n/a $36,161 $0 Professional Fees n/a $0 $0 Operations n/a $6,346 $0 Supplies n/a $15,494 $0 Equipment n/a $83,756 $83,756 Other: Contractual n/a $17,844 $0 Other: n/a Other: n/a Other: n/a Other: n/a TOTAL n/a $159,601 $83,756 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Substance Use Disorder and Mental Health 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Bay Clinic Inc. POSITION: N/A May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, c k here. ;o January 30, 2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Substance Use Disorder and Mental Health 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Substance Use Disorder and Mental Health ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. January 30, 2019 Signature of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bay Clinic Inc. Program Name: Substance Use Disorder and Mental Health 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Telehealth system networked at 6 sites Increase of 95 new SUD-MH patients Increase of 310 new encounter TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $0 Professional Fees $0 Operations $0 Supplies $0 Equipment $83,756 Other: Contractual $0 Other: n/a Other: n/a Other: n/a Other: n/a TOTAL $83,756 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Big Brothers Big Sisters of Hawaii Island One-to-One Mentoring 17 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Big Brothers Big Sisters of Hawaii Island Program Name: One-to-One Mentoring Agency Director: Dennis Brown, President/ CEO Phone No.: (808 ) 695 - 4570 Contact Person: Tyler Kurashige, Chief Programs Officer Phone No.: (808 ) 695 - 4572 Mailing Address: Address: 418 Kuwili Street, Suite 106 Address: City,ST,Zip Honolulu, HI 96817 Facility Address: Address: N/A Address: City,ST,Zip Email Address: dbrown@bbbshawaii.org Fax No.: ( ) — Accountant/CPA: Glacen Florita Phone No.: (808 ) 695 - 4561 Firm (if applicable): Mailing Address: Address: 418 Kuwili Street, Suite 106 Address: City,ST,Zip Honolulu, HI 96817 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ✓❑ North Kohala ❑✓ South Kona ❑✓ North Hilo ✓❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑ Aged ❑✓ Victims of Health or Social Crises ✓❑ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019 -2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Brothers Big Sisters of Hawai'i Island Program Name: One-to-One Mentoring 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $7,250 $7,500 $8,050 2. Agency Mission Statement: The mission of Big Brothers Big Sisters of Hawai'i Island is to provide children facing adversity with strong and enduring, professionally-supported one-to-one relationships that change their lives for the better,forever. Hawaii's youth face a variety of challenges, and being matched with a Big Brothers or Big Sister can help them navigate these challenges and reach their fullest potential.When children and teens have the influence of a caring adult,they are more likely to avoid risky behaviors and to focus on academics.The core of our programming is one-to-one mentoring relationships that are carefully created and professionally supported at every stage.This results in youth achieving higher aspirations, greater confidence, and better relationships, succeeding in high school and college, and avoiding negative influences like drugs and alcohol. 3. Program Description: Big Brothers Big Sisters of Hawai'i Island pairs children in one-to-one friendships with volunteer mentors from nearby high schools, colleges, or the community.We work with school counselors, administrators, and community partners to identify youth who may benefit from the program. Every child we serve is unique, but we target youth from low-income and single parent households,as well as kids that are of Native Hawaiian or Pacific Islander descent. Case Managers meet with interested students to interview, screen, train, and enroll youth and volunteer mentors. Children and mentors are carefully and intentionally paired by our staff based on gender, geography, interests, hobbies, career goals,and personal preferences.The child and mentor meet weekly and participate in activities led by a BBBS Case Manager. In East and West Hawaii we currently work with the Hawaii Department of Education to host mentoring programs for children at four schools: Keaau Elementary(with mentors from Keaau High); Konawaena Elementary(with mentors from Konawaena High); Hilo Intermediate(with mentors from Hawaii Community College&University of Hawaii); and Waiakea Elementary(with mentors from Waiakea High). The goal of Big Brothers Big Sisters of Hawaii Island's mentoring programs give children facing adversity the tools to achieve success in life by matching them in long-term relationships with role models.This results in positive outcomes for youth in three main areas: educational success, avoidance of risky behaviors, and increased social and emotional well-being. 4.Total Budget & Position Count: Total Program Budget: $187,008 Total Program Position Count: .3 Total Agency Budget: $2,005,056 Total Agency Position Count: 29 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Brothers Big Sisters of Hawai'i Island Program Name: One-to-One Mentoring 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Fundraising Events $11,000 Big Brothers Big Sisters Hawaii Foundation, Inc. $25,151 Hawaii Island United Way $6,000 Unrestricted Donations $10,800 Restricted Grants $133,081 TOTAL: $186,032 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We plan to increase revenues by cutting administrative costs.We have removed the East/West Regional Director position, and instead adjusted our staff to have one Regional Director/Case Manager on East and one Regional Director/Case Manager on West Hawaii. Based on the geography of Hawaii Island, having one staff member on each coast will allow us to be more responsive and more dedicated to that specific community, instead of having an oversight position to travel between both areas. By reducing our overhead costs,we will be able to dedicate more grant revenues, individual donations, and event funds to support our programs. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our goal at Big Brothers Big Sisters of Hawaii Island is to be the defenders of potential and ensure the biggest possible future for our youth. We do this by matching at-risk and in-need youth with positive role models at a critical time in development. Mentors help students to see beyond their current circumstances,to achieve academically,to have better relationships with family and friends,to avoid risky negative influences like drugs, alcohol, and gang activity, and to dream big-to become the best versions of themselves. Our staff are professional coaches responsible for recruiting, enrolling, matching,training, and supporting at-risk children and volunteer mentors. It is this professional support of one-to-one relationships that sets our program apart from other mentoring programs and produces lifelong friendships.We respectfully request support from the County of Hawaii to help us achieve these goals and to help us build the next generation of Hawaii. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of FIawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Brothers Big Sisters of Hawai'i Island Program Name: One-to-One Mentoring 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of children and mentors served 90 • Length of one-to-one mentoring friendships 70%remain matched for+6 months Youth Outcomes Survey results 90%show improvement in at least one area Number of weekly afterschool mentoring sessions facilitated by Case Managers 18-20 sessions per program from Oct-May Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $116,543 $116,035 $10,000 Professional Fees • $1,361 $712 Operations $7,388 $12,558 Supplies $1,816 $3,201 Equipment $1,864 $5,699 Other: Program Supplies $2,608 $4,350 Other: Travel/Mileage $6,113 $14,820 Other: Service Fees $3,094 $2,306 Other: Training $238 $1,000 Other: Employee Payroll Taxes and Benefits $26,936 $26,327 TOTAL $167,961 $187,008 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Big Brothers Big Sisters of Hawai'i Island Program Name: One-to-One Mentoring ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor The Managing Director The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: El If no conflicts exist, check here. 9S, J L Q 1—g e—20161 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Brothers Big Sisters of Hawai'i Island Program Name: One-to-One Mentoring 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Brothers Big Sisters of Hawai'i Island Program Name: One-to-One Mentoring 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Brothers Big Sisters of Hawai'i Island Program Name: One-to-One Mentoring 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 90 70%remain matched for+6 months 90%show improvement in at le 18-20 sessions per program from Oct-May TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $10,000 Professional Fees Operations Supplies Equipment Other: Program Supplies Other: Travel/Mileage Other: Service Fees Other: Training Other: Employee Payroll Taxes and Benefits TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Big Island Mediation, Inc. dba West Hawaii Mediation Center Community Mediation 18 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: BigIsland Mediation, Inc. DBA West Hawaii Mediation Center g Y Program Name: Community Mediation Agency Director: Eric Paul Phone No.: (808) 365 — 5444 Contact Person: Eric Paul Phone No.: (808) 365 — 5444 Mailing Address: Address: PO Box 7020 Address: City,ST,Zip Kamuela, HI 96743 Facility Address: Address: 65-1291 Kawaihae Rd. Address: City,ST,Zip Kamuela, HI 96743 Email Address: epaul@whmediation.org Fax No.: ( ) — Accountant/CPA: John Carbonaro Phone No.: (808 ) 930 — 6850 Firm (if applicable): Carbonaro CPAs&Management Group Mailing Address: Address: 136 Kinoole St. Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑✓ Hamakua ❑✓ North Kona ❑South Hilo ❑✓ North Kohala ❑✓ South Kona ❑ North Hilo ❑✓ South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) • ❑ Educational concerns ✓❑Youth ❑✓ Victims of Crimes ❑Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community Mediation 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $7500 $8750 $9,050 2.Agency Mission Statement: Since its founding in 1988,West Hawaii Mediation Center(WHMC)has provided alternative dispute resolution and education services to empower individuals and build communities that view conflict resolution as a catalyst for positive change.Through our mediation and education programs,WHMC provides tools and opportunities for people to resolve their differences in a safe and neutral environment. Recognizing that we all inevitably face conflict as some point in our lives,WHMC provides our clients with the resources necessary for creating lasting, holistic solutions that build bridges and community, rather than barriers and discord. 3. Program Description: WHMC is requesting funding from the County of Hawaii to help sustain and expand its community mediation programs. WHMC's community mediation services are at the core of the work we do. In FY 2017-18,WHMC provided mediation services for 240 cases,serving approximately 516 clients. Of those cases, 133 were court referred(98-District Court; and 35-family court).A total of 107 were self-referred or referred by other sources(social agencies,condo associations, etc.).We are pleased to report that more than 85%of clients served reported being satisfied with their mediation experience. Furthermore, more than 95%said they would recommend our services to others.64%of our clients reported household incomes less than$42,000, while 37%reported household incomes of less than$21,000. WHMC mediation services have proven to help reduce court congestion and provide critical pathways to justice for those who otherwise might lack access. Community mediation fosters meaningful opportunities to reduce stress and anxiety, build stronger relationships,and creates mutual agreements between the individuals involved. It provides an opportunity for all people to access a form ofjustice regardless of income. No one is denied services due to an inability to pay. In the past year,two new judges have been appointed in West Hawaii.Judge Hiatt and Judge DeWeese are strong proponents of community mediation and regularly refer our services to community members.We continue to offer volunteer mediator trainings throughout the year, both basic training and in depth trainings,to retain mediators and ensure the quality of our mediation services.This past year,we implemented mandatory observations/reviews and quarterly mediator roundtables to discuss the challenges mediators face and how to overcome them. • 4.Total Budget& Position Count: Total Program Budget: 168,419 Total Program Position Count: 2 Total Agency Budget: 256,000 Total Agency Position Count: 3.5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community Mediation 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Grants-Private Foundation and Government 67,000 Individual Contributions 27,000 Contracts 40,000 Program Revenue (Mediation/Service Fees) 9,000 Fundraising Events 25,000 TOTAL: 168,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In 2018,WHMC adopted a three-year Strategic plan that outlines an approach to ensure a diversification of income streams. WHMC continues to diversify our board, having added three board member in the past Fiscal Year.We continue to explore new funding opportunities through grants and foundations.We are also intentionally cultivating new individual donor relationships through"friend-raisers"and using fundraising events as an opportunity to share our story and add new partnerships for the future.As per the strategic plan,our 2019 goal is increase the percentage of the budget from 10%donor reliance to 15%. 7. Program Objectives Using County Nonprofit Grant Program Funds: WHMC's Community Mediation program objectives are to 1).continue to provide affordable, accessible mediation and conflict resolution services to the West Hawaii Community;2).expand community training and outreach efforts by continuing to develop our partnerships with the District Courts, Civil Courts, Hawaii Island United Way, Ku'Ikahi Mediation Center, Legal Aid of Hawaii, the Prosecutor's Office,West Hawaii Condo Associations, and other potential community groups;3). recruit and train new volunteer mediators;4). continue to raise awareness about the important services that WHMC provides and the critical role we play in providing access to justice all West Hawaii residents. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community Mediation 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Case Management Hours 2000 Cases Mediated(Court and Self-referred) 200 Individual Clients Served (non-duplicated) 600 Active Volunteer Mediators 35 Volunteer Mediator Hours Served 1000 Workshops and Trainings Offered 15 Attach additional pages as necessary. 9.TABLE II: 11-1S PROGRAM EXPENDITURES FY,.13-±9' FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $97,165.01 $103,000 $6000 Professional Fees $8,096 $6,000 $500 Operations $28,063 $30,500 $6500 Supplies $2259 $2000 $700 Equipment $4,806 $2,300 Other: Benefits And Payroll $15,616.03 $15,000 Other: Training Costs $7,389 $6,350 $800 Other: Advertising & Promotion $533 $850 $500 • Other: Other: TOTAL $163,927.04 $166,000 *If applicable i 62?0 42 Obi`v� (/ 1 ?-(6( r��' � �-et (om�l se r 11,c13 qe JA AcL J s � rccl¢A P,' 17- nuMU'' c0,10 e- 6r`a ✓l� 3-0 i ° EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community Mediation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai`i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Eric Paul POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. e D'o rp±os I — 2 -19 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community Mediation 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community Mediation 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. January 28, 2019 Signature of Authorized Person (see checklist, 2nd item) Date rXPcut;ve Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community Mediation 12. COUNCIL AWARD WORKSHEET TABLE I: . PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Case Management Hours 2000 Cases Mediated 200 Individual Clients Served 600 Active Volunteer Mediators 35 1000 Volunteer Mediator Hours Workshops and Trainings Offered 15 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $6000 Professional Fees $500 Operations $6500 Supplies $700 Equipment Other: Benefits And Payroll Other: Training Costs $800 Other: Advertising & Promotion $500 Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Big Island Mediation, Inc. dba West Hawai'i Mediation Center Peer Mediation and Youth Conflict Resolution 19 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation and Youth Conflict Resolution Agency Director: Eric Paul Phone No.: (808) 365 — 5444 Contact Person: Eric Paul Phone No.: (808) 365 — 5444 Mailing Address: Address: PO Box 7020 Address: City,ST,Zip Kamuela, HI 96743 Facility Address: Address: 65-1291 Kawaihae Rd., Suite 202 Address: City,ST,Zip Kamuela, HI 96743 Email Address: epaul@whmediation.org Fax No.: ( ) — Accountant/CPA: John Carbonaro Phone No.: (808 ) 930 — 6850 Firm (if applicable): Carbonaro CPAs&Management Group Mailing Address: Address: 136 Kinoole St. Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ✓❑ Hamakua ❑✓ North Kona ❑South Hilo ✓❑ North Kohala ❑✓ South Kona ❑ North Hilo ✓❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ✓❑Youth ❑Victims of Crimes ❑Culture and the arts ['Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation and Youth Conflict Resolution 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $8750 $13,644 2.Agency Mission Statement: Since its founding in 1988,West Hawaii Mediation Center(WHMC)has provided alternative dispute resolution and education services to empower individuals and build communities that view conflict resolution as a catalyst for positive change.Through our mediation and education programs,WHMC provides tools and opportunities for people to resolve their differences in a safe and neutral environment. 3. Program Description: West Hawaii Mediation Center(WHMC)is seeking funding for our Peer Mediation Program.This critical program aims to equip Hawaii Island Youth in grades K-12 with conflict resolution skills that will enable them to constructively solve problems in their lives,their communities and the world.WHMC believes that by teaching kids to think creatively about resolving their differences with others,we can prepare them to address more complex problems in adulthood as consensus-builders and community leaders.WHMC Peer Mediation program is involved in conflict resolution training in 11 (eleven)West Hawaii schools, collectively serving more than 3200 students. Peer mediation is a voluntary, non-punitive process that helps students resolve disputes before they escalate into violence. Students in conflict(disputants)can request mediation or be referred by staff or other students. Peer mediators,who work in pairs,do not"make decisions"but rather help disputants work towards a win-win solution for both parties.A unique and essential characteristic of peer mediation is that it is student-focused and student-led.Through peer mediation students become empowered agents of change, co-creating a more peaceful and productive school environment where both teachers and students can focus on learning. 4. Total Budget& Position Count: Total Program Budget: $66,400 Total Program Position Count: 1 Total Agency Budget: $256,000 Total Agency Position Count: 3.5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation and Youth Conflict Resolution 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Grants $40,000 Donations(Individuals and Corporations) $15,000 Fundraising Events $10,000 TOTAL: $65,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In 2018,WHMC adopted a three-year Strategic plan that outlines an approach to ensure a diversification of income streams. WHMC continues to diversify our board, having added three board member in the past Fiscal Year.We continue to explore new funding opportunities through grants and foundations.We are also intentionally cultivating new individual donor relationships through"friend-raisers"and using fundraising events as an opportunity to share our story and add new partnerships for the future.As per the strategic plan, our 2019 goal is increase the percentage of the budget from 10%donor reliance to 15%. 7. Program Objectives Using County Nonprofit Grant Program Funds: WHMC program goals for Peer Mediation include: (1)teaching conflict resolution skills; (2)helping students gain perspective and understanding of themselves and other students; (3)providing a safe forum for kids to resolve differences; (4)reducing suspensions and other disciplinary actions;and(5)addressing problems before they escalate into violence. Our program goals more generally include: 1). Establishing new relationships with schools in order to implement peer mediation; 2). Provide ongoing training to peer mediators;3). Develop Program sustainability in each school;4). Deepen our partnership with the Department of Education through collaborative measures for Restorative Practices; 5). Offer community leadership voice to Restorative Practices cadre through the Department of Education. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation and Youth Conflict Resolution 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Peer Mediators Trained 225 Peer Mediation Trainings/workshops/meeting Hours Delivered 250 Students Indirectly impacted by Peer Mediation Program 3500 Total Peer Mediations Conducted 80 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $37,806.08 $37,500 $8000 Professional Fees Operations $7,428.43 $10,000 $6500 Supplies $307.28 $500 Equipment $776.98 $480 Other: Benefits and Payroll $10,496 $10,000 $500 Other: Other: Other: Other: TOTAL $56,814.77 $58,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation and Youth Conflict Resolution 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Eric Paul POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. 1110 January 28, 2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation and Youth Conflict Resolution 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation and Youth Conflict Resolution IA. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. January 28, 2019 Signature of Authorized Person (see checklist, 2nd item) Date EV-ec,:k v-e Cr e c..2f—c9/- Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Peer Mediation and Youth Conflict Resolution 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Peer Mediators Trained 225 Peer Mediation Trainings/Workshops/Meeting Hours Delivered 250 Students Indirectly impacted by Peer Mediation Program 3500 Peer Mediations Conducted 80 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $8000 Professional Fees Operations $6500 Supplies Equipment Other: Benefits and Payroll $500 Other: Other: Other: Other: . TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Big Island Resource Conservation & Development Council Beyond Organic Consulting 20 Countyof Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: Beyond Organic Consulting Agency Director: Lc, C e<<ct ) Phone No.: ( ) — Contact Person: Brandi Milare, Program Manager Phone No.: (808 ) 217 - 7234 Mailing Address: Address: 200 Kanoelehua Ave. Address: PMB 285 City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 433 Ulu Mau PI. Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: bircd1@gmail.com Fax No.: (888 ) 857 - 1238 Accountant/CPA: N/A Phone No.: ( ) — Firm (if applicable): N/A Mailing Address: Address:N/A Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: Beyond Organic Consulting 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 0 0 2.Agency Mission Statement: The mission of Big Island Resource Conservation and Development Council(BIRCDC)is to assist the people of the Big Island in achieving sustainable development,while caring for,and appreciating their natural environment;to ensure broadened economic opportunities,enriched communities,and better lives. The vision of Big Island Resource Conservation and Development Council(BIRCDC)is to conserve,enhance,and promote the economic, cultural,and natural environment of Hawaii. Beyond Organic Consulting provides food production consulting from garden and farm,to food product and nutritional supplement production with a focus on the ultimate nutritional content,superior flavor,and extended shelf life achieved with environmentally-sustainable methods.The aim is to"Create Health from the Soil Up"by producing nutrient-rich foods using"Beyond Organic"techniques. 3. Program Description: The Nutrition Grown Farming Educational Program was designed to assist Big Island food producers in improving crop success, including the nutritional quality and quantity of foods grown,and their marketability. Scientific studies show significant losses(up to 70%)of soil mineral content and food nutrient content over the past 80 years. Dr.Jana Bogs,(PhD horticulture/food science)developed methods to restore soil and food nutrient content, Nutrition Grown foods have greater nutrient content than typically grown foods,even organically grown,due to a focus on improving nutrient content. Nutrition Grown food nutrient values are approximately double as compared to the USDA food nutrient database values. Growing methods are environmentally friendly,and may be certified organic. Other potential benefits of using these growing methods include greater yields,better flavor, longer shelf life, increased pest and disease resistance,and improved marketability. Additional information may be seen at www.beyondorganicresearch.com. We propose an interactive, online educational program to educate three Big Island farmers about Nutrition Grown methods and to assist them in implementing these methods. The beta-tested course consists of 19 half-hour teaching videos with quizzes, pre-and post-comprehensive soil analyses, plant tissue analyses for food nutrient content compared to USDA values,online group Zoom calls to further teach and answer questions,and on-site one-on-one consulting and materials as necessary to implement the program.Some funding will be allocated for soil amendments/fertilizers,which will be highly beneficial to encourage participation and implementation. The students will grow 200 square foot plots as Nutrition Grown projects, keeping detailed records of crop progression from soil preparation through harvest,along with photo documentation. Data will be posted online and shared by Dr.Bogs at live public presentations for additional educational purposes. Each student successfully completing the course will receive a certificate as proof that they understand the concepts of Nutrition Grown production. 4.Total Budget& Position Count: Total Program Budget: '$59,500 Total Program Position Count: 1 Total Agency Budget: $41,330 Total Agency Position Count: 1 Big Island RC & D Coanu( EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: Beyond Organic Consulting 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate FY 2019-20 State Grant in Aid (Applied/Decision Pending) $49,500 FY 2019-20 County of Hawaii Nonprofit Grant in Aid $10,000 TOTAL: $59,500 • Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This program budget is tailored to fit a total of three farming students. We have submitted an application to the Hawaii State Grant In Aid program for FY 2019-20. If funded,the State GIA will allow us to accommodate up to twelve more students to take part in the program. We plan to apply to other programs,like Hawaii Community Foundation for their FLEX grant and a grant through the Atherton Family Foundation. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Teach Nutrition Grown TM farming techniques to three(3)Big Island food producers primarily via online methods, but also including on-site, hands-on application education. 2)Establish Nutrition Grown TM trial plots on food producers ' land for educational purposes. 3)Perform pre-and post-soil analyses,and plant tissue nutrient analyses with comparisons to USDA values documented. 4)Share information and knowledge gained through online and offline resources,and live presentations at agricultural events. 5)Allow food producers to learn farming techniques which improve crop success and food quality with environmentally-friendly methods. 6)Make more and better quality foods available to Hawaii residents from locally-grown,environmentally-friendly sources. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: Beyond Organic Consulting 8.TABLE]: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of students completing the program 3 students Students responses on evaluation questionnaire 3 questionnaires that evaluate program value Differences in soil quality parameters compared over time(pre-and post-intervention) 3 analyses showing soil parameter improvemer Increases in food nutrient content as compared to USDA Food Nutrient Database values 3 analyses showing increase over USDA value Crop parameters tracked by students regarding crop health,yields,flavor,appearance 3 analyses showing favorable results overall Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages34,300 5,300 Professional Fees 7,500 1,500 Operations Supplies 4,500 900 Equipment Other: Administrative fee for Fiscal Sponsor(10%of total grant) 5,950 1,000 Other: Telecommunication 800 100 Other:Advertising and Promotion 3,000 500 Other: Travel Expense(1,273 miles x$0.55/mile) 3,450 700 Other- TOTAL 59,500 10,000 *If applicable Please Note: The total budget for FY2019-20 would allow for up to 15 students to participate in the program. The County of Hawaii Nonprofit Grant would cover the cost of 3 of those students. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: Beyond Organic Consulting 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: N/A POSITION: N/A May have a conflict or potential conflict of interest, including any familial'relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no conflicts exist, check here. Larry M , Komails , Petc iAn. 01 -25-2019 Signature of Aut'orized Person •= ify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: Beyond Organic Consulting 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: Beyond Organic Consulting 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 01 -25-2019 Signature of Auth• ized Person (see checklist, 2nd item) Date Larry M . Kornad-2 , Presid€n/ Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: Beyond Organic Consulting 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 3 students Number of students completing the program Students responses on evaluation questionnaire 3 questionnaires that evaluateprogram value Differences in soil quality parameters compared over time(pre-and post-intervention) 3 analyses showing soil params 3 analyses showing increase Increases in food nutrient content as compared to USDA Food Nutrient Database values over USDA value 3 analyses showing favorable Crop parameters tracked by students regarding crop health,yields,flavor,appearance results overall TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 5,300 Professional Fees Operations 1,500 Supplies • 900 Equipment Other: Administrative fee for Fiscal Sponsor(10% of total grant) 1,000 Other: Telecommunication 100 Other: Advertising and Promotion 500 Other: Travel Expense (1,273 miles x$0.55/mile) 700 Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Big Island Resource Conservation & Development Council Big Island Invasive Species Committee Invasive Plant Program 21 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: Big Island Invasive Species Committee Invasive Plant Program Agency Director: ixtal �� QHS Phone No.: ( ) — Contact Person: Brandi Milare, Program Manager Phone No.: (808 ) 217 — 7234 Mailing Address: Address: 200 Kanoelehua Ave. Address: pMB 285 City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 433 Ulu Mau PI. Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: bircdl@gmail.com Fax No.: (888 ) 857 — 1238 Accountant/CPA: N/A Phone No.: ( ) — Firm (if applicable): N/A Mailing Address: Address:N/A Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES . Amount of Request for County Nonprofit Grant Program Funds: $64,930 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation & Development Council Program Name: Big Island Invasive Species Committee Invasive Plant Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 n/a n/a n/a 2.Agency Mission Statement: BIISC works island-wide to address invasive species threats to our island's economy,environment,and way of life. In everything we do,our guiding principle is public service. BIISC is a 100%grant-funded project,guided by a volunteer steering committee of expert advisors from agricultural and natural resources conservation agencies. For 20 years we have done the arduous work of going after those high-impact invasive species that have slipped through our state's biosecurity protocols to become established on Hawaii Island. We are often referred to as a gap-filling program,because we focus on those areas where there is a gap in funding,human resources, regulation,jurisdiction,or a literal geographic gap,for example,between the port of entry and a precious native forest,where a new invasive species may be on the loose. Our projects vary from urgent rapid responses(eradicating the illegally introduced Axis Deer and containing Rapid Ohia Death in N. Kohala)to long-term community engagement programs to help address entrenched pests(our community Fire Ant Fighters and Albizia Assassins programs). With each new pest that is introduced,and each new demand for time and attention,we risk setting our successfully run, longer-term projects on the back burner. Of course,when it comes to a fast-growing,rapidly reproducing invasive species, there is no such thing as the back-burner! In this proposal,therefore,we are asking for the County's support for our longest running,core program:invasive plant control.With the county's help we can preserve our farms,forests,and watersheds. 3. Program Description: With a few exceptions, invasive plants are not regulated in Hawaii. Nonetheless,plants like miconia&strawberry guava have caused tremendous harm to our native forest and depleted our watersheds;torpedo grass,fireweed,&fountain grass have inflicted great costs to our farms and ranches as weeds and as fuel for raging fires;and hazardous albizia,thorny vines,and allergen-inducing weeds impact our health,safety,and enjoyment of the outdoors. These impacts are felt island-wide. Sadly, many invasive plants were intentionally introduced for sale before anyone knew their impact. Worse,while knowing the risks, the state continues to allow new invasive plants a free pass to be introduced to Hawaii and sold in the nursery trade today! To address this"growing"issue,the Big Island Invasive Species Committee(BIISC)Plant Control Program uses a four-dimensional approach and seeks partial financial support from the County to carry out this core programming: 1. Plant Pono Business Endorsement:We work with the landscape&nursery industry to voluntarily screen and phase out the import and sale of harmful invasive plants. 2. Early Detection:Through active surveillance and a citizen"eyes and ears"network,we monitor the island for new invasive plants,so they can be eradicated while it is still cost effective. 3. Rapid Response:We have an narrow window of time to act. For those species that have recently become established on the island and can still be eradicated,our dedicated team works tirelessly until the last seedling is removed. 4.Containment and Control: For some species, like albizia and fountain grass, it is too late to eradicate—yet the harm inflicted is to great to ignore! We work with a broad range of partners to prioritize effort where significant gains can be made. 4. Total Budget& Position Count: Total Program Budget: $657,632 Total Program Position Count: 10 13lISC Total Agency Budget: $1,662,365 Total Agency Position Count: 24 Big /stand RC 8,0 Cou#i ;/ .fi4I, 33& / (paid) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation & Development Council Program Name: Big Island Invasive Species Committee Invasive Plant Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Hawaii Invasive Species Council $357,908 Hawaii Department of Agriculture $31,350 Hawaii Tourism Authority $25,000 TOTAL: $414,258 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BIISC has survived for 20 years as a 100%grants funded project of the University of Hawaii,and during the past five years has become fiscally sponsored by the non-profits Big Island RC&D and the UH Foundation. As a result,we have increased revenues from private foundations and other out of state sources to supplement an ever-shifting landscape of government grant support. We rely on scientific research and engagement with public agencies and our community to increase awareness of the harm caused by invasive plants to our economy,environment,and way of life. To the extent that we can make that case clear,our work is financially supported,but our capacity does shrink or expand as public funding and attention waxes and wanes. In 2019 to make up the expected shortfall in core funding,we expect to take on two service contracts to control invasive plants on Hawaii DOD training areas and Natural Area Reserves. These contracts allow us to maintain our highly trained staff year-round and support the mission of these state agencies,without stepping away from our core invasive plant control mission. While we always need new sources of funds,rather than increasing revenues,we seek to maintain a steady,reliable program, and to improve public policy,for example by restricting the import of known invasive species,so that we can one day work our way out of business. 7. Program Objectives Using County Nonprofit Grant Program Funds: In FY2019-2020 the requested funds,approximately 10%of the program's annual cost,will help us achieve three primary objectives. All species listed are eradication targets—if we are successful,they will no longer be able to harm our island. 1.Complete the third round of surveys for three aggressive invasive plant species:toxic rubbervine(Kona-S.Kohala); smokebush(Waimea to Volcano);and silver-leaved cotoneaster(Ka'u and S.Hilo).Roughly half of the third round of surveys were completed in 2018,with the second half scheduled for the coming year,approximately 600 acres. 2.Complete the initial control operations of a thorny vining cactus called Pereskia at three sites in Puna, Ka'u and Kona,on seven parcels of land. 3.Complete the annual on-site survey of 33 retail nurseries on the island,to measure our success at reducing sales of invasive plants.This survey is designed to measure overall progress at reducing invasive plant sales,and to compare rates of sales in Plant Pono participating and non-participating nurseries. Previous results indicated that all participating nurseries had phased out sales,and even non-participating nurseries had significantly reduced the number of invasive plants in their inventory--from 86%to 59%selling invasives. The 2019 survey is important to confirm whether these are lasting results,and to detect any new high-risk invasive plants that may have entered the island's ornamental plant supply chain. Funds will support one field technician(1 FTE)and the Plant Pono Specialist(0.2 FTE),plus a portion of operations and supplies. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 - Page 3 of 8 Countyof Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation & Development Council Program Name: Big Island Invasive Species Committee Invasive Plant Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Survey and remove invasive plants from all phase-3 parcels not surveyed in 2018 600 acres. Conduct intial control operations on 7 parcels known to have Pereskia aculeata 7 parcels,about 20 acres. Conduct annual survey of retail nurseries to detect invasive plants in inventory 33 businesses. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 468,385 51,030 Professional Fees 12,500 1,500 Operations 28550 2,400 Supplies 19,500 3,215 Equipment 0 0 Other: BackcountryTravel 1,776 292 Other: Conference Travel (one conference on Oahu, once every two yrs) 13,500 0 Other: Rental: Baseyard and Office Facility, utilities, 24,444 0 Other: PCSU (UH Direct Rate for TOTAL BUDGET Line) 30,581 Other: Indirect Rate 10% (varies on some categories, grants) 58,396 6,493 TOTAL $657,672 $64,930 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: Big Island Invasive Species Committee Invasive Plant Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in genera!to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Q If no conflicts exist, check here. L trry M. Korna-a. , PrtSic e.n I 01 -28-2019 Signature of Authorized Pers (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation & Development Council Program Name: Big Island Invasive Species Committee Invasive Plant Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: Big Island Invasive Species Committee Invasive Plant Program Zi. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 01 -28-2019 Signature of Authorized Person (see checklist, 2nd item) Date Lam! M M. R'omaf-a, � Prnsidzn i Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation & Development Council Program Name: Big Island Invasive Species Committee Invasive Plant Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Survey and remove invasive plants from all phase-3 parcels not surveyed in 2018 600 acres. Conduct intial control operations on 7 parcels known to have Pereskia aculeata 7 parcels,about 20 acres. Conduct annual survey of retail nurseries to detect invasive plants in inventory. 33 businesses. TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 51,030 Professional Fees 1,500 Operations 2,400 Supplies 3,215 Equipment 0 Other: Backcountry Travel 292 Other: Conference Travel (one conference on Oahu, once every two yrs) 0 Other: Rental: Baseyard and Office Facility, utilities, 0 Other: PCSU (UH Direct Rate for TOTAL BUDGET Line) Other: Indirect Rate 10% (varies on some categories, grants) 6,493 TOTAL $64,930 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Big Island Resource Conservation & Development Council UHH College of Agriculture, Forestry & Natural Resource Management 22 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: UHH College of Agriculture, Forestry & Natural Resource Manac Agency Director: N/A v r l `on , I PrcA, Phone No.: ( ) — Contact Person: Brandi Milare, Program Manager Phone No.: (808 ) 217 — 7234 Mailing Address: Address: 200 Kanoelehua Ave. Address: PMB 285 City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 433 Ulu Mau PI. Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: bircd1@gmail.com Fax No.: (888 ) 857 — 1238 Accountant/CPA: N/A Phone No.: ( ) — Firm (if applicable): N/A Mailing Address: Address:N/A Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona South Kohala r 111 North Hilo ❑ Ka'u❑ Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: UHH College of Agriculture, Forestry & Natural Resource Manac 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 � FY 18-19 0 0 0 2.Agency Mission Statement: The mission of Big Island Resource Conservation and Development Council(BIRCDC)is to assist the people of the Big Island in achieving sustainable development,while caring for,and appreciating their natural environment;to ensure broadened economic opportunities,enriched communities,and better lives. The vision of Big Island Resource Conservation and Development Council(BIRCDC)is to conserve,enhance,and promote the economic,cultural,and natural environment of Hawai'i. The mission of our University of Hawaii at Hilo'ohana(family)is to challenge students to reach their highest level of academic achievement by inspiring learning,discovery and creativity inside and outside the classroom. Our kuleana(responsibility)is to improve the quality of life of the people of Hawai'i,the Pacific region,and the world. Link: http://hilo.hawaii.edu/catalog/mission 3. Program Description: The College of Agriculture, Forestry,and Natural Resource Management(CAFNRM)is part of the University of Hawai'i at Hilo. The main objective of CAFNRM is to prepare students for a broad and full understanding of basic factors involved in production, management, processing,distribution, marketing,sales,and services in the field of agricultural sciences. To achieve this goal, CAFNRM offers the Bachelor of Science degree(BS)in four areas of specialization:Animal Science,Aquaculture,Tropical Horticulture,and Tropical Plant Science&Agroecology. In order to prepare students for immediate careers in agriculture,as well as further graduate study,the program blends comprehensive classroom instruction with practical,technology-based education through use of the University of Hawai'i at Hilo Agricultural Farm Laboratory. On 110 acres in Pana'ewa,five miles south of the main campus,students can experience putting theory into practice with hands-on learning in various enterprises such as hydroponics,floriculture plants,forestry,vegetables, sustainable agriculture,livestock production,equine science,beekeeping,tropical fruit,and aquaculture. Link:http://hilo.hawaii.edu/academics/cafnrm/ Recently,CAFNRM has planned to extend its hands on education through experiential learning on the dominant and staple crop of the tropics, rice(Oryza sativa L.). In Hawai'i, rice production was established in the 1860's (http://ricefest.com/all-about-rice/). However,none of the Hawaiian farmers are growing rice currently. This situation could be reversed if high value rice varieties such as Koshikihari and Carolina Gold are successfully tested in Hawai'i. 4. Total Budget& Position Count: Total Program Budget: $87,000 Total Program Position Count: 1 Total Agency Budget: $41,330 Total Agency Position Count: 1 B;9 Island e c&o C oun cH EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: UHH College of Agriculture, Forestry & Natural Resource Manac 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate State of Hawaii (General Funds) (annual salary for PI) $77,000.00 County of Hawaii (this proposal) $10,000.00 TOTAL: $87,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: As mentioned,the CAFNRM educates through experiential learning and hands on projects.As a part of class/laboratory, students are involved in growing plants, and selling those college grown plants(such as poinsettia)to the college/university community.Collected monies are used to purchase educational supplies and expand programs where applicable. 7. Program Objectives Using County Nonprofit Grant Program Funds: The broad objective of this project is to evaluate the performance of selected rice varieties in Hawai'i.The specific objective of this proposal is to educate undergraduate students on rice husbandry practice through an experiential learning approach. Rice varieties(i)Carolina Gold,(ii)Koshikihari, (iii)White Basmati and (iv)Jefferson will be seeded separately in community pots at the UH-Hilo greenhouse.At 1-month, rice seedlings will be transplanted into pots and/or field plots. Each transplanted rice variety will be replicated at least four times and rice transplanted pots/plots will be arranged in randomized complete blocks. Students enrolled in an agriculture/horticulture course such as Principles of Horticulture(HORT 262)will be mentored in rice growing and experiment conducting procedures.Activities such as rice seed sowing,seedling transplanting,experiment pot/plot setting, labeling,fertilizer applying,data recording, harvesting,data analyzing and presenting will be performed with the involvement of students.At the end of rice growing,soil samples from rice rhizosphere will be taken,soil nematodes will be extracted, identified and correlated with rice yield. Potential economic viability of rice production will be assessed. Project findings will be presented at an annual CAFNRM symposium at UH-Hilo. It is expected that 15 students will be directly involved in this proposed experiential learning. Moreover, about 300 CAFNRM/UH-Hilo community members will review this work at the CAFNRM symposium.The findings of this project could benefit the farmers and the entire agriculture community of Hawai'i. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: UHH College of Agriculture, Forestry & Natural Resource Manac B.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Student number directly involved in proposed project 15 students Conducting rice varietal experiment(with the involvement of students) 1 experiment Presenting experiment findings at CAFNRM symposium at UH-Hilo 1 event Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $77,000.00 $77,000.00 $0.00 Professional Fees $0.00 $0.00 $0.00 Operations $0.00 $0.00 $0.00 Supplies $0.00 $0.00 $2053.00 Equipment $0.00 $0.00 $6,947.00 Other: Fiscal Sponsor Administrative Fee (10% of total grant) $1000.00 Other: Other: Other: Other: TOTAL $77,000.00 $77,000.00 $10,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: UHH College of Agriculture, Forestry & Natural Resource Manac 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: N/A POSITION: N/A May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Q If no conflicts exist, check here. Lett- M. K , Pre-sidem f 01 -25-2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Council Island Resource Conservation and Development Agency Name: Big Isla d p Program Name: UHH College of Agriculture, Forestry & Natural Resource Manac 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: UHH College of Agriculture, Forestry & Natural Resource Manac g 9 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 01 -25-2019 Signature of Authorized Person (see checklist, 2nd item) Date Larry IV) • Komata. , Presidenf Title/Position of Authorized Person EXHIBIT.A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Resource Conservation and Development Council Program Name: UHH College of Agriculture, Forestry & Natural Resource Manac 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 15 students Student number directly involved in proposed project Field/greenhouse experiment number 1 experiment Symposium presentation 1 event TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $0.00 Professional Fees $0.00 Operations $0.00 Supplies $2053.00 Equipment $6,947.00 Other: Fiscal Sponsor Administrative Fee (10% of total grant) $1000.00 Other: Other: Other: Other: TOTAL $10,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Big Island Substance Abuse Council (Mahi 'ai Ola) Wellness Garden 23 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: (Mahi'ai Ola) Wellness Garden Agency Director: Dr. Hannah Preston-Pita Phone No.: (808) 969 - 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 - 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 Facility Address: Address: TMK#1-6-003-007 Address: City,ST,Zip Keaau, Hawaii 96749 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 - 7570 Accountant/CPA: Carbonaro CPA Phone No.: (808 ) 930 - 7570 Firm (if applicable): Carbonaro CPA Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ['South Kona ❑✓ North Hilo ['South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑✓ Victims of Crimes ❑✓ Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment 1 Mil EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: (Mahi'ai Ola) Wellness Garden 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 $8750.00 0 2. Agency Mission Statement: Agency Mission Statement: Inspiring individuals to reclaim and enrich their lives by utilizing innovative resources and harnessing the strengths within each person. Program's goal is to provide opportunities for individuals to regain identity through land-based interventions that help: restore and nurture native forest and create a viable food garden in a kipuka within the ahupua'a of Kea'au while empowering participants through a variety of hands-on experiences that encourage cultural pride, respect for the'aina, responsible land stewardship and increased awareness of sustainable agricultural practices. Policies and procedures comply with all State and Federal laws prohibiting discrimination against all individuals regardless of their race, color, national origin, religion, creed,gender, sexual orientation, age or disability.The agency strives to instill dignity, respect, hope and compassion to all our clients and families. 3. Program Description: The Garden is congruent with all aspects of BISAC's mission,vision and values. This program focuses on therapeutic horiticulture which works alongside an individual's treatment. The program utilizes cultural concepts to help rediscover one's self. The cultural approach is intended to educate and encourage the individual and support their sobriety. Lessons are focused on food systems,sustainable agricultural, and healthy lifestyle practices. The ultimate goal is to learn about being stewards of the land through physical, emotional and spiritual connections with their environment. 4. Total Budget& Position Count: Total Program Budget: $150,000 Total Program Position Count: 11 Total Agency Budget: $4,500,000 Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: (Mahi'ai Ola) Wellness Garden 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Kamehameha School's Community Grants $88,000 OHA $25,000 County of Hawaii $37,000 TOTAL: $150,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BISAC plans to incorporate farm to table(farm to trailer)activities to help support our sustainability plan. This sustainability plan provides opportunities for BISAC to diversify revenue streams to help fund treatment. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Increase opportunities for individuals to participate in land-based interventions that help build a sense of purchase and reclaim identity. 2. Achieve an efficient level of food production and create a viable agricultural enterprise within an existing portion of the parcel that has initially been cleared and designated for farming. 3. Create revenue streams from Garden activities that help sustain the program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: (Mahi'ai Ola) Wellness Garden 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Clients Served 100 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 56,305 91,9000 23,732 Professional Fees 1,521 15,107 0 Operations 6,536 31,310 8,500 Supplies 1,296 6,647 1,768 Equipment 5,170 5,100 3,000 Other: Other: Other: Other: Other: TOTAL 70,830 150,000 37,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: (Mahi'ai Ola) Wellness Garden 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the Council n The Mayor n The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. �Aitoiliarychief Executive Officer 1 /27/19 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: (Mahi'ai Ola) Wellness Garden 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 r County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: (Mahrai Ola) Wellness Garden 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. ��( 0 (56\l 1 /27/1 9 Signature of Authorized Person (see checklist, 2nd item) Date Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 . County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: (Mahi'ai Ola) Wellness Garden 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Clients Served 100 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 23,732 Professional Fees 0 Operations 8,500 Supplies 1,768 Equipment 3,000 Other: Other: Other: Other: Other: TOTAL 37,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Big Island Substance Abuse Council Community Outreach 24 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Community Outreach Agency Director: Dr. Hannah Preston-Pita Phone No.: (808) 969 — 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 — 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 Facility Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Keaau, HI 96749 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 — 7570 Accountant/CPA: Carbonaro CPA Phone No.: (808 ) 930 — 7570 Firm (if applicable): Carbonaro CPA Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns Q✓ Youth ❑✓ Victims of Crimes ❑✓ Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 , County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Community Outreach 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $6125.00 0 0 2. Agency Mission Statement: Agency Mission Statement: Inspiring individuals to reclaim and enrich their lives by utilizing innovative resources and harnessing the strengths within each person. Program's goal is to enhance well-being and create meaningful changes in the community that we serve. Policies and procedures comply with all State and Federal laws prohibiting discrimination against all individuals regardless of their race, color, national origin, religion, creed, gender,sexual orientation, age or disability.The agency strives to instill dignity, respect, hope and compassion to all our clients and families. 3. Program Description: BISAC's continuity of services has provided the opportunity to expand in outreach areas. BISAC's experience in these community efforts include: 1)facilitating community events to bring awareness and support to rural under-served communities; 2)provided outreach support in a multi-disciplinary crisis team; and 3)participated in community coalitions which encourages partnerships to focus on various community needs, Expansion of BISAC's outreach efforts will continue to help us educate and empower community to improve overall community well-being with the main purpose of strengthening community partnerships, building resource capacity, providing community awareness by enhancing protective factors and minimizing psycho-social risk factors. 4. Total Budget& Position Count: Total Program Budget: $25,000.00 Total Program Position Count: 10 Total Agency Budget: $4,500,000 Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Community Outreach 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate OHA $5000 County $10,000 Other Sources $10,000 TOTAL: $25,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BISAC continues efforts to diversify funding sources, expand services, and increase efficiency. BISAC's electronic medical records system increased efficiency in both clinical and billing areas. BISAC's current system allows for quicker response time for payment of claims. BISAC continues to utilize our vocational training tracks(e.g. culinary food trailer, BISAC Koho Pono products, and garden produce)as a means of generating funds that support treatment. BISAC's sound fiscal policies are incorporated into decisions related to program expansion or to enter market niches that would expand the behavioral health continuum.These additional revenue streams are an effort to support capacity building,sustainability efforts, and reduce reliance on State and County funds. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Expand outreach efforts to help educate and empower communities. 2. Strengthen community partnerships. 3. Building resource capacity. 4. Provide community awareness. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Community Outreach 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Outreach event attendees 1000 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations 4000 Supplies Equipment Other: Equiptment 2500 Other: Site Rental 2500 Other: Other: Other: TOTAL 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Community Outreach 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor n The Managing Director n The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. cm-Chief Executive Officer 1 /27/19 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: BigIsland Substance Abuse Council g Y Program Name: Community Outreach 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Community Outreach 11. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. C— 1 /27/1 9 Signature of Authorized Person (see checklist, 2nd item) Date Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Community Outreach 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Community Outreach Attendees 1000 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees Operations 4000 Supplies Equipment Other: Equiptment 2500 Other: Site Rental 2500 Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Big Island Substance Abuse Council East Hawaii Substance Abuse Treatment Services 25 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: East Hawaii Substance Abuse Treatment Services Agency Director: Dr. Hannah Preston-Pita Phone No.: (808) 969 — 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 — 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 Facility Address: Address: 297 Waianuenue Avenue(Bldg.2) Address: City,,ST,Zip Hilo, Hawaii 96720 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 — 7570 Accountant/CPA: Carbonaro CPA Phone No.: (808) 930 — 7570 Firm (if applicable): Carbonaro CPA Mailing Address: Address: P.O. Box4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona Q✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Kali Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ❑Youth ❑✓ Victims of Crimes Q✓ Culture and the arts Q✓ Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: East Hawaii Substance Abuse Treatment Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $21,250.00 $19,750.00 0 2.Agency Mission Statement: Agency Mission Statement: Inspiring individuals to reclaim and enrich their lives by utilizing innovative resources and harnessing the strengths within each person. Program's Goal is supporting our community to live an enriched life of health, happiness and overall well-being. Policies and procedures comply with all State and Federal laws prohibiting discrimination against all individuals regardless of their race, color, national origin, religion, creed, gender, sexual orientation, age or disability.The agency strives to instill dignity, respect, hope and compassion to all our clients and families. 3. Program Description: BISAC's EH programs provide comprehensive substance abuse treatment services for adults and adolescents through evidenced-based methods and best-practices designed for the area's target population. BISAC's continuum of care includes: Day Treatment, Intensive Outpatient, Outpatient, Continuing Care, Therapeutic Living, and Clean Sober Living, and Prevention Programs. BISAC recognizes the significant impact of substance abuse on individuals,families, children, and communities and has designed programs to intervene in the addiction process and build on an individual's and/or family's strengths to abstain from the use of substances, increase protective factors, and relapse prevention skills to maintain their sobriety. Our comprehensive program includes the following supplementary programs to address risk factors(e.g. unemployment, mental illness,trauma, etc.).These programs include: 1) Po'okela Program which provides vocational training and application(e.g. resume building, interviewing,time management, etc.). Upon completion several trades within the organization have been established for on the job training(e.g.food truck, maintenance, clerical,etc.).2)The Hawaii Island Health and Wellness Center is a mental health department with Licensed Providers who provide specialized MH treatment. 4. Total Budget & Position Count: Total Program Budget: $1,500,000 Total Program Position Count: 11 Total Agency Budget: $4,500,000 Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: East Hawaii Substance Abuse Treatment Services 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate SOH, DOH Alcohol and Drug Abuse Division 443,050 SOH, Judiciary(BI Drug Court) 80,313 SOH, Dept. of Public Safety, Hawaii Paroling Authority 56,330 3rd Party Insurance 785,243 Client Fees 14,056 County of Hawaii 106,953 Other Sources 14,056 TOTAL: $1,500,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BISAC continues efforts to diversify funding sources,expand services, and increase efficiency. BISAC's electronic medical records system increased efficiency in both clinical and billing areas. BISAC's current system allows for quicker response time for payment of claims. BISAC continues to utilize our vocational training tracks(e.g. culinary food trailer, BISAC Koho Pono products, and garden produce)as a means of generating funds that support treatment. BISAC's sound fiscal policies are incorporated into decisions related to program expansion or to enter market niches that would expand the behavioral health continuum.These additional revenue streams are an effort to support capacity building,sustainability efforts, and reduce reliance on State and County funds. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide immediate access to assessment and treatment services to any individuals who are assessed and diagnosed with any substance related disorders and/or 2. Increase the availability of extended outpatient and therapeutic living/Clean and Sober program treatment services for uninsured or under-insured individuals who have no funding available for treatment services and/or other specialized services provided by BISAC and/or 3. Identify social support networks and community linkages which support continuity of treatment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: East Hawaii Substance Abuse Treatment Services 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Treatment Units 200 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 842,246 1,125,098 69,387 Professional FP?.s 0 29,727 0 Operations 143,611 251,671 28,242 Supplies 38,679 44,310 9,324 Equipment 0 49,194 0 Other: Other: Other: Other: Other: TOTAL 1,024,537 1,500,000 106,953 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: East Hawaii Substance Abuse Treatment Services 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. , 7--,R,-.07614\itChief Executive Officer 1 /27/19 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: East Hawaii Substance Abuse Treatment Services 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: East Hawaii Substance Abuse Treatment Services 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's uture undin. re.uest and ma result in actions taken to recover these unds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1 /27/19 Signature of Authorized Person (see checklist, 2nd item) Date Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: East Hawaii Substance Abuse Treatment Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Treatment Units 200 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 69,387 Professional Fees 0 Operations 28,242 Supplies 9,324 Equipment 0 Other: Other: Other: Other: Other: TOTAL 106,953 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Big Island Substance Abuse Council Hawai'i Island Health and Wellness Center- Hilo 26 { �i` Fri County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Hilo Agency Director: Dr. Hannah Preston-Pita Phone No.: (808) 969 — 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 — 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 Facility Address: Address: 297 Waianuenue Avenue(Bldg.2) Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 — 7570 Accountant/CPA: Carbonaro CPA Phone No.: (808) 930 — 7570 Firm (if applicable): Carbonaro CPA Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ✓ Puna n Hamakua E North Kona 0 South Hilo ❑✓ North Kohala ❑South Kona ❑✓ North Hilo Q✓ South Kohala 0✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ✓Q Educational concerns ✓❑Youth [Victims of Crimes ❑ Culture and the arts ✓Z Aged ❑✓ Victims of Health or Social Crises Z✓ Needs of the poor Physical/Emotional Disabilities ✓Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 `[a County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Hilo 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $15,000.00 $18,500.00 0 2.Agency Mission Statement: Agency Mission Statement: Inspiring individuals to reclaim and enrich their lives by utilizing innovative resources and harnessing the strengths within each person. Program's Goal is to enhance well-being and create meaningful changes in the community that we serve. Policies and procedures comply with all State and Federal laws prohibiting discrimination against all individuals regardless of their race, color, national origin, religion, creed, gender, sexual orientation, age or disability.The agency strives to instill dignity, respect, hope and compassion to all our clients and families. 3. Program Description: The Hawaii Island Health and Wellness Center(HIHWC)is a subsidiary of the Big Island Substance Abuse Council. Established in 2011, HIHWC has treated over 1500 individuals on the island of Hawaii. HIHWC provides individual,group, couple's and family treatment to adults, children, and adolescents. Licensed therapists use evidenced-based therapies focusing on mental health issues such as depression, anxiety, relationships,parenting,adjustment,smoking cessation,weight management,sleep difficulties,etc. Other components of the program is to assist with closing gaps in service for rural under-served areas and providing training opportunities to Licensure Candidates to gain licensure and provide well needed services. Currently,we have 2 licensed professionals, 1 post doc,2 pre-doc, and 1 pre-licensure. 4.Total Budget& Position Count: Total Program Budget: $300,000.00 Total Program Position Count: 3.5 Total Agency Budget: $4,500,000.00 Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Hilo 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Third Party Billing 240,000.00 HIUW 7,000.00 Kokua EAP 3,000.00 County 50,000.00 TOTAL: 300,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BISAC continues efforts to diversify funding sources,expand services,and increase efficiency. BISAC's electronic medical records system increased efficiency in both clinical and billing areas. Its capacity to do electronic billing has helped because of quick turn around time and baseline cash flow. HIHWC complied with federal law requirements by implemented the IC-10 and DSM V codes to allow for quick turnaround time for insurances to pay on claims. New programs and policies increased revenue and expanded BISAC's capacity to treat clients. HIHWC built their capacity to treat by including a licensure training program to help address needs in services and revenue. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide immediate access to psychological evaluations and treatment services to any adults requiring mental health services and/or 2. Increase the availability of psychological services(e.g. individual and groups)to adults who may have no funding or under-insured for treatment services and/or 3. Provide mobile treatment services in rural areas(e.g.Wellness Groups at micro-units). EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Hilo 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Mental Health Units 100 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 212,405 252,431 30,765 Professional Fees 956 16,937 2,500 Operations 1,528 21,407 14,100 Supplies 57 4,131 2,000 Equipment 87 5,100 635 Other: Other: Other: Other: Other: TOTAL 215,023 300,000 $50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council. Program Name: Hawaii Island Health and Wellness Center - Hilo 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): I-1 Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓ If no conflicts exist, check here. - (? Chief Executive Officer 1/27/19 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Hilo ii. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Hilo 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 eneral liability, 50 000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1 /27/19 Signature of Authorized Person (see checklist, 2nd item) Date Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Hilo 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Mental Health Units 100 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 30,765 Professional Fees 2,500 Operations 14,100 Supplies 2,000 Equipment 635 Other: Other: Other: Other: Other: TOTAL $50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Big Island Substance Abuse Council Hawai'i Island Health and Wellness Center- Kea'au 27 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Keaau Agency Director: Dr. Hannah Preston-Pita Phone No.: (808) 969 — 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 — 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 Facility Address: Address: 297 Waianuenue Avenue(Bldg. 2) Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 — 7570 Accountant/CPA: Carbonaro CPA Phone No.: (808) 930 — 7570 Firm (if applicable): Carbonaro CPA Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna Hamakua [' North Kona ❑✓ South Hilo Q North Kohala ['South Kona 0 North Hilo ['South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ✓❑Youth ❑✓ Victims of Crimes ❑ Culture and the arts Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ✓❑ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Keaau 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $15,000 $18,500 0 2. Agency Mission Statement: Agency Mission Statement: Inspiring individuals to reclaim and enrich their lives by utilizing innovative resources and harnessing the strengths within each person. Program's Goal is to enhance well-being and create meaningful changes in the community that we serve. Policies and procedures comply with all State and Federal laws prohibiting discrimination against all individuals regardless of their race, color, national origin, religion, creed, gender, sexual orientation, age or disability.The agency strives to instill dignity, respect, hope and compassion to all our clients and families. 3. Program Description: The Hawaii Island Health and Wellness Center(HIHWC)is a subsidiary of the Big Island Substance Abuse Council. Established in 2011, HIHWC has treated over 1500 individuals on the island of Hawai'i. HIHWC provides individual,group, couple's and family treatment to adults, children, and adolescents. Licensed therapists use evidenced-based therapies focusing on mental health issues such as depression, anxiety, relationships, parenting, adjustment,smoking cessation,weight management, sleep difficulties, etc. Other components of the program is to assist with closing gaps in service for rural under-served areas and providing training opportunities to Licensure Candidates to gain licensure and provide well needed services. Currently,we have 2 licensed professionals, 1 post doc, 2 pre-doc, and 1 pre-licensure. 4. Total Budget & Position Count: Total Program Budget: $300,000.00 Total Program Position Count: 3.5 Total Agency Budget: $4,500,000.00 Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Keaau 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Third Party Billing 240,000 HIUW 7,000 Kokua EAP 3,000 County 50,000 TOTAL: 300,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BISAC continues efforts to diversify funding sources, expand services, and increase efficiency. BISAC's electronic medical records system increased efficiency in both clinical and billing areas. Its capacity to do electronic billing has helped because of quick turn around time and baseline cash flow. HIHWC complied with federal law requirements by implemented the IC-10 and DSM V codes to allow for quick turnaround time for insurances to pay on claims. New programs and policies increased revenue and expanded BISAC's capacity to treat clients. HIHWC built their capacity to treat by including a licensure training program to help address needs in services and revenue. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide immediate access to psychological evaluations and treatment services to any adults requiring mental health services and/or 2. Increase the availability of psychological services(e.g. individual and groups)to adults who may have no funding or under-insured for treatment services and/or 3. Provide mobile treatment services in rural areas . EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Keaau 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Mental Health Units 100 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 212,405 252,431 30,765 Professional Fees 956 16,931 2,500 Operations 1,528 21,407 14,100 Supplies 57 4,131 2,000 Equipment 87 5,100 635 Other: Other: Other: Other: Other: TOTAL 215,023 300,000 $50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Keaau 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. Chief Executive Officer 1 /27/19 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Keaau 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Keaau 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1 /27/1 9 Signature of Authorized Person (see checklist, 2nd item) Date Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 , County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Keaau 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Mental Health Units 100 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 30,765 Professional Fees 2,500 Operations 14,100 Supplies 2,000 Equipment 635 Other: Other: Other: Other: Other: TOTAL $50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Big Island Substance Abuse Council Hawaii Island Health and Wellness Center- Provider Training 28 r County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Provider Training Agency Director: Dr. Hannah Preston-Pita Phone No.: (808) 969 - 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 - 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 Facility Address: Address: 297 Waianuenue Avenue(Bldg.2) Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 - 7570 Accountant/CPA: Carbonaro CPA Phone No.: (808 ) 930 - 7570 Firm (if applicable): Carbonaro CPA Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna Hamakua [' North Kona ✓❑South Hilo ❑✓ North Kohala ❑South Kona ✓❑ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ❑✓ Youth ❑✓ Victims of Crimes ❑ Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ✓❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 T County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Provider Training 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 0 0 2.Agency Mission Statement: Agency Mission Statement: Inspiring individuals to reclaim and enrich their lives by utilizing innovative resources and harnessing the strengths within each person. Program's Goal is to enhance well-being and create meaningful changes in the community that we serve. Policies and procedures comply with all State and Federal laws prohibiting discrimination against all individuals regardless of their race, color, national origin, religion, creed, gender, sexual orientation, age or disability.The agency strives to instill dignity, respect, hope and compassion to all our clients and families. 3. Program Description: The Hawaii Island Health and Wellness Center(HIHWC)is a subsidiary of the Big Island Substance Abuse Council. Established in 2011, HIHWC has treated over 1500 individuals on the island of Hawai'i. HIHWC provides individual, group, couple's and family treatment to adults, children, and adolescents. Licensed therapists use evidenced-based therapies focusing on mental health issues such as depression,anxiety, relationships, parenting, adjustment,smoking cessation,weight management,sleep difficulties, etc. Other components of the program is to assist with closing gaps in service for rural under-served areas and providing training opportunities to Licensure Candidates to gain licensure and provide well needed services. Currently,we have 2 licensed professionals, 1 post doc,2 pre-doc, and 1 pre-licensure. BISAC is a designated National Health Service Corp providing opportunities for licensed individuals to pay down their student loans. 4. Total Budget& Position Count: Total Program Budget: $300,000.00 Total Program Position Count: 3.5 Total Agency Budget: $4,500,000.00 Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Provider Training 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Third Party Billing 240,000.00 HIUW 7,000.00 Kokua EAP 3,000.00 County 50,000.00 TOTAL: 300,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BISAC continues efforts to diversify funding sources, expand services, and increase efficiency. BISAC's electronic medical records system increased efficiency in both clinical and billing areas. Its capacity to do electronic billing has helped because of quick turn around time and baseline cash flow. HIHWC complied with federal law requirements by implemented the IC-10 and DSM V codes to allow for quick turnaround time for insurances to pay on claims. New programs and policies increased revenue and expanded BISAC's capacity to treat clients. HIHWC built their capacity to treat by including a licensure training program to help address needs in services and revenue. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Increase opportunities for providers to receive training hours for licensure. 2. Secure therapist to assist with rural underserved areas with low provider turn-out. 3. Build opportunities for provider retention and recruitment for providers to remain on island. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Provider Training 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Provider Training Hours 1000 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 212,405 252,431 30,765 Professional Fees 956 16,937 2,500 Operations 1,528 21,407 14,100 Supplies 57 4,131 2,000 Equipment 87 5,100 635 Other: Other: Other: Other: Other: TOTAL 215,023 300,000 $50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 • ti County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Provider Training 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. (1704cChief Executive Officer 1 /27/19 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Provider Training 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 . t: County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Provider Training 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1 /27/1 9 Signature of Authorized Person (see checklist, 2nd item) Date Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 1 � County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Island Health and Wellness Center - Provider Training 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Provider Training Hours 1000 • TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 30,765 Professional Fees 2,500 Operations 14,100 Supplies 2,000 Equipment 635 Other: Other: Other: Other: Other: TOTAL $50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Big Island Substance Abuse Council Po'okela Vocational Training Program 29 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Po'okela Vocational Training Program Agency Director: Dr. Hannah Preston-Pita Phone No.: (808) 969 - 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 - 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 Facility Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Keaau, HI 96749 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 - 7570 Accountant/CPA: Carbonaro CPA Phone No.: (808) 930 - 7570 Firm (if applicable): Carbonaro CPA Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To BeServed: (One or more can be checked) n✓ Puna ❑✓ Hamakua n✓ North Kona n✓ South Hilo ❑✓ North Kohala n South Kona ❑✓ North Hilo ❑✓ South Kohala n Kali Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ✓n Youth ❑./ Victims of Crimes n Culture and the arts ✓❑Aged Q✓ Victims of Health or Social Crises Q✓ Needs of the poor ✓❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Po'okela Vocational Training Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 $8750.00 0 2.Agency Mission Statement: Agency Mission Statement: Inspiring individuals to reclaim and enrich their lives by utilizing innovative resources and harnessing the strengths within each person. Program's goal is to enhance well-being and create meaningful changes in the community that we serve. 3. Program Description: The Po'okela Vocational Training Program is a program that provides vocational training opportunities in the form of job seeking skills,training and development, career-planning, and on the job training.The program provides support services to existing adult clients within BISAC's live in program and adolescents within our 32 school based programs island-wide. Po'okela Vocational Training Program will pilot a program in the DOE (Waiakea High School)to help athletics prepare for college. 4. Total Budget& Position Count: Total Program Budget: $250,000 Total Program Position Count: 7 • Total Agency Budget: $4,500,000 Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Po'okela Vocational Training Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Office of Hawaiian Affairs $62,000.00 Kamehameha School Community Investment Grant $150,000.00 County $38,000.00 TOTAL: $250,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BISAC continues efforts to diversify funding sources, expand services, increase efficiency,and align CARF standards. Currently, BISAC's vocational training program has expanded to include vocational tracks which allow for on the job training within the following fields: clerical, garden/maintenance, culinary, and retail. This social enterprise provides revenue to provide more treatment opportunities for individuals to enter treatment(e.g. Big Island Fusion and Koho Pono Products). 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide vocational training opportunities for all individuals within Therapeutic Living Program and school based programs. 2. Increase opportunities for on the job training within the following vocations: clerical, maintenance/gardening, culinary, and retail. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Po'okela Vocational Training Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Vocational Units 100 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 39,199 69,920 16,179 Professional Fees 3,676 126,700 0 Operations 6,077 25,907 6,367 Supplies 380 27,473 15,453 Equipment Other: Other: Other: Other: Other: TOTAL 49,333 250,000 $38,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Po'okela Vocational Training Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. L` ` Chief Executive Officer 1 /27/19 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Po'okela Vocational Training Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Po'okela Vocational Training Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1 /27/19 Signature of Authorized Person (see checklist, 2nd item) Date Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Po'okela Vocational Training Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 100 Vocational Units TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 16,179 Professional Fees 0 Operations 6,367 Supplies 15,453 Equipment Other: Other: Other: Other: Other: TOTAL $38,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Big Island Substance Abuse Council Therapeutic Living& Clean and Sober Program 30 II T County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Therapeutic Living & Clean and Sober Program Agency Director: Dr. Hannah Preston-Pita Phone No.: (808) 969 - 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 - 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 Facility Address: Address: 279 Waianuenue Ave. (Main Location-homes at various sites) Address: City,ST,Zip Hilo, Hawaii 96720 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 - 7570 Accountant/CPA: Carbonaro CPA Phone No.: (808) 930 - 7570 Firm (if applicable): Carbonaro CPA Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑✓ Victims of Crimes ❑✓ Culture and the arts 0✓ Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Therapeutic Living & Clean and Sober Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $14,375.00 $13,875.00 0 2.Agency Mission Statement: Agency Mission Statement: Inspiring individuals to reclaim and enrich their lives by utilizing innovative resources and harnessing the strengths within each person. 3. Program Description: Our Therapeutic Living Program (TLP)for men provides the planned, supportive structure of a 24-hour staffed facility providing ongoing evaluation, care, life skills training, self-help, encouragement,transportation to social activities and therapeutic services.There is also a specialized TLP program for Pregnant, Parenting,Women and Children(PPWC)program that provides a variety of case management and treatment services focused on women with children in order to ensure the wellbeing of the mother and to establish a safe,solid and nurturing foundation for the children to grow.The Clean and Sober Program serves as an interim placement between treatment and transition.The women's programs are supported by a house manager. Clients are expected to attend meetings,seek jobs, and take the appropriate steps to transitioning back into society. 4.Total Budget& Position Count: Total Program Budget: $900.000 r Total Program Position Count: 15 Total Agency Budget: $4,500,000 Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Therapeutic Living & Clean and Sober Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate SOH, DOH ADAD $578,000 SOH, Judiciary(Drug Court) $155,000 County of Hawaii $62,000 Client Fees $100,000 Other Sources $5000 TOTAL: $900,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BISAC continues efforts to diversify funding sources,expand services, and increase efficiency. BISAC's electronic medical records system increased efficiency in both clinical and billing areas. BISAC's current system allows for quicker response time for payment of claims. BISAC continues to utilize our vocational training tracks(e.g. culinary food trailer, BISAC Koho Pono products, and garden produce)as a means of generating funds that support treatment. BISAC's sound fiscal policies are incorporated into decisions related to program expansion or to enter market niches that would expand the behavioral health continuum.These additional revenue streams are an effort to support capacity building, sustainability efforts, and reduce reliance on State and County funds. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide funding for placement in sober housing and/or 2. Provide additional support services which help improve quality of care. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Therapeutic Living & Clean and Sober Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Treatment Units 250 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 299,476 544,873 34,986 Professional Fees 2,969 153,281 0 Operations 8,296 44,951 4,314 Supplies 1,487 61,543 9,145 Equipment 3,694 95,353 0 Other: Other: Other: Other: Other: • TOTAL 415,923 900,000 48,445 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Therapeutic Living & Clean and Sober Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. Chief Executive Offier 1 /27/19 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Therapeutic Living & Clean and Sober Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application 19-20 Agency Name: Big Island Substance Abuse Council Program Name: Therapeutic Living & Clean and Sober Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1 /27/1 9 Signature of Authorized Person (see checklist, 2nd item) Date Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Therapeutic Living & Clean and Sober Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Treatment Units 250 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 34,986 Professional Fees 0 Operations 4,314 Supplies 9,145 Equipment 0 Other: Other: Other: Other: Other: TOTAL 48,445 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Big Island Substance Abuse Council West Hawai'i Dual Diagnosis Program • 31 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance-Abuse Council Program Name: West Hawaii Dual Diagnosis Program II II►\I Agency Director: Dr. Hannah Preston-Pita Phone No.: (808) 969 - 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 - 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 Facility Address: Address: 74-5555 Kaiwi Street Unit F4 Address: City,ST,Zip Keaau, HI 96749 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 - 7570 Accountant/CPA: Carbonaro CPA Phone No.: (808 ) 930 - 7570 Firm (if applicable): Carbonaro CPA Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑✓ Hamakua ❑✓ North Kona ['South Hilo ❑✓ North Kohala ❑✓ South Kona ❑ North Hilo ✓❑South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑✓ Victims of Crimes ✓❑ Culture and the arts ❑✓ Aged n Victims of Health or Social Crises • ❑✓ Needs of the poor ✓❑ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 , I County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Dual Diagnosis Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $16,000.00 $13,375.00 0 2.Agency Mission Statement: Agency Mission Statement: Inspiring individuals to reclaim and enrich their lives by utilizing innovative resources and harnessing the strengths within each person. Program's goal is to enhance well-being and create meaningful changes in the community that we serve. 3. Program Description: BISAC's WH programs provide comprehensive substance abuse and mental health treatment services for adults through evidenced-based methods and best-practices designed for the area's target population. BISAC's comprehensive approach to substance abuse treatment also includes treating client's underlying issues that either trigger and/or maintain use. BISAC recognizes the significant impact of substance abuse on individuals,families, children, and communities and has designed programs to intervene in the addiction process and build on an individual's and/or family's strengths to abstain from the use of substances, increase protective factors, and relapse prevention skills to maintain their sobriety. 4. Total Budget & Position Count: Total Program Budget: $500,000 Total Program Position Count: 5 Total Agency Budget: $4,500,000 Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Dual Diagnosis Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Third Party Insurance $125,000 County $45,000 Other Sources $10,000 TOTAL: $180,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BISAC continues efforts to diversify funding sources,expand services, and increase efficiency. BISAC's electronic medical records system increased efficiency in both clinical and billing areas. BISAC's current system allows for quicker response time for payment of claims. BISAC continues to utilize our vocational training tracks(e.g. culinary food trailer, BISAC Koho Pono products, and garden produce)as a means of generating funds that support treatment. BISAC's sound fiscal policies are incorporated into decisions related to program expansion or to enter market niches that would expand the behavioral health continuum.These additional revenue streams are an effort to support capacity building,sustainability efforts, and reduce reliance on State and County funds. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide immediate access to psychological evaluations and treatment services to any individuals requiring mental health services and/or 2. Increase the availability of psychological services(e.g. individual and groups)to individuals who may have no funding for treatment services(e.g. DUI classes)or the service is not covered by insurance and/or EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Dual Diagnosis Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Treatment Units 100 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 93,575 125,000 28,628 Professional Fees 0 0 0 Operations 25,675 45,000 12,578 Supplies 8,729 10,000 3,795 Equipment Other: Other Other: Other Other 127 982 180 000 $45,000 TOTAL � *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Dual Diagnosis Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. Chief Executive Officer 1 /27/19 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Dual Diagnosis Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Dual Diagnosis Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates;that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cosi:of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. L � 1 /27/1 9 Signature of Authorized Person (see checklist, 2nd item) Date Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Dual Diagnosis Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Treatment Units 100 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 28,628 Professional Fees 0 Operations 12,578 Supplies 3,795 Equipment Other: Other: Other: Other: Other: TOTAL $45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Big Island Substance Abuse Council Youth Services Skill Building Activities 32 110 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Youth Services Skill Building Activities Agency Director: Dr. Hannah Preston-Pita Phone No.: (808) 969 - 9994 Contact Person: Dr. Hannah Preston-Pita Phone No.: (808) 854 - 2837 Mailing Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Kea'au, Hawaii 96749 / Facility Address: Address: 16-179 Melekahiwa Street Address: City,ST,Zip Keaau, HI 96749 Email Address: dr.hannah@bisac.com Fax No.: (808 ) 969 - 7570 Accountant/CPA: Carbonaro CPA Phone No.: (808 ) 930 - 7570 Firm (if applicable): Carbonaro CPA Mailing Address: Address: P.O. Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) [' Puna ❑✓ Hamakua ❑✓ North Kona n✓ South Hilo ✓❑ North Kohala n South Kona ❑✓ North Hilo ['South Kohala n Kali] Services or Activities To Be Provided: (One or more can be checked) ✓n Educational concerns ❑✓ Youth ❑✓ Victims of Crimes ❑✓ Culture and the arts ❑✓ Aged n Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Youth Services Skill Building Activities 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $16,000.00 0 0 2.Agency Mission Statement: Agency Mission Statement: Inspiring individuals to reclaim and enrich their lives by utilizing innovative resources and harnessing the strengths within each person. Program's goal: Supporting communities by enhancing prevention and intervention services, and creating opportunities for overall wellness. 3. Program Description: BISAC's Youth Services provides an innovative approach to prevention, intervention and outreach programs island-wide, helping ensure our children have the knowledge and the tools needed to make positive and healthy decisions in their daily lives. BISAC's School Based program provides services to 32 middle and high schools island-wide. BISAC's Community Based program provides a higher level of services to schools located on the East side of Hawaii Island. These programs utilize evidenced based curriculum and provide additional supportive services which include skill building groups that focus on prevention, communication, leadership,teamwork, and teach them alternative ways of preventing substance use. 4.Total Budget& Position Count: Total Program Budget: $2,000,000 Total Program Position Count: 14 Total Agency Budget: $4,500,000 Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Youth Services Skill Building Activities 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate DOH ADAD $1,950,000 County $50,000 TOTAL: $2,000,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BISAC continues efforts to diversify funding sources,expand services, and increase efficiency. BISAC's electronic medical records system increased efficiency in both clinical and billing areas. BISAC's current system allows for quicker response time for payment of claims. BISAC continues to utilize our vocational training tracks(e.g. culinary food trailer, BISAC Koho Pono products,and garden produce)as a means of generating funds that support treatment. BISAC's sound fiscal policies are incorporated into decisions related to program expansion or to enter market niches that would expand the behavioral health continuum.These additional revenue streams are an effort to support capacity building,sustainability efforts, and reduce reliance on State and County funds. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide immediate access to psychological evaluations and treatment services to any individuals requiring mental health services and/or 2. Increase the availability of psychological services(e.g. individual and groups)to individuals who may have no funding for treatment services(e.g. DUI classes)or the service is not covered by insurance and/or 3. Provide mobile treatment services in rural areas. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Youth Services Skill Building Activities 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Skill building Group Attemdees 300 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 1,200,000 35,000 Professional Fees 0 Operations 400,000 Supplies 369,230 15,000 Equipment 30,770 Other: Other: Other: Other: Other: TOTAL 2,000,000 $50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Youth Services Skill Building Activities so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 2 If no conflicts exist, check here. „7"/"/f44/9(AV(thief Executive Officer 1 /27/19 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Youth Services Skill Building Activities 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 J , County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Youth Services Skill Building Activities Certification of Understanding (Page 2 of 11. 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. C,B 1/27/19 Signature of Authorized Person (see checklist, 2nd item) Date Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Big Island Substance Abuse Council Program Name: Youth Services Skill Building Activities 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Skill building Group Attendees 300 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 35,000 Professional Fees Operations Supplies 15,000 Equipment Other: Other: Other: Other: Other: TOTAL $50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Boy Scouts of America Scoutreach 33 County of Hawai`i Nonprofit Grant Application FY2019-20 ' Agency Name: Boy Scouts of America, Aloha Council Program Name: Scoutreach Agency Director: Jeff Sulzbach, Scout Executive, CEO Phone No.: (808) 595 — 0859 Contact Person: Eric McFee, Hawaii Island Field Director Phone No.: (808) 959 — 0079 • Mailing Address: Address: PO Box 5327 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 580 Stainback Highway Address: City,ST,Zip Hilo, HI 96720 Email Address: Eric.McFee@scouting.org Fax No.: (808 ) 959 — 3568 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): KKDLY LLC Mailing Address: Address: Topa Financial Center Address: 745 Fort Street Suite 2100 City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑.Hamakua ❑✓ North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ['Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Boy Scouts_of_America,_Aloha Council ____ _-_ _ __ Program Name: Scoutreach 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 11,250 17,500 2.Agency Mission Statement: Boy Scouts of America,Aloha Council's vision is to positively impact the lives of Hawaii's youth through Scouting's leadership development and outdoor education programs.Our work supports the Boy Scouts of America's Mission to prepare young people to make ethical and moral choices over their lifetime by instilling in them the values of the Scout Oath and Law. The Scout Oath:On my honor I will do my best,To do my duty to God and my country and to obey the Scout Law;To help other people at all times;To keep myself physically strong, mentally awake,and morally straight. The Scout Law:A Scout is:Trustworthy, Loyal, Helpful, Friendly, Courteous, Kind,Obedient,Cheerful,Thrifty, Brave,Clean, and Reverent Scouting was organized in the territory of Hawaii in 1911,with the formation of the Honolulu Council which oversaw Scouting through the Hawaiian Islands. In 1919,the Kilauea Council was formed on the Island of Hawaii and remained in existence until 1972 when it merged with the Aloha Council.Throughout a storied century, boys have been exposed to nature,outdoor adventures and skill-building and along the way learned teamwork, leadership, independence and resilience.Today there are over 2 million youth involved in Scouting nationwide, 10,830 youth in Hawaii's Aloha Council.On Hawaii Island alone,there are more than 1,300 young people served annually in year-round programs.Many things have changed over the decades In Hawaii -but Scouting and it's mission remain constant and continue to thrive. 3. Program Description: Scoutreach is committed to enrich the lives of at-risk youth by ensuring that quality programs are available to them.While we seek to serve youth throughout the Big Island,the Scoutreach program will place specific emphasis on expanding support to youth living in Hamakua, Puna, Kau and North Kona. Our program partners with public schools to provide access and opportunity to serve at risk youth.Select schools are located in neighborhoods where many families live at or below poverty levels,where public schools are not yielding adequate yearly progress results, and youth have limited opportunities for positive alternatives via self-development programs.75%or more of the students are on Free/Reduced lunch programs. Many of the schools are listed as a Title 1 school which indicates a greater need for academic support.Scoutreach provides after-school program Monday through Friday during the school year and each boy or girl attends on a designated day based on his or her grade level. No meetings are conducted on Wednesday due to weekly faculty meetings.We choose to locate programs at school sites because it increases the likelihood of attendance, links after-school instruction to the school day,takes advantage of existing infrastructure and reduces transportation costs. Being at the school opens access to children of working parents, where lack of transportation to off-campus activities is a barrier for participation.This structure enables partner relationship between Scouting,teachers and administrators.Teachers/faculty are hired and serve as positive role models for the youth. Through positive peer group interaction and adult guidance,youth experience advancement through adventures that are age-appropriate and engaging. Leadership, life skills,teamwork,self-confidence,accepting responsibility, right vs.wrong, conflict resolution,family involvement,self-reliance,outdoor awareness&participatory citizenship are skills gained in the after-school program. 4.Total Budget& Position Count: Total Program Budget: $85,123 Total Program Position Count: 9 Total Agency Budget: $2,832,700 Total Agency Position Count: 23 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boy Scouts of America, Aloha Council Program Name: Scoutreach 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Hawaii Electric Industries Charitable Foundation $5,000 The Harry&Jeanette Weinberg Foundation $14,500 � I TOTAL: $19,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Expanding outreach to at risk youth is a top priority of the Aloha Council Board.The council board recognizes that there are many barriers to participation and is working vigilantly to overcome these obstacles. Funding will remain a critical role in ensuring that services and activities will continue to benefit the community through Scoutreach. In order to sustain activities beyond the county Grant,we will look at other avenues similar to traditional scouting units.We would reach out to families of youth participating in the Scoutreach program who may be able to dedicate a small amount of money to help support the program their son is benefiting from.We will invite sponsoring organizations to budget money to help offset a portion of the program expenses. We will engage our Scouts to do product sales to help offset costs as well.The product sales will-be supervised by the unit leader and managed through a unit budget plan.The product sales will be part of the council sponsor events to include Makahikl Card Sales and Popcorn Sales.Our Scoutreach committee will actively reach out to the community to secure Adopt-A-Site partners.Adopt-A-Site partners will provide financial resources necessary to fund the program at each site. • 7. Program Objectives Using County Nonprofit Grant Program Funds: li Through active and consistent participation in the Scoutreach program,youth throughout the Big Island will display healthy social and emotional development and improve academic confidence and performance. Our Scoutreach objectives include: 1. Participation: Increase participation in the Scoutreach program to impact at-risk youth. 2. Community Collaboration: Collaborate with community organizations and elementary schools to conduct Scouting programs to increase reach within the area. Hire and train program staff to serve as mentors for at risk youth. 3. Skill Proficiency:Teach Scouting curriculum so Scouts may learn and practice life skills and values. 4.Outdoor Experiences: Expose Scouts to outdoor experiences by providing offsite excursions since opportunities to camp, family hike, practice outdoor skills and learn about nature are limited. Include entire families or weekend dates to encourage greater attendance. 5. Community Service: Implement community service program so members can learn the values of caring for and giving back to their community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency__Name:_____Boy__Scouts_of_America, Aloha Council_ Program Name: Scoutreach 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) #of youth enrolled in program 175 #of participating schools 5 %of youth completing program adventures&rank advancement 60% %of youth participating in outdoor day camp or overnight experience 50% #of service hours given back to the community 1500(8 hours of service per youth) Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $21,857 $60,860 $43,960 Professional Fees Operations Supplies $1,530.90 $6,763 $6,763 Equipment Other: Assistance to Individuals-Membership, Activity and Camping Fees $4,485 $14,900 $14,900 Other: Conference&Training $2,600 0 Other: Other: Other: • TOTAL 27,872.90 $85,123 $65,623 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boy Scouts of America, Aloha Council Program Name: Scoutreach 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): n Member Or members of the Council n Staff appointed by a member of the Council ❑ The Mayor ri The Managing Director The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n. If no conflicts exist, check here. . ? 1/ i )Swk* �,.e..c. �a ( ( Zs(20L9 Si: urs. of A:horized Pero•n (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 _ .__ __ Agenc_y_.Name: __Boy Scouts_of America, Aloha Council Program Name: Scoutreach 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.-The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Boy Scouts of America, Aloha Council Program Name: Scoutreach 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. I id-9/Z-0 I 7 Signature of Authorized Person (see checklist, 2nd item) Date C a v ��-� vc C C 6 Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency_Name:___Boy Scouts of America, Aloha_.Council Program Name: Scoutreach 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result #of youth enrolled in program 75 ##of participating schools 5 %of youth completing program adventures&rank advancement 60% %of youth participating in outdoor day camp or overnight experience soi #of service hours given back to the community yoout (8 hours of service per h) TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $43,960 Professional Fees Operations Supplies $6,763 Equipment Other: Assistance to Individuals-Membership, Activity and Camping Fees $14,900 Other: Conference&Training 0 Other: Other: Other: TOTAL $65,623 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Boys & Girls Club of the Big Island Daily Nutritional Security to Support Income Challenged Youth 34 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island Program Name: Daily Nutritional Security to Support Income Challenged Youth Agency Director: Chad Cabral Phone No.: (808) 961 — 5536 Contact Person: Chad Cabral Phone No.: (808) 961 — 5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI, 96720 Facility Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI, 96720 Email Address: chad@bgcbi.org Fax No.: (808 ) 961 — 5534 Accountant/CPA: Ann Fukuhara,CPA, MBA Phone No.: (808 ) 961 — 5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku Street Address: City,ST,Zip Hilo, HI, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑ North Kohala ['South Kona ✓❑ North Hilo ❑South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ✓ Needs of thepoor Physical/Emotional Disabilities ❑ ❑ Y ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 1 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island Program Name: Daily Nutritional Security to Support Income Challenged Youth 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $6,750.00 $6,375.00 $16,375.00 2. Agency Mission Statement: Boys&Girls Club of the Big Island's mission is"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment."For 67 years, Boys&Girls Club of the Big Island(BGCBI) has been at the forefront of afterschool youth development services in Hawaii County,continuously focusing on educational, character development,and health/wellness enrichment programs to guide youth toward being and doing their best,for just$10 per year.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala,Ocean View and Kealakehe. BGCBI youth and the families we serve:20%report a combined annual income of$10,000 or less and face economic insecurity with housing and food, resulting in high levels of stress and academic disadvantages.Without our programs, many of our serviced families would not be able to afford safe,afterschool enrichment opportunities that can equate to the quality, life-enhancing programs we provide at almost no cost. BGCBI's high quality, low-cost services to our local island communities cannot continue without the support of Hawaii County and local businesses. 3. Program Description: • BGCBI has successfully delivered over 28,000 full hot meals since the inception of our meal program in June 2017.Within the first few days of the meal program starting,staff and parents noticed behavioral changes in the youth with an increased focus, willingness to learn,and higher respect for others. The meal program has fed our Hilo youth for almost 2 years and BGCBI is ready to expand its meal services to feed our Pahoa youth.With a dedicated staff and strong community and business partnerships,the expanded meal program will be able to serve upwards of 100 Pahoa youth every weekday of the school year. BGCBI has received high demand from families to expand the meal program,and now with the experience and staff in place,we are working hard to meet community demands. In conjunction with expansion to Pahoa,all other Clubs will continue to receive daily healthy snacks(since 2014,BGCBI has served over 168,000 snacks). BGCBI recognizes that many local Big Island youth often receive a full meal only at school,as many families are not able to provide daily nutritious meals due to economic challenges. The national child poverty rate is 22%, and the State of Hawaii rate is 14%.The Big Island's child poverty rate is 26%, more than double Honolulu County's 12%average(US Census,2013).Additionally, Hawaii County,at 66%,has the highest rate of students receiving free or reduced school lunch,which is significantly higher than the combined State average of 50%. Organization-wide,65%of the enrolled BGCBI youth are currently receiving free or reduced school lunches.These Hawaii County statistics combined with BGCBI's yearly average of over 10,300 full hot meals served shows that we are making a difference in the health and wellbeing of community youth and families.With the help of Hawaii County,the number of BGCBI's annual meals served has the potential to double to 20,600 meals to feed hungry youth. 4. Total Budget& Position Count: Total Program Budget: $45,000 Total Program Position Count: 3 Total Agency Budget: $1,461,746 Total Agency Position Count: 41 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island Program Name: Daily Nutritional Security to Support Income Challenged Youth 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii, 2019-20 45,000 Hawaii Electric Light 100,000 First Hawaiian Bank Foundation 100,000 Rotary Club of Hilo Bay 10,000 Rotary Club of South Hilo 10,000 Atherton Family Foundation 80,000 Private Community Individual 25,000 TOTAL: 370,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island(BGCBI) believes that to create changes in a community, it begins with the keiki;these changes do not happen overnight,but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth who need these programs the most in our local, rural communities.Our motto, "When school is out, Clubs are in,"ensures that the youth of our community have continuous opportunities to be in a safe and enriching environment.BGCBI Administration and Board work relentlessly to operate as effectively and efficiently as possible and to secure funding from sources with missions that correspond with ours. BGCBI continues not to advertise our services,because with more children attending the program,we would need to hire,train and employ more staff,driving up the cost of our programming and increasing the amount of funding needed to operate. However,despite not advertising,our membership has been steadily growing so much that we are now expanding our meal program.There is clearly a need in our County for after-school youth development and preventative services; in other words, BGCBI makes a difference. BGCBI has sought and secured funding for the most critical needs of our County's youth--Educational Support and Food Security. Below is a list of our current supporters: Hawaii Electric Industries,The Atherton Family Foundation, Private Community Individual,Clark Realty Foundation 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase the number of Club locations operating the full-meal program from 1 Club to 2(Hilo and Pahoa). Increase to 100 the number Pahoa youth participating in the full-meal program. Serve an estimated 10,300 of meals of by the end of the academic year. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 1 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island Program Name: Daily Nutritional Security to Support Income Challenged Youth 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Club locations operating the full-meal program Increase from 1 to 2 Number of Pahoa participants receiving full meals 100 Number of estimated meals to be served for the 2019-20 school year 10,300 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 892510 981,761 22,600 Professional Fees 52000 57,200 10,000 Operations 308600 339,460 10,000 Supplies 28000 30,800 2,000 Equipment 8500 9,350 400 Other: Travel & Per Diem 5250 5,775 Other: Fundraising &GET 26000 28,600 Other: Permits, Bank Fees, Other Misc Expenses 8000 8.800 Other: Other: TOTAL 1,328,860 1,461,746 45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Daily Nutritional Security to Support Income Challenged Youth 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. CJcu& O'_— Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Daily Nutritional Security to Support Income Challenged Youth 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Daily Nutritional Security to Support Income Challenged Youth 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (see checklist, 2nd item) Date RDCOLCCI e_kaa Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island Program Name: Daily Nutritional Security to Support Income Challenged Youth 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Club locations operating the full-meal program Increase from 1 to 2 Number of Pahoa participants receiving full meals 100 Number of estimated meals to be served for the 2019-20 school year 10,300 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 22,600 Professional Fees 10,000 Operations 10,000 Supplies 2,000 Equipment 400 Other: Travel & Per Diem Other: Fundraising &GET Other: Permits, Bank Fees, Other Misc Expenses Other: Other: TOTAL 45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Boys & Girls Club of the Big Island Daily Transport Services for Income-Challenged Youth 35 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Islands Program Name: Daily Transport Services for Income-Challenged Youth Agency Director: Chad Cabral Phone No.: (808) 961 - 5536 Contact Person: Chad Cabral Phone No.: (808) 961 - 5536 Mailing Address: Address: 100 Kamakahonu St. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: Headquarters: 100 Kamakahonu St. Address: City,ST,Zip Hilo, HI 96720 Email Address: chad@bgcbi.org Fax No.: (808 ) 961 - 5534 Accountant/CPA: Ann Fukuhara,CPA, MBA Phone No.: (808 ) 961 - 5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku St. Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona ❑✓ North Hilo ❑South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Islands Program Name: Daily Transport Services for Income-Challenged Youth 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 • n/a n/a n/a 2. Agency Mission Statement: g Y Boys&Girls Club of the Big Island's mission is"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment."For 67 years, Boys&Girls Club of the Big Island(BGCBI) has been at the forefront of afterschool youth development services in Hawaii County,continuously focusing on educational, character development,and health/wellness enrichment programs to guide youth toward being and doing their best,for just$10 per year.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala,Ocean View and Kealakehe. 20%of BGCBI youth members come from families with a combined annual income of$10,000 or less and face economic insecurity with housing and food, resulting in high levels of stress and academic disadvantages.Additionally,over 50%of our members report receiving free or reduced school lunches,a further indication of economic hardship.Without our programs, many of our serviced families would not be able to afford safe, afterschool enrichment opportunities that can equate to the quality,life-enhancing programs we provide at a worry-free$10 annual fee. BGCBI's high quality, low-cost services to our local island communities cannot continue without the support of Hawaii County and local businesses. 3. Program Description: The proposed program will provide daily(M-F)shuttle transportation services(free of charge)for income-challenged youth (i.e. homeless youth and youth from poverty and low-income family households),providing access to BGCBI hosted afterschool youth development programs that are located in the communities of Hilo, Puna,and Ka'u(Na'alehu-Ocean View). Transportation is the major barrier and limiting factor in accessing critical support resources among economically disadvantaged families that reside in the rural area communities on Hawaii Island.Often specialized social-support services are affordable to income-challenged families but are not accessible for utilization due to the geographic distance of the service location and family transport limitations. Hawaii Island's current public transportation services often do not provide the frequency and consistency needed for struggling families to rely on and as a result, rural area income-challenged youth often go unsupervised and unattended afterschool not having affordable and available transportation to and from youth development services. Throughout the academic school year(10-months), BGCBI will provide free afterschool van shuttle transport from public and charter schools located in Waiakea, Puna,and Na'alehu,to BGCBI youth development program site locations in Hilo, Pahoa and Ka'u.Transport offerings will be targeted to support income-challenged youth that currently do not have transportation access to daily afterschool youth development resources and are currently going unsupervised afterschool. SEE ATTACHED PAGE:CONTINUATION OF 3: PROGRAM DESCRIPTION 4. Total Budget& Position Count: Total Program Budget: $45,000.00 Total Program Position Count: 4 Total Agency Budget: 1,461,746 Total Agency Position Count: 41 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 Continuation of#3:Program Description County Nonprofit Grant Application FY 2019-20 Agency Name: Boys & Girls Club of the Big Island Program: Daily Transport Services for Income-Challenged Youth While at BGCBI youth development programs, income-challenged youth (ages 6-17) will receive (Free of charge): • Daily homework support and academic tutoring; • Full evening meal and healthy snacks before going home; • Organized and recreational sport opportunities; • Healthy lifestyles activities, cultural programming; civic engagement opportunities; • Access to technology, computers, printing services and internet. Upon the conclusion of daily BGCBI support services, rural area community youth will be provided BGCBI operated transport shuttle services from programming site locations to their home residence (e.g. Ocean View youth shuttled home from BGCBI Na'alehu site location 25-miles away). County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Islands Program Name: Daily Transport Services for Income-Challenged Youth 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate CDBG/OHCD $98,000 TOTAL: $98,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island (BGCBI)believes that to create changes in a community,it begins with the keiki;these changes do not happen overnight, but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth who need these programs the most in our local, rural communities. Our motto, "When school is out,Clubs are in,"ensures that the youth of our community have continuous opportunities to be in a safe and enriching environment. BGCBI Administration and Board work relentlessly to operate as effectively and efficiently as possible and to secure funding from sources with missions that correspond with ours. BGCBI continues not to advertise our services,because with more children attending the program,we would need to hire,train and employ more staff,driving up the cost of our programming and increasing the amount of funding needed to operate. However,despite not advertising,our membership has been steadily growing so much that we are now expanding our meal program.There is clearly a need in our County for after-school youth development and preventative services;in other words,BGCBI makes a difference. BGCBI has sought and secured funding for the most critical needs of our County's youth--Educational Support and Food Security. Below is a list of our current supporters: OHA Educational Grant, Hawaii Island United Way, Kamehameha Schools, Hawaii State Alcohol&Drug Abuse Division SEE ATTACHED PAGE: CONTINUATION OF 6: Explain Plans to Increase Revenues to Support Program 7. Program Objectives Using County Nonprofit Grant Program Funds: The proposed program objective is to provide new and increased access for income-challenged youth that reside in the areas of Puna,Waiakea/Panaewa,and Ocean View(i.e. homeless youth and youth from poverty and low-income level households).The youth can then participate, and utilize(M-F throughout the academic school year)critical youth development resources hosted by BGCBI.These resources will support their academic learning and educational achievement(through daily homework assistance/academic tutoring)and overall physical health(through the access of daily evening meals/healthy snacks provided by BGCBI). Daily(M-F)van shuttle service transportation (a free of charge service)will be conducted by BGCBI and will provide identified income-challenged youth (ages 6-17) access to essential afterschool resources that are currently unavailable due to: 1. Household Financial Limitations and;2. Daily Access Challenges(not having youth development program offerings within their geographic reach). Because of the minimal participation cost for youth to participate in daily(M-F)afterschool youth development services, ($10.00 annual membership fee), BGCBI has become the youth development resource agency for youth and families that are struggling financially. This proposed program will provide the essential daily transportation needed for income-challenged youth to access critical BGCBI support resources afterschool and to provide rural area community youth (e.g. residing in Ocean View,25-miles away) with safe transportation back home after the service activities have ended. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 Continuation of#6:Explain Plans to Increase Revenues to Support Program County Nonprofit Grant Program FY 2019-20 Agency Name: Boys &Girls Club of the Big Island Program: Daily Transport Services for Income-Challenged Youth In addition, BGCBI has secured (as of February 2019) one (1) brand new youth transport vehicle dedicated to our Pahoa youth development program,which will be utilized to offer income-challenged youth daily (M-F) free shuttle transport from Puna based public and charter schools to our BGCBI program located in Pahoa town. BGCBI has also engaged agencies and established formal partnerships with the DOE, Hawaii County Nonprofit agency HCEOC, and Na'alehu Elementary School,to institute a M-F afterschool youth development support program for Ocean View income-challenged youth attending Na'alehu elementary school (which initiated on January 23, 2019). BGCBI secured the agency partnerships that ultimately reduced the annual financial encumbrance of operating a daily youth development program (totaling$60,000 annually) now needing only to secure annual youth shuttle transportation costs (estimated at$6,000 total for the year).An innovative approach and intentional partnership development has brought a significant reduction to the overall operating cost, reducing Ocean View support program expenses.by 90%. County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Islands Program Name: Daily Transport Services for Income-Challenged Youth 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) PLEASE SEE ATTACHED PAGE:#8 PROGRAM PERFORMANCE MEASURES Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 892,510 981,761 23,000 Professional Fees 52,000 57,200 0 Operations 308,600 339,460 19,600 Supplies 28,000 30,800 2,000 Equipment 8,500 9,350 400 Other: Travel & Per Diem 5,250 5,775 Other: Fundraising&GET 26,000 28,600 Other: Permits, Bank Fees, Other Misc Expenses 8,000 8,800 Other: Other: TOTAL 1,328,860 1,461,746 45,000 "If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 #8 Table:Program Performance Measures County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Boys &Girls Club of the Big Island Program Name: Daily Transport Services for Income-Challenged Youth Program Performance Measures Applicant Projected Results Daily (M-F) afterschool transport of 50 Puna A minimum of 50 Income-challenged community, income-challenged youth, from Puna Puna region youth will have a means based schools to BGCBI's youth development program of accessing essential afterschool based in Pahoa town, throughout the academic school youth development services and year (10-months of daily services) resources daily (M-F) throughout the academic school year. Daily(M-F) afterschool transport of 50 income- A minimum of 50 Income-challenged challenged youth attending Waiakea based public youth attending Waiakea based schools to BGCBI's youth development site program public schools will have a means of located in Hilo,throughout the academic school year accessing essential afterschool youth (10-months of daily services) development services and resources daily(M-F) throughout the academic school year. Daily(M-F) afterschool transport of 25 income- A minimum of 25 Income-challenged challenged Ocean View youth attending Na'alehu youth attending Na'alehu school will public school will receive free shuttle service post have a means to access essential BGCBI youth development services back to their homes afterschool youth development in Ocean View (25-miles away from the BGCBI service services daily(M-F) throughout the location in Na'alehu),throughout the academic school academic school year. year (10-months of daily services) Access for 50 Puna community, income-challenged A minimum of 50 Income-challenged youth to receive safe afterschool shuttle transport to Puna region youth will demonstrate obtain daily (M-F) academic/homework support and improved study habits, better grades, nutritional supplementation, throughout the academic and greater physical health school year (10-months of daily services) Access for 50 Waiakea community, income-challenged A minimum of 50 Income-challenged youth to receive safe afterschool shuttle transport to Waiakea region youth will obtain daily (M-F) academic and homework support, demonstrate improved study habits, and nutritional supplementation,throughout the better grades, and greater physical academic school year (10-months of daily services) health Access for 25 Ocean View community, income- A minimum of 25 Income-challenged challenged youth to receive safe afterschool shuttle Ocean View region youth will transport services (post daily program services), and demonstrate improved study habits, obtain daily(M-F) academic and homework support, better grades, and greater physical and nutritional supplementation,throughout the health academic school year (10-months of daily services) County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Islands Program Name: Daily Transport Services for Income-Challenged Youth 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council Ti Staff appointed by a member of the Council n The Mayor ❑ The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. � I Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. jOYU-AeK. Signature of Authorized Person (sp cify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Islands Program Name: Daily Transport Services for Income-Challenged Youth 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Islands Program Name: Daily Transport Services for Income-Challenged Youth 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. kakit tr4 laq 11 Signature of Authorized Person (see checklist, 2nd item) Date r\3e)a ry) dra Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Islands Program Name: Daily Transport Services for Income-Challenged Youth 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result PLEASE SEE ATTACHED PAGE:#12.COUNCIL AWARD WORKSHEET PROGRAM PERFORMANCE MEASURES TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 23,000 Professional Fees 0 Operations 19,600 Supplies 2,000 Equipment 400 Other: Travel & Per Diem Other: Fundraising &GET Other: Permits, Bank Fees, Other Misc Expenses Other: Other: TOTAL 45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 12. Council Award Worksheet. Program Performance Measures County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island Program Name: Daily Transport Services for Income-Challenged Youth Program Performance Measures Applicant Projected Results Daily (M-F) afterschool transport of 50 Puna A minimum of 50 Income-challenged community, income-challenged youth, from Puna Puna region youth will have a means based schools to BGCBI's youth development program of accessing essential afterschool based in Pahoa town,throughout the academic school youth development services and year (10-months of daily services) resources daily (M-F) throughout the academic school year. Daily (M-F) afterschool transport of 50 income- A minimum of 50 Income-challenged challenged youth attending Waiakea based public youth attending Waiakea based schools to BGCBI's youth development site program public schools will have a means of located in Hilo,throughout the academic school year accessing essential afterschool youth (10-months of daily services) development services and resources daily (M-F) throughout the academic school year. Daily (M-F) afterschool transport of 25 income- A minimum of 25 Income-challenged challenged Ocean View youth attending Na'alehu youth attending Na'alehu school will public school will receive free shuttle service post have a means to access essential BGCBI youth development services back to their homes afterschool youth development in Ocean View (25-miles away from the BGCBI service services daily(M-F) throughout the location in Na'alehu),throughout the academic school academic school year. year (10-months of daily services) Access for 50 Puna community, income-challenged A minimum of 50 Income-challenged youth to receive safe afterschool shuttle transport to Puna region youth will demonstrate obtain daily (M-F) academic/homework support and improved study habits, better grades, nutritional supplementation,throughout the academic and greater physical health school year (10-months of daily services) Access for 50 Waiakea community, income-challenged A minimum of 50 Income-challenged youth to receive safe afterschool shuttle transport to Waiakea region youth will obtain daily(M-F) academic and homework support, demonstrate improved study habits, and nutritional supplementation,throughout the better grades, and greater physical academic school year (10-months of daily services) health Access for 25 Ocean View community, income- A minimum of 25 Income-challenged challenged youth to receive safe afterschool shuttle Ocean View region youth will transport services (post daily program services), and demonstrate improved study habits, obtain daily(M-F) academic and homework support, better grades, and greater physical and nutritional supplementation,throughout the health academic school year (10-months of daily services) Boys & Girls Club of the Big Island, Hilo Club Literacy, Homework&Tutoring Support for Income Challenged 36 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged Agency Director: Chad Cabral Phone No.: (808) 961 - 5536 Contact Person: Chad Cabral Phone No.: (808) 961 - 5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI,96720 Facility Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI,96720 Email Address: chad@bgcbi.org Fax No.: (808 ) 961 - 5534 Accountant/CPA: Ann Fukuhara, CPA, MBA Phone No.: (808 ) 961 - 5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku Street Address: City,ST,Zip Hilo, HI,96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua 0 North Kona ['South Hilo ❑ North Kohala ❑South Kona ❑✓ North Hilo ❑South Kohala ❑ Katt] Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $8,750.00 $15,150.00 $15,875.00 2.Agency Mission Statement: Boys&Girls Club of the Big Island's mission is"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment."For 67 years, Boys&Girls Club of the Big Island(BGCBI) has been at the forefront of afterschool youth development services in Hawaii County,continuously focusing on educational, character development,and health/wellness enrichment programs to guide youth toward being and doing their best,for just$10 per year.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala, Ocean View and Kealakehe. BGCBI youth and the families we serve:20%report a combined annual income of$10,000 or less and face economic insecurity with housing and food,resulting in high levels of stress and academic disadvantages.Additionally,65%of Hilo members report receiving free or reduced school lunches, a further indication of economic hardship.Without our programs,many of our serviced families would not be able to afford safe, afterschool enrichment opportunities that can equate to the quality, life-enhancing programs we provide at a worry-free$10 annual fee. BGCBI's high quality, low-cost services to our local island communities cannot continue without the support of Hawaii County and local businesses. 3. Program Description: "Literacy,Homework&Tutoring Support for Income Challenged"will provide 3 educational initiatives to support the acute academic needs of youth members encouraging greater literacy,better study habits&a higher rate of on-time graduation or advancement to the next grade level.The program utilizes 3 of Boys&Girls Club of America's nationally certified educational support programs. 1: Project REACH (Reading Enhances All Children's Hope)engages youth to participate in literacy enhance- ment activities that help develop their overall reading,spelling&writing proficiency through daily reading&a site wide Spelling Bee.2: "PowerHour,"an incentive-based homework support program, awards participants points for time dedicated to home- work completion.The points collected can be redeemed for sought after items to encourage them to do their homework. Nationally, "Power Hour"has proven to effectively engage youth in developing strong, life-long learning habits that facilitate daily homework completion&test score improvement.3: "Project Learn" reinforces&enhances skills&knowledge youth learn at school.The strategy,based on Dr. Reginald Clark's research,shows students do much better in school when they spend non- school hours engaged in fun, academically beneficial activities.Communication&collaboration amongst parents,school&Club have proven to boost the academic performance of youth members.Our Clubs partner with the schools&host at least 1 Ohana Event a year to bring all the Club youth&families together for fun team-building activities,where Club staff are able to make important announcements&form stronger relationships with families. Following the research/best practices presented by the Carnegie Corporation of New York's Council on Advancing Adolescent Literacy in "Out of School Time,"there are 4 types of literacy initiatives: 1) Literacy&development,2) Literacy& Enhancement,3)Academic Enhancement,4) Social Development. BGCBI youth development programs encompass these 4 initiatives which help establish a strong foundation&desire to gain greater knowledge&shape effective lifelong educational learning habits. 4. Total Budget& Position Count: Total Program Budget: $45,000 Total Program Position Count: 4 Total Agency Budget: 1,461,746 Total Agency Position Count: 41 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii, 2019-20 45,000 Office of Hawaiian Affairs 500,000 Kamehameha Schools 100,000 Rotary Club of South Hilo 10,000 TOTAL: 655,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island(BGCBI)believes that to create changes in a community, it begins with the keiki;these changes do not happen overnight,but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth who need these programs the most in our local, rural communities.Our motto, "When school is out,Clubs are in," ensures that the youth of our community have continuous opportunities to be in a safe and enriching environment. BGCBI Administration and Board work relentlessly to operate as effectively and efficiently as possible and to secure funding from sources with missions that correspond with ours. BGCBI continues not to advertise our services,because with more children attending the program,we would need to hire,train and employ more staff,driving up the cost of our programming and increasing the amount of funding needed to operate. However,despite not advertising, our membership has been steadily growing so much that we are now expanding our meal program.There is clearly a need in our County for after-school youth development and preventative services; in other words, BGCBI makes a difference. BGCBI has sought and secured funding for the most critical needs of our County's youth-- Educational Support and Food Security. Below is a list of our current supporters: OHA Educational Grant, Hawaii Island United Way, Kamehameha Schools 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase literacy among Income Challenged Youth that BGCBI services through homework, reading,and spelling programs to aid in growing their academic skill set. Participants in our reading program will take pre and post homework surveys,and our objective will yield 50%of participant scores showing increased penchant of youth participants to finish their daily homework. BGCBI will host a site wide Spelling Bee that will include 20 participants from each Club.Tutoring is provided to participants who are struggling academically as revealed through staff observation and report cards BGCBI is able to obtain. BGCBI's objective is to increase rates of student homework completion while attending Club.Through surveys,50%of participants will show that they complete more of their homework during Club hours vs.outside of Club.An additional goal is to increase the number of program youth who complete their daily homework to ensure the establishment of good study habits from daily participation in "Power Hour"while at the Club.60%of Club members will participate in the homework support program.Since it is proven that the most effective programs include clubs,schools,and families,we will host one Ohana Event each academic year to allow parents to explore and celebrate their child's successes at the Club. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Participant surveys will show increased willingness to finish their daily homework 50%increase Number of participants in Spelling Bee 20 Participants show they complete more of their homework during Club hrs vs. outside Club 50%increase Family Nights 1 per academic year Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 892,510 981,761 22,600 Professional Fees 52,000 57,200 10,000 Operations 308,600 339,460 10,000 Supplies 28,000 30,800 2,000 Equipment 8,500 9,350 400 Other: Travel & Per Diem 5,250 5,775 Other: Fundraising & GET 26,000 28,600 Other: Permits, Bank Fees, Other Misc Expenses 8,000 8,800 Other: Other: • TOTAL 1,328,860 1,461,746 45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. (mkt ct 7-Dr11 aqIlc/ Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. jOYlki& t(D-Cf Signature of Authorized Person (see checklist, 2nd item) Date c—D�Oarel Mf d Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Hilo Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participant surveys will show increased willingness to finish their daily homework 50%increase Number of participants in Spelling Bee 20 Participants show they complete more of their homework during Club hrs vs.outside Club 50%increase Family Nights 1 per academic year TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 22,600 Professional Fees 10,000 Operations 10,000 Supplies 2,000 Equipment 400 Other: Travel & Per Diem Other: Fundraising &GET Other: Permits, Bank Fees, Other Misc Expenses Other: Other: TOTAL 45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Boys & Girls Club of the Big Island, Kea'au Club Literacy, Homework &Tutoring Support for Income Challenged 37 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged Agency Director: Chad Cabral Phone No.: (808) 961 — 5536 Contact Person: Chad Cabral Phone No.: (808) 961 — 5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI,96720 Facility Address: Address: Keaau Elementary School Address: 16-680 Keaau-Pahoa Road City,ST,Zip Keaau, HI,96749 Email Address: chad@bgcbi.org Fax No.: (808 ) 961 — 5534 Accountant/CPA: Ann Fukuhara,CPA, MBA Phone No.: (808 ) 961 — 5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku Street Address: City,ST,Zip Hilo, HI,96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019 -2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $8,750.00 $16,125.00 $15,875.00 2. Agency Mission Statement: Boys&Girls Club of the Big Island's mission is"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." For 67 years, Boys&Girls Club of the Big Island (BGCBI) has been at the forefront of afterschool youth development services in Hawaii County,continuously focusing on educational, character development,and health/wellness enrichment programs to guide youth toward being and doing their best,for just$10 per year.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala, Ocean View and Kealakehe. BGCBI youth and the families we serve:20%report a combined annual income of$10,000 or less and face economic insecurity with housing and food,resulting in high levels of stress and academic disadvantages.Additionally, 65%of Keaau members report receiving free or reduced school lunches,a further indication of economic hardship.Without our programs, many of our serviced families would not be able to afford safe,afterschool enrichment opportunities that can equate to the quality, life-enhancing programs we provide at a worry-free$10 annual fee. BGCBI's high quality, low-cost services to our local island communities cannot continue without the support of Hawaii County and local businesses. 3. Program Description: "Literacy, Homework&Tutoring Support for Income Challenged"will provide 3 educational initiatives to support the acute academic needs of youth members encouraging greater literacy, better study habits&a higher rate of on-time graduation or advancement to the next grade level.The program utilizes 3 of Boys&Girls Club of America's nationally certified educational support programs. 1: Project REACH (Reading Enhances All Children's Hope)engages youth to participate in literacy enhance- ment activities that help develop their overall reading,spelling&writing proficiency through daily reading&a site wide Spelling Bee.2: "PowerHour,"an incentive-based homework support program, awards participants points for time dedicated to home- work completion.The points collected can be redeemed for sought after items to encourage them to do their homework. Nationally, "Power Hour"has proven to effectively engage youth in developing strong, life-long learning habits that facilitate daily homework completion&test score improvement.3: "Project Learn" reinforces&enhances skills&knowledge youth learn at school.The strategy, based on Dr. Reginald Clark's research,shows students do much better in school when they spend non- school hours engaged in fun, academically beneficial activities.Communication&collaboration amongst parents,school&Club have proven to boost the academic performance of youth members.Our Clubs partner with the schools&host at least 1 Ohana Event a year to bring all the Club youth&families together for fun team-building activities,where Club staff are able to make important announcements&form stronger relationships with families. Following the research/best practices presented by the Carnegie Corporation of New York's Council on Advancing Adolescent Literacy in"Out of School Time,"there are 4 types of literacy initiatives: 1) Literacy&development,2) Literacy&Enhancement,3)Academic Enhancement,4)Social Development. BGCBI youth development programs encompass these 4 initiatives which help establish a strong foundation &desire to gain greater knowledge&shape effective lifelong educational learning habits. 4. Total Budget& Position Count: Total Program Budget: $45,000 Total Program Position Count: 4 Total Agency Budget: $1,461,746 Total Agency Position Count: 41 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii, 2019-20 45,000 Office of Hawaiian Affairs 500,000 Kamehameha Schools 100,000 Rotary Club of South Hilo 10,000 TOTAL: 655,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island(BGCBI)believes that to create changes in a community, it begins with the keiki;these changes do not happen overnight, but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth who need these programs the most in our local, rural communities.Our motto, "When school is out,Clubs are in,"ensures that the youth of our community have continuous opportunities to be in a safe and enriching environment.BGCBI Administration and Board work relentlessly to operate as effectively and efficiently as possible and to secure funding from sources with missions that correspond with ours. BGCBI continues not to advertise our services,because with more children attending the program,we would need to hire,train and employ more staff,driving up the cost of our programming and increasing the amount of funding needed to operate. However, despite not advertising,our membership has been steadily growing so much that we are now expanding our meal program.There is clearly a need in our County for after-school youth development and preventative services; in other words, BGCBI makes a difference. BGCBI has sought and secured funding for the most critical needs of our County's youth-- Educational Support and Food Security. Below is a list of our current supporters: OHA Educational Grant, Hawaii Island United Way, Kamehameha Schools 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase literacy among Income Challenged Youth that BGCBI services through homework, reading,and spelling programs to aid in growing their academic skill set. Participants in our reading program will take pre and post homework surveys,and our objective will yield 50%of participant scores showing increased penchant of youth participants to finish their daily homework. BGCBI will host a site wide Spelling Bee that will include 20 participants from each Club.Tutoring is provided to participants who are struggling academically as revealed through staff observation and report cards BGCBI is able to obtain. BGCBI's objective is to increase rates of student homework completion while attending Club.Through surveys,50%of participants will show that they complete more of their homework during Club hours vs. outside of Club.An additional goal is to increase the number of program youth who complete their daily homework to ensure the establishment of good study habits from daily participation in"Power Hour"while at the Club.60%of Club members will participate in the homework support program.Since it is proven that the most effective programs include clubs,schools,and families,we will host one Ohana Event each academic year to allow parents to explore and celebrate their child's successes at the Club. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Participant surveys will show increased willingness to finish their daily homework 50%increase Number of participants in Spelling Bee 20 Participants show they complete more of their homework during Club hrs vs. outside Club 60%increase Family Nights 1 per academic year Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 892,510 981,761 22,600 Professional Fees 52,000 57.200 10,000 Operations 308,600 339,460 10,000 Supplies 28,000 30,800 2,000 Equipment 8,500 9,350 400 Other: Travel & Per Diem 5,250 5,775 Other: Fundraising & GET 26,000 28,600 Other: Permits, Bank Fees, Other Misc Expenses 8,000 8.800 Other: Other: TOTAL 1,328,860 1,461,746 45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure form's must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. C3(m.x.i a ni i/meq//q Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. ifoq/ q Signature of Authorized Person (see checklist, 2nd item) Date TDOCUrel Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Keaau Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participant surveys will show increased willingness to finish their daily homework 50%increase Number of participants in Spelling Bee 20 Participants show they complete more of their homework during Club hrs vs.outside Club 60%increase Family Nights 1 per academic year TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 22,600 Professional Fees 10,000 Operations 10,000 Supplies 2,000 Equipment 400 Other: Travel & Per Diem Other: Fundraising &GET Other: Permits, Bank Fees, Other Misc Expenses Other: Other: TOTAL 45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Boys & Girls Club of the Big Island, Kealakehe Club Literacy, Homework &Tutoring Support for Income Challenged 38 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged Agency Director: Chad Cabral Phone No.: (808) 961 — 5536 Contact Person: Chad Cabral Phone No.: (808) 961 — 5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI,96720 Facility Address: Address: Kealakehe Intermediate School Address: 74-5062 Onipaa Street City,ST,Zip Kailua-Kona, HI, 96740 Email Address: chad@bgcbi.org Fax No.: (808 ) 961 — 5534 Accountant/CPA: Ann Fukuhara,CPA, MBA Phone No.: (808 ) 961 — 5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku Street Address: City,ST,Zip Hilo, HI,96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000 Geographical Areas To Be Served: (One or more can be checked) n Puna n Hamakua n North Kona n South Hilo n North Kohala n South Kona n North Hilo n South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns n Youth ❑Victims of Crimes n Culture and the arts ❑Aged n Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 n/a $38,087.50 $17,625.00 2. Agency Mission Statement: Boys&Girls Club of the Big Island's mission is"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." For 67 years, Boys&Girls Club of the Big Island(BGCBI) has been at the forefront of afterschool youth development services in Hawaii County,continuously focusing on educational, character development,and health/wellness enrichment programs to guide youth toward being and doing their best,for just$10 per year.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala,Ocean View and Kealakehe. BGCBI youth and the families we serve:20%report a combined annual income of$10,000 or less and face economic insecurity with housing and food, resulting in high levels of stress and academic disadvantages.Additionally,63%of BGCBI members report receiving free or reduced school lunches,a further indication of economic hardship.Without our programs, many of our serviced families would not be able to afford safe,afterschool enrichment opportunities that can equate to the quality, life-enhancing programs we provide at a worry-free$10 annual fee. BGCBI's high quality, low-cost services to our local island communities cannot continue without the support of Hawaii County and local businesses. 3. Program Description: : "Literacy, Homework&Tutoring Support for Income Challenged"will provide 3 educational initiatives to support the acute academic needs of youth members encouraging greater literacy, better study habits&a higher rate of on-time graduation or advancement to the next grade level.The program utilizes 3 of Boys&Girls Club of America's nationally certified educational support programs. 1: Project REACH (Reading Enhances All Children's Hope)engages youth to participate in literacy enhance- ment activities that help develop their overall reading,spelling&writing proficiency through daily reading&a site wide Spelling Bee.2:"PowerHour,"an incentive-based homework support program,awards participants points for time dedicated to home- work completion.The points collected can be redeemed for sought after items to encourage them to do their homework. Nationally, "Power Hour"has proven to effectively engage youth in developing strong, life-long learning habits that facilitate daily homework completion&test score improvement.3:"Project Learn" reinforces&enhances skills&knowledge youth learn at school.The strategy, based on Dr. Reginald Clark's research,shows students do much better in school when they spend non- school hours engaged in fun,academically beneficial activities.Communication&collaboration amongst parents,school&Club have proven to boost the academic performance of youth members.Our Clubs partner with the schools&host at least 1 Ohana Event a year to bring all the Club youth&families together for fun team-building activities,where Club staff are able to make important announcements&form stronger relationships with families. Following the research/best practices presented by the Carnegie Corporation of New York's Council on Advancing Adolescent Literacy in"Out of School Time,"there are 4 types of literacy initiatives: 1) Literacy&development,2) Literacy&Enhancement,3)Academic Enhancement,4)Social Development. BGCBI youth development programs encompass these 4 initiatives which help establish a strong foundation&desire to gain greater knowledge&shape effective lifelong educational learning habits. 4. Total Budget& Position Count: Total Program Budget: $45,000 Total Program Position Count: 4 Total Agency Budget: 1,461,746 Total Agency Position Count: 41 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii, 2019-20 45,000 Office of Hawaiian Affairs 500,000 Kamehameha Schools 100,000 Rotary Club of South Hilo 10,000 TOTAL: 655,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island(BGCBI)believes that to create changes in a community, it begins with the keiki;these changes do not happen overnight,but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth who need these programs the most in our local, rural communities.Our motto, "When school is out,Clubs are in,"ensures that the youth of our community have continuous opportunities to be in a safe and enriching environment. BGCBI Administration and Board work relentlessly to operate as effectively and efficiently as possible and to secure funding from sources with missions that correspond with ours. BGCBI continues not to advertise our services,because with more children attending the program,we would need to hire,train and employ more staff, driving up the cost of our programming and increasing the amount of funding needed to operate. However,despite not advertising,our membership has been steadily growing so much that we are now expanding our meal program.There is clearly a need in our County for after-school youth development and preventative services;in other words, BGCBI makes a difference. BGCBI has sought and secured funding for the most critical needs of our County's youth--Educational Support and Food Security. Below is a list of our current supporters: OHA Educational Grant, Hawaii Island United Way, Kamehameha Schools 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase literacy among Income Challenged Youth that BGCBI services through homework, reading,and spelling programs to aid in growing their academic skill set. Participants in our reading program will take pre and post homework surveys,and our objective will yield 50%of participant scores showing increased penchant of youth participants to finish their daily homework. BGCBI will host a site wide Spelling Bee that will include 20 participants from each Club.Tutoring is provided to participants who are struggling academically as revealed through staff observation and report cards BGCBI is able to obtain. BGCBI's objective is to increase rates of student homework completion while attending Club.Through surveys,50%of participants will show that they complete more of their homework during Club hours vs. outside of Club.An additional goal is to increase the number of program youth who complete their daily homework to ensure the establishment of good study habits from daily participation in"Power Hour"while at the Club.60%of Club members will participate in the homework support program.Since it is proven that the most effective programs include clubs,schools,and families,we will host one Ohana Event each academic year to allow parents to explore and celebrate their child's successes at the Club. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Participant surveys will show increased willingness to finish their daily homework 50%increase Number of participants in Spelling Bee 20 Participants show they complete more of their homework during Club hrs vs.outside Club 60%increase Family Nights 1 per academic year Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 892,510 981,761 22,600 Professional Fees 52,000 57,200 10,000 Operations 308,600 339,460 10,000 Supplies 28,000 30,800 2,000 Equipment 8,500 9,350 400 Other: Travel & Per Diem 5,250 5,775 Other: Fundraising&GET 26,000 28,600 Other: Permits, Bank Fees, Other Misc Expenses 8,000 8,800 Other: Other: TOTAL 1,328,860 1,461,746 45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i_Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. ,l (a g 1 is Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 • Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I.(we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a'credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. Oftla 0, 19-611 Signature of Authorized Person (see checklist, 2nd item) Date Oa G1CL/12- Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Kealakehe Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participant surveys will show increased willingness to finish their daily homework 50%increase Number of participants in Spelling Bee 20 Participants show they complete more of their homework during Club hrs vs.outside Club 60%increase Family Nights 1 per academic year TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 22,600 Professional Fees 10,000 Operations 10,000 Supplies 2,000 Equipment 400 Other: Travel & Per Diem Other: Fundraising &GET Other: Permits, Bank Fees, Other Misc Expenses Other: Other: TOTAL 45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Boys & Girls Club of the Big Island, Pahala Club Literacy, Homework&Tutoring Support for Income Challenged 39 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged Agency Director: Chad Cabral Phone No.: (808) 961 - 5536 Contact Person: Chad Cabral Phone No.: (808) 961 - 5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI,96720 Facility Address: Address: Pahala Community Center Address: 96-1149 Kamani Street City,ST,Zip Pahala, HI,96777 Email Address: chad@bgcbi.org Fax No.: (808 ) 961 - 5534 Accountant/CPA: Ann Fukuhara,CPA, MBA Phone No.: (808 ) 961 - 5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku Street Address: City,ST,Zip Hilo, HI,96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $8,750.00 $16,600.00 $16,425.00 2. Agency Mission Statement: Boys&Girls Club of the Big Island's mission is"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment."For 67 years, Boys&Girls Club of the Big Island(BGCBI) has been at the forefront of afterschool youth development services in Hawaii County,continuously focusing on educational, character development,and health/wellness enrichment programs to guide youth toward being and doing their best,for just$10 per year.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala, Ocean View and Kealakehe. BGCBI youth and the families we serve:20%report a combined annual income of$10,000 or less and face economic insecurity with housing and food,resulting in high levels of stress and academic disadvantages.Additionally, 84%of Pahala members report receiving free or reduced school lunches,a further indication of economic hardship.Without our programs,many of our serviced families would not be able to afford safe,afterschool enrichment opportunities that can equate to the quality, life-enhancing programs we provide at a worry-free$10 annual fee. BGCBI's high quality, low-cost services to our local island communities cannot continue without the support of Hawaii County and local businesses. 3. Program Description: :"Literacy, Homework&Tutoring Support for Income Challenged"will provide 3 educational initiatives to support the acute academic needs of youth members encouraging greater literacy,better study habits&a higher rate of on-time graduation or advancement to the next grade level.The program utilizes 3 of Boys&Girls Club of America's nationally certified educational support programs. 1: Project REACH (Reading Enhances All Children's Hope)engages youth to participate in literacy enhance- ment activities that help develop their overall reading,spelling&writing proficiency through daily reading&a site wide Spelling Bee.2: "PowerHour,"an incentive-based homework support program,awards participants points for time dedicated to home- work completion.The points collected can be redeemed for sought after items to encourage them to do their homework. Nationally, "Power Hour"has proven to effectively engage youth in developing strong, life-long learning habits that facilitate daily homework completion&test score improvement.3: "Project Learn" reinforces&enhances skills&knowledge youth learn at school.The strategy,based on Dr. Reginald Clark's research,shows students do much better in school when they spend non- school hours engaged in fun, academically beneficial activities.Communication&collaboration amongst parents,school&Club have proven to boost the academic performance of youth members.Our Clubs partner with the schools&host at least 1 Ohana Event a year to bring all the Club youth&families together for fun team-building activities,where Club staff are able to make important announcements&form stronger relationships with families. Following the research/best practices presented by the Carnegie Corporation of New York's Council on Advancing Adolescent Literacy in"Out of School Time,"there are 4 types of literacy initiatives: 1) Literacy&development,2) Literacy&Enhancement,3)Academic Enhancement,4) Social Development. BGCBI youth development programs encompass these 4 initiatives which help establish a strong foundation&desire to gain greater knowledge&shape effective lifelong educational learning habits. 4.Total Budget& Position Count: Total Program Budget: $45,000 Total Program Position Count: 4 Total Agency Budget: 1,461,746 Total Agency Position Count: 41 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii, 2019-20 45,000 Office of Hawaiian Affairs 500,000 Kamehameha Schools 100,000 Rotary Club of South Hilo 10,000 TOTAL: 655,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island(BGCBI)believes that to create changes in a community, it begins with the keiki;these changes do not happen overnight,but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth who need these programs the most in our local, rural communities.Our motto, "When school is out,Clubs are in,"ensures that the youth of our community have continuous opportunities to be in a safe and enriching environment. BGCBI Administration and Board work relentlessly to operate as effectively and efficiently as possible and to secure funding from sources with missions that correspond with ours. BGCBI continues not to advertise our services,because with more children attending the program,we would need to hire,train and employ more staff,driving up the cost of our programming and increasing the amount of funding needed to operate. However,despite not advertising,our membership has been steadily growing so much that we are now expanding our meal program.There is clearly a need in our County for after-school youth development and preventative services;in other words,BGCBI makes a difference. BGCBI has sought and secured funding for the most critical needs of our County's youth-- Educational Support and Food Security. Below is a list of our current supporters: OHA Educational Grant, Hawaii Island United Way, Kamehameha Schools 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase literacy among Income Challenged Youth that BGCBI services through homework, reading,and spelling programs to aid in growing their academic skill set. Participants in our reading program will take pre and post homework surveys,and our objective will yield 50%of participant scores showing increased penchant of youth participants to finish their daily homework. BGCBI will host a site wide Spelling Bee that will include 20 participants from each Club.Tutoring is provided to participants who are struggling academically as revealed through staff observation and report cards BGCBI is able to obtain. BGCBI's objective is to increase rates of student homework completion while attending Club.Through surveys,50%of participants will show that they complete more of their homework during Club hours vs. outside of Club.An additional goal is to increase the number of program youth who complete their daily homework to ensure the establishment of good study habits from daily participation in"Power Hour"while at the Club.60%of Club members will participate in the homework support program.Since it is proven that the most effective programs include clubs,schools,and families,we will host one Ohana Event each academic year to allow parents to explore and celebrate their child's successes at the Club. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Participant surveys will show increased willingness to finish their daily homework 50%increase Number of participants in Spelling Bee 20 Participants show they complete more of their homework during Club hrs vs.outside Club 60%increase Family Nights 1 per academic year Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 892510 981,761 22,600 Professional Fees 52000 57,200 10,000 Operations 308600 339,460 10,000 Supplies 28000 30,800 2,000 Equipment 8500 9,350 400 Other: Travel & Per Diem 5250 5,775 Other: Fundraising & GET 26000 28,600 Other: Permits, Bank Fees, Other Misc Expenses 8000 8,800 Other: Other: TOTAL 1,328,860 1,461,746 45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your\organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n S- taff appointed by a member of the Council n The Mayor n The Managing Director n T- he Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. l Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. jOrki6 ( a i Signature of Authorized Person (see checklist, 2nd item) Date fel e}V-0(2-- Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Pahala Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participant surveys will show increased willingness to finish their daily homework 50 increase Number of participants in Spelling Bee 20 Participants show they complete more of their homework during Club hrs vs.outside Club 60%increase Family Nights 1 per academic year TABLE II: PROGRAM EXPENDITURES FY 19-20 Grant Council Request Award Salary and Wages 22,600 Professional Fees 10,000 Operations 10,000 Supplies 2,000 Equipment 400 Other: Travel & Per Diem Other: Fundraising & GET Other: Permits, Bank Fees, Other Misc Expenses Other: Other: TOTAL 45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Boys & Girls Club of the Big Island, Pahoa Club Literacy, Homework &Tutoring Support for Income Challenged 40 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged Agency Director: Chad Cabral Phone No.: (808) 961 — 5536 Contact Person: Chad Cabral Phone No.: (808) 961 — 5536 Mailing Address: Address: 100 Kamakahonu Street Address: City,ST,Zip Hilo, HI,96720 Facility Address: Address: YBA Hall Address: 15-3003 Kauhale Street City,ST,Zip Pahoa, HI,96778 Email Address: chad@bgcbi.org Fax No.: (808 ) 961 — 5534 Accountant/CPA: Ann Fukuhara, CPA, MBA Phone No.: (808 ) 961 — 5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku Street Address: City,ST,Zip Hilo, HI,96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna n Hamakua n North Kona n South Hilo n North Kohala n South Kona ❑ North Hilo ❑ South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) [' Educational concerns n Youth ❑Victims of Crimes ❑ Culture and the arts ❑ Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $8,750.00 $7,625.00 $17,250.00 2. Agency Mission Statement: Boys&Girls Club of the Big Island's mission is"To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment."For 67 years, Boys&Girls Club of the Big Island (BGCBI) has been at the forefront of afterschool youth development services in Hawaii County,continuously focusing on educational, character development,and health/wellness enrichment programs to guide youth toward being and doing their best,for just$10 per year.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala,Ocean View and Kealakehe. BGCBI youth and the families we serve:20%report a combined annual income of$10,000 or less and face economic insecurity with housing and food, resulting in high levels of stress and academic disadvantages.Additionally,67%of Pahoa members report receiving free or reduced school lunches, a further indication of economic hardship.Without our programs, many of our serviced families would not be able to afford safe,afterschool enrichment opportunities that can equate to the quality, life-enhancing programs we provide at a worry-free$10 annual fee. BGCBI's high quality,low-cost services to our local island communities cannot continue without the support of Hawaii County and local businesses. 3. Program Description: : "Literacy, Homework&Tutoring Support for Income Challenged"will provide 3 educational initiatives to support the acute academic needs of youth members encouraging greater literacy,better study habits&a higher rate of on-time graduation or advancement to the next grade level.The program utilizes 3 of Boys&Girls Club of America's nationally certified educational support programs. 1: Project REACH (Reading Enhances All Children's Hope)engages youth to participate in literacy enhance- ment activities that help develop their overall reading,spelling&writing proficiency through daily reading&a site wide Spelling Bee.2: "PowerHour,"an incentive-based homework support program,awards participants points for time dedicated to home- work completion.The points collected can be redeemed for sought after items to encourage them to do their homework. Nationally, "Power Hour"has proven to effectively engage youth in developing strong, life-long learning habits that facilitate daily homework completion&test score improvement.3: "Project Learn"reinforces&enhances skills&knowledge youth learn at school.The strategy,based on Dr. Reginald Clark's research,shows students do much better in school when they spend non- school hours engaged in fun,academically beneficial activities. Communication&collaboration amongst parents,school&Club have proven to boost the academic performance of youth members.Our Clubs partner with the schools&host at least 1 Ohana Event a year to bring all the Club youth&families together for fun team-building activities,where Club staff are able to make important announcements&form stronger relationships with families. Following the research/best practices presented by the Carnegie Corporation of New York's Council on Advancing Adolescent Literacy in"Out of School Time,"there are 4 types of literacy initiatives: 1) Literacy&development,2) Literacy&Enhancement,3)Academic Enhancement,4)Social Development. BGCBI youth development programs encompass these 4 initiatives which help establish a strong foundation&desire to gain greater knowledge&shape effective lifelong educational learning habits. 4. Total Budget& Position Count: Total Program Budget: $45,000 Total Program Position Count: 4 Total Agency Budget: 1,461,746 Total Agency Position Count: 41 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii, 2019-20 45,000 Office of Hawaiian Affairs 500,000 Kamehameha Schools 100,000 Rotary Club of South Hilo 10,000 TOTAL: 655,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Boys&Girls Club of the Big Island(BGCBI)believes that to create changes in a community, it begins with the keiki;these changes do not happen overnight, but over a generation. BGCBI works tirelessly to provide quality and safe after-school programs that enrich the lives of youth who need these programs the most in our local, rural communities.Our motto, "When school is out, Clubs are in,"ensures that the youth of our community have continuous opportunities to be in a safe and enriching environment. BGCBI Administration and Board work relentlessly to operate as effectively and efficiently as possible and to secure funding from sources with missions that correspond with ours. BGCBI continues not to advertise our services,because with more children attending the program,we would need to hire,train and employ more staff,driving up the cost of our programming and increasing the amount of funding needed to operate. However, despite not advertising,our membership has been steadily growing so much that we are now expanding our meal program.There is clearly a need in our County for after-school youth development and preventative services; in other words, BGCBI makes a difference. BGCBI has sought and secured funding for the most critical needs of our County's youth--Educational Support and Food Security. Below is a list of our current supporters: OHA Educational Grant, Hawaii Island United Way, Kamehameha Schools 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase literacy among Income Challenged Youth that BGCBI services through homework, reading,and spelling programs to aid in growing their academic skill set. Participants in our reading program will take pre and post homework surveys,and our objective will yield 50%of participant scores showing increased penchant of youth participants to finish their daily homework. BGCBI will host a site wide Spelling Bee that will include 20 participants from each Club.Tutoring is provided to participants who are struggling academically as revealed through staff observation and report cards BGCBI is able to obtain. BGCBI's objective is to increase rates of student homework completion while attending Club.Through surveys,50%of participants will show that they complete more of their homework during Club hours vs.outside of Club.An additional goal is to increase the number of program youth who complete their daily homework to ensure the establishment of good study habits from daily participation in"Power Hour"while at the Club.60%of Club members will participate in the homework support program.Since it is proven that the most effective programs include clubs,schools,and families,we will host one Ohana Event each academic year to allow parents to explore and celebrate their child's successes at the Club. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Participant surveys will show increased willingness to finish their daily homework 50%increase Number of participants in Spelling Bee 20 Participants show they complete more of their homework during Club hrs vs. outside Club 60%increase Family Nights 1 per academic year Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 892,510 981,761 22,600 Professional Fees 52,000 57,200 10,000 Operations 308,600 339,460 10,000 Supplies 28,000 30,800 2,000 Equipment 8,500 9,350 400 Other: Travel & Per Diem 5,250 5,775 Other: Fundraising & GET 26,000 28,600 Other: Permits, Bank Fees, Other Misc Expenses 8,000 8,800 Other: Other: TOTAL 1,328,860 1,461,746 45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. C JCSYLL IMO Signature of Autho^ized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. (Jam. (� a ( 1.* /9 Signature of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Boys & Girls Club of the Big Island, Pahoa Club Program Name: Literacy, Homework & Tutoring Support for Income Challenged 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participant surveys will show increased willingness to finish their daily homework 60i increase Number of participants in Spelling Bee 20 Participants show they complete more of their homework during Club hrs vs.outside Club 60%increase Family Nights 1 per academic year TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 22,600 Professional Fees 10,000 Operations 10,000 Supplies 2,000 Equipment 400 Other: Travel & Per Diem Other: Fundraising &GET Other: Permits, Bank Fees, Other Misc Expenses Other: Other: TOTAL 45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Brantley Center Inc. Job Skills Development Program 41 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Brantley Center Inc Program Name: Job Skils Development Program Agency Director: Dareth Pung-Boteilho Phone No.: (808 ) 775 — 7245 Contact Person: Dareth Pung-Boteilho Phone No.: (808 ) 775 — 7245 Mailing Address: Address: PO Box 1407 Address: City,ST,Zip Honokaa, HI 96727 Facility Address: Address: 45-370 Ohelo Rd Address: City,ST,Zip Honoka'a, HI 96727 Email Address: dboteilho@gmail.com • Fax No.: (808 ) 775 — 0211 Accountant/CPA: MGE Bookkeeping Phone No.: (808 ) 217 — 1299 Firm (if applicable): Mailing Address: Address: PO Box 246 Address: City,ST,Zip Laupahoehoe, HI 96764 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑✓ Hamakua ❑ North Kona ❑ South Hilo ❑✓ North Kohala ❑ South Kona ✓❑ North Hilo ❑✓ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑ Youth n Victims of Crimes ❑ Culture and the arts ❑Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Brantley Center Inc Program Name: Job Skils Development Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 14906.25 0 2. Agency Mission Statement: Our mission is to provide quality rehabilitation services that empower people with disabilites to participate independently within his or her community. 3. Program Description: Brantley Center, Inc clients recieve daily curb-to-curb transportation both to and from the Center free of charge. While at the Center clients recieve a thorough job skills readiness asessment. Bases on assessment results they are given an appropriate service array. These services include job readiness classes, hand on the Job readiness training in the field, competitie employment placement services,and on the job follow up services. At the Center lients have the opportunity to explore different jobs and skills ranging from janitorial services,yard maintenance, landscaping,agriculture and hydroponic skills,green house maintenane, car wash and detailing, as well as small craft production. Clients are paid based on their productivity levels and are rewarded for increased and improved productivity. Once the necessary skills are obtained clients are then placed in compettive jobs within the community and continue to recieve suppportive follow up services for the initial siz months of employment. The Job Skills Development staff and clients develop a stron relationship and rapport with community businesses and member leading owards community bases vocational training as well as providing the public with an additional workforce. 4. Total Budget & Position Count: Total Program Budget: 145,900 Total Program Position Count: 3 Total Agency Budget: 390,00 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Brantley Center Inc Program Name: Job Skils Development Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Auto Detailing Services 2,000 Fish Bag Manufactoring 3,000 Janitorial Services 17,000 Yard Maintenance Services • 111,300 TOTAL: 133,300 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Brantley Center Staff and Board Members have made a collective and concerted effort to expand its fund development capabilities whether it be through pursuing new grants or coming up with fresh ideas on fundraising efforts. Brantley center will increase revenues and continue to support the Job Skills Development Program through pursuing and securing more community contracts. Examples of currently secured contracts are numerous yard maintenance and landscaping jobs in the Waimea, Kohala, Hilo and Honoka'a areas,approximately five different jaitorial contracts within Honoka'a, as well as providing goods in the form of hydroponic greens to numerous resturants and small craft production for a Kona Tropical fish farm. With the funding and intake of more clients we will be able to secure more contracts thus leading to a self sustained program. 7. Program Objectives Using County Nonprofit Grant Program Funds: If funds are awarded, beginning July 01, 2019 Brantley Center, Inc. will immediatly increse the number of clients brought into the Job Skills Development Program. A full restoration will be made to the Program allowing for more clients getting necessary job-readiness training in the form of vocational evaluations, indiidualized employment planning services,work adjustment training, occupational skils, competitive job placement within the community and work transition services. A minimum of fifteen additional clients will be served during the fiscal year that would otherwise not have been provided these benefical services. With the increase in intake clients Brantley Center will be able to pursue and secure more contracts within the community thus allowing for more revenue. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit,Grant Application FY2019-20 • Agency Name: Brantley Center Inc Program Name: Job Skils Development Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of clients who recieved employment rehab services 20 Number of consumers who improved scored on the vocational evaluation training report 10 Number of consumers with improed productivity percentages 10 Number of consumers who successfully completed the job-readines classes 15 Number of consumers placed in competitive employment for a minimum of 90 days 5 Number of students who recieve work transition services and were paced in competitive 3 employment Attach additional pages as necessary. 9. TABLE II: • PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 80,800 105,700 Professional Fees 0 8,100 Operations Supplies 4,600 5,000 Equipment 1,000 6,000 Other: Employee Benefits 5,200 7,000 Other: Equiptment/Auto Repairs and Maintenance 5,000 5,500 Other: GE Taxes 2,868 3,000 Other: Insurance 4,600 5,600 Other: TOTAL 103,868 145,900 $40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Brantley Center Inc Program Name: Job Skils Development Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council n Staff appointed by a member of the Council The Mayor ❑ The Managing Director ❑ The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. l`r , ram P\tefrk I go Signature of Authorized Person (specify title) Date • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Brantley Center Inc Program Name: Job Skils Development Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. • 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Brantley Center Inc Program Name: Job Skils Development Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a(current Certificate of Liability ($1,000,000 eneral liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you,acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. g2 1(' "LW-1°1 Signature of Authorized Person (see checklist, 2nd item) Date PrQgrcwn DireC-Vor Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Brantley Center Inc Program Name: Job Skils Development Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 20 Number of clients who recieved employment rehab services Number of consumers who improved scores on the vocational evaluation training report 10 Number of consumers with improved productivity percentages 10 15 Number of consumers who successfully completed the job-readiness classes 5 Number of consumers placed in competitve employment for a minimum of 90 days Number of students who reciee work transition services and were placed in competitive 3 employment TABLE II: PROGRAM EXPENDITURES FY 19-20 Grant Council Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Employee Benefits Other: Equiptment/Auto Repairs and Maintenance Other: GE Taxes Other: Insurance Other: TOTAL $40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Bridge House, Inc. Clean &Sober Living Program 42 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bridge House, Inc. Program Name: Clean & Sober Living Program Agency Director: Andi Pawasarat-Losalio Phone No.: (808) 322 — 3305 Contact Person: Andi Pawasarat-Losalio Phone No.: (808) 938 — 8942 Mailing Address: Address: P.O. Box 2489 • • Address: • City,ST,Zip Kailua-Kona, HI 96745 Facility Address: Address: 78-6687B Mamalahoa Hwy. Address: City,ST,Zip Holualoa, HI 96725 Email Address: director.bridgehouse@gmail.com Fax No.: (808 ) 322 — 3305 Accountant/CPA: Carbonaro CPAs&Management Group Phone No.: (808) 930 — 6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $35,000 Geographical Areas To Be Served: (One or more can be checked) • ❑ Puna ❑✓ Hamakua ❑✓ North Kona ❑South Hilo ❑✓ North Kohala ❑✓ South Kona ❑ North Hilo n South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) • ,❑✓ Educational concerns ❑Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A • NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bridge House, Inc. Program Name: Clean & Sober Living Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0 $ 0 $ 0 2.Agency Mission Statement: New Mission Statement:Guided by our values of Pilina(connection),Aloha'Aina(love of the land), Lokahi(unity), Maluhia (peace),and Pono(virtue)we work with mindful intention and the client's best interest at heart to create a supportive environment for the recovery process. Agency Origin Mission Statement:To assist adults in early recovery from drug and alcohol addiction to develop successful living skills through residential and vocational experiences in a safe,structured and supportive environment. 3. Program Description: Bridge House has recognized the tremendous community need for transitional housing for the recovery population as they move from highly structured settings towards successful independent living. Housing is the number one issue in Kona.To fill this niche, Bridge House's Clean&Sober Housing Program is designed to provide Clean and Sober Housing opportunities for up to fifteen(15)individuals for up to six(6)months at a time at its main facility. It is estimated that forty-eight(48)individuals will be served each year of the contract. All referrals for residency are screened by Bridge House's professional staff and must meet the eligibility requirements with preference given to pregnant women and injection drug users. While residing in the Clean&Sober Housing,clients receive continuum of care services including Care Coordination,Transportation,Vocational Skill-Building and assistance with housing applications and planning for future housing. All individuals accepted for residency complete a Clean and Sober Living Assessment at the time of intake and participate in activities that support established needs from the Health and Wellness plan. Bridge House is very connected to support services provided in and by the West Hawai'i community.The Bridge House Care Coordinator is able to make referrals to external services that may help clients achieve goals for appropriate treatment placement as well as for psychological,social functioning,self-esteem, and coping abilities. Each client is assisted to develop and maintain a Health and Wellness Plan that includes creating a healthy support system that helps with the transition back to family and community. An array of educational and support group services including Smoking Cessation,Vocational Skill-Building and transportation to substance abuse treatment is available. While residing in the Clean and Sober Housing, clients are eligible to participate in health education groups, support group meetings, acupuncture,gardening, cultural services, nutrition education and other supportive services to prevent relapse. 4.Total Budget& Position Count: Total Program Budget: $295,000.00 Total Program Position Count: 3 Total Agency Budget: $433,951.56 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bridge House, Inc. Program Name: Clean & Sober Living Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Department of Health Alcohol& Drug Abuse Division $153,000.00 Judicary $81,000.00 Program Fees $24,000.00 Agricultural Income $1,500.00 Contributtions $500.00 County of Hawai'i $35,000.00 TOTAL: $295,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We have a sustainability plan that works on diversification of income.We have also expanded our on-site agricultural endeavors and are selling new produce to additional vendors.While our agricultural pursuits contribute some income,the current proceeds from these sales are insufficient to support the program.We are working on expanding to provide additional services this year to include outreach and day-treatment.As such,we continue to seek funds from both private and public funders to assist. 7. Program Objectives Using County Nonprofit Grant Program Funds: From its inception, Bridge House has recognized the tremendous community need for transitional housing for the recovery population as they often move from a highly structured selling towards successful independent living. Bridge House is designed to provide clean and sober housing spaces for up to fifteen(15)individuals at any given day. The focus of the Clean and Sober Housing Program is to provide the necessary support and encouragement to assist the client to adjust to a chemically abstinent lifestyle. Most of our clients come to us unemployed and homeless or from unsafe living environments.We provide services to enhance independent living skills that may foster the transition to independent housing and self-management,and to give support to the clients as they rejoin their communities and families as healthy productive people. We do this by providing a six-month stay in a schedule driven and values oriented environment that also provides case management and oversight to assist with ensuring appropriate support services are in place for each client. When a client completes the program he/she will have gained enough support through the program to be working or participating in continuing education, have safe,stable, sober housing, have a network of support, have supports in place for mental health(if needed), be able to keep a schedule and a budget,and have a deeper understanding of what it means to be self-supportive,or working towards self-support,will have a clear idea of what it takes to live a clean&sober life and the supports that they need to have in place to be successful. Clients will also have gained respect for the'aina and the importance of helping others as an island community member. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bridge House, Inc. Program Name: Clean & Sober Living Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 48 clients to be served;those that graduates shall have the following at time of program completion: 1. Stable Housing 100%of graduates will meet this mark 2. Obtain/maintain Income 100%of graduates will meet this mark 3. Sobriety 100%of graduates will meet this mark 4. Support system in place 100%of graduates will meet this mark k- At 6-month Follow-up outcomes will be based on the above four(4)markers 65% of graduates will meet this mark at time of follow-up Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 108,026.78 110,000.00 13,000.00 Professional Fees 7,923.77 8,000.00 1,500.00 Operations 138,303.66 140,000.00 15,600.00 Supplies 8,459.77 8,500.00 1,800.00 Equipment Other: payroll tax&req 23,438.16 23,500.00 2,300.00 Other: staff training 2,191.86 2,500.00 800.00 Other: travel 5,224.37 2,500.00 Other: Other: TOTAL 293,568.37 295,000.00 35,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bridge House, Inc. Program Name: Clean & Sober Living Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate regardless ofwhether a conflict exists. as needed to fullydisclose. All disclosure forms must be signed, eqa f NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council H Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. /./‘4-ta./1"C—Pres- Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bridge House, Inc. Program Name: Clean & Sober Living Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bridge House, Inc. Program Name: Clean & Sober Living Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (see checklist, 2nd item) Date TCEStGQ ' Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bridge House, Inc. Program Name: Clean & Sober Living Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result • 48 clients to be served;those that graduates shall have the following at time of program completion: 1. Stable Housing t160%affk graduates will meet ' 2. Obtain/maintain Income 100%of graduates will meet th 3. Sobriety 100% rfkgraduates will meet 4. this m Supportsystem inplace 100%of graduates will meet this mark At 6-month Follow-upoutcomes will be based on the above four(4)markers 65% of graduates will meet this mark at time of follow-up • TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request • Award Salary and Wages 13,000.00 Professional Fees 1,500.00 Operations 15,600.00 Supplies 1,800.00 Equipment Other: payroll tax&req 2,300.00 Other: staff training • 800.00 Other: travel Other: Other: • TOTAL 35,000.00 Additional Council directives regarding award: • EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Bridge House, Inc. Vocational Skills Building Program 43 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building Program Agency Director: Andi Pawasarat-Losalio Phone No.: (808) 322 — 3305 Contact Person: Andi Pawasarat-Losalio Phone No.: (808) 938 — 8942 Mailing Address: Address: P.O. Box 2489 Address: City,ST,Zip Kailua-Kona, HI 96745 Facility Address: Address: 78-6687B Mamalahoa Hwy. Address: City,ST,Zip Holualoa, HI 96725 Email Address: director.bridgehouse@gmail.com Fax No.: (808 ) 322 — 0809 Accountant/CPA: Carbonaro CPAs&Management Group Phone No.: (808) 930 — 6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $18,000 Geographical Areas To Be Served: (One or more can be checked) n Puna ❑✓ Hamakua ❑✓ North Kona ['South Hilo [' North Kohala n South Kona ❑ North Hilo ❑South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑✓ Victims of Health or Social Crises ❑./ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $18,000.00 $15,750.00 $11,300.00 2.Agency Mission Statement: New Mission Statement:Guided by our values of Pilina(connection),Aloha'Aina(love of the land), Lokahi(unity), Maluhia (peace), and Pono(virtue)we work with mindful intention and the client's best interest at heart to create a supportive environment for the recovery process. Agency Origin Mission Statement:To assist adults in early recovery from drug and alcohol addiction to develop successful living skills through residential and vocational experiences in a safe,structured and supportive environment. 3. Program Description: Ongoing research consistently confirms that employment is a strong correlate with successful recovery from addiction along with re-establishing connections to family and the community.As a result of their substance abuse approximately 90%of all our new admits are unemployed/unemployable upon arrival to Bridge House. Participation in our Vocational Skills Building(VSB) Program is mandatory for all clients in our clean&sober housing program.All new participants complete a vocational skills questionnaire.The results of this evaluation,along with personal observation by staff, identifying needed skills, attitudes and behaviors that may require remediation.This is an integral part of all of our program as reintegrating and becoming accepted into the community,as well as gaining employment, is often a client's biggest fear. The VSB program provides on-site job training and off-site supervised community volunteer experiences.All participants are evaluated on performance of job assignments as an individual and as a group. Participants are given support for improvement. Staff assists by providing coordination services to assist in navigating the process of attaining legal documentation for employment(i.e.:state ID,social security cards, birth certificates...). Many of our participants have never had, or have lost,their legal identification and most often do not have the financial resources to obtain or replace them.The lack of identification can be a major barrier to attaining legal employment.The VSB program is supported through culturally relevant programming as well, and may include the use of a culturally based financial literacy/education program.Vocational staff also assist with resume preparation, provide training in the use of basic office equipment and basic computer skills, may conduct mock interviews,train in use and care of tools,facilitate linkages to other community resources for enhancement of work skills as well as educational opportunities and offers guidance to jobs appropriate to ability.Transportation may also be provided to obtain job applications, attain appropriate work clothing, attend interviews and attain legal documents and identification. 4.Total Budget&Position Count: Total Program Budget: $99,300.00 Total Program Position Count: 1.50 Total Agency Budget: $433,951.56 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawai'i $18,000.00 Hawai'i Island United Way $25,000.00 Department of Health Alcohol& Drug Abuse Division $41,000.00 Contributions $400.00 Program Fees $12,000.00 Agricultural Income $2,900.00 TOTAL: $99,300.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We have a sustainability plan that works on diversification of income.We have also expanded our on-site agricultural endeavors and are selling new produce to additional vendors.While our agricultural pursuits contribute some income,the current proceeds from these sales are insufficient to support the program.We are working on expanding to provide additional services this year to include outreach and day-treatment.As such,we continue to seek funds from both private and public funders to assist. 7. Program Objectives Using County Nonprofit Grant Program Funds: The VSB program's primary objective is to prepare participants to enter/re-enter the workforce.As a result of their addiction most individuals have disengaged from main steam society(e.g.: abandoning family, losing employment, engaging in criminal activity). The substance abuser no longer shares many of the healthy benefits/values that are found within the community. Maintaining employment has consistently been identified as one of the primary components that facilitates successful recovery as well as reconnection with family and community. Every individual that is able to secure employment and begin the process of re-engagement is likely to eliminate self-destructive behaviors, rejoin their family,experience enhanced health,and begin to 'give back'to the community.While we work towards 100%of graduates to be employed,we expect 85%graduates to have secured employment prior to leaving Bridge House and to report still being employed at 6 months post-discharge. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (Le.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Approx 48 adults(men/women)will be served; and of those completing program 85%will be employed or in school/training program,95%will attain legal documents/ID At 6-months post-discharge:will be employed and/or attending school/job training program 75%of graduates will be report no new arrests, report no new relapses. at 6-month follow-up Attach additional pages as necessary. • 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 46,751.00 47,500.00 5,690.00 Professional Fees 5,101.13 5,200.00 2,200.00 Operations 21,478.04 21,500.00 6,500.00 Supplies 10,197.81 10,200.00 1,000.00 Equipment 5,263.06 2,800.00 1,400.00 Other: Fringe Benefits Other: Payroll Taxes 10,445.50 10,500.00 810.00 Other: Staff Training 1,600.00 400.00 Other: Other: TOTAL 99,236.54 99,300.00 18,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): H Member or members of the Council ❑ Staff appointed by a member of the Council n The Mayor ❑ The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. / ? res 3v--/f Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building Program ii. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. it 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bridge House, Inc. Program Name: Vocational Skills Building Program i.i.. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days.of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from, future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's Luture funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. J - / Signature of Authorized Person (see checklist, 2nd item) Date ?res (J ex* Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Bridge House, Inc. • Program Name: Vocational Skills Building Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 85%will be employed or in school/training program,95%will attain legal documents/ID 75%of graduates will be emplo follow-up TABLE II: PROGRAM EXPENDITURES FY 19-20 Grant Council Request • Award Salary and Wages 5,690.00 Professional Fees 2,200.00 Operations 6,500.00 Supplies 1,000.00 Equipment 1,400.00 Other: Fringe Benefits Other: Payroll Taxes 810.00 Other: Staff Training 400.00 Other: Other: TOTAL 18,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Child & Family Service Alternatives to Violence 44 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: Alternatives to Violence Agency Director: Karen Tan Phone No.: (808) 681 — 3500 Contact Person: Joey Keahiolalo Phone No.: (808) 681 — 3500 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,Zip Ewa Beach, HI 96706 Facility Address: Address: 1045A Kilauea Avenue Address: City,ST,Zip Hilo, HI 96720 Email Address: cfscontracts@cfs-hawaii.org Fax No.: (808 ) 681 — 5280 Accountant/CPA: CW Associates, CPAs Phone No.: (808 ) 531 — 1041 Firm (if applicable): CW Associates, CPAs Mailing Address: Address: 700 Bishop Street Address: Suite 1040 City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $73,000 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns Youth ❑✓ Victims of Crimes ❑ Culture and the arts ❑✓ Aged Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: Alternatives to Violence 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $14,375 $14,375 $6,300 2. Agency Mission Statement: The Alternatives to Violence(ATV)Program fits perfectly with Child&Family Service's(CFS)mission of"Strengthening families and fostering the healthy development of children". In partnership with the County of Hawaii,ATV program services have been provided for more than seven years. CFS offers nearly 50 programs statewide with a comprehensive array of effective and culturally relevant services for Hawaii's residents in need.The broad spectrum of services provided by CFS include domestic violence intervention,case management,therapeutic foster care,alternative education for alienated youth, prevention and treatment of child abuse, recovery and prevention of substance abuse,and school and community-based counseling services for children and their families. Infants, children,adolescents,young adults, individuals and families in need all have benefited from these services. In Fiscal Year 2018,CFS directly served 15,798 individuals and their families, ranging from infants to older adults. In addition, the organization has"touched"the lives of over 75,000 individuals annually through hot-line calls, educational presentations, and providing food and clothing to those in need. CFS provides these services through 35 sites on the islands of Oahu, Hawaii, Kauai, Maui, Molokai, and Lanai. CFS's programs are responsive,flexible and focused on positive outcomes. Services are provided in homes, schools,and in the community as well as in CFS's 35 office locations throughout the state. (Continued on Attachment) 3. Program Description: Intimate partner violence, sexual violence, physical violence, and stalking are important public health problems that have enormous short and long-term impact on victims, communities, health-care,justice systems and society as a whole. Child& Family Service(CFS)provided domestic violence(DV)services to 3,702 individuals statewide in FY18. Forty-two percent,of these individuals received assistance from CFS programs on Hawaii Island. In FY16-17,a total of 6,098 Orders for Protection(TRO's)were filed in the State of Hawaii,with 2,985 filed on Oahu, 699 filed on Maui,450 filed on Kauai,and 1,964 filed on Hawaii Island. Taking into account the total number of TRO's filed per county and the population of each county, Hawaii County had the highest number of TRO's per capita in our state. DV affects more than an estimated 50,000 individuals annually statewide(as reported by Hawaii Says No More). Of all crimes, DV has the highest repeat rate; DV offenders have higher rates of recidivism than all non-DV offenders. Recent studies suggest that preventing intimate partner violence requires cross cutting multi-sector efforts, and complementary approaches at different levels of social ecology(individually, relational, community and societal). CFS understands domestic violence is traumatic. It impacts every family member. National statistics regarding domestic violence available through the Centers for Disease Control and Prevention (CDC)indicate that 1 in 4 women will experience domestic violence during her lifetime; it is the third leading cause of homelessness among families according to the U.S. Department of Housing and Urban Development(HUD); more than 3 million children witness domestic violence annually; (Continued on Attachment) 4. Total Budget& Position Count: Total Program Budget: $618,460 Total Program Position Count: 10.25 Total Agency Budget: $6,105,125 Total Agency Position Count: 82 (Continued on Attachment) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: Alternatives to Violence 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Judiciary $528,999 County of Hawaii (funding requested in this proposal) $73,000 HIUW $8,830 Program Fees $3,000 TOTAL: $613,829 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: CFS works hard to maintain, diversify and increase funding for all of our program services. Given the number of individuals and families impacted by domestic violence on the Big Island, domestic violence is a pressing public health and social welfare issue for our community. In an effort to respond to the needs of the Big Island community, CFS has expanded domestic violence services during the past five years. In 2015, CFS was awarded a contract from the State Department of Human Services to provide domestic violence treatment within the context of the family.This contract supports our Domestic Violence Services for Families program. CFS was also awarded Federal funding from The Violence Against Women Act(VAWA)and the Victims of Crime Act(VOCA)to support our Domestic Abuse Shelter Programs. CFS has been challenged to maintain funding for the ATV Program.The program's primary funding source,the State Judiciary, decreased funding by 40% in 2009. In fiscal year 2016, CFS advocated for additional funding from the Judiciary and was granted an additional $65,000 which has been vital for sustaining ATV victim support services. Even with this additional funding,the ATV Program receives 33% less than what was received from the Judiciary in 2009. However,the need for ATV services has increased. (Continued on Attachment) 7. Program Objectives Using County Nonprofit Grant Program Funds: Goal/expected Outcome:To change destructive behaviors and replace them with positive healthy behaviors. Performance Measure:80%of participants will successfully complete the curriculum (Batterer Intervention-SAFE curriculum). Performance Measure:90%of participants who attend batterer intervention services will self report that service has made a positive impact on their lives. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service • Program Name: Alternatives to Violence 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results • (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) #of individuals assisted with completing a TRO application #of batterers who received domestic violence intervention #of Court Assistance services provided Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $426,875 $436,000 $50,319 Professional Fees $268 $300 $0 Operations $120,145 $126,660 $7,781 Supplies $5,464 $5,500 $500 Equipment Other: Participant Assistance- Emergency needs for victims $1,169 $1,500 $250 Other: Rent and Utilities $47,000 $48,500 $14,150 Other: Other: Other: TOTAL $600,921 $618,460 $73,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2018-19 Agency Name: Child & Family Service Program Name: Alternatives to Violence 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council n The Mayor n The Managing Director n The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. kev144471' if f q Sign ure'bf Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2018-2019 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: Alternatives to Violence 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2018-19 Agency Name: Child & Family Service Program Name: Alternatives to Violence 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicountv.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in,a timely manner will impact the evaluation of your agency's future funding requect and may recult in artinnc taken to rernver thecae funds Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities. By signing below, you are acknowledging that you have read and understood these requirements. � /27/iq Signature of Authorized Person (see checklist, 2nd item) Date Pri•riAn-No Tfi:ACA9A) Title/P sition of Authorized Pon EXHIBIT A NONPROFIT GRANT APPLICATION FY 2018-2019 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: Alternatives to Violence 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result #of individuals assisted with completing a TRO application 775 #of batterers who received domestic violence intervention 75 #of Court Assistance services provided 1300 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $50,319 Professional Fees $0 Operations $7,781 Supplies $500 Equipment Other: Participant Assistance- Emergency needs for victims $250 Other: Rent and Utilities $14,150 Other: Other: Other: TOTAL $73,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Attachment Applicant: Child & Family Service Program: Alternatives to Violence 2. Agency Mission Statement (Continued) 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 communities, and individuals we serve. CFS establishes goals to achieve service excellence through our strategic planning process. Our main goals for our participants and families are to: (1) Improve their emotional resilience; (2) Increase economic security; (3) Achieve educational success; (4) Increase social connections and support; (5) Increase feelings of safety; and (6) Increase independence and community engagement. Our strategic planning process involves all levels of the organization, including participants, community stakeholders, direct service staff, management and the Board of Directors. As a family-centered, full-service organization, CFS has established four focus areas to reach our goals. They include: Welcome Families (Developing Family-friendly Points of Entry; Walk With Families (Developing Integrated Family and Community Partnerships); Meet Families Where They Are (Providing Adaptive and Culturally Appropriate Practices); and Prove Effectiveness (Demonstrating Impact and Sustaining Gains). 3. Program Description (Continued) children who live in homes with domestic violence also suffer abuse and neglect at high rates (30%-60%); domestic violence costs more than $37 billion a year in law enforcement involvement, legal work, medical and mental health treatment and lost productivity at work. Funding in the amount of$73,000 is being requested to support the total costs of the ATV Program in the County of Hawaii. This funding will be used to support the following: 1) Part- time, 10 hours per week, Intake Worker in East Hawaii: The Intake Worker will assist individuals who are seeking Temporary Restraining Orders (TRO's); 2) One part-time, 20 hour per week, Domestic Violence Specialist II (DVS II) in the Waimea office: The DVS II will provide assistance with TRO's and court advocacy, and facilitate Batterer Intervention groups; 3) Full occupancy and utilities for the Waimea office. CFS's Waimea office was opened in 2017, in response to the community's request to provide TRO and domestic violence intervention in Waimea. Community members expressed the difficulty for individuals to drive all the way to Kona or Hilo, and in fact this was a significant barrier to residents seeking vital services to protect themselves. CFS's primary and current funding source does not provide enough funding to support the Waimea office and the service operations. In Hawaii County, the demand for services has increased but our funding has never been restored from funding cuts that occurred in 2009. We currently receive 33% less in funding than we received in 2009. The funding requested would allow CFS to provide more efficient, timely services in East Hawaii with the addition of an Intake worker, and would allow Page 1 of 5 Attachment Applicant: Child & Family Service Program: Alternatives to Violence us to maintain our Waimea office, and increase and expand the services provided in Waimea, with the addition of a Domestic Violence Specialist II. The Alternatives to Violence Program offers an array of services for individuals who are victims of domestic violence and their children, youth who are aggressive and or engage in bullying, abusive behavior, and for men and women who abuse.The goal for our program participants is to recognize that domestic violence in intimate relationships generates disrespect and harm that is inconsistent with the values, beliefs, and conduct of every culture. Our goal is to end domestic violence through providing services, partnering with community resources, and participating in community education about domestic violence,thereby creating a tipping point in our community awareness that healing from trauma is an imperative, and we can't tolerate domestic violence. Funding from the County of Hawaii would support the much-needed DVS II and Intake Worker positions. The Intake Worker will provide services in the Hilo office and the DVS II will provide court advocacy and longer hours in the Waimea office.The following services will be provided: 1) Providing assistance with obtaining Temporary Restraining Order (TRO). This is often the first step victims will take to increase their safety and the safety of their children. In addition to assisting individuals with completing the application for a TRO, program staff talk with victims about how to make a safety plan, provide a brochure on how to develop and use a safety plan for all family members, assess the victim for risk of further domestic violence and inform victims of their options to stay at a domestic violence shelter. Both the Intake Worker and the DVS II will provide assistance with TRO's; 2) Court Advocacy for program participants during a TRO hearing in Family Court. This service would be added to the Waimea operations and performed by the DVS II; 3) Case Management for victims and facilitation of referrals and warm linkages to community resources that will assist victims with re-building their lives.The DVS II works with participants to engage with community partners for needed resources to support them in addressing the need to enhance protective factors. This service would be expanded in the Waimea office; 4) Facilitating support groups for individuals who have experienced domestic violence. This service would be added to the Waimea operations and performed by the DVS II; and 5) Facilitating Domestic Violence Intervention groups for those who abuse. To end the cycle of domestic violence and help families to fully heal, it is critical that those who perpetrate the violence receive comprehensive treatment to include group education and intervention and case management. In many cases, perpetrators of domestic violence were themselves victims at one time or another in their lives and domestic violence is deeply entrenched Page 2 of 5 Attachment Applicant: Child & Family Service Program: Alternatives to Violence within their childhood upbringing and is what they know to cope with stressors. Supporting offenders in their development of alternative coping strategies, is a primary goal of the Domestic Violence Intervention groups. This service would be expanded in the Waimea office and provided by the DVS II. CFS closely adheres to the Hawaii Batterers Standards, to include providing 26 weeks of intensive group intervention that focuses on holding the batterer accountable for their behavior, educating participants about the different forms of domestic violence, increasing participant's awareness of their own thought patterns and triggers for abuse, helping participants to understand the relationship between thought and behavior using cognitive behavioral therapeutic methods and motivational interviewing, providing hands-on strategies for changing unhelpful thoughts and or interrupting learned responses of reacting immediately and in abusive ways, i.e. choosing to take a cool down rather than responding right away and facilitating opportunities for social support with other group participants who understand what it is like to struggle with domestic violence. All CFS Hawaii Island ATV program sites (Hilo, Kona & Waimea offices) utilize the Stop Abuse for Everyone (SAFE) curriculum for the men's Domestic Violence Intervention (DVI) program.This is a curriculum that incorporates evidence-based components including motivational interviewing, cognitive behavior therapy and the change theory into our,work with offenders. There are separate DVI groups for women and adolescents. All CFS ATV program services are provided through the lens of trauma-informed care. We follow the Risking Connection® model which was developed by the Sidran Institute, to work with individuals and families who have experienced trauma.This model provides a foundation for all the work we do with families and emphasizes the RICH® relationship approach where we offer "Respect, Information Sharing, Connection, and Hope" to everyone we engage within services. In alignment with evidence-based practices and a trauma-informed care framework, staff operate with the understanding that: • Traumatic events such as abuse can cause overwhelming feelings of horror, terror, and hopelessness; • Caregivers with histories of trauma may avoid experiencing their own emotions, which impacts and hinders their ability to respond appropriately to their child's emotional state and needs; • Traumatic stress occurs when exposure to traumatic events‘overwhelm the individual's ability to cope; • A strong relationship with a trusted caregiver is a potential buffer against traumatic stress for children; • Positive attachment and connections are essential for healthy child and adolescent development; and • Working with families that have experienced abuse and trauma impacts staff, who may also need to be supported and nurtured. Page 3 of 5 Attachment Applicant: Child & Family Service Program: Alternatives to Violence AN program participants are encouraged to access services and resources that can help them to break the cycle of violence and move forward to lead safer, healthier lives. CFS hopes to be able to better meet the needs of our community by increasing and expanding ATV services in Hawaii County. 4.Total Budget and Position Count, (Continued): The ATV program for CFS in West Hawaii consists of a Program Director I, two (3/4 time) DVS Ils and one (1/2 time) DVS II providing court advocacy for TRO hearings and all DVS II's provide support for TRO coverage M - F 8am -1pm at the Kona office, Pattern Changing Groups for Survivors, Men's Domestic Violence Intervention groups in the Kona office. They also provide intakes and individual case management for all program participants. One additional DVS II is allotted 4 hours a week to conduct the Youth Services Program support for Juvenile Offenders.The program also includes staffing one DVS IV who provides oversight for the Men's and Women's Domestic Violence Intervention groups. The Waimea office for CFS requires one (3/4 time) DVS II for TRO office coverage and to conduct DVI groups once a week. One additional (1/2 time) DVS II will provide court advocacy in Waimea for TRO support and allow for additional office coverage if funding is received to staff this position. The Program Director I serves as back up for the direct service providers, and the Director of West Hawai'i Island Programs backs up the Program Director I. The ATV program for CFS in East Hawaii consists of a Program Director II, two (full time) DVS Ils and two (1/2 time) DVS Ils that provide assistance with TRO's Mon- Fri 8am— 1pm, as well as court advocacy from two to three times weekly. DVS Ils conduct intakes and case management for participants who are court mandated or self-referred in need of Domestic Violence Intervention groups, youth anger management services or Pattern changing for victims. Another DVS II whose role is facilitation of DVI groups works two to six hours a week. The East Hawaii program has one DVS IV who provides supervision and oversight to the DVI facilitator. An additional Intake Worker will provide assistance with TRO's. As in West Hawaii, the Program Director serves as a backup for direct service providers, and the Director of East Hawaii Island Programs backs up the Program Director. 6. Explain what plans your agency or program has to increase revenues to support this program (Continued) CFS continues to seek funding from other sources to sustain these essential program services, as well as to meet the increasing need for services. Funding from the Hawaii Island United Way Page 4 of 5 Attachment Applicant: Child & Family Service Program: Alternatives to Violence (HIUW) supports the Domestic Violence Intervention (DVI) component of ATV. Additionally, funding from the Annual Visitor Industry Charity Walk helps to support AN program services. CFS does collect a group fee of$300 for our Domestic Violence Intervention program.This covers all 26 groups, a workbook and a certificate of completion. (This fee can be waived and replaced with work exchange for indigent or unemployed program participants.) CFS maintains high accountability to the participants we serve, the community and to our funders. CFS uses Results-Based Accountability (RBA)", a decision-making framework, to demonstrate that we are making an impact in the lives of the individuals and families we serve. RBA follows a simple, commonsense process, builds collaboration and consensus, and uses data and transparency to ensure accountability. RBA asks 3 questions: How much did we do?; How well did we do it?; and Is anyone better off? Positive participant outcomes lead to better community health, safety, well-being and productivity. RBATM is a rigorous and dynamic process that requires a willingness for our organization to really look at the truth of how we are performing and the impact of our services. CFS hopes that our commitment to participant outcomes, high accountability and the stewardship of program services and funding, as demonstrated by the implementation of RBATM will encourage funders to invest in our programs. CFS is committed to remaining a leader in the domestic violence field by staying focused on implementing evidence-based programs and outcomes that will attract additional funding resources. The Domestic Violence Intervention program had the following outcome/goal for Fiscal Year 2018: Goal/expected Outcome:To change destructive behaviors and replace them with positive healthy behaviors. The following are the performance measures and achievements: Performance Measure: 75% of participants will successfully complete the curriculum (Batterer Intervention-SAFE curriculum). Quarter 1: 97% Quarter 2: 96% Quarter 3: 98% Quarter 4: 96% Performance Measure: 75% of participants who attend batterer intervention services will self- report that service has made a positive impact on their lives. Quarter 1: 100% Quarter 2: 100% Quarter 3: 100% Quarter 4: 100% Page 5 of 5 Child & Family Service East Hawai'i Domestic Abuse Shelter 45 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter Agency Director: Karen Tan Phone No.: (808) 681 - 3500 Contact Person: Joey Keahiolalo Phone No.: (808) 681 - 3500 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,Zip Ewa Beach, HI 96706 Facility Address: Address: 1045A Kilauea Avenue Address: City,ST,Zip Hilo, HI 96720 Email Address: cfscontracts@cfs-hawaii.org Fax No.: (808 ) 681 - 5280 Accountant/CPA: CW Associates, CPAs Phone No.: (808 ) 531 - 1041 Firm (if applicable): CW Associates, CPAs Mailing Address: Address: 700 Bishop Street Address: Suite 1040 City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna 0 Hamakua 0 North Kona ❑✓ South Hilo ❑✓ North Kohala 0 South Kona O North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑✓ Victims of Crimes ❑ Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $17,500 $14,375 $6,300 2. Agency Mission Statement: The East Hawaii Domestic Abuse Shelter(EHDAS/Hale`Ghana)Program fits perfectly with Child&Family Service's(CFS) mission of"Strengthening families and fostering the healthy development of children". In partnership with the County of Hawaii, Hale'Ghana has been continuously providing emergency shelter for victims of domestic violence since 1995, (since 1988 at the West Hawaii Domestic Abuse Shelter.) CFS offers nearly 50 programs statewide with a comprehensive array of effective and culturally relevant services to Hawaii's residents in need.These services include domestic violence interventions,case management,therapeutic foster care,education for alienated youth, prevention and treatment of child abuse, recovery and prevention supports for substance abuse,and school/community-based counseling service for adolescents and their families. Since 1899, CFS has been dedicated to making a difference in the lives of the communities we serve. In Fiscal Year 2018, CFS directly served 15,798 individuals and their families, ranging from infants to older adults. In addition, the organization has"touched"the lives of over 75,000 individuals annually through hot-line calls, educational presentations, and providing food and clothing to those in need.CFS provides these services through 35 sites on the islands of Oahu,Hawaii, Kauai, Maui, Molokai,and Lanai. CFS's programs are responsive,flexible and focused on positive outcomes.Services are provided in homes,schools,and in the community as well as-in CFS's 35 office locations throughout the state. (Continued on Attachment) 3. Program Description: Proposed Project: Funding in the amount of$40,000 is being requested to provide a part-time Client Advocate position.The Client Advocate would provide 20 hours of additional direct services weekly. Duties of the Client Advocate include: assessments,service planning, and group and individual services to survivors in our shelters. In addition to these vital services,funding would be utilized to expand&enhance current services to include a focus on housing assistance. Lack of Safe housing is a primary barrier to leaving an abuser. No one should have to choose between being homeless and being abused. Housing assistance from staff who are knowledgeable about the Hawaii Coordinated Entry System, have collaborative relationships with the Continuum of Care Organization, understand the unique safety risks of survivors of domestic violence,and who can help survivors gain access to an array of housing options,can make all the difference when survivors are feeling overwhelmed and stuck. During the summer of 2018, Hawaii Island was profoundly affected by volcanic activity.The volcanic activity caused ongoing earthquakes and eruptions of lava which produced active lava flows and hazardous gas emissions. Many homes and structures were destroyed or declared uninhabitable. Residents of the Leilani Estates housing community, located in East Hawaii,were under a mandatory evacuation. (Continued on Attachment) 4. Total Budget& Position Count: Total Program Budget: $518,000 Total Program Position Count: 7.5 Total Agency Budget: $6,105,125 Total Agency Position Count: 82 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of FIawai i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Department of Human Services $345,250 County of Hawaii (funding requested in this proposal) $40,000 Department of Human Services BESSD HPO Emergency Shelter Grant $12,906 Attorney Generals Office-VAWA $24,564 Count of Hawaii -VOCA $63,673 Private Grants $1,000 TOTAL: $487,393 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continue to apply for alternative funding sources for CFS programs.The East Hawaii Domestic Abuse Shelter is primarily funded by the Hawaii State Department of Human Services. In fiscal year(FY)2009,the DHS funding for the East Hawaii Domestic Abuse Shelter/Hale'Ghana was decreased from$393,936 to$340,000,with no restoration of this funding.We used to collect shelter fees from participants but this was disallowed with our most recent DHS contract.CFS was awarded funding from VAWA and VOCA for FY 19. However,the funding received was significantly less than applied for and required CFS to cut staffing at the shelter. Positions supported by VAWA and VOCA funding were created in response to the trend of shelter residents coming into the program with very high needs and multiple barriers to getting out of domestic violence relationships and rebuilding their lives. A majority of participants who enter the shelter program are living in poverty and qualify for public benefits,many are homeless and or do not have safe and secure housing to go to,and many are unemployed. Additionally, many residents struggle with a lifetime accumulation of trauma, mental illness and substance abuse. Many participants rely solely on the shelter for all of their basic needs,such as food, clothing,transportation, etc. Even with the additional funding secured through VOCA and VAWA,CFS has struggled to meet the complex needs of shelter participants. (Continued on Attachment) 7. Program Objectives Using County Nonprofit Grant Program Funds: 80%of survivors leave the shelter for a secure and safe place. Measurement occurs during anticipated discharge with DAS Safety Questionnaire. 80%of survivors will create a safety plan. The initial safety plan to be developed with Shelter staff at intake, reviewed and updated as needed during shelter stay and reviewed again prior to discharge. 80%of survivors will report that they are Mostly or Always confident in their ability to accomplish safety related goals, i.e., following through on safety plan. The MOVERS/Measure of Victim Empowerment in the Domain of Safety survey will be given to participants at intake,monthly thereafter,and at discharge. 80%of survivors will report that they are Mostly or Always confident that they have the support needed to move towards safety. The MOVERS/Measure of Victim Empowerment in the Domain of Safety survey will be given to participants at intake,monthly thereafter,and at discharge. (Continued on Attachment) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) #of survivors that receive housing assistance #of survivors who complete a safety plan #of survivors who receive client assistance(taxi,fees for rental applications) #of adult survivors served #of children served #of bed days provided(adults and children combined) (Continued on Attachment) Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $341,915 $345,800 $29,065 Professional Fees $250 $250 $0 Operations $101,063 $101,500 $7,573 Supplies $4,990 $5,000 $200 Equipment Other: Participant Assistance-Emergency needs for victims $7,850 $8,000 $2,162 Other: Food for Shelter Participants $9,000 $9,200 $0 Other: Shelter Rent and utilities $47,500 $48,250 $1,000 Other: Other: TOTAL $512,568 $518,000 $40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2018-19 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): H Member or members of the Council H Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ri If no conflicts exist, check here. F I lrt /00( t Signa "'e •Outhorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2018-2019 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2018-19 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 11. Certification of Understanding (Page z of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2018 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding rerllect rind may recult in rirtinnc taken to rerrnier thecP funds, Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities. By signing below, you are acknowledging that you have read and understood these requirements. 1-97-1(1-40444€4.4 1 X31 / . O t a Signature of Authorized Person (see checklist, 2nd item) Date Aim . 1U Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2018-2019 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result #of survivors that receive housing assistance 40 #of survivors who complete a safety plan 100 #of survivors who receive client assistance(taxi,fees for rental applications) 20 #of adult survivors served 120 #of children served 80 #of bed days provided(adults and children combined) 6,000 (Continued on Attachment) TABLE II: 1 FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $29,065 Professional Fees $0 Operations $7,573 Supplies $200 Equipment Other: Participant Assistance- Emergency needs for victims $2,162 Other: Food for Shelter Participants $0 Other: Shelter Rent and utilities $1,000 Other: Other: TOTAL $40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter 2. Agency Mission Statement (Continued) 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, communities, and individuals we serve. CFS establishes goals to achieve service excellence through our strategic planning process. Our main goals for our participants and families are to: (1) Improve their emotional resilience;(2) Increase economic security; (3) Achieve educational success; (4) Increase social connections and support; (5) Increase feelings of safety; and (6) Increase independence and community engagement. Our strategic planning process involves all levels of the organization, including participants, community stakeholders, direct service staff, management and the Board of Directors. As a family-centered, full-service organization, CFS has established four focus areas to reach our goals. They include: Welcome Families (Developing Family-friendly Points of Entry; Walk With Families (Developing Integrated Family and Community Partnerships); Meet Families Where They Are (Providing Adaptive and Culturally Appropriate Practices); and Prove Effectiveness (Demonstrating Impact and Sustaining Gains). 3. Program Description (Continued) Proposed Project (Continued): Neighboring communities were also impacted by the Sulphur Dioxide emissions, causing many individuals and families to voluntarily evacuate. Hundreds of families suddenly found themselves homeless and in need of new housing. Even after the volcanic activity ceased, many residents chose not to return to their homes due to the extensive damage caused by the volcanic emissions and the fear that the volcanic eruptions would happen again. With numerous families displaced and in need of housing, the competition for affordable housing increased significantly. The increased need for housing in a community with a very limited rental inventory, coupled with rising rents, has made it increasingly difficult for families to obtain housing. Although the volcanic activity occurred from May 2018 through August 2018, the impact will have long-term effects on the Hawaii island community for years to come. Given the significant barriers that survivors are faced with when looking for safe housing in Hawaii County, the Client Advocate would work hand-in hand with survivors to search for affordable housing, get document ready, apply for housing and to move into new housing. In addition to supporting a part-time Client Advocate, funds are also being requested to provide participant assistance with daily needs and resources. Client assistance includes, taxi coupons, bus passes, rental application fees etc. Page 1 of 5 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter About the Shelter Program: CFS's East Hawaii Domestic Abuse Shelter (EHDAS/Hale 'Ohana) and West Hawaii Domestic Abuse Shelter (WHDAS) are the only shelters on the Big Island to serve the immediate needs of residents seeking safety from domestic violence. The Hale 'Ohana program provides emergency shelter to single women/men and those with children who are victims of domestic violence (for a maximum of 120 days). The victims accessing program services generally are fleeing from the geographic areas of Volcano to Puna, Puna to Hilo, and Hilo to Hamakua. Victims from West Hawaii often access Hale `Ghana in East Hawaii for safety reasons. CFS understands domestic violence is traumatic! It impacts every family member. National statistics regarding domestic violence available through the Centers for Disease Control and Prevention (CDC) indicate that 1 in 4 women will experience domestic violence during her lifetime; it is the third leading cause of homelessness among families according to the U.S. Department of Housing and Urban Development (HUD); more than 3 million children witness domestic violence annually; children who live in homes with domestic violence also suffer abuse or neglect at high rates (30%-60%); domestic violence costs more than $37 billion a year in law enforcement involvement, legal work, medical and mental health treatment and lost productivity at work. Through current research we know that children of domestic violence have difficulty processing what has happened. They can internalize their feelings manifesting into guilt, shame, anger, anxiety and sadness; they are at higher risk of achieving poor academics; are at greater risk of child abuse and neglect; and can continue to be involved in the cycle of violence when they are older. According to the Hawaii Department of Health, 9.5% of the adults who responded to the Behavioral Risk Factor Surveillance Survey (BRFSS) in 2013 reported they had been the victim of physical injury by an intimate or ex-intimate partner over the past 12 months, up from 8.8% as reported in 2011. There are no restrictions to enter the shelter as long as the circumstances of need are identified within 48 hours of a domestic violence incident. Hale 'Ohana operates 24 hours a day/365 days a year including holidays, with staff monitoring and providing oversight of 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 for residents. Our experienced staff will help families identify their needs, barriers associated with becoming self-sufficient, and develop plans to meet their needs and overcome barriers. The Hale 'Ohana program offers education to residents on the dynamics of domestic violence, safe emergency shelter, emergency food, transportation, referrals as needed, case management, individual counseling, advocacy, outreach services, safety planning, housing referrals, employability trainingand job Page 2 of 5 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter search supports,TRO assistance, support groups, and personal planning based on individualized needs. Shelter staff also work with program participants to build healthy relationships and strengthen their role as 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. In addition, Hale 'Ohana operates a 24-hour domestic violence hotline which provides crisis intervention, information, and referral services. During the last 6 years, the hotline utilization by victims of domestic violence has increased due to the added economic stressors in the communities of the Big Island. The staff provides a safety assessment, makes recommendations and provides referral and resource information for callers. It is expected that the hotline will continue to see a high volume of calls due to the violence resulting from increased poverty and homelessness across the island. The Hale 'Ohana facility is set back from the roadway on approximately three acres of agricultural/residentially zoned land in East Hawaii, in a two-story home. The home has three full bathrooms, four bedrooms, with a capacity to serve 30 residents. 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 and adjoining bathroom is accessible via the laundry room, and a short walkway connects this area with the spacious kitchen. There is an adjoining dining room and pantry which are also accessible via an entrance off the side of the kitchen that exits into the side yard of the property. Hale 'Ohana is ADA compliant; it has an ADA ramp which leads to the lower floor where an ADA bedroom is located. 6. Explain what plans your agency or program has to increase revenues to support this program: (Continued) CFS maintains high accountability to the participants we serve, the community and to our funders. CFS uses Results-Based Accountability(RBA)TM, a decision-making framework, to demonstrate that we are making an impact in the lives of the individuals and families we serve. RBA follows a simple, commonsense process, builds collaboration and consensus, and uses data and transparency to ensure accountability. RBA asks 3 questions: How much did we do?; How well did we do it?; and Is anyone better off? Positive participant outcomes lead to better community health, safety, well-being and productivity. RBATM is a rigorous and dynamic process that requires a willingness to really look at the truth of how we are performing and the impact of our services. CFS hopes that our commitment to participant outcomes, high accountability and the stewardship of program services and funding, as demonstrated by the implementation of RBATM will encourage funders to invest in our programs. CFS is committed to remaining a leader in the domestic violence field by staying Page 3 of 5 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter focused on implementing evidence-based programs and outcomes that will attract additional funding resources to address the specific needs of this population. CFS has a strong history of fundraising and is committed to continuing to grow our private donations and grants. We 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. 7. Program Objectives Using County Nonprofit Grant Program Funds: (Continued) 80% of survivors will report that they are Mostly or Always confident that action toward the goal of safety will not cause new problems in other areas (domains) of their life. The MOVERS/Measure of Victim Empowerment in the Domain of Safety survey will be given to participants at intake, monthly thereafter, and at discharge. 8.Table I: What are the intended measurable outputs or outcomes that would be achieved with this funding? (Continued) PROGRAM PERFORMANCE MEASURES Applicant Projected Results #of survivors that report that they are Mostly or Always confident in 100 their ability to accomplish safety related goals #of survivors that report that they are Mostly or Always confident 100 that they have the support needed to move towards safety # of survivors that report that they are Mostly or Always confident that action toward the goal of safety will not cause new problems in 100 other areas (domains) of their life. Page 4 of 5 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter 12. COUNCIL AWARD WORKSHEET:Table I (Continued) PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result #of survivors that report that they are Mostly or Always confident in their ability to accomplish 100 safety related goals #of survivors that report that they are Mostly or Always confident that they have the support 100 needed to move towards safety #of survivors that report that they are Mostly or Always confident that action toward the goal of 100 safety will not cause new problems in other areas (domains) of their life. Page 5 of 5 Child & Family Service Hale Kahua Pa'a Transitional Housing Program 46 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child and Family Service Program Name: Hale Kahua Pa'a Transitional Housing Program Agency Director: Karen Tan Phone No.: (808) 681 — 3500 Contact Person: Joey Keahiolalo • Phone No.: (808) 681 — 3500 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,Zip Ewa Beach, HI 96706 Facility Address: Address: 1045 A Kilauea Ave. Address: City,ST,Zip Hilo, HI 96720 Email Address: cfscontracts@cfs-hawaii.org Fax No.: (808 ) 681 — 5280 Accountant/CPA: CW Asociates, CPAs Phone No.: (808 ) 531 — 1041 Firm (if applicable): CW Associates, CPAs Mailing Address: Address: 700 Bishop Street Address: Suite 1040 City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $30,000 Geographical Areas To Be Served: (One or more can be checked) H Puna 0✓ Hamakua ❑✓ North Kona . n South Hilo 0 North Kohala n South Kona O North Hilo 0 South Kohala n Ka Ti Services or Activities To Be Provided: (One or more can be checked) n Educational concerns ❑Youth n Victims of Crimes • n Culture and the arts ❑✓ Aged n Victims of Health or Social Crises ❑✓ Needs of the poor n Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child and Family Service Program Name: Hale Kahua Pa'a Transitional Housing Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $13,750 $14,375 $5,800 2. Agency Mission Statement: The Hale Kahua Pa'a Transitional Housing Program fits perfectly with Child&Family Service's(CFS)mission of"strengthening families and fostering the healthy development of children". In partnership with the County of Hawaii, CFS's Hale Kahua Pa'a Transitional Housing Program has provided services since 2008. CFS has nearly 50 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,therapeutic foster care,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, immigrants,older adults, individuals, and families in need benefit from these services. In Fiscal Year 2018, CFS directly served 15,798 individuals and their families, ranging from infants to older adults. In addition, the organization has"touched"the lives of over 75,000 individuals annually through hot-line calls, educational presentations, and providing food and clothing to those in need. CFS provides these services through 35 sites on the islands of Oahu, Hawaii, Kauai, Maui, Molokai,and Lanai. CFS's programs are responsive,flexible and focused on positive outcomes. Services are provided in homes,schools,and in the community as well as in CFS's 35 office locations throughout the state. (Continued on Attachment) 3. Program Description: The Hale Kahua Pa'a Transitional Housing Program is a program that assists victims of domestic violence and their children to heal from trauma and rebuild their lives.The goal of the program is to provide a safe environment and a variety of supportive services that will increase opportunities for victims and their children to gain stability and independence while transitioning into a violence-free lifestyle. Referrals are received island-wide from multiple agencies, including the East and West Hawaii Domestic Abuse Shelters. During their participation,victims and their families receive intensive support services that help them navigate towards self determination.The program provides weekly home visits, case management, individual family service plans, along with information and referrals to community resources. Safe transitional housing and an array of support services,allows both the victims and their children time to heal, regain their independence and set goals for their future. Victims of domestic violence are faced with many challenges when making the courageous decision to finally leave their abusers.When leaving the abuser,the survivor embarks upon a path that is as fearful for her/him and her/his children as it is to stay with an abusive partner. Often victims leave with just the clothes that they are wearing, seeking shelter,safety and, most of all, assurances that they made the right choice. Some victims lack the skills,tools and resources needed to sustain themselves and their children away from their abuser. (Continued on Attachment) 4.Total Budget & Position Count: Total Program Budget: $153,550 Total Program Position Count: 0.95 Total Agency Budget: $6,105,125 Total Agency Position Count: 82 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child and Family Service Program Name: Hale Kahua Pa'a Transitional Housing Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate U.S. Department of Justice, Office on Violence Against Women (OVW) $116,500 County of Hawaii (funding requested in this proposal) $30,000 Program Fees $1,500 TOTAL: $148,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Hale Kahua Pa'a Transitional Housing Progrm has been primarily funded by the Department of Justice, Office on Violence Against Women (OVW). CFS is always engaged in seeking new funding opportunities to sustain program services. A small program fee is charged to participants, and no one is turned away if they cannot afford to pay. CFS has a strong history of fundraising and is committed to continue 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. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. 80%of program participants will increase their knowledge of community resources, i.e., housing employment and finances. 2. 80%of program participants will report that they are confident in their ability to take precautions and utilize their safety plan to prevent future incidents of domestic violence. 3. 100%of program participants will complete a Safety Plan for themselves and their children. 4. 80%of program participants will secure independent housing after 24 months of transitional housing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 Countyof Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child and Family Service Program Name: Hale Kahua Pa'a Transitional Housing Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) #of adults who increase their knowledge of community resources #of adults who completed a safety plan for themselves and their children #of adults provided shelter #of children provided shelter #of adults that reported that they were confident in their ability to take safety precaution &utilize their safety plan to prevent future incidents of DV #of adults that secured independent housing after 24 months Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $43,500 $48,500 $5,226 Professional Fees $200 $200 $0 Operations $28,420 $34,200 $5,010 Supplies $2,700 $3,000 $0 Equipment $0 $0 $0 Other: Rent and Utilities for Aparments $52,200 $58,450 $14,750 Other: Participant Assistance- Emergency needs for victims $2,500 $2,700 $514 Other: Furniture for Apartments $5,500 $6,500 $4,500 Other: Other: TOTAL $135,020 $153,550 $30,000 *If applicable EXHIBIT A • NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child and Family Service Program Name: Hale Kahua Pa'a Transitional Housing Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. Sig ure Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child and Family Service Program Name: Hale Kahua Pa'a Transitional Housing Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child and Family Service Program Name: Hale Kahua Pa'a Transitional Housing Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 9a---14/4) l3 ( lcO(q Signature of Authorized Person (see checklist, 2nd item) Date 4:6)1-15e,10471 Title/P sition of Authorized Per n EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child and Family Service Program Name: Hale Kahua Pa'a Transitional Housing Program 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result #of adults who increase their knowledge of community resources 4 #of adults who completed a safety plan for themselves and their children 4 #of adults provided shelter 5 #of children provided shelter 5 #of adults that reported that they were confident in their ability to take safety precaution 5 &utilize their safety plan to prevent future incidents of DV #of adults that secured independent housing after 24 months 4 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $5,226 Professional Fees $0 Operations $5,010 Supplies $0 Equipment $0 Other: Rent and Utilities for Aparments $14,750 Other: Participant Assistance- Emergency needs for victims $514 Other: Furniture for Apartments $4,500 Other: Other: TOTAL $30,000 Additional Council directives regarding award: } EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Attachment Applicant: Child & Family Service Program: The Hale Kahua Pa'a Transitional Apartment Program 2. Agency Mission Statement 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, communities, and individuals we serve. CFS establishes goals to achieve service excellence through our strategic planning process. Our main goals for our participants and families are to: (1) Improve their emotional resilience;(2) Increase economic security; (3) Achieve educational success; (4) Increase social connections and support; (5) Increase feelings of safety; and (6) Increase independence and community engagement. Our strategic planning process involves all levels of the organization, including participants, community stakeholders, direct service staff, management and the Board of Directors. As a family-centered, full-service organization, CFS has established four focus areas to reach our goals. They include: Welcome Families (Developing Family-friendly Points of Entry; Walk With Families (Developing Integrated Family and Community Partnerships); Meet Families Where They Are (Providing Adaptive and Culturally Appropriate Practices); and Prove Effectiveness (Demonstrating Impact and Sustaining Gains). 3. Program Description: Many victims have no financial resources and are unable to access resources due to marital assets retained by the abusers which disqualifies them from eligibility for public assistance or subsidized housing. Often victims turn to the East or West Hawaii Domestic Abuse Shelters initially for temporary shelter and to escape abuse. The Domestic Abuse Shelters provide safety, basic needs, counseling and support for up to 120 days, which is not nearly enough time to stabilize their finances and find safe affordable housing. At the end of the 120 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. During the summer of 2018, Hawaii Island was profoundly affected by volcanic activity. The volcanic activity caused ongoing earthquakes and eruptions of lava which produced active lava flows and hazardous gas emissions. Many homes and structures were destroyed or declared uninhabitable. Residents of the Leilani Estates housing community, located in East Hawaii, were under a mandatory evacuation. Neighboring communities were also impacted by the Sulphur Dioxide emissions, causing many individuals and families to voluntarily evacuate. Hundreds of families suddenly found themselves homeless and in need of new housing. Even after the volcanic activity ceased, many residents chose not to return to their homes due to the extensive damage caused by the volcanic emissions and the fear that the volcanic eruptions would happen again. With numerous families displaced and in need of housing, the competition for affordable housing increased significantly.,-The increased need for housing in a community with a very limited rental inventory, coupled with rising rents, has made it increasingly difficult Page 1 of 2 Attachment Applicant: Child & Family Service Program: The Hale Kahua Pa'a Transitional Apartment Program for families to obtain housing. Although the volcanic activity occurred from May 2018 through August 2018,the impact will have long-term effects on the Hawaii island community for years to come. With the impact of the Puna eruption, competition has increased for the limited amount of housing on the Big Island, it has also created a rippling effect on the economy. The increase in Rental costs has resulted in the program reducing the amount of transitional housing it has to offer from 4 housing units to 3. The program is requesting funding from the County of Hawaii to lease one additional apartment. Funds will be used to increase the transitional housing from 3 units back up to 4. The County of Hawaii funding, matched by other funding, would enable the program to assist more victims in the community. Funding is also being requested to support new and existing apartments, to include furnishings, repairs and maintenance. In addition, funding will be utilized to provide participant assistance, such as rental application fees and emergency provisions. A furnished apartment alleviates a huge amount of stress for participants who are already struggling with finances. Furnishings would include, beds, linens, household items,that participants would also have the option of taking with them when transitioning out of the program and into their own private housing. 8.Table 1:What are the intended measurable outputs or outcomes that would be achieved with this funding?Continued Number enrolled in education program 3 Number with secure employment 4 Number obtained permanent housing 4 12. Council Award Worksheet:Table I Continued Program Performance Measures (i.e. Number of clients served workshops or Applicant Projected Council Proposed events held,volunteer hours, etc. Describe, be Results Projected Result specific.) Number enrolled in education program 3 Number with secure employment 4 Number obtained permanent housing 4 Page 2 of 2 PROOF OF AUTHORIZATION Corporate Resolution L Child & Family Service West Hawai'i Domestic Abuse Shelter 47 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: West Hawai'i Domestic Abuse Shelter Agency Director: Karen Tan Phone No.: (808) 681 — 3500 Contact Person: Joey Keahiolalo Phone No.: (808) 681 — 3500 Mailing Address: Address: 91-1841 Fort Weaver Road Address: City,ST,Zip Ewa Beach, HI 96706 Facility Address: Address: 81-6587 Mamalahoa Highway Address: City,ST,Zip Kealakekua, HI 96750 Email Address: cfscontracts@cfs-hawaii.org Fax No.: (808 ) 531 — 1041 Accountant/CPA: CW Associates, CPAs Phone No.: ( ) — Firm (if applicable): CW Associates,CPAs Mailing Address: Address: 700 Bishop Street Address: Suite 1040 City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $60,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ✓0 North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑✓ Victims of Crimes [' Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: West Hawai'i Domestic Abuse Shelter 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $18,750 $15,000 $6,050 2.Agency Mission Statement: Child&Family Service(CFS)is guided by this mission statement: "Strengthening families and fostering the healthy development of children." The organization's main service targets are to: (1)improve an individual's functional and coping status(emotional, psychological well-being,development and independent living skills); (2)improve individual or a family system's ability to cope with stressors in their life; (3)improve the health,welfare,and safety of individuals so that they are free of harm,abuse and neglect.The strategic vision of CFS is to become a family-centered,full-service organization ncluding the values of Cultural competence; Person-and Family-Centered Approaches;Community and Stakeholder Partnerships;Trauma Informed Care; Positive Client Outcomes;Commitment to Learning;Quality Monitoring; Employee Excellence,and Coordination of Care.The organization has established four focus areas to fulfill this vision, namely, Welcome Families(Develop family-friendly points of entry);Walk With Families(Develop integrated family and community partnerships); Meet Families Where They Are(Provide adaptive and culturally appropriate practices);and Prove Effectiveness(Demonstrate impact and sustain gains). To realize our vision,we have organized our programs into four impact areas that include"Caring for Keiki, Healing From Trauma, empowering Youth,and Honoring Kupuna." Proving the effectiveness of our programs is the ultimate achievement within these, four program focus areas. CFS demonstrates our commitment to service excellence and quality care through the provision of services that are responsive,effective and efficient. (continued on attached pages). 3. Program Description: The Aunty's House program provides emergency shelter to single women and men, including those with children who are victims of domestic violence(for a maximum of 120 days).Aunty's House supports domestic abuse victims from the geographic areas of Honoka'a to Waimea/Kohala region;Kohala to Waikoloa and the Kailua area,South Kona down to Naalehu and Naalehu through the Kau/Pahala area. For safety reasons participants may also be housed in Aunty's House who cannot safely remain housed in Hilo;or may be transferred to our shelter on Oahu for their protection.There are no restrictions to enter the shelter if the circumstances of need are identified within 48 hours of a domestic violence incident. Hawaii Island Domestic Abuse Shelters operate 24 hours per day,365 days per year including holidays,with staff monitoring and providing oversight of the safety and needs of the residents.The victims are from all walks of life,and socioeconomic backgrounds,and all neighborhoods of Hawai'i County. Key areas of focus for the DVS II and Client Advocate are strengthening their family's protective factors offering support on an on-going basis with safety planning,obtaining permanent housing,healing from trauma for both the victim and their children,and support groups for both adults and children. The DVS II and Client Advocate positions are developed with dual coverage as a focus to offer the services outlined for each position.Typically,the funding for the Domestic Abuse Shelters is limited and does not provide for the program to consistently have two staff available during times of high need or to provide those additional services and desperately needed supports when self-sufficiency is the goal to reach. The limitation of the program time frame creates a situation in which the residents and staff are working very diligently and quickly to achieve housing and safety.These two positions focus on the ultimate goals of the shelter program.When there is only one staff member scheduled, it is very challenging to provide support services beyond emergency shelter to approximately 20 participants daily,while maintaining the DV caller hotline.(continued on attached pages). 4. Total Budget& Position Count: Total Program Budget: $519,500 Total Program Position Count: 8.50 Total Agency Budget: $6,105,125 Total Agency Position Count: 80 (continued on attached pages) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: West Hawai'i Domestic Abuse Shelter 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Department of Human Services $345,250 County of Hawaii (funding requested in this proposal) $60,000 Department of Human Services BESSD HPO Emergency Shelter Grant $12,906 Attorney General's Office-VAWA $24,564 HIUW $18,000 County of Hawaii VOCA $45,000 Private Grants $1,000 TOTAL: $506,720 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: CFS has a strong history of fundraising and is committed to continuing to grow our private donations and grants.We 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. CFS utilizes Stronger Families Funds, HIUW,VOCA,VAWA, private donors, private foundation grants such as from the Mary Kay Foundation.We seek grant funding for needed equipment such as computers that support our work efforts with participants. We seek available sources for covering transportation costs for participants such as bus passes and taxi coupons to assist with the lack of available public transport routes or rural transportation to schools. Even with the additional funding secured through these and other sources,CFS has struggled to fully fund all the complex array of supports lacked by shelter participants that rebuild their lives and the lives of their children.This ranges from literal material needs such as clothing through transportation,flights to safety or relocation, and access to counseling to process their emotional adjustments to the disruption that has impacted their everyday living. Leveraging funding streams and opportunities is particularly important at this time in which available funding is being reduced or thinly spread out due to high demands and governmental support on all levels seems uncertain from day to day. (continued on attached pages) 7. Program Objectives Using County Nonprofit Grant Program Funds: Child&Family Service has created a RBATM scorecard for the Kona DAS as follows; Survivors will enhance their resiliency,build upon their social connections and increase their concrete supports: •%of survivors with no incidents of violence with his/her abuser in the past seven days o 2019 Q1 81%v the target of 70% o 2018 84.5%v the target of 70% •%of survivors who have a secure and safe place to go at discharge o 2019 Q1 100%v target of 70% , o 2018 66%v target of 70% •%of survivors will enhance their resiliency. 0 2019 Q1 60%v target of 75% o 2018 66%v target of 75% (scorecard for Domestic Abuse Shelter:Kona is attached)continued on attached pages EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: West Hawai'i Domestic Abuse Shelter 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) #of bed days provided (adults&children combined) #of survivors that report that they are Mostly or Always confident in their ability to accomplish safety related goals #of survivors that report that they are Mostly or Always confident that they have the support needed to move towards safety Y #of survivors that report that they are Mostly or Always confident that action toward the goal of safety will not cause new problems in other areas(domains of their life) Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $336,342 $340,100 $34,812 Professional Fees $200 $200 $0 Operations $97,584 $98,000 $12,288 Supplies $6,443' $6,500 $1,600 Equipment Other: Participant Assistance-Emergency need for victims $3,935 $4,200 $1,800 Other: Food for Shelter participants $11,875 $12,000 $6,200 Other: Rent and Utilities $58,000 $58,500 $3,300 Other: Other: TOTAL $514,379 $519,500 $60,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: West Hawai'i Domestic Abuse Shelter 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council 1 ❑ Staff appointed by a member of the Council ❑ The Mayor n The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. CreCl [ bogSig ur�of A? IZ zed Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: West Hawai'i Domestic Abuse Shelter 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: West Hawai'i Domestic Abuse Shelter ii. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. (7., : /-?/-114: t I ta offfi SigFiatu a of uthorized Person (see checklist, 2nd item) Date c 1 rl'`"4x(17Or;97f / Title Position of Authorized Per on EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Child & Family Service Program Name: West Hawai'i Domestic Abuse Shelter 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result #of bed days provided (adults&children combined) 6,000 #of survivors that report that they are Mostly or Always confident in their ability to 128 accomplish safety related goals #of survivors that report that they are Mostly or Always confident that they 128 have the support needed to move towards safety #of survivors that report that they are Mostly or Always confident that action toward the 128 goal of safety will not cause new problems in other areas(domains of their life) TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $34,812 Professional Fees $0 Operations $12,288 Supplies $1,600 Equipment Other: Participant Assistance- Emergency need for victims $1,800 Other: Food for Shelter participants $6,200 Other: Rent and Utilities $3,300 Other: Other: TOTAL $60,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter 2. Agency Mission Statement, (continued) In April 2016, the Hawai'i Appleseed Center for Law and Economic Justice reported on the State of Poverty in Hawai'i declaring that "low wages, high housing costs, and disproportionately high taxes on low-income workers...have combined to give Hawai'i the sixth highest rate of poverty in the country. Forty-five percent of families with children do not have enough money to meet their basic needs." In 2018, participants at Aunty's House had very low incomes, falling below 30% of federal HUD median household income guidelines. When these factors combine at the same time as very challenging natural disasters unique to this county, Hawai'i county residents are highly stressed! While our County officials did an epic job responding to the recent natural disasters, Hawai'i County residents are still in recovery from the stressors that often result in increased public safety issues including domestic violence. Recent data from the Third Circuit Court & Family Court in the period of 2011-2015 showed a 30% increase statewide in arrests for violations of TROs; however, for Hawai'i County the increase was 71% in this period that included an unprecedented lava flow in 2014 in Puna (Protection Order Filings, by Circuit, FY 11-15; Judiciary, Annual Reports; Hawai'i Criminal Justice Data Center). Child & Family Service's strengths lie not only in the organization's size and ability to share expertise and resources statewide, but also in our ability to adapt services so that they are unique and appropriate to the island, communities, and individuals we serve. CFS has years of experience working with the diverse demographics and cultural identities of Hawai'i's residents while partnering beside funding sources to implement new models of service delivery to address changing social needs. CFS establishes goals to achieve service excellence through its strategic planning process. This process involves all levels of the organization, including program participants, community stakeholders, direct service staff, management and the Board of Directors. 3. Program Description, (continued): CFS's Hawaii Domestic Abuse Shelters including Aunty's House (WHDAS) are the only shelters on Hawaii Island to serve the immediate needs of residents seeking safety from domestic violence and its related crimes. CFS understands that domestic violence can be traumatic! It impacts every family member. National statistics regarding domestic violence available through the Centers for Disease Control and Prevention (CDC) indicate that 1 in 4 women will experience domestic violence during her lifetime; it is the third leading cause of homelessness among families according to the U.S. Department of Housing and Urban Development (HUD); more than 3 million children witness domestic violence annually; children who live in homes with Page 1 of 5 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter domestic violence also suffer abuse or neglect at high rates (30% -60%); domestic violence costs more than $37 billion a year in law enforcement involvement, legal work, medical and mental health treatment and lost productivity at work. Through current research we know that children of domestic violence have difficulty processing what has happened. They can internalize their feelings manifesting as guilt, shame, anger, anxiety and sadness; they are at higher risk of achieving poor academics; are at greater risk of child abuse and neglect; and can continue to be involved in the cycle of violence when they are older. In the Hawai'i Department of Health's 2013 Behavioral Risk Factor Surveillance Survey (BRFSS), the question was asked to adult responders (n=123,900) in Hawaii County, "[Have you]experienced physical abuse by a current or former intimate partner?" for all of Hawaii County, 11.5%said "Yes;" For Kona respondents, 14.2%said "Yes;" for North Hawai'i respondents 7.3% said "Yes;" This indicates a high incidence of violence experienced by responders to this survey, although it does not include the entire population of Hawaii County. We also know that intimate partner violence is often unreported or underreported due to shame or embarrassment. Nevertheless, CFS program staff work to address these issues in participant's lives. 4. Total Budget and Position Count, (continued): Currently, Aunty's House has the following staffing pattern: 2-part time Shelter Managers; one full time DVS II and one%time DVS II, one%time (.75 FTE) Client Advocate and 2.75 Shelter Workers. Aunty's House is requesting County of Hawaii funding to further support another part time DVS II and to support the Client Advocate position extending services to all participants and their children in terms of added hours. The DVS II position provides intensive case management for all participants in the shelter program by meeting with each resident individually twice monthly to work on defined goals leading towards self-sufficiency. These goals typically revolve around safety and locating housing for self and minor children, budgeting, and financial management. The DVS II also provides peer counseling supporting the communal living arrangement, weekly trauma informed educational support groups covering the dynamics of domestic violence in the family unit and ensuring all basic needs for each participant is met daily. The Client Advocate provides valuable children's groups at the shelter. These groups focus on safety education/planning (with personal safety being the key component); positive behavioral supports, and individual time for each child to receive support for their needs around domestic violence and residing at the shelter.The children's groups also provide a space for appropriate arts and crafts designed for the developmental stage of the children. The Client Advocate provides aftercare for discharged residents and their children._For FY 18-19 the Client Advocate assisted the Program Director in completing 25 backpacks filled with school supplies for both in house and for recently discharged Page 2 of 5 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter families. This was a huge blessing for the children and the mothers. The Client Advocate acts as backup staff for case management when DVS 11 is unavailable to support residents and provides transportation for community engagements such as for housing, mental and physical wellbeing, school concerns, shopping for basic needs and offers peer counseling to all residents as needed. Typically, the funding for the Domestic Abuse Shelters is limited and does not provide for the program to consistently have two staff available during times of high need or to provide those additional services and desperately needed supports when self-sufficiency is the goal to reach.The limitation of the program time frame creates a situation in which the residents and staff are working very diligently and quickly to achieve housing and safety. These two positions focus on the ultimate goals of the shelter program. When there is only one staff member scheduled, it is very challenging to provide support services beyond emergency shelter to approximately 20 participants daily, while maintaining the DV caller hotline. 5. Program funding Sources, (continued) Current funding for the Hawai'i Island Domestic Violence Shelters including Aunty's House is a combination of state, federal, private donors, charity donors, as well as Hawai'i county grant awards. We gladly accept private donations and corporate donations also of goods such as the school back pack with supplies distribution described; celebrations meals such as the annual Thanksgiving meal donation; Santa's visit to the shelter; the personal goods and diaper supplies donations; giving valuable time donations that are received during our annual Domestic Violence Vigil, sign waving, and walk in Kona. Our employees participated in the yearly Charity Walk and other sponsored HIUW events; as well as the 2018 volunteering our staff provided for feeding those in Puna and delivering personal care items that staff purchased to assist in the disaster relief efforts. We work collaboratively with our stakeholders and fellow non-profit agencies in supporting and giving back in full measure across all demographic lines. 6. Explain what plans your agency or program has to increase revenues so support this program, (continued): CFS has a strong history of fundraising and is committed to continuing to grow our private donations and grants. We 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. CFS utilizes Stronger Families Funds, HIUW, VOCA, VAWA, private donors, private foundation grants such as from the Mary Kay Foundation. We seek grant funding for needed equipment such as computers that support our work efforts with participants. We Page 3 of 5 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter seek available sources for covering transportation costs for participants such as bus passes and taxi coupons to assist with the lack of available public transport routes or rural transportation to schools. Even with the additional funding secured through these and other sources, CFS has struggled to fully fund all the complex array of supports lacked by shelter participants that rebuild their lives and the lives of their children. This ranges from literal material needs such as clothing through transportation, flights to safety or relocation, and access to counseling to process their emotional adjustments to the disruption that has impacted their everyday living. Leveraging funding streams and opportunities is particularly important at this time in which available funding is being reduced or thinly spread out due to high demands and governmental support on all levels seems uncertain from day to day. 7. Program Objectives Using County Nonprofit Grant Program Funds, (continued): RBATM is a rigorous and dynamic process that requires a willingness to really look at the truth of how we are performing and the impact of our services. CFS hopes that our commitment to participant outcomes, high accountability and the stewardship of program services and funding, as demonstrated by the implementation of RBATM will encourage funders to invest in our programs. CFS will remain a leader in the domestic violence field by staying focused on implementing evidence-based programs and outcomes that will attract additional funding resources to address the specific needs of this population. 8. What are the intended measurable outputs or outcomes that would be achieved with this funding? (continued) Child & Family Service has created a RBATM scorecard for the Kona DAS as follows (attached): Survivors will enhance their resiliency, build upon their social connections and increase their concrete supports: • % of survivors with no incidents of violence with his/her abuser in the past seven days o 2019 Q1 81%v the target of 70% o 2018 84.5%v the target of 70% • % of survivors who have a secure and safe place to go at discharge o 2019 01 100%v target of 70% o 2018 66%v target of 70% • % of survivors will enhance their resiliency. o 2019 Q1 60%v target of 75% o 2018 66%v target of 75% Page 4 of 5 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter (scorecard for Domestic Abuse Shelter: Kona is attached) 12. COUNCIL AWARD WORKSHEET:Table I PROGRAM PERFORMANCE Applicant Council Proposed- MEASURES Projected Projected Result Results #of bed days provided 6,000 (adults &children combined) #of survivors that report 128 that they are Mostly or Always confident in their ability to accomplish safety related goals #of survivors that report 128 that they are Mostly or Always confident that they have the support needed to move towards safety #of survivors that report 128 that they are Mostly or Always confident that action toward the goal of safety will not cause new problems in other areas (domains of their life) Page 5 of 5 Domestic Abuse Shelter: Kona The Domestic Abuse Shelters provide temporary shelter, provision for basic needs(food, clothing, etc.), counseling and services for families experiencing domestic violence.Clients learn dynamics of domestic violence,develop safety plan, improve self-esteem and learn healthy parenting skills. •Additionally,a 24-hour access hotline is available to provide information, referrals, and a system for handling emergencies Goal/expected Outcome:To provide a safe haven(shelter)for families, and offer education to the public and other organizations. • Population Served:All services are delivered on a voluntary basis. It is the survivors choice to enter the shelter and the survivor must choose to remain in the shelter on a voluntary basis or to leave by self-choice.All survivors of domestic violence are served. • • Survivors"will`.enhance their resiliency, build upon their social connections and increase their Most current current P" TargetetRecent Actual Valueconcrete supports. : Period Value • • • •QPM %of survivors with no incidents of violence with his/her abuser in the past seven days. Q7 2019 �f-�} =3" 70% 120- r; Q 2018 70% rti ... •;r r. :: •� [ • �r l,•tt .r.� ........ ..:r..... �.:... :..r r.r.. Q 2018 - 70% • ri 70./ s."7 r : 717 _ ' l.Il • tl: •I I. : 70/Q42017ea • ..r :i. ........:. • . ..,-r.-....,... .. .. .. .._..,_..::..... ...., r :.:..:.:..,:.'.....I.I..,... :�'1 .�.:....,.I 'r. . —nap/ Q3 ^4-. ,."a4;0`E: • I t..:...,..., ...I ..... :I ;;. 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'e i';•-••.;;•:;...:1.',..;I.,:...1;,..:".i.:.:;:.E..!...,,...7.,,,..;„,..,...... 04 201 3 2_._ -,21.. ...,:•.•,•:-- • Q 1116 .. 0.!..::.;.::;'::.;.,?;.:..'............ 0,3 2m7 (12 2017 . . Children's Law Project of Hawaii, The Abolishing Barriers to Learning& Education ("ABLE") Program 48 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Children's Law Project of Hawaii Program Name: Abolishing Barriers to Learning & Education ("ABLE") Program Agency Director: Valerie J. Grab, Esq., Executive Director Phone No.: (808) 825 — 4081 Contact Person: Valerie J. Grab, Esq., Executive Director Phone No.: (808) 825 — 4081 Mailing Address: Address: The Children's Law Project of Hawaii. Address: PO Box 6249 City,ST,Zip Hilo, HI 96720 Facility Address: Address: The Children's Law Project of Hawaii Address: 101 Aupuni St.,Ste. 1014A City,ST,Zip Hilo,HI 96720 Email Address: valerie.grab@clphi.org Fax No.: (808 ) 443 — 0131 Accountant/CPA: Not Applicable Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna ❑✓ Hamakua ✓❑ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ✓❑South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ❑✓ Youth ['Victims of Crimes ❑Culture and the arts ❑Aged ['Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Children's Law Project of Hawaii Program Name: Abolishing Barriers to Learning & Education ("ABLE") Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 not applicable not applicable $10,050 (ABLE) 2.Agency Mission Statement: Every Child Has a Voice. The Children's Law Project of Hawaii is a nonprofit law firm seeking to empower children through youth-focused legal advocacy. Children's Law Project attorneys specialize in acting as Guardians ad Litem("GALs")in Family Court matters. GALs are attorneys with the power to investigate children's circumstances,advocate for them in court,and make regular reports and recommendations. We believe that providing a legal advocate for a child is a powerful tool both in and out of the courtroom. GALs not only have the power to fully participate in family court cases,but can also advocate for children's best interests in a wide range of administrative and collateral settings. We believe that by ensuring children have the medical care,mental health care, educational accommodations,and public benefits they are entitled to,we help lay the foundation for them to go on to become positive and productive citizens. 3. Program Description: The Children's Law Project of Hawaii is seeking funding for our Abolishing Barriers to Learning&Education("ABLE")Program, which provides GALs for our county's most difficult school nonattendance cases. All children have a fundamental need for education. When a child is regularly absent from school,it can often be a sign of distress elsewhere in his or her life. The reasons behind absenteeism are often complex and dynamic,requiring a consistent supportive intervention to determine what barriers a child is facing,and what can be done to overcome those obstacles. The ABLE Program allows family court judges island-wide to identify the school nonattendance cases most in need of additional attention and appoint a GAL to help uncover and address the issues causing a child's truancy. GALs have proven to be a useful tool in addressing barriers to school attendance. We hope that by demonstrating the effectiveness of comprehensive investigation and assertive advocacy for truant youth,we can help change how the Juvenile Probation,the Family Court,and the Department of Education approach school nonattendance cases. 4.Total Budget&Position Count: Total Program Budget: $62,500 Total Program Position Count: 4 Total Agency Budget: $150,000 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Children's Law Project of Hawaii Program Name: Abolishing Barriers to Learning & Education ("ABLE") Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Lili`uokalani Trust $40,000 County of Hawaii $20,000 Private Donor Contributions $2,500 Children's Law Project Professional Services Contribution $35,000 TOTAL: $62,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Children's Law Project has provided Guardian ad Litem services for families involved with the Holomua project,a collaborative effort with the Hawaii State Judiciary, Hawaii County Office of the Prosecuting Attorney, Hawaii State Department of the Attorney General,Salvation Army,Lill'uokalani Trust, Kamehameha Schools,and Keonepoko Elementary School. We have also collaborated with these stakeholders on the Kea'au Truancy project.We aim to engage these same stakeholders as potential contributors to the ABLE program. 7. Program Objectives Using County Nonprofit Grant Program Funds: By assigning Children's Law Project GALs in school nonattendance cases,this project aims to: *Provide Guardian ad Litem services to students most in need of advocacy; *Help break the cycle of poverty for Hawaii Island families by ensuring students in our community enter adulthood with the foundation of a solid education; *Change how the Juvenile Probation,the Family Court,and the Department of Education approach school nonattendance cases by demonstrating the effectiveness of comprehensive investigation and assertive advocacy for truant youth; *Intervene during the Summer of 2019 to set our clients on a better path for the 2019-2020 school year; *Reduce and eliminate the barriers to school attendance for identified students; *Improve student success and academic progress for identified students; *Resolve nonattendance issues and their attendant school non-attendance petitions for at least seventy-five percent students within nine months of appointment; *Improve long-term outcomes for identified students. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: The Children's Law Project of Hawaii Program Name: Abolishing Barriers to Learning & Education ("ABLE") Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Appointment as Guardian ad litem for 40-60 students with School Nonattendance 40-60 cases (or Truancy)cases pending in Family Court. Reaularlv report to the Family Court(throuah written reports and court appearances) 80- 120 reports student progress and make recommendations to ameliorate barriers to school attendance. Resolve nonattendance issues and their attendant school non-attendance petitions 30-45 case closures for at least seventy-five percent of students within the academic year. Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 P o'ect Ac1tuaf Total Budget Grant Req Salary and Wages $40,000 $50,000 $15,000 Professional Fees $2,000 $2,000 Operations $7,000 $7,000 $5,000 Supplies $3,000 $3,000 Equipment Other: Other: Other: Other: Other: TOTAL $50,000 $60,000 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Children's Law Project of Hawaii Program Name: Abolishing Barriers to Learning & Education ("ABLE") Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. .(.7 / —/T Si ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Children's Law Project of Hawaii g Y Program Name: Abolishing Barriers to Learning & Education ("ABLE") Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express,and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Children's Law Project of Hawaii Program Name: Abolishing Barriers to Learning & Education ("ABLE") Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. ' 2 0 —3/ Si ature of Authorized Person (see checklist, 2nd item) Date 0, a. ,/,v es/le/1 Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Children's Law Project of Hawaii Program Name: Abolishing Barriers to Learning & Education ("ABLE") Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 40-60 cases BO-120 reports 30-45 case closures TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $15,000 Professional Fees Operations $5,000 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Children's Law Project of Hawaii, The Project Permanence: Guardianships/Adoptions for At-Risk Kids 49 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Children's Law Project of Hawaii Program Name: Project Permanence: Guardianships/Adoptions for At-Risk Kids Agency Director: Valerie J. Grab, Esq., Executive Director Phone No.: (808) 825 — 4081 Contact Person: Valerie J. Grab, Esq., Executive Director Phone No.: (808) 825 — 4081 Mailing Address: Address: The Children's Law Project of Hawaii Address: PO Box 6249 City,ST,Zip Hilo, HI 96720 Facility Address: Address: The Children's Law Project of Hawaii Address: 101 Aupuni St.,Ste.1014A City,ST,Zip Hilo, HI 96720 Email Address: valerie.grab@clphi.org Fax No.: (808 ) 443 — 0131 Accountant/CPA: Not Applicable Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ✓❑ North Kona ❑✓ South Hilo ❑✓ North Kohala ✓❑South Kona ❑✓ North Hilo ❑✓ South Kohala ✓❑ Kati] Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ['Victims of Crimes ❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises dp Needs of the poor ❑✓ Physical/Emotional Disabilities [' Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Children's Law Project of Hawaii Program Name: Project Permanence: Guardianships/Adoptions for At-Risk Kids 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 Not Applicable Not Applicable $10,050 2.Agency Mission Statement: The Children's Law Project is dedicated to providing holistic advocacy services for court-involved children and youth,children at-risk of child protective services involvement,and their caregivers. Executive Director Valerie J.Grab and Managing Attorney Madeline M. Reed,two experienced family law litigators,co-founded Children's Law Project in May 2017 to address systemic gaps they experienced in advocating for court-involved youth. Children's Law Project attorneys typically serve as court-appointed Guardians ad!item("GALs")for children in foster custody, juvenile law violation,Persons in Need of Supervision and contested custody proceedings. We also assist children and families in danger of becoming court-involved. In all of our cases,Children's Law Project attorneys seek to evaluate the needs of our clients beyond the traditional scope of family court representation. In doing so,we advocate for children's best interests in a wide range of areas such as permanency(powers of attorney,guardianships and adoptions),special education, behavioral accommodation,mental health services and disability benefits. Using this more expansive legal approach,we aim to limit or eliminate family court interventions and ensure better overall outcomes for the children we serve. The Children's Law Project serves all of Hawaii County and our attorneys regularly appear in Hilo, Kona and Waimea family courts. 3. Program Description: Every child deserves a family,every kid needs a home. The aim of Project Permanence is to establish adoptions and legal guardianships for sibling groups whose parents are not able to safely care for them. The Adoption Assistance and Child Welfare Act of 1980 recognized the importance of placing children with families.[1]When removed from their parents,children do best in families. Living in families,regardless of whether those families consist of relative or foster caregivers,is critical to a child's success and supports their physical,emotional and social development.[2] Children's Law Project launched Project Permanence in August 2018,funded in part by a Hawaii County Nonprofit Grant.Our attorneys represent foster and non-foster caregivers in guardianship and adoption proceedings,and to date have finalized five guardianships and two adoptions. We first seek to prevent family court involvement by establishing a legal relationship between children and non-parent caregivers prior to child protective services interventions. Project Permanence also seeks to help children in foster custody: Through assisting foster caregivers in establishing guardianships and adoptions,court-involved children are more likely to live in permanent homes and forge lifelong connections to stable families. [1] See Adoption Assistance and Child Welfare Act of 1980, Pub. L.96-272,42 USC§675(2012),visit www.gpo.gov/fdsys/pkg/USCOD E-2011-title42/pdf/USCODE-2011-title42-chap7-subchap IV-partE-sec675.pdf [2]The Annie E.Casey Foundation,Kids Count Policy Report, Every Kid Needs a Family(2015)at: h ttp://www.aecf.org/m/reso u rced o c/aecf-EveryKi d N e ed s A Fam i ly-2015.pdf 4.Total Budget&Position Count: Total Program Budget: $87,500 Total Program Position Count: 4 Total Agency Budget: $150,000 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Children's Law Project of Hawaii Program Name: Project Permanence: Guardianships/Adoptions for At-Risk Kids 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii (Proposed) $20,000.00 HIUW(Proposed) $5,000.00 Hawaii Women's Legal Foundation $7,500.00 Victoria S. and Bradley L. Geist Foundation (Proposed) $40,000.00 Sliding Scale Fee-For-Service Contributions $5,000.00 Lili`uokalani Trust(Proposed) $10,000.00 Children's Law Project Professional Services Contribution ($40,000) TOTAL: $87,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Hawaii Women's Legal Foundation awarded Project Permanence$7,500.00 Other potential funding sources include private organizations that support foster children and their caregivers,such as The Annie E.Casey Foundation, Hawaii Island United Way,and the Victoria S.and Bradley L Geist Foundation(through Hawaii Community Foundation) . Finally,Children's Law Project provides representation in legal guardianship and adoption matters on a sliding scale basis,and caregivers with financial resources are expected to contribute to the cost of Children's Law Project's representation and associated fees. 7. Program Objectives Using County Nonprofit Grant Program Funds: Project Permanence will secure adoptions and legal guardianships for 45 sibling groups whose parents are not able to safely care for them. Project Permanence provides attorneys to represent caregivers in uncontested adoption and guardianship matters. Project Permanence also works with a wide range of community partners and stakeholders,including the Hawaii State Department of Human Services, Hawaii State Judiciary,child welfare attorneys and foster caregiver associations and has developed a referral system. Project Permanence conducts informational sessions for community partners and stakeholders to explain the purpose of the project and how caregivers can be referred for representation. To facilitate representation,Children's Law Project attorneys assigned to Project Permanence developed retainer agreements, consents to release information,client questionnaires,guardianship and adoption petitions and other court-mandated documents necessary to finalize guardianships and adoptions. Children's Law Project attorneys regularly meet with caregivers to explain court processes and obtain the information needed to initiate legal proceedings. Attorneys remain in regular contact with caregivers to update them regarding their cases. Attorneys also attend court hearings with their caregiver clients and represent them in proceedings to establish legal guardianship or adoption. Uncontested legal guardianships and adoptions typically require one court appearance. After these proceedings, Children's Law Project ensures that all necessary court orders are in place and that any other necessary documentation(such as a revised birth certificate)is issued. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Children's Law Project of Hawaii Program Name: Project Permanence: Guardianships/Adoptions for At-Risk Kids 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Representation of caregivers(foster and non-foster family) in legal guardianshipand Establish legal guardianships/adoptions for P 9 9 adoption matters 45 sibling groups(same parents/caregivers) Outreach to organizations supporting caregivers and continued development of Referral of at least 45 caregivers in need of referral process representation in guardianship/adoption Caregiver Satisfaction and Effectiveness Surveys 40-45 positive evaluation surveys Attach additional pages as necessary. 9.TABLE II: FY 18-19 FY 19-20 FY 19-20 PROGRAM EXPENDITURES Projected Actual* Total Budget Grant Req Salary and Wages $7,500.00 $55,000.00 $12,500.00 Professional Fees $550.00 $2,000.00 Operations $1,000.00 $20,000.00 $7,500.00 Supplies $200.00 $7,500.00 Equipment Other Publication $1,200.00 $3,000.00 Other: Other: Other: Other: TOTAL $10,050 $87,500.00 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Children's Law Project of Hawaii Program Name: Project Permanence: Guardianships/Adoptions for At-Risk Kids 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. ignature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Children's Law Project of Hawai'i Program Name: Project Permanence: Guardianships/Adoptions for At-Risk Kids 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Children's Law Project of Hawai'i Program Name: Project Permanence: Guardianships/Adoptions for At-Risk Kids 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30t''shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 3 / - / Signature of Authorized Person (see checklist, 2nd item) Date Aaa /dew f Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Children's Law Project of Hawaii Program Name: Project Permanence: Guardianships/Adoptions for At-Risk Kids 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Establish legal guardianships/adoptions for 45 sibling groups(same parents/caregivers) Referral of at least 45 caregivers in need of representation in guardianship/adoption 40-45 positive evaluation surveys TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $12,500.00 Professional Fees Operations $7,500.00 Supplies Equipment Other: Publication Other: Other: Other: Other: TOTAL $20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Easter Seals Hawaii Adult Day Health 50 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Easterseals Hawaii Program Name: Adult Day Health Agency Director: Jennifer La'a, President& CEO Phone No.: (808) 529 — 1701 Contact Person: Tisha Takazawa, Senior Program Manager Phone No.: (808) 769 — 5734 Mailing Address: Address: 710 Green Street Address: City,ST,Zip Honolulu, HI 96813 Facility Address: Address: 16-204 Melekahiwa Place Address: Suite 3 City,ST,Zip Keeau, HI 96749 Email Address: Tisha@eastersealshawaii.org Fax No.: (808 ) 769 — 5785 Accountant/CPA: Katha Combs Phone No.: (808 ) 791 — 1414 Firm (if applicable): Wikoff Combs&Co, LLC Mailing Address: Address: 1001 Bishop St. Address: Suite 2760 City,ST,Zip Honolulu, HI 96813 • YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $38,055 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑ North Kona n South Hilo n North Kohala ❑South Kona n North Hilo n South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns n Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged n Victims of Health or Social Crises n Needs of the poor n Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 • Agency Name: Easterseals Hawaii Program Name: Adult Day Health 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0 $0 $10,925 2.Agency Mission Statement: The mission of Easterseals Hawaii is to provide exceptional, individualized, family-centered services to empower people with disabilities or special needs to achieve their goals and live independent,fulfilling lives.We are a well-established and respected statewide organization that has been serving Hawaii Island residents for over 70 years. In 2017, our efforts across five islands uplifted the lives of 1,962 people affected by autism spectrum disorder, Down syndrome, cerebral palsy, muscular dystrophy, spina bifida,speech/language delays,vision or hearing impairments,etc. Easterseals Hawaii aims to give participants life-changing,equal opportunities to live, learn,work, and play in our local communities.We deliver Early Intervention programming,Autism Services,Adult Services, Employment Services, and Assistive Technology resources informed by evidence-based practice, research, client surveys, and stakeholder input. Our organization maintains the highest 3-year level of accreditation by the Commission on the Accreditation of Rehabilitation Facilities, indicating adherence to more than 300 internationally accepted standards of excellence. Through our programs, Easterseals Hawaii supports participants with evaluations and assessments, design of individualized plans, and implementation of appropriate interventions by therapists,teachers, and other health professionals. Coaching and support for the family,caregivers, or others in the participant's circle are integrated. Services for children are family-centered. • Services for adults emphasize individual choice and pursuit of opportunities that match their interest and skills,while fostering dignity, growth, and independence in a variety of one-to-one,small group, and community settings. 3. Program Description: Easterseals Hawaii's Keaau Adult Day Health Center is open five days per week and currently serves 36 adults with intellectual and developmental disabilities such as autism, muscular dystrophy, cerebral palsy, spina bifida, Down syndrome, sensory impairments, and other special needs.There are only two other programs besides Easterseals Hawaii in the Hilo area for people with these types of disabilities, who typically face major barriers to self determination and social inclusion which contribute to physical inactivity, mental health problems,fewer social support networks, and a lack of voice in their community. To combat these risks and help participants maximize their potential, the Adult Day Health program provides educational, social, health,and recreational opportunities in high-quality, small group environments with a 1:3 staff to participant ratio. Our staff utilize an evidence-based Person-Centered Planning model--a process-oriented approach to empower people with disabilities that focuses on their needs and puts them in charge of defining the direction for their lives. Comprehensive support is offered for participants to benefit from a variety of experiences that enrich their lives,with an emphasis on facilitating their inclusion within the community, rather than isolating them within large institutions or disabled-only groups. Adult Day Health activities increase self-sufficiency and quality of life by creating opportunities for participants to learn to: care for their personal health and safety; communicate; advocate for their personal needs, choices, and goals; build interpersonal relationships and social capital; utilize assistive technology;enjoy recreational activities; and access and contribute to their community. Participants'families and caregivers also benefit greatly from the respite time that the Adult Day Health program provides,so that they can give attention to their own pursuits and attain relief from the stress, depression, poor health, and financial hardship associated with constant caregiving duties. 4. Total Budget& Position Count: Total Program Budget: $546,765 Total Program Position Count: 9 Total Agency Budget: $14,646,668 Total Agency Position Count: 368 • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 • Agency Name: Easterseals Hawaii Program Name: Adult Day Health 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Medicaid 508,710 County of Hawaii Nonprofit Grant 38,055 TOTAL: $546,765 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Easterseals Hawaii's Adult Day Health programming is primarily supported by Medicaid funding received through a contract with the State of Hawaii Department of Health,which is a stable source of revenue renewed every five years. In response to new Medicaid waiver rules emphasizing community integration of participants, our organization is transitioning from a center-based program delivery system to a more community-based one. However, our current state contract does not adequately cover the costs of Community Learning Services being expanded under our Adult Day Health programs.To ensure that our participants have access to life-changing opportunities for community integration, our organization is committed to raising funds for Community Learning Services through private foundation grants, special event fundraisers, and solicitation of individual, corporate, and in-kind donations.We are also in the process of adopting Electronic Health Record and Case Management systems,deploying devices with apps, and educating staff on workflows that will, in part, increase efficiency and financial sustainability of programming. In the long-term, changes in Medicaid waiver guidelines rolling out over the next three years will result in greater revenue generated by our Adult Day Health programming due to higher reimbursement rates(increasing from an average of$68 to$90 per day), capturing of a greater number of billable hours, and covering of certain expenses that were not reimbursable under previous contracts.Therefore, in the future, Easterseals Hawaii will be reimbursed more fully for actual expenses incurred, instead of using general revenues to cover costs.This will further increase our capacity and financial resources for sustaining and expanding Community Learning Services beyond the grant period. 7. Program Objectives Using County Nonprofit Grant Program Funds: Grant support is respectfully requested from the County of Hawaii to fund Community Learning Services for our Keaau Adult Day Health Center participants. Our goal is to promote the dignity, independence, and social inclusion of adults with special needs by facilitating valuable community-based learning opportunities that they might not otherwise access,with transportation provided. Specific objectives will be to 1)serve at least 38 Adult Day Health participants throughout the year by 2)facilitating an average of 260 hours of Community Learning Services per month,which will consists of small, group-based outings spanning a full range of healthy living, recreational, educational and volunteer activities. For example,Adult Day Health Center participants stay active by accessing zumba classes, gyms, and pools;enjoy excursions such as to the county fair, Imiloa Astronomy Center, bowling, and movies;participate weekly in"Music at the Park"where they learn songs,dance the hula, make lei, and socialize with the kupuna there;and help to feed the hungry weekly at The Salvation Army. Experience has shown us that community activities are essential to improving the quality of life of adults with intellectual and development disabilities through the social belonging that results from opportunities to interact with others in an authentic, natural way, as well as through learning life skills, living healthy lifestyles, and giving back by volunteering.The effects of our Community Learning Services can be life-changing by countering loneliness, expanding participants'social life beyond their family and service providers, reversing their largely sedentary lives towards greater physical activity, helping them to develop and expand • their individual interests by exploring activities taking place within community settings, increasing their independence through development of life skills,and enhancing their socially valued roles in a more inclusive community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 • Agency Name: Easterseals Hawaii Program Name: Adult Day Health 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of ADH participants to be served over one year 38 participants Average number of group Community Learning Services per month 260 hours Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 334,218 410,000 27,795 • Professional Fees 9,000 1,324 Operations 1,975 688 Supplies 3,500 13,000 6,260 Equipment 2,596 3,009 Other: Rent/CAM/Utilities 16,707 17,490 Other: Mileage/Travel 21,200 24,866 4,000 Other: Insurance 9,286 9,024 Other: Depeciation 17,665 17,664 Other: Admin. 41,614 49,700 TOTAL 457,761 546,765 38,055 *If applicable 1111 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 • Agency Name: Easterseals Hawaii Program Name: Adult Day Health 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director , 0 ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. (,3-5 k • Sign. - of Authorized Person (specify title) Date EXH A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Easterseals Hawaii Program Name: Adult Day Health 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. 4111 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 • Agency Name: Easterseals Hawaii Program Name: Adult Day Health 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead 411 costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. P/` (f O I D-0 (� Signat re of A uthorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Easterseals Hawaii Program Name: Adult Day Health 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of ADH participants to be served over one year: 38 participants Average number of Group community learning services per month: 260 hours TABLE II: FY 19-20 Grant Council • PROGRAM EXPENDITURES Request Award Salary and Wages 27,795 Professional Fees Operations • Supplies 6,260 Equipment Other: Rent/CAM/Utilities Other: Mileage/Travel 4,000 Other: Insurance Other: Depeciation Other: Admin. TOTAL 38,055 Additional Council directives regarding award: I EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Easter Seals Hawaii Support Services 51 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Easterseals Hawaii Program Name: Support Services Agency Director: Jennifer La'a, President&CEO Phone No.: (808) 529 — 1701 Contact Person: Tisha Takazawa, Senior Program Manager Phone No.: (808) 769 — 5734 Mailing Address: Address: 710 Green Street Address: City,ST,Zip Honolulu, HI 96813 Facility Address: Address: 16-204 Melekahiwa Place Address: Suite 3 City,ST,Zip Keeau, HI 96749 Email Address: Tisha@eastersealshawaii.org Fax No.: (808 ) 769 — 5785 Accountant/CPA: Katha Combs Phone No.: (808 ) 791 — 1414 Firm (if applicable): Wikoff Combs&Co, LLC Mailing Address: Address: 1001 Bishop St. Address: Suite 2760 City,ST,Zip Honolulu, HI 96813 • YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,533 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua n North Kona ❑✓ South Hilo ❑ North Kohala ❑ South Kona n North Hilo n South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns n Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor Q Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 • Agency Name: Easterseals Hawaii Program Name: Support Services an,x^i„x' +mwrsn tnap aF ..Y- m'✓ ?'. _.cese._ m " %4A tc3 na'xe wva'W^^-a.wlwt¢s�.v�evd' :..�e+d enmffN'a� x ftiw.�'u_;b m.s�arekauwwm -.tavea:« «F.wvw^s m .A'SM ^�'�o..Y stisti .x x..w'.na x.n^P 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0 $0 $7,925 2. Agency Mission Statement: The mission of Easterseals Hawaii is to provide exceptional, individualized, family-centered services to empower people with disabilities or special needs to achieve their goals and live independent,fulfilling lives.We are a well-established and respected statewide organization that has been serving Hawaii Island residents for over 70 years. In 2017, our efforts across five islands uplifted the lives of 1,962 people affected by autism spectrum disorder, Down syndrome, cerebral palsy, muscular dystrophy, spina bifida, speech/language delays,vision or hearing impairments,etc. Easterseals Hawaii aims to give participants life-changing,equal opportunities to live, learn,work, and play in our local communities.We deliver Early Intervention programming,Autism Services,Adult Services, Employment Services, and Assistive Technology resources informed by evidence-based practice, research, client surveys, and stakeholder input. Our organization maintains the highest 3-year level of accreditation by the Commission on the Accreditation of Rehabilitation Facilities, indicating adherence to more than 300 internationally accepted standards of excellence. Through our programs, Easterseals Hawaii supports participants with evaluations and assessments, design of individualized . plans,and implementation of appropriate interventions by therapists,teachers, and other health professionals. Coaching and support for the family, caregivers, or others in the participant's circle are integrated. Services for children are family-centered. • Services for adults emphasize individual choice and pursuit of opportunities that match their interest and skills,while fostering dignity,growth, and independence in a variety of one-to-one, small group, and community settings. ' 3. Program Description: Easterseals Hawaii's Support Services deliver intensive, one-on-one assistance to adults in the home or community that can range from several hours per week to 10 hours per day.The program currently serves 76 individuals with intellectual and developmental disabilities. Our Support Services allow participants to work towards their personal goals of independence and may be required by those who have multiple disabilities/special needs, are medically fragile, possess challenging behaviors, live on their own,or because their elderly parents are no longer able to physically assist them with daily living tasks.A majority of adults receiving our Support Services do not have legally designated guardians and are unemployed. Support Services focus on providing individualized support that will enable the participant to reach their personal goals of independence and become a participating member of his or her community. Our staff utilize an evidence-based Person-Centered Planning model--a process-oriented approach to empower people with disabilities that focuses on their needs and puts them in charge of defining the direction for their lives. Comprehensive support is offered for participants to benefit from personalized learning experiences that enrich and improve their lives, rather than isolating them within large institutions,disabled-only groups, or at home. Participants gain independent living,job development, and socialization skills. Opportunities and appropriate supports are also provided to help participants learn how to access, recreate in, and contribute to their community,such as with planning, organizing,transportation, money,time management,communication, and problem-solving. 4. Total Budget& Position Count: Total Program Budget: $1,985,401 Total Program Position Count: 86 Total Agency Budget: $14,646,668 Total Agency Position Count: 368 4111 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 i County of Hawai`i Nonprofit Grant Application FY2019-20 • Agency Name: Easterseals Hawaii Program Name: Support Services 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Medicaid 1,944,868 County of Hawaii Nonprofit Grant 40,533. TOTAL: $1,985,401 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Easterseals Hawaii's Support Services programming is primarily supported by Medicaid funding received through a contract with the State of Hawaii Department of Health,which is a stable source of revenue renewed every five years. In response to new Medicaid waiver rules emphasizing community integration of participants, our organization is transitioning from a center-based program delivery system to a more community-based one. However, our current state contract does not adequately cover the • costs of Community Learning Services being expanded under our Support Services program.To ensure that our participants have access to life-changing opportunities for community integration, our organization is committed to raising funds for Community Learning Services through private foundation grants,special event fundraisers, and solicitation of individual, corporate, and in-kind donations.We are also in the process of adopting Electronic Health Record and Case Management systems,deploying devices with apps, and educating staff on workflows that will, in part, increase efficiency and financial sustainability of programming. In the long-term, changes in Medicaid waiver guidelines rolling out over the next three years will result in greater revenue generated by our Support Services programming due to higher reimbursement rates(increasing from an average of$68 to$90 per day), capturing of a greater number of billable hours, and covering of certain expenses that were not reimbursable under previous contracts.Therefore, in the future, Easterseals Hawaii will be reimbursed more fully for actual expenses incurred, instead of using general revenues to cover costs.This will further increase our capacity and financial resources for sustaining and expanding Community Learning Services beyond the grant period. 7. Program Objectives Using County Nonprofit Grant Program Funds: I Grant support is respectfully requested from the County of Hawaii to fund Community Learning Services for our Support Services participants. Our goal is to promote the dignity, independence, and social inclusion of adults with special needs by facilitating valuable community-based learning opportunities that they might not otherwise access. Specific objectives will be to 1)serve at least 79 Support Services participants throughout the year by 2)facilitating an average of 1,190 hours of individualized Community Learning Services per month.With the County of Hawaii's support, participants will be able to receive a variety of supports that match their personal interests and goals,such as with learning how to utilize public transportation;finding employment or volunteer opportunities in the community, at schools,with the Humane Society,etc.; and participating in healthy living and recreational activities like swimming,zumba, bowling, spending time at the beach and parks,and arts&crafts classes. Experience has shown us that community activities are essential to improving the quality of life of adults with intellectual and development disabilities through the social belonging that results from opportunities to interact with others in an authentic, natural way, as well as through learning life skills, living healthy lifestyles, and giving back by volunteering.The effects of our Community Learning Services can be life-changing by countering loneliness,expanding participants'social life beyond their family and service providers, reversing their largely sedentary lives towards greater physical activity, helping them to develop and expand their individual interests by exploring activities taking place within community settings, increasing their independence through IIIdevelopment of life skills, and enhancing their socially valued roles in a more inclusive community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 • Agency Name: Easterseals Hawaii Program Name: Support Services 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Support services participants to be served over one year 79 participants Average number of Individualized community learning services to be provided per month 1,190 hours Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 1,511,116 1,600,000 20,533 • Professional Fees 37,173 35,000 Operations 5,965 15,000 Supplies 8,180 15,000 10,000 Equipment 2,431 7,500 Other: Rent/CAM/Utilities 49,675 50,000 Other: Mileage/Travel 65,139 72,701 10,000 Other: Insurance 10,693 10,200 Other: Admin. 169,037 180,000 Other: TOTAL $1,859,409 $1,985,401 $40,533 *If applicable III EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 • Agency Name: Easterseals Hawaii Program Name: Support Services 1.o. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor n The Managing Director • ❑ The Director of Finance Ti The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. (cg-5 0 I� • Si . e of Aut • ized Person (specify title) Date IT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 • Agency Name: Easterseals Hawaii Program Name: Support Services 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 0 Agency Name: Easterseals Hawaii Program Name: Support Services 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes ill stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. .i (la-5 I -0(1 S.:natur: of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 • Agency Name: Easterseals Hawaii Program Name: Support Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES I Applicant Council Proposed Projected Results Projected Result Number of Support Services participants to be served over one year 79 Participants Average number of Individualized community learning services to be provided per month 1,190 hours TABLE II: FY 19-20 Grant Council 111/ PROGRAM EXPENDITURES Request Award Salary and Wages 20,533 Professional Fees Operations Supplies 10,000 Equipment Other: Rent/CAM/Utilities Other: Mileage/Travel 10,000 Other: Insurance Other: Admin. Other: TOTAL $40,533 Additional Council directives regarding award: S EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Family Support Hawaii Healthy Keiki 52 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Hawaii Program Name: Healthy Keiki Agency Director: Ray Wofford Phone No.: (808 ) 334 —4115 Contact Person: Stacy Brown Phone No.: (808 ) 443 — 8530 Mailing Address: Address: 75-127 Lunapule Rd.Suite 11 Address: City,ST,Zip Kailua-Kona, Hawaii, 96740 Facility Address: Address: Same as mailing address Address: City,ST,Zip Email Address: sbrown@fsswh.org Fax No.: (808 ) 323 — 3393 Accountant/CPA: Phone No.: (808 ) 242 — 5002 Firm (if applicable): Carbanaro CPA's and Management Group Mailing Address: Address:1885 Main Street Address:Suite 408 City,ST,Zip Wailuku, Hawaii,96793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $24,000 Geographical Areas To Be Served: (One or more can be checked) n Puna ❑ Hamakua [' North Kona ❑South Hilo [' North Kohala ['South Kona ❑ North Hilo ❑✓ South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ['Youth Victims of Crimes [' Culture and the arts ❑Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Hawaii Program Name: Healthy Keiki 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0 $18,500 $0 2. 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 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 home visiting,occupational,speech, and physical therapies, infant/toddler child development centers, parent education/support programs,fatherhood initiative, breastfeeding support,and youth programs. The second is assisting communities to develop the capacity to provide a supportive environment for families and individuals. These are achieved through our community development activities,collaboration building,and advocacy work for a better quality of life for the people of Hawaii. Our mission statement encompasses the work that we do with parents,grandparents, 'ohana caregivers, infants,toddlers,youth, homeless,disabled, disenfranchised,and those living in poverty. We strive daily to make a long lasting positive difference in their lives. 3. Program Description: Healthy Keiki is a program to provide poverty level parents(who lack transportation or resources of their own)transportation supports to assure that their children are cared for and supported in preventative, maintenance,and individual health/medical needs. In the Family Support Hawaii Early Head Start,99%of the enrolled families are at or below the Federal Poverty Level and only approximately 35%of the enrolled families have ongoing, reliable sources of transportation. It is for this reason that we are proposing to provide transportation to poverty-level parents to assure that their children ages birth-three(or they themselves if they are an expectant mother)are receiving: *Prenatal care throughout pregnancy(approximately six visits per mother per year); *Well-baby visits throughout the first three years of life,including immunizations and regularly scheduled testing,such as tuberculosis and lead testing(approximately four visits per child per year); *Preventative and maintenance dental care(approximately two visits per child per year); *WIC(Women, Infants,and Children)nutrition appointments(approximately three visits per child or expectant mother per year). If funded,the program will provide for a 18-hour/week staff member to provide transportation for families to the above-mentioned health appointments. Fuel, repairs,and ongoing maintenance of agency vehicles is also included in the budget request. 4.Total Budget& Position Count: Total Program Budget: $24,000 Total Program Position Count: .45 Total Agency Budget: $2,661,000 Total Agency Position Count: 53 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Hawaii Program Name: Healthy Keiki 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii $24,000 TOTAL: $24,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Family Support Hawaii will review and evaluate the effectiveness and results of this program to determine if it should be supported in the future. It is successful at the objective and performance measures,we will seek additional funds from Hawaii Island United Way, Hawaii Community Foundation, and other private funds. Transportation programs across the nation will be researched and sought out. In addition, FSH participates in several fundraising events each year which could supplement funding for such a program. 7. Program Objectives Using County Nonprofit Grant Program Funds: The program plans to use Hawaii County grant funds to provide one part-time staff member and vehicle costs in order to provide transportation services to low-income families in the districts of North Kohala,South Kohala, North Kona,South Kona,and Kau on Hawaii Island. Transportation will be provided to ensure families meet their children's well-baby visits,dental visits,WIC visits,and prenatal visits for expectant women. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Hawaii Program Name: Healthy Keiki 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Pregnant women will receive prenatal care as scheduled by a physician. 5 women x 6 prenatal visits=30 transports Children age 0-3 will receive well-baby visits as scheduled by a physician. 55 children x 4 well-baby visits=220 transports Children age 0-3 will receive preventative dental care as scheduled by a dentist. 55 children x 2 dental visits=110 transports WIC services will be accessed by those eligible as scheduled by WIC. 55 children x 3 WIC visits=165 transports Number of families to be served. 55 *Based on more than one trip being completed per day and/or multiple families scheduled. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $13,520 $13,520 Professional Fees Operations $10,480 $10,480 Supplies Equipment Other: • Other: Other: Other: Other: TOTAL $24,000 $24,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 1 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Hawaii Program Name: Healthy Keiki 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council n Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓I If no conflicts exist, check here. /s67 a}/ ' f 01/25/19 Signature Authorized Pe fon (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Hawaii Program Name: Healthy Keiki 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to.Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Hawaii Program Name: Healthy Keiki 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of allgrant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. i&e.t Z1610 ,, _ 01 /25/1 9 Signature of Authorized Person (see checklist, 2nd item) Date �C1i�v4tyec-Vo Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Hawaii Program Name: Healthy Keiki 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 5 women x 6 prenatal visits= Pregnant women will receive prenatal care as scheduled by a physician. 30 transports 55 children x 4 well-baby Children age 0-3 will receive well-baby visits as scheduled by a physician. visits=220 transports Children age 0-3 will receive preventative dental care as scheduled by a dentist. 55 children x z dental visits=11 55 children x 3 WIC visits= WIC services will be accessed by those eligible as scheduled by WIC. 165 transports 55 Number of families to be served. TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $13,520 Professional Fees Operations $10,480 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $24,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Family Support Services of West Hawaii Pathways School Mentoring 53 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Services Hawaii Program Name: Pathways School Mentoring Agency Director: Ray Wofford Phone No.: (808) 747 — 5564 Contact Person: Caleb Milliken Phone No.: (808) 747 — 0267 Mailing Address: Address: 75-127 Lunapule Rd. Address: Suite 11 City,ST,Zip Kailua Kona, Hawaii 96740 Facility Address: Address: 75-127 Lunapule Rd. Address: Suite 11 City,ST,Zip Kailua Kona, Hawaii 96740 Email Address: crmilliken@hotmail.com Fax No.: (808 ) 326 — 4063 Accountant/CPA: Phone No.: (808 ) 242 — 5002 Firm (if applicable): Carbano CPA's&Management Group Mailing Address: Address: 1885 Main St. Address: Suite 408 City,ST,Zip Wailuku, HI 96793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ❑South Hilo ❑ North Kohala ❑✓ South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns II Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Services Hawaii Program Name: Pathways School Mentoring 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 0 $19,725 2.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 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 and individuals. These are achieved through our community development activities,collaboration building and advocacy work for a better quality of life for the people of Hawaii. Our mission statement encompasses our work-Dads, Moms,infants,toddlers, youth, homeless,disabled,disenfranchised, living in poverty. We strive daily to make a long lasting positive difference in their lives. 3. Program Description: The mission for the Pathways Mentoring program is to Support, Empower and Equip our youth with the tools to overcome societal and life challenges.Our vision is to create a generation of youth actively engaging with their community and planet to resolve the many challenges that exist.They will solve these challenges by developing a deep understanding of how Social Emotional Awareness and Cultural Understanding can resolve conflict and pave the way for deeper,more meaningful relationships and lives. The problems Pathways seeks to solve are:chronic absenteeism, bullying, harassment and suicide that have reached alarming rates among our youth.Many of our youth turn to drugs,alcohol and crime to cope with their challenges or slip into depression and aggression as an outlet. The problem is largely caused by a general breakdown in the family unit(divorce rate over 50%)and a breakdown in society's support of our youth (access to higher education,extra curricular programs,etc)resulting in our youth growing up without a sense of who they are and where they belong. Pathways Mentoring provides project based mentoring around 3 core developmental concepts;Social Emotional Learning, Cultural Identity and Understanding and Conflict Resolution. The youth decide which areas they want to be mentored on(entrepreneurship,social engagement,college prep,etc)and an outline is created for each project. In the course of completing each project,the facilitators integrate the 3 core concepts. The program consists of weekly,school-based,mentoring groups.Participating schools select a group of middle school aged boys and girls to participate.Volunteer mentors are recruited and screened from the community.Caring adults and youth directed projects in a safe and nurturing environment keep our youth engaged and involved and focused on growth rather than coping. 4. Total Budget& Position Count: Total Program Budget: $50,000 Total Program Position Count: 1 Total Agency Budget: $2,661,000 Total Agency Position Count: 53 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Family Support Services Hawaii Program Name: Pathways School Mentoring 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Hawaii County $30,000 Hawaii Island United Way $10,000 Other grant revenue $5,000 Fundraising events $5,000 TOTAL: $50,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Pathways mentoring has strong community support that can be leveraged to raise funds needed through sponsorships,special events(annual Christmas with our Keiki event)and grant proposals.The program seeks to establish itself as an evidence based model that could potentially be a model for the Department of Education and Office of Youth Services to provide additional funding opportunities. 7. Program Objectives Using County Nonprofit Grant Program Funds: Program Objectives: -Support the development of a Hawaii centric mentoring program through research,capacity building and curriculum development. -Certify 2-3 staff in curriculum development. -Youth to show an increase in a)Social Emotional Awareness,b)Multi-Cultural understanding,c)principles of conflict resolution and d)an increase in reported self esteem and reliance measured by the program pre-and post survey. -Decrease in reported bullying and harassment incidents. -Youth to show an increase in school performance measures including;grades,attendance and participation as reported by the school. -Youth to show an decrease in disciplinary referrals and absences/truancy as reported by the school. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Services Hawaii Program Name: Pathways School Mentoring 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Capacity building of volunteers and trainers 2-5 Volunteers&Staff trained as mentors Curriculum development&improvement Mentoring curriculum/model developed&used Youth to show improvement in pre-and post surveys 3-5%improvement on student surveys Youth to show improvement in school performance measures 3-5%improvement on school reporting Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 18000 $18000 $3,000 Professional Fees Operations 6000 $6,000 $4,000 Supplies 6000 $6,000 $5,000 Equipment Other: Training,Advocacy, Travel 3000 $3,000 $3,000 Other: Activities/Events/Outreach/Marketing 5000 $5,000 $5,000 Other: Program Coordinator/Facilitator Stipend 12000 $12,000 $10,000 Other: Other: TOTAL $50,000 $50,000 $30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Services Hawaii Program Name: Pathways School Mentoring so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): • Member or members of the Council n Staff appointed by a member of the Council n The Mayor n T- he Managing Director n T- he Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: n If no conflicts exist, check here. Signature Authorize P son (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 Countyof Hawai`i Nonprofit Grant Application FY2019-20 p pp Agency Name: Family Support Services Hawaii Program Name: Pathways School Mentoring 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests.uests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Services Hawaii Program Name: Pathways School Mentoring 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. &ff k/ t Signature of Authorized Pers (see checklist, 2nd item) Date rec, p , c eveko Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Family Support Services Hawaii Program Name: Pathways School Mentoring 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Capacity building of volunteers and trainers 2-5 Volunteers&Staff trained as mentors Curriculum development&improvement Mentoring curriculum/model P P developed&used Youth to show improvement in pre-and post surveys 3-5%improvement on student 3-5%improvement on school Youth to show improvement in school performance measures reporting TABLE Il: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $3,000 Professional Fees Operations $4,000 Supplies $5,000 Equipment Other: Training,Advocacy,Travel $3,000 Other: Activities/Events/Outreach/Marketing $5,000 Other: Program Coordinator/Facilitator Stipend $10,000 Other: Other: TOTAL $30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Family Support Services of West Hawaii West Hawai'i Fatherhood Initiative 54 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Services Hawaii Program Name: West Hawaii Fatherhood Initiative Agency Director: Ray Wofford Phone No.: (808) 747 — 5564 Contact Person: Caleb Milliken Phone No.: (808) 747 — 0267 Mailing Address: Address: 75-127 Lunapule Rd. Address: Suite 11 City,ST,Zip Kailua Kona, Hawaii 96740 Facility Address: Address: 75-127 Lunapule Rd. Address: Suite 11 City,ST,Zip Kailua Kona, Hawaii 96740 Email Address: Crmilliken@hotmail.com Fax No.: (808 ) 326 — 4063 Accountant/CPA: Phone No.: (808) 242 — 5002 Firm (if applicable): Carbano CPA's&Management Group Mailing Address: Address: 1885 Main St. Address: Suite 408 City,ST,Zip Wailuku, HI 96793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna 0 Hamakua 0North Kona ❑South Hilo ❑ North Kohala 0 South Kona ❑ North Hilo 0 South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged 0 Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Services Hawaii Program Name: West Hawaii Fatherhood Initiative 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 13,250 22,350 2. 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 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 and individuals. These are achieved through our community development activities,collaboration building and advocacy work for a better quality of life for the people of Hawaii. Our mission statement encompasses our work-Dads,Moms,infants,toddlers, youth, homeless,disabled,disenfranchised,living in poverty. We strive daily to make a long lasting positive difference in their lives. 3. Program Description: The West Hawaii Fatherhood Initiative(WHFI),the only program in West Hawaii dedicated to supporting fathers, has been engaging West Hawaii families for over 14 years as a program within Family Support Services of Hawaii.By providing fathers with resources,training,support and advocacy,the WHFI has strengthened families that had been falling apart and reunited fathers that had long disappeared from the lives of their children. In 2018 the WHFI served over 150 fathers through weekly father groups,special events,and advocacy in the courts.The primary tool used to work with the fathers is the 24/7 dad curriculum provided through the national Fatherhood Initiative.This program is a 12 week fathering course that helps fathers to understand their conscious and unconscious beliefs about being a father and how those beliefs support or hinder their efforts to be good role models and partners.At its core,the program is about supporting fathers to understand that their role as a father is so much more than having a job and paying the bills;it's about nurturing,communicating and being a reliable partner. The skills and knowledge that the fathers develop through the program support them to reflect,engage and listen in order to maintain a healthy environment for themselves and their families. In addition,the group format provides space for men to challenge themselves and others about the negative beliefs and norms that exist in our society regarding men and fathers. Fathers who participate in the program learn that it's okay to ask for help. The WHFI exists to keep fathers healthily engaged with their children through whatever challenges they are going through because fathers are crucial to the long term development of children. 4. Total Budget& Position Count: Total Program Budget: $75,000 Total Program Position Count: .75 Total Agency Budget: $2,661,000 Total Agency Position Count: 53 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawaii Nonprofit Grant Application .FY2019-20 Agency Name: Family Support Services Hawaii Program Name: West Hawaii Fatherhood Initiative 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Hawaii County 45,000 Hawaii Island United Way 10000 Other grant revenue 10000 Fundraising events 10000 • TOTAL: I Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The sustainability of the program will be maintained accordingly; a)A proposal for the State and Department of Human Services(DHS)has been developed to consider working with the State Commission on Fatherhood to expand this project statewide.The state commission on fatherhood is planning to expand and improve fatherhood programs throughout the state.The West Hawaii Fatherhood Initiative,as already one of the most successful in the state,will likely be in a position to provide a model for statewide expansion and funds either directly through DHS or from additional funds to be requested through the Fatherhood Commission or through other public/private partnerships. b)In the event that the State or DHS do not provide funding for continuing this program,the WHFI,will continue to focus on providing direct service to fathers scaled to the resources available. In addition to fundraising events and community sponsors, the WHFI will pursue funding through the channels that have supported this program for over a decade including;Hawaii County, the Oneill family foundation,Atherton Family Foundation and other grants and foundations through the Hawaii Community Foundation.Staffing levels and father coach trainings will be determined by funds available. The impact created by this project and the core mission of the WHFI to support fathers,will continue as a primary function at Family Support Hawaii. 7. Program Objectives Using County Nonprofit Grant Program Funds: Program Objectives: 1. Provide community based support for 20 to 30 fathers per month through: a)Support groups b)Public Events c)Activities and Excursions d)Advocacy in Court and CWS e)Individual case management 2. Conduct 3 Public Events to celebrate healthy fathering in the community; a)Fathers Day event b)3rd Annual Chirstmas with our keiki event c)Family event(Movie night, Barbeque,etc...) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Services Hawaii Program Name: West Hawaii Fatherhood Initiative 8.TABLE I: What are the intended measurable outputs or outcomes that would be.achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Weekly father support group with 15-20 fathers per month 15-20 participants per month Activities for fathers to connect and get support 1 activity every 2 months with 10 to 20 fathers Public Events to celebrate healthy fathering 3 events per year serving 40 families/children Fathers to show improvement in healthy fathering metrics from 24/7 dad curriculum 3-5%improvement on Father surveys Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 36000 26,500 $4,500 Professional Fees Operations 6000 $7,000 $6,000 Supplies 12000 $9,000 $6,000 Equipment Other: Training,Advocacy,Travel 6000 $6,000 $5,000 Other: Program Coordinator/Facilitator Stipend 24000 $20,500 $18,500 Other: Outreach/Marketing/Activities/Events 6000 $6,000 $5,000 Other: Other: _ TOTAL $90,000 $75,000 $45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Services Hawaii Program Name: West Hawaii Fatherhood Initiative 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council ❑ The Mayor n The Managing Director n The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ® If no conflicts exist, check here. { Signature of Auihorized Person ( •ecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Services Hawaii Program Name: West Hawaii Fatherhood Initiative 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express,and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Services Hawaii Program Name: West Hawaii Fatherhood Initiative 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. / (- - )1 Signature of Au orized Person see checklist, 2nd item) Date E)(V,/() v ro; c&4~f- Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Family Support Services Hawaii Program Name: West Hawaii Fatherhood Initiative 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Weekly father support group with 15=20 fathers per month 15-20 participants per month Activities for fathers to connect and get support 1 activity every 2 months with 10 to 20 fathers Public Events to celebrate healthy fathering 3 events per year serving 40 fa Fathers to show improvement in healthy fathering metrics from 24/7 dad curriculum 3-5%improvement on Father surveys TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request • Award Salary and Wages $4,500 Professional Fees Operations $6,000 Supplies $6,000 Equipment Other: Training,Advocacy, Travel $5,000 Other: Program Coordinator/Facilitator Stipend • $18,500 Other: Outreach/Marketing/Activities/Events $5,000 Other: Other: TOTAL $45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Five Mountains dba Kipuka o ke Ola Health Services for Underserved Populations 55 County of Hawaii Nonprofit Grant Application FY2019-20 'Agency Name: Five Mountains Hawaii dba Kipuka o ke Ola Program Name: Health Services for Underserved Populations Agency Director: Dr. Claren Kealoha-Beaudet Phone No.: (S08) 885 — 5900 Contact Person: Dr. Claren Kealoha-Beaudet Phone No.: (808) 937 — 7171 Mailing Address: Address: PO Box 818 Address: City,ST,Zip Kamuela, HI, 96743 Facility Address: Address: 64-1035 Mamalahoa Hwy, Suite F Address: City,ST,Zip Kamuela, HI, 96743 Email Address: clarenk@aol.com Fax No.: (808 ) 885 — 6900 Accountant/CPA: Bonnie Gibeault Phone No.: (808 ) 968 — 1002 Firm (if applicable): Carbonaro CPA's&Management Group Mailing Address: Address: 136 Kinoole St Address: City,ST,Zip Hilo, HI, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $47000 dam, gct-, D. kot,c - 4c04.104 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna ❑✓ Hamakua ❑✓ North Kona [' South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ['South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns [' Youth ['Victims of Crimes ❑ Culture and the arts ['Aged ['Victims of Health or Social Crises [' Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Five Mountains Hawaii dba Kipuka o ke Ola Program Name: Health Services for Underserved Populations 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0 $0 $11,425 2. Agency Mission Statement: Five Mountains Hawaii dba Kipuka o ke Ola(KOKO) provides a full range of bio-psycho-social services to the residents of North Hawaii, with a special emphasis on addressing the physical and mental health disparities of the Kanaka Maoli population. KOKO provides culturally-informed direct services, actively collaborates with other like-spirited individuals and organizations, and is led by the community it serves. KOKO offers care to any person that seeks services, but has been especially successful in reaching our target populations,some of Hawaii's most vulnerable and underserved people—Native Hawaiians, uninsured, underinsured, homeless and the mentally-ill. Fifty percent of our patients are Native Hawaiian, and 50%of our patients are Medicaid/Medicare. Kipuka o ke Ola(KOKO) is a private, non-profit health clinic in Waimea on Hawaii Island that was founded in 2013, providing behavioral and mental health care by two psychologists and two office staff, and KOKO has been strategically expanding to now include psychiatry and primary care with 13 staff, over 1,000 patients and—5,000 visits annually. KOKO's services are differentiated from other local healthcare providers by providing: 1) Integrated health services in a culturally competent way, 2) Behavioral and primary care health services, emphasizing interventions to bring about desired lifestyle changes. 3)Treatment to patients regardless of financial resources and insurance provider 3. Program Description: KOKO is seeking funding additional funds to support the continuation of its Ulu Laukahi Project-Native Hawaiian Health & Well-Being Project.The six month program update has already shown improvement and stablization in many patients.This project has been successful in working with Native Hawaiian community members at risk for,or struggling with, diabetes, hypertension, obesity, and mental health issues(particularly depression, anxiety, and substance abuse), and to provide them with prevention/intervention services to mitigate the factors that contribute to the need for emergency interventions,disabilities, and ultimately to premature death.The program staff, along with expert project consultants,will provide services via three strategies:psychoeducation, psychotherapy, and nutrition/fitness training.These modalities will be provided in 1:1, small group (3-5), and large group formats(15-25) as appropriate.The program will recruit,screen, and orient 100 community members and then provide services over the course of the remaining 10-11 months of the program year. Psychoeducation strategies include:presentations, hand-outs, and discussions. Some themes explored within this strategy will include:pain management; mindful movement;body awareness;basic anatomy and physiology;relaxation exercises;safe functional movements;peer success stories;complementary indigenous healing practices;and basics of good sleep. Psychotherapy strategies will include evidence-based,client-centered, assets-focused humanistic/existential psychotherapy. Some of the themes explored will include:legacy of cultural trauma;self-image/body concept;motivation and program adherence;appropriate goal setting;family dynamics;maladaptive/adaptive coping;negative emotion management;family-of- origin patterns;trauma issues;and successfully managing depression/anxiety/substance abuse. Nutrition/Fitness strategies will include live demonstrations and hands-on personal training. Some of the themes explored within this strategy include:traditional and modern nutrition; mindful eating;healthy meal planning;food shopping&preparation; portion control;proper hydration;progressive weight resistance training;cardio-respiratory training;flexibility, balance, and range of motion training;tai chi training, and self-massage. 4. Total Budget & Position Count: Total Program Budget: $131,800 Total Program Position Count: 4 PT Total Agency Budget: $1,243,000 Total Agency Position Count: 11 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Five Mountains Hawaii dba Kipuka o ke Ola Program Name: Health Services for Underserved Populations 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate HMSA Foundation (confirmed) $100,000 Hawaii County Non-profit grants $15,500 Kipuka o ke Ola $16,300 TOTAL: 131,800 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This program supplements the direct health services that KOKO already provides to support Native Hawaiian in making lifestyle changes towards healthier habits and better management of chronic diseases-obesity and diabetes. KOKO's direct services are primarily supported through patient fees and insurance reimbursements. Since prevention programs do not have the same revenue sources KOKO is supporting the program through grants and fundraising efforts. Sponsorships and in-kind donations are also being sought to support this program.As results from the program begin showing real impact on maintaining health and preventing larger or more costly medical issues, we will work with insurance providers to provide more support for these types of programs. Success of this strategy can already be seen in HMSA's doubling of their support from last year to this year. If the program does not reach full funding level, certain program benefits like fitness training, nutrition training, etc, will likely be cut and the program cohort may be reduced in size. We will continue to seek program support to fulfill the vision for the Ulu Laukahi Program. 7. Program Objectives Using County Nonprofit Grant Program Funds: The project is designed to address health disparities of the Native Hawaiian population by helping our Native Hawaiian clients achieve a greater measure of health and well-being. KOKO will inspire, inform, instruct, and help them to successfully integrate lessons into their daily lives.Through this program, KOKO will help clients reduce their weight to healthier Body Mass Index (BM!) levels, decrease and stabilize blood pressure to healthier levels, reduce and stabilize blood sugar levels to healthier levels; decrease psychological stress and dysfunction(depression, anxiety, substance abuse)to more functional levels, increase understanding and ability to prepare and eat healthier foods, and increase understanding and usage of health-promoting self- care activities in daily life.The project will increase engagement in family health and well-being and increase patient access and engagement with preventive/intervention services and care using culturally informed approaches at every step. Encouraging access to prevention and intervention services and promoting healthy, active, lifestyle changes will reduce the likelihood of chronic disease manifestations and progressions. The program will recruit, screen, and orient 100 community members and then provide services for participants over the course of the program year.All strategies are culturally informed and provided directly by culturally fluent staff and consultants. Support from Hawaii County Council will support program staff,direct fitness and nutrition training (ex.fitness trainer/classes or cooking classes) and other incentives, supplies for monitoring health and educational activities, and some administrative costs. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Five Mountains Hawaii dba Kipuka o ke Ola Program Name: Health Services for Underserved Populations 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of program participants recruited (anticipating 30%attrition rate over the year) 100 program participants Improvement from baseline measures for blood sugar/blood pressure/BM I 75%of participants improve from baseline Improvement in mental health screens-anxiety, depression, substance abuse 75%of participants improve from baseline Each client/ohana creates an individualized goal plan guided by KOKO staff —100 individualized goal plans Increased knowledge of basic nutrition and fitness inventories 90%report improved knowledge Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 76,400 9,000 Professional Fees 18,000 2,000 Operations 7,500 2,000 Supplies Equipment Other: Health Activities 14,400 500 Other: Project Promotion 1,500 500 Other: Project Administration 2,000 500 Other: Hent tor large meeting room 12,000 1,000 Other: TOTAL 131,800 15,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Five Mountains Hawaii dba Kipuka o ke Ola Program Name: Health Services for Underserved Populations 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Dr. Claren Kealoha-Beaudet POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ri Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: F/] If no conflicts exist, check here. pI Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Five Mountains Hawaii dba Kipuka o ke Ola Program Name: Health Services for Underserved Populations 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 O County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Five Mountains Hawaii dba Kipuka o ke Ola Program Name: Health Services for Underserved Populations 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1 vD k Signature of Authorized Person (see checklist, 2nd item) Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Five Mountains Hawaii dba Kipuka o ke Ola Program Name: Health Services for Underserved Populations 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 9,000 Professional Fees 2,000 Operations Supplies ' 2,000 Equipment Other: Health Activities 500 Other: Project Promotion 500 Other: Project Administration 500 Other: Rent for large meeting room 1,000 Other: TOTAL 15,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Five Mountains dba Kipuka o ke Ola Ulu Laukahi Project- Native Hawaiian Health and Well-Being 56 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Five Mountains Hawaii dba Kipuka o ke Ola Program Name: Ulu Laukahi Project - Native Hawaiian Health and Well-Being Agency Director: Dr. Claren Kealoha-Beaudet Phone No.: (808) 885 — 5900 Contact Person: Dr. Claren Kealoha-Beaudet Phone No.: (808) 937 — 7171 Mailing Address: Address: PO Box 818 Address: City,ST,Zip Kamuela, HI, 96743 Facility Address: Address: 64-1035 Mamalahoa Hwy, Suite F Address: City,ST,Zip Kamuela, HI, 96743 Email Address: clarenk@aol.com Fax No.: (808 ) 885 — 6900 Bonnie Gibeault Phone No.: sob 968 — 1002 Accountant/CPA: ( ) Firm (if applicable): Carbonaro CPA's&Management Group Mailing Address: Address: 136 Kinoole St Address: City,ST,Zip Hilo, HI, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $1.570-60— / 5tr Geographical Areas To Be Served: (One or more can be checked) ❑ Puna Q Hamakua [' North Kona [' South Hilo 0 North Kohala [' South Kona ❑ North Hilo ['South Kohala ❑ Kali Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑Victims of Crimes [' Culture and the arts ❑✓ Aged ['Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities [' Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Five Mountains Hawaii dba Kipuka o ke Ola Program Name: Ulu Laukahi Project - Native Hawaiian Health and Well-Being 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0 $0 $11,425 2. Agency Mission Statement: Five Mountains Hawaii dba Kipuka o ke Ola(KOKO) provides a full range of bio-psycho-social services to the residents of North Hawaii, with a special emphasis on addressing the physical and mental health disparities of the Kanaka Maoli population. KOKO provides culturally-informed direct services, actively collaborates with other like-spirited individuals and organizations, and is led by the community it serves. KOKO offers care to any person that seeks services, but has been especially successful in reaching our target populations, some of Hawaii's most vulnerable and underserved people—Native Hawaiians, uninsured, underinsured, homeless and the mentally-ill. Fifty percent of our patients are Native Hawaiian, and 50%of our patients are Medicaid/Medicare. Kipuka o ke Ola(KOKO) is a private, non-profit health clinic in Waimea on Hawaii Island that was founded in 2013, providing behavioral and mental health care by two psychologists and two office staff, and KOKO has been strategically expanding to now include psychiatry and primary care with 13 staff, over 1,000 patients and 5,000 visits annually. KOKO's services are differentiated from other local healthcare providers by providing: 1) Integrated health services in a culturally competent way, 2) Behavioral and primary care health services, emphasizing interventions to bring about desired lifestyle changes. 3)Treatment to patients regardless of financial resources and insurance provider 3. Program Description: - KOKO is seeking funding additional funds to support the continuation of its Ulu Laukahi Project-Native Hawaiian Health & Well-Being Project.The six month program update has already shown improvement and stablization in many patients.This project has been successful in working with Native Hawaiian community members at risk for, or struggling with, diabetes, hypertension, obesity, and mental health issues(particularly depression, anxiety, and substance abuse), and to provide them with prevention/intervention services to mitigate the factors that contribute to the need for emergency interventions, disabilities, and ultimately to premature death.The program staff, along with expert project consultants, will provide services via three strategies:psychoeducation, psychotherapy, and nutrition/fitness training.These modalities will be provided in 1:1, small group (3-5), and large group formats(15-25) as appropriate.The program will recruit, screen, and orient 100 community members and then provide services over the course of the remaining 10-11 months of the program year. Psychoeducation strategies include:presentations, hand-outs, and discussions. Some themes explored within this strategy will include:pain management; mindful movement;body awareness;basic anatomy and physiology;relaxation exercises;safe functional movements; peer success stories;complementary indigenous healing practices;and basics of good sleep. Psychotherapy strategies will include evidence-based, client-centered, assets-focused humanistic/existential psychotherapy. Some of the themes explored will include:legacy of cultural trauma;self-image/body concept; motivation and program adherence;appropriate goal setting;family dynamics;maladaptive/adaptive coping; negative emotion management;family-of- origin patterns;trauma issues;and successfully managing depression/anxiety/substance abuse. Nutrition/Fitness strategies will include live demonstrations and hands-on personal training. Some of the themes explored within this strategy include:traditional and modern nutrition; mindful eating; healthy meal planning;food shopping&preparation; portion control;proper hydration; progressive weight resistance training;cardio-respiratory training;flexibility, balance, and range of motion training;tai chi training, and self-massage. 4. Total Budget & Position Count: Total Program Budget: $131,800 Total Program Position Count: 4 PT Total Agency Budget: $1,243,000 Total Agency Position Count: 11 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Five Mountains Hawaii dba Kipuka o ke Ola Program Name: Ulu Laukahi Project - Native Hawaiian Health and Well-Being 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate HMSA Foundation (confirmed) $100,000 Hawaii County Non-profit grants $15,500 Kipuka o ke Ola $16,300 TOTAL: 131,800 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This program supplements the direct health services that KOKO already provides to support Native Hawaiian in making lifestyle changes towards healthier habits and better management of chronic diseases-obesity and diabetes. KOKO's direct services are primarily supported through patient fees and insurance reimbursements. Since prevention programs do not have the same revenue sources KOKO is supporting the program through grants and fundraising efforts. Sponsorships and in-kind donations are also being sought to support this program.As results from the program begin showing real impact on maintaining health and preventing larger or more costly medical issues, we will work with insurance providers to provide more support for these types of programs. Success of this strategy can already be seen in HMSA's doubling of their support from last year to this year. If the program does not reach full funding level, certain program benefits like fitness training, nutrition training, etc, will likely be cut and the program cohort may be reduced in size. We will continue to seek program support to fulfill the vision for the Ulu Laukahi Program. 7. Program Objectives Using County Nonprofit Grant Program Funds: The project is designed to address health disparities of the Native Hawaiian population by helping our Native Hawaiian clients achieve a greater measure of health and well-being. KOKO will inspire, inform, instruct, and help them to successfully integrate lessons into their daily lives.Through this program, KOKO will help clients reduce their weight to healthier Body Mass Index (BM I) levels,decrease and stabilize blood pressure to healthier levels, reduce and stabilize blood sugar levels to healthier levels; decrease psychological stress and dysfunction(depression, anxiety, substance abuse)to more functional levels, increase understanding and ability to prepare and eat healthier foods, and increase understanding and usage of health-promoting self- care activities in daily life.The project will increase engagement in family health and well-being and increase patient access and engagement with preventivelintervention services and care using culturally informed approaches at every step. Encouraging access to prevention and intervention services and promoting healthy, active, lifestyle changes will reduce the likelihood of chronic disease manifestations and progressions. The program will recruit, screen, and orient 100 community members and then provide services for participants over the course of the program year.All strategies are culturally informed and provided directly by culturally fluent staff and consultants. Support from Hawaii County Council will support program staff, direct fitness and nutrition training (ex.fitness trainer/classes or cooking classes) and other incentives, supplies for monitoring health and educational activities, and some administrative costs. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Five Mountains Hawaii dba Kipuka o ke Ola Program Name: Ulu Laukahi Project - Native Hawaiian Health and Well-Being 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of program participants recruited (anticipating 30%attrition rate over the year) 100 program participants Improvement from baseline measures for blood sugar/blood pressure/BM I 75%of participants improve from baseline Improvement in mental health screens-anxiety, depression, substance abuse 75%of participants improve from baseline Each client/ohana creates an individualized goal plan guided by KOKO staff —100 individualized goal plans Increased knowledge of basic nutrition and fitness inventories 90%report improved knowledge Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 76,400 9,000 Professional Fees 18,000 2,000 Operations Supplies 7,500 2,000 Equipment Other: Health Activities 14,400 500 Project Promotion 1,500 500 Other: Other: Project Administratlon 2,000 500 Other Hent tor large meeting room 12,000 1,000 Other: TOTAL 131,800 15,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Five Mountains Hawaii dba Kipuka o ke Ola Program Name: Ulu Laukahi: Native Hawaiian Health and Well-Being 10, ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those`Fisted below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Dr. Claren Kealoha-Beaudet POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council T Staff appointed by a member of the Council n The Mayor ❑ The Managing Director ❑ The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Five Mountains Hawaii dba Kipuka o ke Ola Program Name: Ulu Laukahi: Native Hawaiian Health and Well-Being 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Five Mountains Hawaii dba Kipuka o ke Ola Program Name: Ulu Laukahi: Native Hawaiian Health and Well-Being 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 117/011.01 Signature of Authorized Person (see checklist, 2nd item) Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Five Mountains Hawaii dba Kipuka o ke Ola Program Name: Ulu Laukahi Project - Native Hawaiian Health and Well-Being 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of program participants recruited (anticipating 30%attrition rate over the year) 100 program participants Improvement from baseline measures for blood sugar/blood pressure/BM 75%of participants improve 9 P from baseline Improvement in mental health screens-anxiety, depression, substance abuse 75%of participants improve frc Each client/ohana creates an individualized goal plan guided by KOKO staff —ioo individualized goal plans Increased knowledge of basic nutrition and fitness inventories 90%report improved g knowledge TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 9,000 Professional Fees 2,000 Operations Supplies 2,000 Equipment Other: Health Activities 500 Other: Project Promotion 500 Other: Project Administration 500 Other: Rent for large meeting room 1,000 Other: TOTAL 15,500 Additional Council directives regarding award: EXHIBIT B • NONPROFIT F GRANT APPLICATION FY 2019-2020 Page 8 of 8 Food Basket Inc., The Emergency Food Program 57 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Food Basket Inc. Program Name: Emergency Food Program Agency Director: Kristin Frost Albrecht Phone No.: (808) 933 — 6030 Contact Person: Kristin Frost Albrecht Phone No.: (808) 933 — 6030 Mailing Address: Address: 40 Holomua St. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 40 Holomua St. Address: 73-4161 Ulu Wini Place City,ST,Zip Hilo, HI 96720 Kailua Kona, HI 96740 Email Address: Fax No.: (808 ) 934 — 0701 Accountant/CPA: Ann Fukuhara Phone No.: (808) 961 — 5532 Firm (if applicable): Mailing Address: Address: PO Box 6691 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna Hamakua ❑✓ North Kona ['South Hilo Q✓ North Kohala ❑✓ South Kona Q✓ North Hilo South Kohala ❑✓ Kali Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Youth ['Victims of Crimes ['Culture and the arts Aged ['Victims of Health or Social Crises ✓J Needs of the poor Physical/Emotional Disabilities ✓l Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Food Basket Inc. Program Name: 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $24,500.00 $29,625.00 $42,075.00 2.Agency Mission Statement: The mission of The Food Basket is to end hunger in Hawaii County. The Food Basket shall accomplish its mission by: 1) Providing cost effective and reliable services that supply food to those in need and prevent food waste. 2)Coordinating food supply and distribution during emergencies. 3) Facilitating community economic development that sustains and improves the island's food security. 4) Developing and implementing innovative programs to reduce hunger at its source. 5)Cultivating and maintaining a positive work environment,organizational structure,and professional relationships with partners,donors and the community. 6) Establishing a reputation as a trusted and reliable organization among all stakeholders. 7)Achieving and sustaining positive financial operating results. 3. Program Description: The Food Basket is seeking support for its Emergency Food Program,which provides food assistance and disaster response, relief,and recovery to the residents in Hawai'i County. Funds will help provide food to more than 136 partner organizations that collectively serve more than 14,000 unduplicated low-income individuals each month and help ensure adequate food supplies for approximately 3,000-5,000 individuals in emergency situations. In 2018,The Food Basket distributed over 2 million pounds of emergency food to 226,238 individuals(includes individuals who are served multiple times)island-wide through partner agencies and our community programs, including 2000 children with our "We Got Your Back"Keiki Backpack program and 1080 Seniors with our"Kupuna Pantry"Commoditity Supplemental Food Program and"Senior Brown Bag"program. Additionally,we distributed over 200,000 pounds of emergency food during the Kilauea Lava Flow Disaster to residents in the affected areas of Puna through the disaster relief distribution site in Pahoa as well as the various emergency shelter sites and Puna pantries. We are currently serving hundreds of federal employees affected by the partial government shutdown with'Ghana Drops of emergency food weekly in both Kona and Hilo, 4.Total Budget&Position Count: Total Program Budget: $450,000 Total Program Position Count: 8.0 FTE Total Agency Budget: $1,400,000 Total Agency Position Count: 16.0 FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Food Basket Inc. Program Name: 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Contributions- individual $125,000 Contributions-fundraising agency $120,000 Contributions-corporate,foundations and trusts $50,000 County of Hawaii request $50,000 Earned revenue- shared maintenance fees $65,000 Hawaii Island United Way $10,000 All other revenue- Federal TEFAP $30,000 TOTAL: $450,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 30%of our agency revenues come from individual donors. Additional revenue sources include: 13%in state contracts for programs;31%from private foundations,trusts and corporate donations;4%of our income is from local and federal grant awards;11%in earned income from our economic development programs;4%from non-profit organizations,3%through fundraising events and 4%from miscellaneous income. For private donations,TFB employs RKD Alpha Dog Direct Marketing service for monthly direct mail donor campaigns which has reliably provided successful results of individual donations for the past five years.Additionally,we have several fundraising events throughout the year,including our annual Charity Golf Tournament,the annual Feed-a-thon and numerous food drives that yield monetary contributions.We contract with the Williams Grant Writing firm to bolster our general operations(to include staffing,warehouses,transport and utilities)funding with grants from previously untapped resources. In 2018 The Food Basket went through a reorganization resulting in better efficiencies, cost reductions and stronger financial stability. in 2019 we plan to improve data collection and dissemination with the hope that we can better inform donors and the communities we serve of the scope and breadth of need in Hawaii County and for their continued support to end hunger on Hawai'i Island. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Food Basket's goal is to end hunger in Hawai'i County.There are three objectives associated with this goal: 1. Provide food to more than 136 non-profit and community organizations, including soup kitchens,public housing,churches and religious organizations,clean and sober houses,domestic violence shelters,same-day pantries,and after-school programs that collectively serve over 14,000 low-income individuals each month; 2. Deliver food to county sites,schools,and community centers through various TFB programs to address food insecurity for an estimated 23,000 qualified individuals annually(including school children,working adults and senior citizens);and, 3. Ensure adequate food supplies for approximately 3,000-5,000 individuals in emergency situations,victims of natural disasters including the Lower East Rift Zone lava flows,and low-income families during economically challenging times(such as Christmas,New Year's,Thanksgiving,and Easter)and or crisis such as the partial government shutdown in which hundreds of federal employees required our services. TFB's goal will be accomplished via the continuation of its core emergency food distribution programs and the supplying of disaster relief efforts to the affected community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: The Food Basket Inc. Program Name: 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Provide food to more than 136 partner agencies for distribution weekly and monthly 5,000 distributions of food to PAs annually Serve 14,000 plus unduplicated needy individuals on Hawai'i Island monthly Serve 168,000 individuals(duplicated)annually Deliver food to community sites monthly through TFB programs to address food insecurity 225 community distributions annually Ensure adequate food supply for 3,000-5,000 residents for disaster relief Ability to respond to crisis as needed with food E"°" ''-�T "' -+r4ms,� v:"^ °'s �i^R 2 4 e a y q '" 1 y"w,,,t'y S "S vL'i r .. a�^.. a,n�,.,�,�,.,..xm.....v.;._.. s....'.. .::z :'tC"..'..�,.u.. ._,._. .K....:.rw, ,. ss,.a .�,'.ku" w.a�',w,. .s..,....n^z.,�.*.'.°` w<aaw:..,... Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $307,564 $320,000 $25,000 Professional Fees Operations Supplies Equipment Other: Non-personnel - supplies, tood, gas, snipping $47,099 $40,000 $12,500 Facility and Equipment maintenance $85,885 $88,500 $12,500 Other: Other: I ravel and meetings $169 $1500 Other: ('ontract services $9,975 Other: other $1,390 TOTAL $452,084 $450,000 $50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: The Food Basket Inc. Program Name: 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. fJanuary 31, 2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Food Basket Inc. Program Name: 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Food Basket Inc. Program Name: Emergency Food Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. January 31,2019 Signature of Authorized Person (see checklist, 2nd item) Date ik eC/d/Vr /0%/ems Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Food Basket Inc. Program Name: 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Friends of the Children's Justice Center of East Hawaii Special Needs, Enhancement, Support, Education &Training 58 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support , Education & Training Agency Director: Robin Benedict Phone No.: (808) 935 — 8755 Contact Person: Robin Benedict Phone No.: (808) 935 — 8755 Mailing Address: Address: P.O. BOX 6908 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1290 Kinoole St Address: City,ST,Zip Hilo, HI 96720 Email Address: fcjceh@hawaii.rr.com Fax No.: (808 ) 935 — 8757 Accountant/CPA: Evelyn Paiva Phone No.: (808) 969 — 9023 Firm (if applicable): EMP Business Services Mailing Address: Address: 474 Kalanikoa St. Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) n Puna n Hamakua n North Kona n South Hilo n North Kohala n South Kona n North Hilo n South Kohala n Kai() Services or Activities To Be Provided: (One or more can be checked) ri Educational concerns n Youth ri Victims of Crimes n Culture and the arts n Aged n Victims of Health or Social Crises n Needs of the poor n Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support , Education & Training 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $12,375.00 $14,000.00 $11,750.00 2.Agency Mission Statement: In partnership with the Children's Justice Center,we exist to meet the needs of abused and neglected children of East Hawaii. We focus our efforts on helping child victims with resources and hope,while striving to educate the public about child abuse. 3. Program Description: The Program serves children between the ages of 0-18,who are documented victims of abuse,or are witnesses to crime, residing in East Hawaii,filling requests for special needs and enhancements(i.e.clothing, hygiene items, beds, bedding, transportation, school supplies, intercession activities,tutoring, holiday and birthday gifts,Winners Camp,sports,dance,arts, and music). The Program provides Center support to the Children's Justice Center of East Hawaii, by providing for resources to help reduce trauma and ensure the safety and comfort of the children that come to the Center for interviews. The Friends maintain the Center's safe, child-friendly and homelike atmosphere,with toys, books, stuffed animals,games,snacks, and a gently used children's clothes closet.Through education and prevention,the Friends educates the community regarding child abuse issues.The Program plans events for the public,and maintains and updates the Friends website, promoting child abuse awareness and prevention.The Program sponsors training, by supporting the attendance of professionals at seminars and conferences,to learn state-of-the-art interviewing techniques to enhance and refine their overall skills. 4.Total Budget& Position Count: Total Program Budget: 180,630.00 Total Program Position Count: Total Agency Budget: 220,800.00 Total Agency Position Count: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support , Education & Training 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii 20,000.00 Donations 7,830.00 Fundraising 10,000.00 Special Events-Phantom, Charity Walk, etc. 20,000.00 Foundations: Teresa Hughes, and Victoria and Bradley Geist 100,000.00 Hawaii Island United Way 8,800.00 Corporate and other grants 14,000.00 TOTAL: 180,630.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 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, Gala dinner event,and our Masquerade event fundraiser. 7. Program Objectives Using County Nonprofit Grant Program Funds: Provide funds for emergency needs(clothing, hygiene items, bedding,car seats, baby needs, health related needs,etc.)and enhancements(sports-equipment,fees and registration,dance,drama, music,art,school supplies, school pictures,tutoring, intercession activities,ground and air transportation, holiday and birthday gifts, prom and graduation expenses, etc.).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 support their attendance at training workshops and seminars. Provide privacy,comfort and safety for children and family members who come to the Center, by maintaining its warm environment. Participate with the East Hawaii Coalition for Child Abuse Prevention in community education activities to increase public awareness. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support , Education & Training 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Fill"Special Need &Enhancement" Requests 1200 requests Serve child victims of abuse and or neglect 600 children will be served Volunteers will donate hours to help children receive services 8 Volunteers Ongoing Center support for the Children's Justice Center for a child friendly environment 160 children and youth comfortably served Abused and neglected children will receive holiday gift cards 250 youth will receive a holiday gift card Participation in community education and training events to prevent child abuse 5 events Attach additional pages as necessary. 9.TABLE I1: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $48,283.00 $49,130.00 $1,200.00 Professional Fees $37.00 $250.00 - Operations - - - Supplies $1545.00 $1000.00 $600.00 Equipment $1,202.00 $250.00 Other: Special Needs Requests $102,282.00 $119,300.00 $13,100.00 Other: Center Support $2,676.00 $2,750.00 $2,500.00 Other: Education and Prevention $5,060.00 $6,100.00 $2,100.00 Other: Volunteer Expense $1,233.00 $1,250.00 $500.00 Other: Liability Insurance - $600.00 - TOTAL $162,318.00 $180,630.00 $20,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support , Education & Training 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. 409 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support , Education & Training 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council I I The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: `Q If no conflicts exist, check here. Signatu a of Au horized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support , Education & Training 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support , Education & Training 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1424/, 4zik iigpature of Aut rized Person (see checklist, 2nd item) Date eecidgfi Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 . County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Children's Justice Center of East Hawaii Program Name: Special Needs, Enhancement, Support , Education & Training 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Fill"Special Need&Enhancement"Requests 1200 requests Serve child victims of abuse and or neglect 600 children will be served Volunteers will donate hours to help children receive services 8 Volunteers On oin Center su ort for the Children's Justice Center for a child friend) enviornment 160 children and youth 9 9 PP y comfortably served Abused and neglected children will receive holidaygift cards 250 youth will receive a g holiday gift card Participation in community education and training events to prevent child abuse 5 events TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $1,200.00 Professional Fees _ Operations - Supplies $600.00 Equipment - Other: Special Needs Requests $13,100.00 Other: Center Support $2,500.00 Other: Education and Prevention $2,100.00 Other: Volunteer Expense $500.00 Other: Liability Insurance - TOTAL $20,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 ATTACHMENT Friends of the Children's Justice Center of East Hawaii • Special Needs, Enhancement, Support, Education &Training Program P. 0. Box 6908, Hilo, HI 96720 Bus: (808) 935-8755 A Fax: (808) 935-8757 E-Mail: fcjceh(a,hawaii.rr.com • www.fcjcEastHawaii.org 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 !item, 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. 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. 11Page ATTACHMENT '®' Friends of the Children's Justice Center of East Hawaii Special Needs, Enhancement, Support, Education &Training Program er% P. 0. Box 6908, Hilo,HI 96720 .. Bus: (808) 935-8755 A Fax: (808) 935-8757 E-Mail: fcjceh@hawaii.rr.com A www.fcjcEastHawaii.org 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 support 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. 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. 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 extracurricular activities i.e.: 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. 2IPage Friends of the Palace Theater Fall Musical 59 County of Hawai`i Nonprofit Grant Application . FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Fall Musical Agency Director: Robin Worley Phone No.: (808) 934 - 7120 Contact Person: Robin Worley Phone No.: (808) 934 - 7120 Mailing Address: Address: 38 Haili Street . Address: City,ST,Zip Hilo,Hawaii 96720 Facility Address: Address: same as above Address: City,ST,Zip Email Address: robin.worley@hilopalace.com Fax No.: ( ) — Accountant/CPA: Bob Nutt Phone No.: (8os) 963 - 6160 Firm(if applicable): East Hawaii Business Services Mailing Address: Address: 15 Kahoa Street Address: City,ST,Zip Hilo,Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $19,000 Geographical Areas To Be Served: (One or more can be checked) ®Puna I1 Hamakua ❑North Kona ®South Hilo ❑North Kohala ❑South Kona North Hilo 0 South Kohala ❑Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑Educational concerns Youth ❑Victims of Crimes ®Culture and the arts ®Aged 0 Victims of Health or Social Crises 0 Needs of the poor ❑Physical/Emotional Disabilities ❑Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Fall Musical 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0 $3000 $4550 2.Agency Mission Statement: The Friends of the Palace Theater is a community-based non-profit organization established in 2002. Its mission is"to revitalize,restore,and sustain Hilo's historic theater as a venue that will educate,entertain,and inspire our diverse community." The Palace Theater is the largest downtown venue in Hilo,and contributes significantly to the vitality of Hilo's business district. It has served many generations as a cultural gathering place,and as a popular fundraising space for other community non-profits. It is a showcase for Hawaii's performing artists,local and international filmmakers,and for community-based, multi-cultural events. In 1992,the building was placed on both the State and National Historic Registers. The Friends of the Palace Theater continues its historic tradition by developing programs to engage an increasingly diverse audience of nearly 25,000,which includes approximately 4000 visitors from other locales,each year. Its programs foster an environment that cultivates an appreciation for music,theater,culture,and multi-generational,multi-ethnic dialogue and discourse. 3.Program Description: The Fall Musical is the signature event and biggest fundraiser of the year for the Palace Theater. Proceeds from the Box Office and other donations for this event are used to support productions and operations for the balance of the year. Each year,a different Broadway show is chosen by May.Local performers audition and rehearse from August to October,when the event is held over three weekends.Excitement about the event increases over these months,as word spreads by word of mouth. 2018 will be the 17th consecutive musical. This popular event attracts the residents of East Hawaii,along with visitors from the mainland,who frequently make their vacation plans around the Fall Musical. Due to our current capital campaign for critically-needed physical repairs to the theater,we have not been able to raise the upfront capital to pay our Directors and technicians,or to pay the cost of the orchestra. Not having this upfront capital means that all costs of the musical,including licensing,marketing,wardrobe and sets will have to be paid out of our operating funds. Annual continuity of this popular signature event is critical;skipping it or trying to replace it with something else would place the theater in a precarious financial position,and put other productions and operations at risk. Historically,a major benefactor has contributed and participated in this event;a monetary contribution valued at$20,000. However,that benefactor no longer participates directly in the event;nor we are not able to count on this contribution; necessitating our request to the County. 4.Total Budget&Position Count: Total Program Budget: 45,300 _- - Total Program Position Count: 1 FT;10+PT Total Agency Budget: 449,907 Total Agency Position Count: 3 FT;10+PT EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i:Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Fall Musical 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii 19,000 Box Office - 25,000 Cafe,Gift shop 1,300 TOTAL: 45,300 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Palace Theater supports all of its programs through eight primary sources:Box office revenue,Cafe revenue,donations, major sponsors,grants,rentals,volunteers,and in-kind donations-all of which will be leveraged to support this program.County funding to support Directors'fees,musicians,and technical staff is-a key aspect of the program,as a monetary commitment to the Directors and performers will help lay the framework and encourage other donors to support this important program The Board of Directors annually establishes a Strategic Plan with strategies to build a strong financial foundation through increased revenue from individual donors,increased partnerships with local schools,businesses and community groups, increasedaudience numbers and increased revenue from grants.The Board of Directors is actively represented at every Palace event,cultivating prospective audience members and supporters. New branding and marketing strategies are already increasing awareness of the Palace Theater.Continuous advertising to target audiences,assessing customer satisfaction,and adding a new show and performers annually will round out the cumulative results of fundraising-tomake this program sustainable into the future. 7.Program Objectives Using County Nonprofit Grant Program Funds: The primary objective of this request is to ensure the continuity of this major fundraising event to which the local community and visitors to the island look forward with enthusiasm.Profits from this event provide operational funding to the Palace Theater for several months each year. This signature event has historically contributed to annual operations,as well as showcasing the Palace Theater as a excellent venue for large theatrical productions. This is vital,since there is a tremendous amount of talent in East Hawaii,but not many places to showcase it. The Fall Musical at the Palace Theater provides an opportunity for artists to perform in front of a live audience. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Fall Musical 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of dients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Increased revenue from ticket sales +20% Increased audience participation from targeted marketing strategies +20% Increased usage of the theater as a venue for large productions +5% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 2500 2500 Professional Fees 4,500 4500 2000 Operations 1,300 Supplies 215 1300 Equipment 5000 Other: Marketing 5000 7500 5,000 Other: Licensing 7000 7500 Other: Orchestra 7,500 10,000 5000 Other: Sound system/technician 5000 5.000 2500 Other: sets,props and costumes 7000 4500 TOTAL 38,015 45,300 19,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Fall Musical 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance 0 The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: n If no conflicts exist,check here. January 22, 2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Fall Musical 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai`i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility,equipment, property,or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov,complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Youth Theater Program 11.Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence)must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report.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. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. January 22, 2019 Signature of Authorized Person (see checklist,2nd item) Date f)&N Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Fall Musical 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increased revenue from ticket sales +20% Increased audience participation from targeted marketing strategies +20% Increased usage of the theater as a venue for large productions +5% TABLE II: PROGRAM EXPENDITURES FY 19-20 Grant Council Request Award Salary and Wages Professional Fees 2000 Operations Supplies Equipment Other: Marketing 5,000 Other: Licensing Other: Orchestra 5000 Other: Sound system/technician 2500 Other: sets,props and costumes 4500 TOTAL 19,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Friends of the Palace Theater Hawaiian Roots Festival of Talent 60 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Roots Festival of Talent Agency Director: Robin Worley Phone No.: (808) 934 - 7120 Contact Person: Robin Wroley Phone No.: (808) 934 - 7120 Mailing Address: Address: 38 Haili Street Address: City,ST,Zip Hilo Hawaii 96720 Facility Address: Address: same as above Address: City,ST,Zip Email Address: robin.worley@hilopalace.com Fax No.: ( ) — Accountant/CPA: Bob Nutt Phone No.: (808) 963 - 6160 Firm (if applicable): East Hawaii Business services Mailing Address: Address: 15 Kahoa Street Address: City,ST,Zip Hilo Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 17,700 Geographical Areas To Be Served: (One or more can be checked) ®Puna ®Hamakua ['North Kona ®South Hilo ❑North Kohala ❑South Kona ®North Hilo ❑South Kohala ❑Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑Educational concerns ®Youth ❑Victims of Crimes J Culture and the arts ®Aged ❑Victims of Health or Social Crises ❑Needs of the poor ❑ Physical/Emotional Disabilities ❑Public Health and Welfare of the People and the Environment m EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Roots Festival of Talent 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 Pt 17-18 FY 18-19 0 0 $4550 2.Agency Mission Statement: The Friends of the Palace Theater is a community-based non-profit organization established in 2002. Its mission is"to revitalize,restore,and sustain Hilo's historic theater as a venue that will educate,entertain,and inspire our diverse community." The Palace Theater is the largest downtown venue in Hilo,and contributes significantly to the vitality of Hilo's business district. It has served many generations as a cultural gathering place,and as a popular fundraising space for other community non-profits. It is a showcase for Hawaii's performing artists,local and international filmmakers,and for community-based, multi-cultural events. In 1992,the building was placed on both the State and National Historic Registers. The Friends of the Palace Theater continues its historic tradition by developing programs to engage an increasingly diverse audience of nearly 25,000,which includes approximately 4000 visitors from other locales,each year. Its programs foster an environment that cultivates an appreciation for music,theater,culture,and multi-generational,multi-ethnic dialogue and discourse. 3. Program Description: The Hawaiian Islands comprise a diverse collection of many different ethnicities and age groups.Traditionally,Hawaiians have used music and performance to define themselves and to celebrate"aloha'aina",or love of the land,and to record their history, daily lives,feelings and beliefs. This program will consist of a series of 4 performances,each highlighting a different variety of song,musical instrument and/or performance. Drawing from a diverse community of local performers of all ages,the'practitioners'who will be performing in this program will include locally revered elders,adults, youth,and school children. Examples of what will be showcased include slack key guitar,ukulele,hula dancing,taiko,traditional dance,and falsetta singing. All age groups will be represented in this mix,supporting our understanding that arts and culture plays an essential role in promotingsustainable social and economic development for future generations. This program incorporates all the elements of cultural and historic interest-the experiential,emotional,and visual.Therefore,it is anticipated that increased ticket sales,increased attendance at the concerts and a desire of the community,visitors,and new performers to repeat the production in the future will serve as positive indicators of its sustainability beyond this year. 4.Total Budget&Position Count: Total Program Budget: 43,000 - Total Program Position Count: 1 FT;10+PT Total Agency Budget: 449,907 Total Agency Position Count: 3 FT;10+PT EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater_ Program Name: Hawaiian Roots Festival of Talent 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Box Office 20,000 Cafe/Gift,Shop 1,300 State Foundation on Culture and the Arts 4,000 County of Hawaii 17,700 TOTAL: 43,000 Attach additional pages,if needed. 6.Explain what plans your agency or program has to increase revenues to support this program: The Palace Theater supports all of its programs through eight primary sources:Box office revenue,Cafe revenue,donations, major sponsors,grants,rentals,volunteers,and in-kind donations-all of which will be leveraged to support this program.County funding to support Directors'fees,"musicians,and technical staff is a key aspect of the program,as a monetary commitment to the Directors and performers will help lay the framework and encourage other donors to support this important program The Board of Directors annually establishes a Strategic Plan with strategies to build a strong financial foundation through increased revenue from individual donors,increased partnerships with local schools,businesses and community groups, increased audience numbers and increased revenue from grants.The Board of Directors is actively represented at every Palace event,cultivating prospective audience members and supporters. New branding and marketing strategies are already increasing awareness of the Palace Theater.Continuous advertising to target audiences,assessing customer satisfaction,and adding a new show and performers annually will round out the cumulative results of fundraising to make this program sustainable into the future_ 7.Program Objectives Using County Nonprofit Grant Program Funds: The primary objective of this program is to actively encourage and support native Hawaiian culture,art,artists,and practitioners. Specifically,the program seeks to: -recognize and encourage local artists,and to highlight and showcase the immense amount of local talent in East Hawaii -provide opportunities to the public,both local residents and visitors,to experience and appreciate Hawaiian music -encourage and develop target audiences for Hawaiian music -serve as a vehicle for passing on the oral records of Hawaiian history,culture,and lifestyle -promote sustainable cultural tourism by providing authentic,place-based experiences. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Roots Festival of Talent 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.:Number of clients served,workshops or events held,volunteer hours,etc Describe,be specific.) Applicant Projected Results Increased Revenue from higher ticket sales +20% Increased audience engagement through a targeted marketing strategy +10% Increased visibility of the Palace Theater as a venue for Hawaiian cultural events +5% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 3,500 3,500 1,500 Professional Fees 6,000 Operations 1,500 500 Supplies 2,400 2,400 1,200 Equipment 2,400 Other: Technical-sound and lighting 3,600 1,500 Other: Marketing and Advertising 10,000 12,000 5,000 Other: Artist fees 18,000 20,000 8.000 Other: Other: TOTAL 42,300 43,000 17,700 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai `i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Roots Festival of Talent 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. January 22, 2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Roots Festival of Talent 11.Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code,relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility,equipment, property,or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express,and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov,complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Roots Festival of Talent 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report.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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. January 22, 2019 Signature of Authorized Person (see checklist,2nd item) Date I IDEA)-lam' Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Hawaiian Roots Festival of Talent 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increased Revenue from higher ticket sales +20% Increased audience engagement through a targeted marketing strategy +10% Increased visibility of the Palace Theater as a venue for Hawaiian cultural events +5% TABLE II: PROGRAM EXPENDITURES FY 19-20 Grant Council Request Award Salary and Wages 1,500 Professional Fees Operations 500 Supplies 1,200 Equipment Other: Technical-sound and lighting 1,500 Other: Marketing and Advertising 5,000 Other: Artist fees 8.000 Other: Other: TOTAL 17,700 Additional Councildirectives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Friends of the Palace Theater Youth Theater Program 61 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Youth Theater Program Agency Director: Robin Worley Phone No.: (808) 934 — 7120 Contact Person: Robin Wroley Phone No.: (808) 934 — 7120 Mailing Address: Address: 38 Haili Street Address: City,ST,Zip Hilo Hawaii 96720 Facility Address: Address: same as above Address: City,ST,Zip Email Address: robin.worley@hilopalace.com Fax No.: ( ) — Bob Nutt Phone No.: 808 963 — 6160 Accountant CPA. ( ) Firm (if applicable): East Hawaii Business services Mailing Address: Address: 15 Kahoa Street Address: City,ST,Zip Hilo Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 13,500 Geographical Areas To Be Served: (One or more can be checked) Puna ®Hamakua ❑North Kona ®South Hilo ❑North Kohala ❑South Kona ®North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) [' Educational concerns Youth ❑Victims of Crimes Culture and the arts ❑Aged ❑Victims of Health or Social Crises ® Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application lication FY2019-20 P Agency Name: Friends of the Palace Theater Program Name: Youth Theater.Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 • FY 18-19 0 0 $0 2.Agency Mission Statement: The Friends of the Palace Theater is a community-based non-profit organization established in 2002. Its mission is"to revitalize,restore,and sustain Hilo's historic theater as a venue that will educate,entertain,and inspire our diverse community." The Palace Theater is the largest downtown venue in Hilo,and contributes significantly to the vitality of Hilo's business district. It has served many generations as a cultural gathering place,and as a popular fundraising space for other community non-profits. It a showcase for Hawaii's performing artists,local and international filmmakers,and for community-based, multi-cultural events. In 1992,the building was placed on both the State and National Historic Registers. The Friends of the Palace Theater continues its historic tradition by developing programs to engage an increasingly diverse audience of nearly 20,000,which includes approximately 4000 visitors from other locales,each year. Its programs foster an environment that cultivates an appreciation for music,theater,culture,and multi-generational,multi-ethnic dialogue and discourse. 3. Program Description: East Hawaii is a diverse community with many different age groups,income levels,and enthnicities. The Board of Directors feels that it is vital to discoverand assess each group to respond effectively to their unique needs. An emerging interest is the development of arts programming for youth,and the Board has decided on an exciting new educative endeavor. This program will involve a full-scale musical-theater presentation of a beloved children's theater classic,such as Beauty and the Beast or Annie. It will involve acting,singing,dancing and stagecraft featuring up to 100 young performers. Classes in audition technique,scene study,improv,singing,dancing and design will be held for 2 weeks leading up to auditions for the cast.This will be followed by a full production,with 6 weeks of rehearsals and 6 shows over 2 weekends. The program will be overseen and directed by Larry Reitzer,a Board member with over 20 years experience touring,writing, producing and working on Broadway(Les Miserables,Phantom of the Opera)and in television for such shows as Spin City, Just Shoot me,Ugly Betty,and Melissa and Joey. In addition,several local choreographers,designers,and technicians will work with the youth to teach about production,lighting and stagecraft,to expand their interest and love of the arts and its possibilities. 4.Total Budget&Position Count: Total Program Budget: 28,800 Total Program Position Count: 1 FT Total Agency Budget: 449,907 Total Agency Position Count: 3 FT;10+PT EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Youth Theater Program • 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Box Office 13,800 Cafe/Gift Shop 1,500 County of Hawaii 13,500 TOTAL: 28,800 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Palace Theater supports all of its programs through eight primary sources:Box office revenue,Cafe revenue,donations, major sponsors,grants,rentals,volunteers,and in-kind donations-all of which will be leveraged to support this program.County funding to support Directors'fees,musicians,and technical staff is a key aspect of the program,as a monetary commitment to the Directors and performers will help lay the framework and encourage other donors to support this important program The Board of Directors annually establishes a Strategic Plan with strategies to build a strong financial foundation through increased revenue from individual donors,increased partnerships with local schools,businesses and community groups, increased audience numbers and increased revenue from grants.The Board of Directors is actively represented at every Palace event,cultivating prospective audience members and supporters. New branding and marketing strategies are already increasing awareness of the Palace Theater.Continuous advertising to target audiences,assessing customer satisfaction,and adding a new show and performers annually will round out the cumulative results of fundraising to make this program sustainable into the future. 7.Program Objectives Using County Nonprofit Grant Program Funds: The importance of teaching the arts to young people has been debated at length by educators and youth development professionals. Today,the prevailing wisdom is that an understanding of arts and culture plays an essential role in promoting sustainable social and economic development for future generations.Promoting creativity,collaborative effort,and motivations is therefore a priority to finding solutions to today's challenges.(Culture and Youth Development United Nations,2017) The youth theater program being developed by the Palace theater will not only create new opportunities for a broader engagement of children and their parents,but will serve to test some of these theories and inform programming decisions in the future. Specifically,the program will provide opportunities for youth to develop and share their gifts and talents in a"hands-on" experiential and exploratory learning environment,and will encourage a sense of pride and self-esteem. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Youth Theater Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc Describe,be specific.) number of youth participating in program 100 number of new patrons(parents family,teachers)engaged as audience 200 percent of positive feedback about the program and requests to continue it 90% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 P119-20 Actual* Total Budget Grant Req Salary and Wages 800 Professional Fees 7,000 3,000 Operations 1,000 Supplies 3,000 Equipment Other: Scholoarships 6,000 6,000 Other: Sets,costumes and props 2,000 Other: Sound Engineer and Equipment 5,000 2,500 Other: Advertising and marketing 4,000 2,000 Other: TOTAL 28,800 13,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Youth Theater Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawai`i.Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: Mayhave a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor O The Managing Director n The Director of Finance f 7 The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: 0 If no conflicts exist,check here. January 22, 2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Youth Theater Program _ ii. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai`i Compliance Express,and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Youth Theater Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report.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. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. GO-01—cti January 22, 2019 Signature of Authorized Person (see checklist,2nd item) Date A-P-D DE/0 r Title/Position of Authorized Person EXHIBIT A • NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Friends of the Palace Theater Program Name: Youth Theater Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of youth participating in program 100 number of new patrons(parents family,teachers)engaged as audience 200 percent of positive feedback about the program and requests to continue it 90% TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees 3,000 Operations Supplies Equipment Other: Scholoarships 6,000 Other: Sets,costumes and props Other: Sound Engineer and Equipment 2,500 Other: Advertising and marketing 2,000 Other: TOTAL 13,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Full Life Adult Day Health Community Learning and Transportation 62 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Adult Day Health Community Learning and Transportation Agency Director: Jim Kilgore Phone No.: (808) 322 — 9333 Contact Person: Jim Kilgore Phone No.: (808) 322 — 9333 Mailing Address: Address: 75-5995 Kuakini Hwy.Ste 432 Address: City,ST,Zip Kailua-Kona. HI 96740 Facility Address: Address: 79-7460 Mamalahoa Hwy.Ste 112 Address: City,ST,Zip Kealakekua, HI 96750 Email Address: jim@fulllifehawaii.org Fax No.: (808 ) 322 — 9334 Accountant/CPA: Ann Fukuhara Phone No.: (808 ) 961 — 5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku Street,Suite 102 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ['South Hilo [' North Kohala ❑✓ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Adult Day Health Community Learning and Transportation 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 10,500 8,625 7,994 (program) 19,738(total) 2. Agency Mission Statement: Full Life assists individuals with developmental disabilities to achieve and enjoy a self-determined quality of life. 3. Program Description: Located in Mango Court in Kainaliu,the Learning Center is a day time program for adults with developmental disabilities where social skills, recreational pursuits,and independent living skills are encouraged,developed,and shared. Individuals who reflect various levels of intellectual,social and physical abilities are given the environment,opportunity,care,and encouragement to thrive. Desired results include measurable improvements in individual independence and other skill building that leads to increased community integration. Full Life is developing innovative strategies to provide more services in the community.Our strategy is to collaborate with other local nonprofit organizations,community businesses,and individuals to maximize opportunities for community inclusion.We are not just addressing physical inclusion but social and economic inclusion as well.True community inclusion strengthens communities by participating side by side with citizens, not just special classes or programs, but a movement that like an ocean wave, moves our communities forward. The Full Life Adult day Health Community Learning and Transportation program will assist Full Life in providing transportation from participants homes to the Learning Center and back to their homes.The program will also assist participants with accessing a variety of community activities and classes.The program will also foster relationships and collaboration with others in order to achieve our program objectives. 4.Total Budget& Position Count: Total Program Budget: 140,600 Total Program Position Count: 7 Total Agency Budget: 2,700,000 Total Agency Position Count: 94 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Adult Day Health Community Learning and Transportation 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii Nonprofit Grant-Associated Costs for Independent Living 10,000 State of Hawai'i Contracts Adult Day Health 125,600 Fundraising and other grants 5,000 TOTAL: 140,600 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Full Life plans to increase enrollment and participation in the Adult Day Health Community Learning program.Through a non-traditional solution of providing more and more services based in the community,we will reduce the limits on the amount of people who can participate in the program due to physical space limitations. Increased enrollment leads to increased revenues. We are working with the State of Hawaii to increase reimbursements for adult day health services that are provided in the community. Full Life continues to use the results from the County of Hawai'i Nonprofit Grant to build a greater case for additional grant funding and private donations. Furthermore,we are developing additional community partners that will increase awareness and involvement in our programs.This will also be used to develop additional funding through grants and individual donations. Community integration allows growth where participants can transition into employment/volunteer opportunities allowing for additional participants to join the program. Full Life has begun to target youth with disabilities transitioning from high school.This is a valuable service to young participants and a great support to family members.This has resulted in increasing revenues from the State of Hawai'i and will be a large component of plans to increase revenues this coming year. 7. Program Objectives Using County Nonprofit Grant Program Funds: The intended outcome is to improve the participant's social and networking skills, develop and retain social-valued roles, independently use community resources,develop adaptive and leisure skills and hobbies,and exercise civil rights and self-advocacy skills required for active community participation.Addressing inclusion at the County level strengthens our communities in many ways-develops relationships with community partners and strengthens families to promote communities that live, learn and thrive together. Full Life requires funding to support transportation of individuals from north of Palisades and as far south as Honaunau to and from the program daily. 1. Full Life plans to serve up to 12 individuals in the Adult Day Health Program. 2. Full Life participants will attend at least 3 community based activities per week totaling 156 community based activities facilitating inclusion,development of social skills,and community participation. 3. Maintain relationships with current community partners and develop 3 additional community partnerships.The partnerships will be developed to foster inclusion in areas of participants interests such as:art and music, health and fitness,social networking, hobby development such as gardening,etc. 4. Develop at least 2 new opportunities for volunteering and community service. Full Life participants gain meaningful skills and social-valued roles through community volunteering. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Adult Day Health Community Learning and Transportation 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of clients served 12 Number of youth with disabilities transitioning from high school served 3 Number of community based activities per year 156 Number of community partners to provide classes and community activities 6 Number of new volunteer activities for participants 2 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 85,799 90,100 5000 Professional Fees 0 0 0 Operations 28370 29000 1,500 Supplies 2969 3000 0 Equipment 210 500 0 Other: Transportation and vehicle maintenance 12318 13000 3000 Other: Activities 2500 5000 500 Other: Other: Other: TOTAL 132,166 140,600 10,000 If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Adult Day Health Community Learning and Transportation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council • ❑ Staff appointed by a member of the Council ❑ The Mayor n The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. 77 6-e(whiA t-e 1 /31 /2019 ture of Authorize' 'erson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Adult Day Health Community Learning and Transportation 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Adult Day Health Community Learning and Transportation 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1/31/2019 << Sig . e of Authorized Pers.n (see checklist, 2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Adult Day Health Community Learning and Transportation 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of clients served 12 Number of youth with disabilities transitioning from high school served 3 Number of community based activities per year 156 Number of community partners to provide classes and community activities 6 Number of new volunteer activities for participants 2 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 5000 Professional Fees 0 Operations 1,500 Supplies 0 Equipment 0 Other: Transportation and vehicle maintenance 3000 Other: Activities 500 Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Full Life Associated Costs for Self-Determined Living 63 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Associated Costs for Self-Determined Living Agency Director: Jim Kilgore Phone No.: (808) 322 — 9333 Contact Person: Jim Kilgore Phone No.: (808) 322 — 9333 Mailing Address: Address: 75-5995 Kuakini Hwy.Ste.432 Address: City,ST,Zip Kailua-Kona, HI 96740 Facility Address: Address: 120 Keawe St.Ste.201 Address: City,ST,Zip Hilo, HI 96720 Email Address: jim@fulllifehawaii.org Fax No.: (808 ) 322 — 9334 Accountant/CPA: Ann Fukuhara Phone No.: (808) 961 — 5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku Street,suite 102 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $6,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ KaTi Services or Activities To Be Provided: (One or more can be checked) [' Educational concerns ❑✓ Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities [' Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Associated Costs for Self-Determined Living 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 10,500 8,625 5,869 (program) 19,735(total) 2. Agency Mission Statement: Full Life assists individuals with developmental disabilities to achieve and enjoy a self-determined quality of life. 3. Program Description: Full Life believes that every person, regardless of ability,deserves to lead a happy,fulfilled,and self-determined life based on their own individual strengths, preferences,and dreams. We believe that families,communities,and workplaces are made stronger when we embrace all of our members. Our goal is for each and every one of us to be empowered to create, live,and share a full life. With funding from Associated Costs for Self-Determined Living, people with disabilities will have opportunities to explore employment,access public events,improve and maintain a safe and comfortable standard of living,and evolve through educational opportunities and technology.Associated Costs are expenses related to Personal Assistance and Community Learning Services that may pay for costs required for a Direct Support Worker to accompany a participant to an activity and/or purchase items that support a person with a disability to reach goals for independence. Associated Costs include: scholarships that support eager participants explore entrepreneurship in the arts;items or scholarships that allow participants to take part in job readiness programs;items or activities that support development of social valued roles;participants with financial obstacles can access public events which maximizes community integration; replacement of old or upgrading needed equipment and supplies allow participants to feel comfortable and safe in their home; cost supports for educational and technological piques ensures our participants keep in pace toward a thriving full life. All associated costs will be related to the participants individualized goals written in their individual service plans. 4.Total Budget& Position Count: Total Program Budget: 15,000 Total Program Position Count: 55 Total Agency Budget: 2,700,000 Total Agency Position Count: 94 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Associated Costs for Self-Determined Living 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawai'i Nonprofit Grant-Associated Costs for Self-Determined Living 6000 Fundraising and other grant initiatives 9000 TOTAL: 15000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Full Life continues to build programs with the support and funding from the County of Hawai'i to leverage State of Hawai'i contracts to serve people with developmental disabilities and their families.The State of Hawai'i contracts allows Full Life to build capacity to provide innovative service delivery such as offering associated costs for self-determined living to participants in State of Hawai'i Waiver programs. Full Life continues to use results from the County of Hawaii Nonprofit Grant to build a greater case for additional grant funding and private donations.We plan on increasing capacity for social media fundraising initiatives to pay for larger associated cost expenses for certain participants requiring more significant resources to reach self-determined goals. 7. Program Objectives Using County Nonprofit Grant Program Funds: Full Life plans to continue providing Associated Costs for Self-Determined Living to participants and direct support workers. With County Nonprofit Grant Program funds, Full Life's Associated Costs for Self-Determined Living Program objectives include: 1. Provide Associated Cost Funds to 40 participants with Developmental Disabilities based on goals in their individual service plans.The use of the funds will be monitored by a program coordinator and an associated costs committee. 2.Support 10 participants to pursue and/or explore self-employment. 3. Develop capacity to expand associated costs to at least 75%of Full Life participants by January,2021. 4. Increase outcomes of self-determination through monitoring the impact of associated costs on pursuing individual goals. 5. Participants using associated costs to support inclusion will increase their participation in community related activities by 25%. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Associated Costs for Self-Determined Living 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Total number of clients served with Associated Costs for Self-Determined Living 40 Number of clients using associated costs to pursue and explore self-employment 10 Number of clients using associated costs to participate fully in the life of the community 25 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees 0 0 0 Operations 0 0 0 Supplies 2900 3800 1680 Equipment 3389 3800 1680 Other: community events, tickets, admissions, and classes 3411 3800 1680 Other: meals, snacks, beverages for social activities 2214 3600 960 Other: Other: Other: TOTAL 11,914 15,000 6000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Associated Costs for Self-Determined Living 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. dr, ci P ee--- 1 /31/2019 ure of Authorized Pers/(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Associated Costs for Self-Determined Living 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Associated Costs for Self-Determined Living 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1 /31/2019 Sign:ture •f Authorized Pers. (see checklist, 2nd item) Date E.)recta(.. �k Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 r c County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Associated Costs for Self-Determined Living 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Total number of clients served with Associated Costs for Self-Determined Living 40 Number of clients using associated costs to pursue and explore self-employment 10 Number of clients using associated costs to participate fully in the life of the community 25 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 0 Professional Fees 0 Operations 0 Supplies 1680 Equipment 1680 Other: community events, tickets, admissions, and classes 1680 Other: meals, snacks, beverages for social activities 960 Other: Other: Other: TOTAL 6000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Full Life Empowering Creativity- Pua Na Pua and Abled Hawaii Artists 64 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Empowering Creativity - Pua Na Pua and Abled Hawaii Artists Agency Director: Jim Kilgore Phone No.: (808) 322 — 9333 Contact Person: Jim Kilgore Phone No.: (808) 322 — 9333 Mailing Address: Address: 75-5995 Kuakini Hwy.Ste. 432 Address: City,ST,Zip Kailua-Kona, HI 96740 Facility Address: Address: 120 Keawe St,Ste.201 Address: City,ST,Zip Hilo, HI 96720 Email Address: jim@fulllifehawaii.org Fax No.: (808 ) 322 — 9334 Accountant/CPA: Ann Fukuhara Phone No.: (808 ) 961 — 5532 Firm (if applicable): An Accountancy Corportaion Mailing Address: Address: 45 Pohaku Street,Suite 102 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $7,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka% Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ['Victims of Crimes ❑✓ Culture and the arts ['Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Empowering Creativity - Pua Na Pua and Abled Hawaii Artists 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 10,500 8,625 5875 (Program) 19,738 (total) 2. Agency Mission Statement: Full Life assists individuals with developmental disabilities to achieve and enjoy a self-determined quality of life. 3. Program Description: Full Life's Empowering Creativity program provides people with developmental disabilities and other disabilities opportunities for enrichment in the arts by empowering them to develop and exhibit artistic talents.This program has been made possible and expanded through support by Hawai'i County.Two art festivals are the key components of this program:Abled Hawai'i Artists (AHA)and Pua Na Pua.AHA is an annual Hawai'i Island community art festival showcasing the artistic work of people with disabilities in East Hawai'i.AHA was formed by a group of advocates and self-advocates in an effort to raise awareness of the disabled community and the arts,celebrating both as an integral part of our vibrant culture in Hawai'i. Pua Na Pua is a result of collaboration between AHA organizers, Full Life,and Donkey Mill Art Center and features an annual inclusive Art Festival in West Hawai'i. We believe that art has no limitations and that art culture and diversity should be experienced and celebrated by all. Our goal is for the community to embrace the creativity and talents of people with disabilities and to encourage awareness and inclusion of people with perceived differences in the art community. Full Life is seeking additional funding through the Hawai'i County Nonprofit Grant to continue expand art classes and cultivate interest for people with developmental disabilities to participate in the AHA and Pua Na Pua.This will support people to develop income earning potential through their art and craft micro-enterprises. We will strengthen our collaboration with established community art organizations such as East Hawai'i Cultural Center, Donkey Mill Art Center,and Kipaipai Art School in Puna. 4.Total Budget & Position Count: Total Program Budget: 36,000 Total Program Position Count: 6 Total Agency Budget: 2,700,000 Total Agency Position Count: 94 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Empowering Creativity - Pua Na Pua and Abled Hawaii Artists 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawai'i Nonprofit Grant- Empowering Creativity 7000 Silent auction donations 4000 Table fees 1500 Other contributions 6000 State of Hawaii Division of Developmental Disabilities 17,500 TOTAL: 36,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Full Life continues to foster collaboration with community partners to increase revenues and support for the Empowering Creativity Program.We are working with Donkey Mill Art Center to develop funding through the sale of items made for the festival as well as funding through individual contributions and silent auction donations.We also partnered with Lanihau Shopping Center(an Alexander and Baldwin property).They plan to continue to sponsor the program Waiver funds from the State of Hawaii DOH-DDD continue to increase as additional people experience outcomes of successful income opportunities in the arts and experience networking and social valued roles resulting in participation in inclusive art festivals.This increases revenues for Full Life's Empowering Creativity Program. 7. Program Objectives Using County Nonprofit Grant Program Funds: With Hawai'i County Nonprofit Grant Funds Full Life will: 1. Expand the AHA and Pua Na Pua Art Festivals to greater participation. 2. Establish ongoing art classes to develop skills at Donkey Mill Art Center and Kipaipai Art School 3.Continue to increase capacity for staff and volunteer coordination necessary to support the program and events. 4.Continue to foster collaborative partnerships with East Hawai'i Cultural Center and Donkey Mill Art Center as well as begin to develop new partnerships to diversify the impact. Other potential partners include:Waimea Arts Council,SKEA(Society for Kona's Education in Art),and Volcano Art Center. 5. Increase income and employment outcomes for people with disabilities pursuing self-employment in making their arts and crafts. 6. Provide outreach to local schools continuing to identify youth with disabilities interested in pursuing and showcasing their artistic talent. 7. Research opportunities of an artist co-op with Full Life participants and local artists. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Empowering Creativity - Pua Na Pua and Abled Hawaii Artists 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (Le.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Hold Annual Inclusive Art Festivals 2 art festivals Increase participation at AHA art Festival 35 artists Increase participation at Pua Na Pua Art Festival 35 artists Increase the number of attendees at both art festivals 600 community members attending Number of art workshops/classes held 6 Number of people with disabilities attending art workshops 15 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 16,800 18,900 3800 Professional Fees 1380 1400 0 Operations 3198 3500 500 Supplies 1170 1200 0 Equipment 602 1000 500 Other: Advertising and promotion 1364 1500 500 Other: recognition for volunteer(t-shirts, leis, meals) 1320 1500 200 Other: Travel and reimbursements-vehicle, mileage, overnight stay 1303 1500 500 Other: Art Class instruction 4600 5500 1000 Other: TOTAL 31,737 36000 7000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Empowering Creativity - Pua Na Pua and Abled Hawaii Artists 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. (f4r-t cJ�=1,4 bI r&c,414 1/31/2019 S : ure of Autherson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Empowering Creativity - Pua Na Pua and Abled Hawaii Artists 11 P 1of2 Certification of Understanding ( age ) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Empowering Creativity - Pua Na Pua and Abled Hawaii Artists 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. ir � ( 1/31/2019 Si: . e of Authorized Per (see checklist, 2nd item) Date Vikev Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Full Life Program Name: Empowering Creativity - Pua Na Pua and Abled Hawaii Artists 12. COUNCIL AWARD WORKSHEET TABLE I: II Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Hold Annual Inclusive Art Festivals 2artfestivals Increase participation at AHA art Festival 35 artists Increase participation at Pua Na Pua Art Festival 35 artists ii 600 community members Increase the number of attendees at both art festivals attending Number of art workshops/classes held 6 Number of people with disabilities attending art workshops 15 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 3800 Professional Fees 0 Operations 500 Supplies 0 Equipment 500 Other: Advertising and promotion 500 Other: recognition for volunteer(t-shirts, leis, meals) 200 Other: Travel and reimbursements-vehicle, mileage, overnight stay 500 Other: Art Class instruction 1000 • Other: TOTAL 7000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Girl Scouts of Hawaii Hawai'i Island Girl Scout Leadership Experience (GSLE) 65 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Girl Scouts.of Hawaii Program Name: Hawaii Island Girl Scout Leadership Experience (GSLE) Agency Director: Shari Chang Phone No.: (808) 675 - 5502 Contact Person: Emmaly Calibraro Phone No.: (808) 675 - 5516 Mailing Address: Address: 410 Atkinson Drive,Suite 2E1 Address: Box 3 City,ST,Zip Honolulu, HI 96814 Facility Address: Address: 410 Atkinson Drive,Suite 2E1 Address: City,ST,Zip Honolulu, HI 96814 Email Address: customerservice@gshawaii.org Fax No.: (808 ) 691 - 9340 Accountant/CPA: Chris Yuen Phone No.: (808 ) 735 - 8585 Firm (if applicable): Ohata Chun Yuen LLP Mailing Address: Address: 3684 Waialae Avenue Address: City,ST,Zip Honolulu, HI 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ✓❑ Hamakua. ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ['South Kohala ❑✓ Kalb' Services or Activities To Be Provided: (One or more canbe checked) O Educational concerns Q Youth ❑Victims of Crimes. ▪ Culture and the arts ❑Aged ['Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 ' Page 1 of 8 1 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name.: Girl Scouts of Hawaii Program Name: Hawaii Island Girl Scout Leadership Experience (GSLE) 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 n/a n/a $12,925 2.Agency Mission Statement: Girl Scouting builds girls of courage,confidence,and character,who make the world a better place. • 3. Program Description: Girl Scouts of Hawaii(GSH)offers activities based on the Girl Scout Leadership Experience(GSLE),a program model used nationally and informed by rigorous research carried out by the Girl Scout Research Institute. GSLE provides girls ages 5-17 with opportunities to acquire leadership abilities and develop their aptitude in STEM(Science,Technology,Engineering,and Mathematics)fields. For the 2018-2019 program year,we are aiming to provide the GSLE to 2,954 girls statewide. At the heart of GSH programming are adventures in STEM,the outdoors,life skills,and entrepreneurship.Girls set and achieve their goals by taking Leadership Journeys--a series of challenging learning experiences grouped around a theme.Journeys develop confidence and core values; promote healthy relationships through teamwork;encourage civic actionthrough the planning and implementation of community service projects;teach entrepreneurship through the cookie program;and inspire challenge-seeking behavior and environmental stewardshipthrough outdoor/camping,experiences: STEM concepts are introduced in creative,age-appropriate ways through earth science,water conservation, energy awareness, citizen science design thinking(engineering),and computational analysis(programming)projects.Our entire curriculum is aligned with the Hawaii Common Core State Standards. GSH's overall goal is to improve girls' leadership abilities and increase their exposure to STEM concepts and opportunities.This is accomplished by making the GSLE available to as many girls as possible.We-currently,serve298 members throughout Hawaii Island. In 2019-2020,we willgrow that number to 335 total members: 4.Total Budget& Position Count: Total Program Budget: 101,199 . gCount: 3 TotaLPro ram Position Count:.. Total Agency Budget: 3,979,517 Total Agency Position Count 42 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Girl Scouts of Hawaii Program.Name: Hawaii Island Girl Scout Leadership Experience (GSLE) 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Hawaii Island United Way 5,000 Hawaii Community Foundation Career Connected Learning 20,000 Hawaii Community Foundation Flex Grant 15,000 Girl Scouts of Hawaii 21,199 County of Hawaii Nonprofit Grant 40,000 TOTAL: 101,199 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Girl Scouts of Hawaii`relies on a diverse mix of revenue sources,with over half(56%)corning from highly reliable and repeatable earned income,followed by 23%from government grants, 13%from our annual"Women of Distinction"special event,and 8% from public support.We are currently seeking to increase revenue from our annual campaign and major gifts, including continuing to build a giving society that we launched last year whose members pledge a major gift annually for three years.Our strategic plan also calls for increasing revenue from camp rental fees,which will be made possible by attracting more users to our Camp Paumalu on the island of Oahu through the building of a new STEM Center for Excellence that is projected to be completed by 2020. 7. Program Objectives Using County Nonprofit Grant Program Funds: GSH offersa variety of STEM-focused activities throughout the year in Hawaii County.The events complement the curricula and principles embedded in the.Leadership Journeys.The following is a sample of recent and.upcoming STEM events. (1)At the annual STEM Fest,girls in grades K-12 sample a wide range of STEM careers through hands-on activities facilitated by professionals. In 2018,91 Hawaii Island girls participated in activities presented by representatives of over a dozen agencies. Topics included exploring the ocean with a wave glider robot;demonstrations of how volcanic magma rises through the ground to erupt on the surface,and how volcanic gases play an important role in eruptions on volcano monitoring;logic puzzles;3D land models;and how oil spills effect birds. (2)During the 2019-2020 membership year, Hawaii Islandgirls will have opportunities to attend the annual STEM Fest,a Cookie Rally,and a Campout,and to participate in World Thinking Day. Additional activities are in the planning stages, including visits to Imiloa Astronomy Center, Honomu Goat Dairy,Atlantis Submarine,and Three Ring Ranch Exotic Animal Sanctuary. (3)Through the Girl Scouts Cookie Program,the largest girl-led business in the world,scouts learn and practice math skills as' they get hands-on experience,in goal-setting,decision making, money management;peopleskills,and business ethics. For girls from low-income families who are in need of services and faced with the highest barriers to participation,we offer the After School Leadership Program(ASLP). ASLP provides the same experiences as a traditional troop, but girls are not charged a membership fee. ASLP participants also receive free transportation to Girl Scout council events. Membership fees and participation costs are often unattainable for girls from low-income areas who are'likely to benefit most from the program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Girl Scouts of Hawaii Program Name: Hawaii Island Girl Scout Leadership Experience.(GSLE) 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Girls attending STEM Fest 80 Girls Source Hawaii Island STEM professionals to present hands-on activities - 15 Presenters Source volunteer assistance for events Secure Volunteers Increase number of outreach program recipients by 20% 24 Girls Increase number of Girl Scout members by 3% 335 Girls Attach additional pages as necessary. 9. TABLE II: PROGRAM.EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total.Budget Grant Req Salary and Wages 75,926 . � 25,500 Professional Fees 175 Operations 3,573 Supplies 4,490 4,490 Equipment Other: .Program Fees for ASLP participants 2,400 2,400 Other: Food and Beverages 5,120 Other: Transportation(to events:for girls and training of staff) 7,755 .. 7,610 Other: Assistance to Girl Scout Members/Troops 1,725. Other: Program Camper Insurance . 35 TOTAL` 101,199. 40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Girl Scouts of Hawaii Program Name: Hawaii Island Girl Scout Leadership Experience (GSLE) so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council • Staff appointed by a member of the Council ❑ The Mayor • The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a.Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to,an industry. Please specify any and all mitigation measures to avoid, in fact"or-appearance, any conflicts or potential conflicts of interest: ❑✓ ° If no conflicts exist, check here. Sig : lure of Authorized Per (specify title) Chief Executive Officer Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Girl Scouts of Hawaii Program Name: Hawaii Island Girl Scout Leadership Experience (GSLE) 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawa'i'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant, contract, or program for which funds were used. 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. (we) understand that applications will,not be reviewed by County personnel receiving 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 current`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 enroll with Hawai`-i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov,complete the easy step-by-step process, and pay the annual registration fee onlineusing a credit card: 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),a complete accounting of all expenditures supported byCounty of Hawaii. grant funds,and a listingof other funding sources and amounts"obtained during the award period. g Failure to submit a timely, complete, and accurate year-end report, using the template provided, wilt impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of.8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Girl Scouts of Hawaii Program Name: Hawaii Island Girl Scout Leadership Experience (GSLE) Certification of Understanding (Page 2of2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County) and exclusion from future grant participation for a minimum of one'year or until a written report is submitted to,and . accepted by,the council: I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements:(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person(see checklist, 2nd item) Date Chief Executive Officer Title/Position of Authorized Person-. EXH I BIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of-Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Girl Scouts,of Hawaii Program Name: Hawaii Island Girl Scout Leadership Experience (GSLE) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES . Applicant Council Proposed Projected Results Projected Result Girls attending STEM Fest 80 c is Source Hawaii Island STEM professionals to present hands-on activities 15 Presenters Source volunteer assistance for events Secure Volunteers Increase the number of outreach program participants by 20°/a 24 Girls Increase the number of Girl.Scout members by:3% 335 c ris TABLE,II: , FY 19-20 Grant Council PROGRAM EXPENDITURES .. Request Award Salary and Wages 25,500 Professional Fees Operations Supplies 4,490 Equipment Other: Program Fees for ASLP participants 2,400 Other: Food and Beverages Other: Transportation (to events for girls and,training of staff)' 7,610 Other: Assistance to Girl Scout Members/Troops Other: Program Camper Insurance TOTAL '40000' Additional Council directives regarding award: EXHIBIT 6 NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Going Home Hawaii Hawaii Island Going Home Consortium 66 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Going Home Consortium Agency Director: Lester Estrella, CEO Phone No.: (808 ) 491 — 2437 Contact Person: Carol Matayoshi Phone No.: (808 ) 491 — 2437 Mailing Address: Address: 80 Pauahi Street, Suite 203 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: same as above Address: City,ST,Zip Email Address: carol.goinghomehawaii@gmail.com Fax No.: (808 ) 498 — 0315 Accountant/CPA: Gretchen Kremeyer, CPA Phone No.: (808 ) 930 — 6850 Firm (if applicable): Carbonaro CPAs& Management Group Mailing Address: Address: P.O. Box 4372 Address: 136 Kinoole Street City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $42,125 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ['Youth Q✓ Victims of Crimes ❑✓ Culture and the arts ['Aged ❑✓ Victims of Health or Social Crises Q✓ Needs of the poor Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Going Home Consortium 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0 $5,750.00 $7,925.00 2. Agency Mission Statement: "Going Home" is the name given to efforts on Hawai'i Island to reintegrate ex-offenders into the community and the workplace. Because this population has such complex needs,we utilize a comprehensive approach that centers on employment and training,while addressing other needs/issues such as housing,transportation, education, substance abuse, and mental/ behavioral health. The Hawai'i Island Going Home Consortium comprises more than 25 public and private entities and their representatives,with a network of over 200 local,state, and national partners. Our mission is to assist Hawai'i Island men,women,and youth released from correctional institutions with reintegration into community life through employment,training,and appropriate supportive services. Accordingly,the overall goal of the Consortium is to reduce recidivism for our target population,alleviate jail and prison overcrowding and the associated costs, and increase public safety in the community. We will do this by helping our program participants to become law-abiding and productive community members. 3. Program Description: While the Hawai'i Island Going Home Consortium has been formally organized since 2004,we trace our initiative back to the late 1990s when the Hawai'i Island Corrections Advisory Committee was created to address severe prison overcrowding. Since the fall of 2004,the Consortium has met monthly,without fail,to identify issues and challenges,coordinate services, develop new approaches,and promote the need for assisting ex-offenders with their reentry into the community. These meetings are also viewed as a safe place to share concerns and challenges, as well as build collaborative relationships with others in the community. More than 25 members actively participate in these meetings, advancing the Consortium's agenda. Many of our members also participate on committees which meet quarterly, at minimum. These committees are as follows: Career Pathways(including Education and Training,Job-Readiness,and Employer Relations), Community Relations, Faith-Based Organizations, Health and Housing,Justice Partners(including Justice-Involved Youth and Restorative Justice), and the West Hawai'i Coalition. Our membership includes social service organizations, criminal justice agencies, mental health and substance abuse treatment providers,educational, employment, and housing specialists, and concerned citizens(including former offenders)islandwide. Virtually every agency that works with criminal offenders on Hawai'i Island is a member of or is aligned with the Consortium. As such,we are ideally situated to address the multiple challenges of offender reintegration. Going Home Hawai'i(GHH)is the nonprofit branch and the governing fiscal body of the Consortium. Its role is to procure funds for trainings, activities,and events that support the Consortium's mission,as well as provide mini grants for Committee projects. 4. Total Budget & Position Count: Total Program Budget: $15,000.00 Total Program Position Count: 2 Total Agency Budget: $595,000.00 Total Agency Position Count: 10 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of HawaiLi Nonprofit Grant Application FY2019-20 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Going Home Consortium 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Hawai'i County Nonprofit Grant Program $40,000.00 Fundraising Events $15,000.00 TOTAL: $55,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our hope is that the funding received from this grant will help build capacity for the Consortium in order to increase its reach and impact. The Social Solutions ETO(Efforts to Outcomes)software will help us to track outcomes and gather comprehensive data that should broaden our funding opportunities and assist in the development of existing and/or new programs. We will continue to seek funding through State and Federal grants and contracts,as well as private charities and foundations. Going Home Hawai'i also holds several fundraisers throughout the year, including our annual Ho'i Hou i Ka Mole(Return to the Root)dinner and silent auction fundraiser,which highlights the activities and programs of Going Home Hawai'i and its Consortium. We are currently in the process of planning for our 8th annual dinner to be held in August of 2019. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Coordinate and facilitate monthly Consortium meetings, including organizing the general activities and agenda for the meetings,taking minutes to document discussions, and keeping members informed of meeting activities and outcomes; 2) Assist with the coordination and facilitation of Committee meetings to keep them on track and moving toward their goals; 3) Coordinate and facilitate educational trainings and workshops to provide resources and tools for those who work in the field; 4) Coordinate and facilitate two(2) Employer Recognition Luncheons to honor those employers who hire ex-offenders; 5) Provide a minimum of six(6)mini grants of up to$250 each for Committee events and activities(e.g., gift cards/incentives for speakers for Victim Impact Classes, bicycle repair supplies for Kulani Correctional Center, books and/or other materials for educational classes, etc.) 6) Coordinate and facilitate educational/awareness events in the community to promote the need for reintegration services; 7) Provide emergency supplies for a minimum of 24 individuals coming out of incarceration with no essential supplies(food, clothing, hygiene items,etc.) 8) Provide mentor incentives for trained volunteer mentors to provide positive mentorship and support for program participants; 9) Purchase the Social Solutions ETO Comprehensive Case Management Software for Reentry Programs to track and manage outcomes and data for research and funding purposes. 10) Hire a consultant to complete our third 5-year Strategic Plan(2020-2024) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Going Home Consortium 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Coordinate and facilitate monthly Consortium meetings and trainings 12 Assist with the coordination and facilitation of Committee meetings 24 Coordinate and facilitate two(2) Employer Recognition Luncheons 2(1 in East Hawaii&1 in West Hawai'i) Provide mini grants for Committee events and activities 6 Coordinate and facilitate educational/awareness events in the community 4 Provide emergency supplies for program participants coming out of incarceration 24 Provide mentor incentives for trained volunteer mentors to work with program participants 48 Attach additional pages as necessary. Corn k:6"16, Cov soiri;ui lts 46r.' &year Ghrix-4e6i0- Plan I 9. TABLE II: ( .o .o.-20 A) PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages Professional Fees ( -1 Co' s i84rdevelorner+oP --um- $7,425.00 Operations a'° td. Plea° Supplies Equipment $25,000.00 Other: Employer Recognition Luncheons (2 @$200) $400.00 Other: Mini grants for committee events/activities (6 @ $250) $1,500.00 Other: Educational/awareness events in the community (4 @ $150) $600.00 Other: Emergency supplies for 24 released from jail/prison with nothing $2,400.00 Other: Mentor incentives (gas/meals for meeting w/mentees-$400x12) $4,800.00 TOTAL $42,125.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Going Home Hawai'i Program Name: Hawaii Island Going Home Consortium 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor D The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Q If no conflicts exist, check here. 1 /30/2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Going Home Consortium 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Going Home Consortium 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of your a.ency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1 /30/2019 Signature of Authorized Person (see checklist, 2nd item) Date C 5.v Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Going Home Hawai'i Program Name: Hawai'i Island Going Home Consortium 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Coordinate and facilitate monthly Consortium meetings and trainings 12 Assist with the coordination and facilitation of Committee meetings 24 Coordinate and facilitate two(2)Employer Recognition Luncheons 2(1 in East HI,1 in West HI) Provide mini grants for Committee events and activities 6 Coordinate and facilitate educational/awareness events in the community 4 Provide emergency supplies for program participants coming out of incarceration 24 Provide mentor incentives for trained volunteer mentors to work with program participants 48 COMpl 4 ConGarihhxn.'s fid- 5S-yecur etro-4*‘a TABLE II: 02r12.0-2ot FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees (7i Conoid-►n- r doxio 4- Bf ;tc2o-2D2* $7,425.00 Operations 5 n P Supplies JJ Equipment $25,000.00 Other: Employer Recognition Luncheons (2 @$200) $400.00 Other: Mini grants for committee events/activities (6 @$250) $1,500.00 Other: Educational/awareness events in the community(4 @$150) $600.00 Other: Emergency supplies for 24 released from jail/prison with nothing $2,400.00 Other: Mentor incentives (gas/meals for meeting with mentees--$400 x 12) $4,800.00 TOTAL $42,125.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Going Home Hawai'i Pu'uhonua Wellness Center (Wahine) 67 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Going Home Hawai'i Program Name: Pu'uhonua Wellness Center (Wahine) Agency Director: Lester Estrella, CEO Phone No.: (808 ) 491 — 2437 Contact Person: Carol Matayoshi Phone No.: (808 ) 491 — 2437 Mailing Address: Address: 80 Pauahi Street,Suite 203 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: To be determined Address: City,ST,Zip Hilo, HI 96720 Email Address: carol.goinghomehawaii@gmail.com Fax No.: (808 )498 — 0315 Accountant/CPA: Gretchen Kremeyer, CPA Phone No.: (808 ) 930 — 6850 Firm (if applicable): Carbonaro CPAs&Management Group Mailing Address: Address: P.O. Box 4372 Address: 136 Kinoole Street City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $22,700 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua [' North Kona ❑✓ South Hilo ❑ North Kohala ['South Kona ❑✓ North Hilo ['South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) [' Educational concerns ['Youth ❑✓ Victims of Crimes ❑✓ Culture and the arts ❑Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Going Home Hawai'i Program Name: Pu'uhonua Wellness Center (Wahine) 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0 $0 $0 2. Agency Mission Statement: Going Home Hawai'i(GHH)is the nonprofit branch and the governing fiscal body of the Hawai'i Island Going Home Consortium, a group of more than 25 public and private entities working together to address the multiple challenges of offender reintegration. Our mission is to assist Hawai'i Island men,women, and youth released from correctional institutions with reintegration into community life through employment,training,and appropriate supportive services. The goals of GHH and its Consortium are to reduce recidivism for our target population, alleviate jail and prison overcrowding and the associated costs, and increase public safety in the community. We will accomplish these goals by helping our program participants to become law-abiding and productive community members. 3. Program Description: Native Hawaiians make up about 20%of the general population of Hawai'i but 27%of all arrests, 33%of people on pretrial detention, 29%of those sentenced to probation,40%of the incarcerated population, 39%of releases on parole,and 41%of parole revocations. Many of them also leave prison or jail without access to services or a place to live. Despite numerous studies and recommendations dating back to at least the 1980s,the State has not taken effective steps to address the over- representation of Native Hawaiians in the criminal justice system. In October of 2017,through a partnership with Blueprint for Change(a nonprofit organization on Oahu that works with children of incarcerated parents), GHH turned its reentry house into the first ever Pu'uhonua(a place of refuge for law breakers)in modern Hawaiian history. This pilot Pu'uhonua project helped to reconnect Native and non-Native Hawaiian pa'ahao(inmates) to cultural roots, values, and principles. Cultural Practitioners provide classes in traditional values, including ho'oponopono(to make right), mookuauhau (genealogy)to increase self-identity and promote a sense of belonging, mahi'ai(to cultivate land and produce food from the ground)for self-sustainability,and lau lapaau (Hawaiian medicinal plants)to promote health and well-being. This pilot project served a total of 17 men last year with most of them (13)obtaining employment and permanent housing. Future plans for this project include a mahi'ai on the grounds to teach agricultural skills and develop self-sustainability. Due to the continued success of this program and in response to a cry from the community for safe housing for women, GHH is currently seeking a site for a Pu'uhonua for women.With input and support and in partnership with a women's prison ministry, GHH will utilize its current Pu'uhonua model to develop a clean and sober SAFE house for justice-involved women transitioning from jail/prison and/or the criminal justice system. GHH will incorporate peer mentoring with this project, a best practice in reentry programs as it provides prosocial benefits, including additional support and association with a positive role model. 4. Total Budget & Position Count: $24,000.00 (est) Count: Total Program Budget: Total Program Position 1.5 Total Agency Budget: $595,000.00 Total Agency Position Count: 10 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Going Home Hawai'i Program Name: Pu'uhonua Wellness Center (Wahine) 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Program Fees (projected) $24,000.00 Blueprint for Change $3,000.00 TOTAL: $27,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: GHH will pursue additional funding through State and Federal grants as well as private charities and foundations.Throughout this grant period,we will also seek funding with the help of the Consortium and other collaborators.When the funding from this solicitation ends, our hope is that the Pu'uhonua will be relatively self-sufficient through participants'payments of monthly program fees and a social enterprise business model. 7. Program Objectives Using County Nonprofit Grant Program Funds: Goals: Directly address the disproportionate representation of Native Hawaiians in the criminal justice system,alleviate overcrowding in our jails and prisons, and reduce the recidivism and continuous cycling in and out of jail by Native and non-Native Hawaiian offenders(thereby, reducing costs to our public systems and increasing public safety). Objectives: 1)Establish a Pu'uhonua Wellness Center for justice-involved women to facilitate the reconciliation of self and families; 2)Through a partnership with Blueprint for Change, utilize its curriculum called E Ho'okanaka(be a person of worth)to reconnect Native and non-Native Hawaiian offenders to their cultural roots, principles, and practices; 3)Contract Cultural Practitioners to conduct cultural workshops,activities,and trainings; 4)Establish a volunteer peer mentorship program to provide additional support and positive role modeling; 5)Provide a clean and sober SAFE place for justice-involved women to regain health and wellness; 6)Provide assistance in building life and pro-social skills; 6)Provide assistance with educational or employment opportunities; 7)Teach production and marketing skills to help build a social enterprise business. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Going Home Hawai'i Program Name: Pu'uhonua Wellness Center (Wahine) 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Justice-involved Native/non-Native Hawaiian adult female offenders will be served 16 80% (13)of the program participants will enroll in school or become employed 13 80%(13)of the program participants will obtain permanent housing within 9 months 13 80%(13)of the program participants will participate in E Ho'okanaka classes 13 80%(13)will participate in cultural workshops,activities, and trainings 13 80%(13)will be matched with a trained volunteer peer mentor 13 100%will be assessed(and referred for substance use/mental health treatment, if needed) 16 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations 41,u,\Nocnen.. ,e yq Supplies €Yna.�rs5en.C/ eat-1%-es Cbtou irwIc/�1 jie (1-4/1;4541z.)q c1 � $3,200.00 Equipment 11 Other: Liability Insurance $1,400.00 Other: Rent(2 months @$1500)to provide 2 month housing subsidies $3,000.00 Other: Utilities (2 months @$350)to provide 2 month utilites subsidies $700.00 Other: Cultural Practitioners ($400 monthly x 12 months) $4,800.00 Other: Mentor Incentives (gas/meals for meeting with mentees) $9,600.00 TOTAL $22,700.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Going Home Hawai'i Program Name: Pu'uhonua Wellness Center (Wahine) 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. G 1 /30/2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Going Home Hawai'i Program Name: Pu'uhonua Wellness Center (Wahine) 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Going Home Hawai'i Program Name: Pu'uhonua Wellness Center (Wahine) 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1 /30/2019 Signature of Authorized Person (see checklist, 2nd item) Date C0 Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Going Home Hawai'i Program Name: Pu'uhonua Wellness Center (Wahine) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Justice-involved Native/non-Native Hawaiian adult female offenders will be served 16 80% (13)of the proram participants will enroll in school or become employed 13 80% (13)of the program participants will obtain permanent housing within 9 months 13 80% (13)of the program participants will participate in E Ho'okanaka classes 13 80%(13)will participate in cultural workshops, activities, and trainings 13 80% (13)will be matched with a trained volunteer peer mentor 13 100%will be assessed(&referred for substance use/mental health treatment, if needed) 16 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees Operations Supplies $3,200.00 Equipment Other: Liability Insurance $1,400.00 Other: Rent(2 months @$1500)to provide 2 month housing subsidies $3,000.00 Other: Utilities (2 months @$350)to provide 2 month utilities subsidies $700.00 Other: Cultural Practitioners ($400 monthly x 12 months) $4,800.00 Other: Mentor incentives (gas/meals for meeting with mentees--$800/monthly) $9,600.00 TOTAL $22,700.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Goodwill Industries of Hawaii, Inc. Job Connections 68 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Goodwill Industries of Hawaii, Inc Program Name: Job Connections Agency Director: Laura Smith, President/CEO Phone No.: (808) 836 — 0313 Contact Person: Emily Lau, Vice President of Mission Services Phone No.: (808) 836 — 0313 Mailing Address: Address: 2610 Kilihau Street Address: City,ST,Zip Honolulu, HI 96719 Facility Address: Address: 200 KanoelehuaAve Address: Suite 102 City,ST,Zip Hilo, HI 96720 Email Address: Elau@higoodwill.org Fax No.: (808 ) 833 — 4943 Accountant/CPA: Phone No.: (808) 524 — 2255 Firm (if applicable): N&K CPAs, Inc. Mailing Address: Address: 1001 Bishop Street Address: Suite 1700 City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $30,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises ✓❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 i , County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Goodwill Industries of Hawaii, Inc Program Name: Job Connections 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 8, 750 9,625 8,800 2.Agency Mission Statement: Goodwill Hawaii's mission is to"help people with employment barriers reach their full potential and become self sufficient." As a nationally accredited human services provider, Goodwill Hawaii has served the State as a reputable non-profit organization for nearly 60 years, providing educational,workforce development,training and social services to 13,000 residents annually. 3. Program Description: For nearly 20 years, Goodwill Hawaii's Job Connection program has been providing employment services to low income persons, Native Hawaiians, and people who are previously incarcerated and are re-integrating into the community on the island of Hawaii, assisting them to obtain and maintain employment. The program offers comprehensive employment services including assessment and identifying barriers and strengths to employment, developing goals and individualized action plan, evidence based Job Readiness Training,vocational training referrals and tuition assistance, interview skills practices and coaching,job search assistance,job development and employer engagement,job leads referrals,job placement and job retention supports. In addition, the Job Connections program collaborates with various community providers such as vocational training schools, correctional facilities, educational institutions including Hawaii Community College and U.H. Hilo, and other human services providers. Program participants receive holistic services through these partnerships and inter-referrals. Over the past 5 years, the Job Connections program served 525 low income individuals, helping them obtain employment and reach self sufficiency. 4.Total Budget& Position Count: Total Program Budget: $230,000 Total Program Position Count: 7 Total Agency Budget: $3,200,000 Total Agency Position Count: 60 EXHIBIT A • NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Goodwill Industries of Hawaii, Inc Program Name: Job Connections 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Office of Hawaiian Affairs 120,000 Office of Community Services 50,000 Department of Public Safety 30,000 County of Hawaii 30,000 TOTAL: $230,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The requested funding will support an Employment Counselor within the Job Connections program in Hawaii County. Goodwill will continue to leverage other existing resources, including facilities and administrative services, other state and private grants, as well as private donations that support employment and training services. 7. Program Objectives Using County Nonprofit Grant Program Funds: The goal of the Job Connections program is to provide low income individuals within Hawaii County quality employment services. It is expected that 60 individuals will be served by the program in FY 2019-20,with 90% (54) successfully completing Job Readiness Training of which 75% (41)obtaining gainful employment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Goodwill Industries of Hawaii, Inc Program Name: Job Connections 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Intake/Assessment 60 Job Readiness Training 54 Job Placement 41 90-Day Retention 31 180-Day retention 24 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $135.000 $144,000 $30,000 Professional Fees $2,000 $2,000 Operations $12,000 $17,000 Supplies $10,000 $15,000 Equipment $2,000 $2,000 Other: Tuition Assistance $45,000 $50,000 Other: Other: Other: Other: TOTAL $206,000 $230,000 $30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Goodwill Industries of Hawaii, Inc Program Name: Job Connections 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the Council n The Mayor n The Managing Director ri The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. OatIA,C 6171,0A \ Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Goodwill Industries of Hawaii, Inc Program Name: Job Connections 1i. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Goodwill Industries of Hawaii, Inc Program Name: Job Connections 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty,gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. OeCLUA4, gt>11-44 2,8\11 Signature of Authorized Person (see checklist, 2nd item) Date President/CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Goodwill Industries of Hawaii, Inc Program Name: Job Connections 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Intake/Assessment 60 Job Readiness Training 54 Job Placement 41 90-day Retention 31 180-day Retention 24 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $30,000 Professional Fees Operations Supplies Equipment Other: Tuition Assistance Other: Other: Other: Other: TOTAL $30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Goodwill Industries of Hawaii, Inc. Work Experience Program 69 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program Agency Director: Laura Smith, President/CEO Phone No.: (808) 836 — 0313 Contact Person: Felicia Panoncialman, Director of Intellectual Disability Phone No.: (sos) 836 — 0313 Mailing Address: Address: 2610 Kilihau Street Address: City,ST,Zip Honolulu, HI 96819 Facility Address: Address: 500 Kalanianaole Ave Address: Suite 3 City,ST,Zip Hilo, HI 96720 Email Address: Fpanoncialman@higoodwill.org Fax No.: (808 ) 836 — 2579 Accountant/CPA: Phone No.: (808 ) 524 — 2255 Firm (if applicable): N &K CPA's Inc Mailing Address: Address: 1001 Bishop St Address: Suite 1700 City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑✓ Hamakua ❑ North Kona 0 South Hilo ❑ North Kohala ❑ South Kona ❑✓ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ri Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 12,500 12,500 9,300 2. Agency Mission Statement: Goodwill Hawaii's mission is to, "Help people with employment barriers reach their full potential and become self-sufficient."A nationally accredited Mission Services provider, Goodwill Hawaii has served the state of Hawaii as a reputable non-profit organization for nearly 60 years, providing education,workforce development,and social services to more than 13,000 residents annually. 3. Program Description: The Work Experience Program provides support and opportunities for individuals with an Intellectual/Developmental Disability to receive training through Goodwill's Janitorial and Maintenance Program, the Hawaii Design and Art Program, and the Sustainability and Self-Sufficiency Program. Each program offers dedicated training and individualized support to the program participants. • The Janitorial and Maintenance Program provides a specific skill set of training. Each trainee not only learns basic janitorial skills,they also develop a job skill set in maintaining and repairing their work space.This specific skill set not only provides them with experience to one day find competitive employment,this will also support them in learning independent living skills. The Hawaii Design and Art Program encourages creative expression through the basic concepts of arts and crafts. Each participant is given the opportunity to explore the possibilities of owning their own business and creating their own brand. This program also encourages the participant to create their own network of support in their own communities,with other community members who have the same entrepreneurial goals. The Sustainability and Self-Sufficiency Program teaches the participants the importance of producing and cultivating different types of plants and vegetables. The participants are given the opportunity to learn about their native plants and vegetables and the relationship the plants have with their own culture and backgrounds.They will also have the opportunity to build their own garden for personal or commercial use. 4. Total Budget& Position Count: Total Program Budget: 375,000 Total Program Position Count: 6 Total Agency Budget: 3,200,000 Total Agency Position Count: 60 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application , FY2019-20 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate State of Hawaii $330,000 County of Hawaii $45,000 TOTAL: 375,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The requested funding will be used to enhance the scope of the services currently offered to the program participants.The Work Experience Program will focus on the participants personal interests and add value to their quality of life. The participants will be able to develop new and different skill sets and have access to additional resources. Overall,the value of the program will increase interest to the broader community and increase enrollment into the program which will increase revenue. The increase in revenue will help sustain the program financially, in the long-term. The Work Experience Program is part of Goodwill Hawaii's Ho'olana program and aligns with Goodwill's overall mission of overcoming barriers to employment, specifically for individual's with an intellectual/developmental disability.The Ho'olana Program encourages and motivates the • participants to become contributing members of the society by learning to be as independentas possible. Goodwill's Ho'olana • program who serves adults with an ID/DD is known in the community as a program that gives back to the community while advocating for the vulnerable populations in the program. Goodwill maintains a positive reputation in the community, and acknowledges how important the community is to Goodwill. 7. Program Objectives Using County Nonprofit Grant Program Funds: The outcomes for the Work Experience Program will be to: 1. Provide wage subsidies to the participants employed under the county grant. 2. Provide individualized on the job training and support. 3. Provide the necessary tools to help the participant gain and retain new work skills. 4. Provide daily living skills to enable the participants to become self-sufficient The Work Experience Program plays a vital role in helping our participants with an Intellectual/Developmental disability find and retain competitive employment. They also develop entrepreneurial and basic business skills while participating in the Janitorial and Maintenance Training Program and the Hawaii Design and Art Program.The skills they learn within the Work Experience Program is enabling the participants to become independent and to sustain a healthy and happy life. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Janitorial and Maintenance Program-Number of participants 10 Hawaii Design and Art Program-Number of participants 5 Sustainability Program-Number of Participants 10 Attach additional pages as necessary. 9.TABLE,II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $216,000 $240,000 $25,000 Professional Fees $4,000 $3,000 $2,000 Operations $45,000 $60,000 Supplies $10,000 $17,000 $1,000 Equipment $5,000 $20,000 $17,000 Other: Special Assistance to Participants $20,000 $35,000 Other: Other: Other: Other: TOTAL $300,000 $375,000 $45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program 3.0. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listedbelow need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the Council n The Mayor ❑ The Managing Director n The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. OCCOMA- • 1\28kkat Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program is. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction;materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 0ea wig- lt ‘54411,(-4-) t 1 2.8\1 Signature of Authorized Person (see checklist, 2nd item) Date President/CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work Experience Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Janitorial and Maintenance Program-Number of Participants 10 Hawaii Design and Art Program-Number of Participants 5 Sustainability Program-Number of Participants 10 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $25,000 Professional,Fees $2,000 Operations Supplies $1,000 Equipment $17,000 Other: Special Assistance to Participants Other: Other: Other: Other: TOTAL $45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Grassroots Community Development Group Hawai'i Youth Business Center: Media Literacy 70 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Media Literacy Agency Director: Lily Chan-Harris Phone No.: (808) 938 — 2387 Contact Person: Lily Chan-Harris Phone No.: (808) 938 — 2387 Mailing Address: Address: PO BOX 1772 Address: City,ST,Zip Keaau, HI 96749 Facility Address: Address: 15-170 South Puni Paka Street Address: City,ST,Zip Pahoa, HI 96778 Email Address: naturehawaii@msn.com Fax No.: (808 ) 974 — 7757 Accountant/CPA: John Carbonaro Phone No.: (808) 968 — 1002 Firm (if applicable): Carbonaro CPA&Assocs. Mailing Address: Address: PO Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $8,000 Geographical Areas To Be Served: (One or more can be checked) Q Puna ❑✓ Hamakua ❑ North Kona ❑✓ South Hilo [' North Kohala ❑South Kona ❑✓ North Hilo ['South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑✓ Aged ['Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Media Literacy 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 Did not apply $5,000 $4,800 2. Agency Mission Statement: To strengthen our communities through the cooperative development of programs and services for all of East Hawaii.To provide quality programs for youth in support of local empowerment, media literacy and environmental activism. 3. Program Description: During the 2018 Legislative session,The Hawaii Senate passed SB2070"A Bill for an Act", indicating the legislature recognized that"Media literacy is a necessary skill that allows all citizens to access, analyze, and evaluate information using a variety of forms of communication."In addition,the"legislature further finds that instruction in media literacy should be incorporated into every classroom and every curriculum content area to prepare students to live and work in a digital world. Teachers have an obligation to guide students'exploration of the digital landscape and encourage them to be critical and creative thinkers." One of the educators affiliated with our agency has developed a seven-hour Media Literacy curriculum.She has offered classes in Pahoa Elementary, Hui Haumana Elementary,and HAAS Middle school.With support of the County of Hawaii grant,the Digital Media program can be taught at other schools. Currently, Hilo Union, Keaau Elementary,Waiakea Elementary and Intermediate schools have shown interest in having the course. Hilo High School is interested in receiving training to their teaches in Media Literacy,so that they can disseminate the curriculum more readily. Therefore the target population of the program ranges from youth 10 years to adult learners on the east side of Hawaii. 4.Total Budget& Position Count: Total Program Budget: 9,480 Total Program Position Count: 2 Total Agency Budget: 60,000 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 • • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Media Literacy 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii grant $8,000 Other Grants/support $1,480 TOTAL: $9,480 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We will support our programs by fundraising with local individuals and businesses in the community, collecting fees from additional umbrella projects serving our community, and partnering with other organizations to seek grants and support. 7. Program Objectives Using County Nonprofit Grant Program Funds: This program is in line with our agency's objectives of 1)Community capacity building, including community leadership development of its members of all ages, and 2)Educating and strengthening families to increase the social capital of the area. Further,this programs aims to 3) Provide workforce development in digital media arts and business entrepreneurship, 4) Provide Youth Leadership opportunities through community engagement, and most importantly 5)Promote media literacy and ethical reporting within media production. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Media Literacy 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 200 youth will recieve training in digital media arts and media literacy education 80%will increase skills 30 adults will recieve training in digital media arts and media literacy education 80%will increase skills Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages _ Professional Fees 6,200 6,200 Operations Supplies 960 600 Equipment Other: Mileage 2,320 1,200 Other: Other: Other: Other: TOTAL 9,480 8,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Media Literacy 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: E If no conflicts exist, check here. ( I 2—ci h.. le awive-ov. PreS1 AS4—t Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Media Literacy is. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the.Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Media Literacy 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. gvv 1,1 Za /2OI Signature of Authorized Person (see checklist, 2nd item) Date hi-e,&I Azrt Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Media Literacy 12. COUNCIL AWARD WORKSHEET TABLE I: • PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 200 youth will recieve training in digital media arts and media literacy education 80%will increase skills 30 adults will recieve training in digital media arts and media literacy education 80%will increase skills TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award • • . Salary and Wages Professional Fees 6,200 Operations Supplies 600 Equipment Other: Mileage • 1,200 Other: Other: Other: Other: TOTAL 8,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Grassroots Community Development Group Hawaii Youth Business Center: OIa'a (Kurtistown) Skatepark 71 • County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Ola'a (Kurtistown) Skatepark Agency Director: Lily Chan-Harris Phone No.: (808) 938 — 2387 Contact Person: Lily Chan-Harris Phone No.: (808) 938 — 2387 Mailing Address: Address: PO BOX 1772 Address: City,ST,Zip Keaau, HI 96749 Facility Address: Address: 15-170 South Puni Paka Street Address: City,ST,Zip Pahoa, HI 967789 Email Address: naturehawaii@msn.com Fax No.: (808 ) 974 — 7757 Accountant/CPA: John Carbonaro Phone No.: (808) 968 — 1002 Firm (if applicable): Carbonaro CPA&Assocs. Mailing Address: Address: PO Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $22,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION ' FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 • Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Ola'a (Kurtistown) Skatepark 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 • FY 17-18 FY 18-19 Did not apply $5,000 $4,800 2.Agency Mission Statement: To strengthen our communities through the cooperative development of programs and services for east Hawaii.To provide quality programs for youth. 3. Program Description: The target population is youth 12-24 years old, from Puna and Hilo districts.We have started collaboration with County of Hawaii Parks and Recreation and the Hilo Skate Plaza Coalition to build out an outdoor skatepark facility in the Kurtistown Park unused tennis court area. Our first work day happened on December.8, 2018 where we gained access to the tennis court.With around 20 volunteers we cleaned debris off the ground, removed overgrown vegetation, and power washed the surface. • 4.Total Budget& Position Count: Total Program Budget: , 50,000 Total Program Position Count: 2 Total Agency Budget: 60,000 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Ola'a (Kurtistown) Skatepark 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii Grant $20,000 Crowdfunding $5,000 Consultation with Hilo Skate Plaza Coalition $5,000 Matthew Kanealii-Kleinfelder contingency fund $15,000 Other grants $5,000 TOTAL: $50,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We have received donations on building materials and will continue to seek donations or discounts from other contractors. Crowdfunding sources through social media will continue to be pursued. 7. Program Objectives Using County Nonprofit Grant Program Funds: As stated in the GCDG by-laws,two of the organization's objectives will be addressed by this project: 1)Community capacity building, including community leadership development of its members of all ages and,2) Educating and strengthening families to increase the social capital of the area.Currently,there is no activities geared for teenagers at the Kurtistown Park.The presence of a skateboard facility will encourage youth to create a healthy social network lacking in the area for this most vulnerable age group who can be easily influenced by negative social and familial factors. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: OIa'a (Kurtistown) Skatepark 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Participation of 10 youth for 10 hours each on construction work skills to gain workforce skill/team building 500 volunteer hours from adults to build the skate park community and family bonding Video/photographic documentation of the project youth community development Participation of area youth-30 per week using skate park increase social capital Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages Professional Fees $5,000 Operations Supplies $4,500 $2,000 Equipment $300 $4,000 $2,000 Other: construction materials ongoing $35,000 $18,000 Other: Insurance $1,500 Other: Other: Other: TOTAL $50,000 $22,000 *If applicable EXHIBIT A NONPROFIT - 0 ROFIT GRANT APPLICATION FY 2019 2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: OIa'a (Kurtistown) Skatepark 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 111 If no conflicts exist, check here. 0/1"-±—' , ,, � t( t 1 0 t� Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Ola'a (Kurtistown) Skatepark is. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. • 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 ( j2)1/21,S1 Signature of Authorized Person (see checklist, 2nd item) Date County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Grassroots Community Development Group Program Name: Hawai'i Youth Business Center: Ola'a (Kurtistown) Skatepark si. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (see checklist, 2nd item) Date Pre,s LAX Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center: Ola'a (Kurtistown) Skatepark 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participation of 10youth for 10 hours each on construction work skills to building workforce skill/team P building 500 volunteer hours from adults to build the skate park community and family bonding Video/photographic documentation of the project youth community development Participation of area youth-30 per week using skate park increase social capital TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award • Salary and Wages Professional Fees Operations • Supplies $2,000 Equipment $2,000 Other: construction materials $18,000 Other: Insurance Other: Other: Other: • TOTAL $22,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Green Will Conservancy Inc., The Hui Mana'o 72 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Green Will Conservancy Inc. Program Name: Hui Mana'o Agency Director: Frank Capatch, LCSW Phone No.: (808) 965 — 5349 Contact Person: David Kazmierczak, LCSW Phone No.: (808) 965 — 5349 Mailing Address: Address: PO Box 1341 Address: City,ST,Zip Pahoa,HI 96778-1341 Facility Address: Address: 14-803 Seaview Rd. Address: City,ST,Zip Pahoa, HI 96778 Email Address: greenwillconservancy@gmail.com Fax No.: (808 ) 965 — 5036 Accountant/CPA: Erin Rose, EA Phone No.: (808) 217 — 7623 Firm (if applicable): Mailing Address: Address: PO Box 70 Address: City,ST,Zip Kea'au,HI 96749-0070 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) n Puna ❑✓ Hamakua n North Kona �✓ South Hilo ✓0 North Kohala 2 South Kona Q✓ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) Q✓ Educational concerns ❑✓ Youth ['Victims of Crimes ❑✓ Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities 0✓ Public.Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Green Will Conservancy Inc. Program Name: Hui Mana'o 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $5,500 $3,750 $6,675 2.Agency Mission Statement: Our mission statement is to inspire in our youth a fiery determination to persevere,sustain and realize their life's potential. Our vision is to empower our Puna youth,their families and professionals with practical knowledge,life skills and expertise that will support fulfilling and productive lives. Fulfilling the Mission The Green Will Conservancy(GWC)continues to grow,develop and expand our services on the Big Island and beyond in 2019. Our services have progressed locally and globally through our online institute(www.thegreenwill.org)and professional trainings. With continued County support we have been able to proceed with curriculum development and hands-on training for our youth,families,individuals and professionals. Our holistic approach takes our youth from the garden to the kitchen to learning computer skills,leadership and community development. Our professional trainings are designed to bring the best and brightest in our field,to Hawaii with a particular focus on"trauma informed care". Our mental health interventions are evidence-based treatments that focus on resiliency,not pathology. Friendship House,our Puna facility,welcomes children, families,volunteers,interns and professionals. GWC continues to be a consistent and reliable resource on the Big Island. 3. Program Description: Existing Programs:Fully qualified Behavioral Mental Health Therapists assess youth,families and individuals. Together,the therapist and client(s)collaborate on treatment plans targeted on overcoming barriers to success. Common challenges such as domestic violence,substance abuse and poor self esteem are addressed confidentially and individually.Two pro-social groups weekly supports clients to participate in projects,relationship and leadership building.Older youth assist in mentoring the younger children(kids helping kids)under the guidance of skilled therapists. Interested family/community members are welcomed to participate in activities when appropriate. GWC continues to offer stipends to our youth(13-18 yrs)as incentives to gain a sense of accomplishment as well as to motivate them to commit to our programs. Many of our participants do not have fundamental social and business skills necessary for the 21st century.We assist our youth to connect with organizations that support education and growth.We are a bridge to other community/state agencies and services that link our youth to see hope in their communities. Community outreach and collaboration in 2019-2020 includes the Department of Education, Pacific Quest(wilderness therapy for teens and young adults),Child Welfare Services(CWS),YWCA Teen Court and the Victims Assistance Program. We openly encourage and welcome cooperation and collaboration with like minded organizations.Our model of individual and group counseling combined with practical skills development is designed to significantly improve the quality of the lives of the youth and families we serve.Trauma informed care It Is especially helpful where natural disasters can and do occur. 4.Total Budget&Position Count: Total Program Budget: 27,500 Total Program Position Count: 1 Total Agency Budget: 72,000 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Green Will Conservancy Inc. Program Name: Hui Mana'o 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Program Service Revenue $ 11,000 Public Contributions: Hawaii County Grant $ 12,000 Atherton Grant $ 15,000 Public Contributions(Training, Cash, Clinical Revenue) $ 29,000 Donations $ 3,000 Pacific Quest Grant $ 2,000 TOTAL: $ 72,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Green Will Conservancy Inc. (GWC)continues to offer professional mental health services and programs on a sliding scale as well as billable treatment to health insurance agencies. In addition,we will continue to collaborate with other like-minded community agencies and schools through practical,skills based workshops and professional trainings on resiliency and trauma informed care. We will offer at least two specialized psychotherapy trainings for mental health specialists in 2019,both focused on"trauma informed care and treatment"paired with cultural competency.GWC will also co-host Irene Siegel's upcoming training retreat on Big Island examines"a Cross Cultural Perspective where East meets West"(Part II,June 2019). In addition to GWC's online forum,professional providers are invited to attend weekly peer reviews at no charge. Peer support and supervision are important links for therapists to connect and compare knowledge. GWC will also continue to offer consulting services,both group and individual,to our experienced and newly trained trauma specialists from intensive trainings hosted by Green Will since 2012. As new research is published it is our intention to make as much current information available as possible to our mental health professionals and the general public.These skills remain invaluable as seen in the healing needed from the recent volcanic-geologic crises on the Big Island. In 2018 the Green Will Conservancy(GWC)envisions a critical group of professionals that will be better prepared to serve the community during both traumatic incidents and times of crisis. The fall out from hurricanes,potential lava challenges,and storms are impetus to give careful attention to how we manage natural disasters. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Green Will Conservancy Inc.(GWC)is committed to serving our community and the Big Island at large. With the support of Hawaii County Grant funds,Green Will is committed to developing trauma-care knowledge and its practical application through continued professional trainings for professional service providers and access to our online institute(thegreenwill.org). The latest psychological research is distilled for our professional and public communities and posted online for easy,24 hour access. With targeted funding,it is our intention to offer specialized programs for youth(ages 13-18)throughout 2019-2020. County funding can allow us to offer free workshops on the island to special interest groups such as foster parents and community organizations including First Responders. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Green Will Conservancy Inc. Program Name: Hui Mana'o 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) EMDR Level 2 Training-12 Behavioral Mental Health Therapists[August 2019] Professional Training X 1 EMDR Consultation for both Level 2&Level 1 [10 hr X 25=250 hrs Consultation]2019 Professional Consultation Youth, Family Therapy,and Group Psychoeducation Skills 400 Units Youth Fund Raising $1,000 Pre-vocational skills development X 10 Individualized skill sets Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wag-s 0 0 0 Professional Fees $5,000 $6,000 $2,000 Operations $ 13,000 $8,500 $2,500 Supplies $4,500 $3,000 $3,000 Equipment 0 0 0 Other: Software Requirements $ 1,500 $ 1,500 $ 1,500 Other: Student Stipends/Honorariums $3,800 $3,500 $3,500 Other: Food $2,800 $4,000 $4,000 Other: Online Web Learning Site development 0 $ 1,000 $ 1,000 Other: TOTAL 30,600 27,500 $17,500 If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Green Will Conservancy Inc. Program Name: Hui Mana'o 3.0. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): -< ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. )(15kAa..), )&Le- a ( 1 /24/2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Green Will Conservancy Inc. Program Name: Hui Mana'o 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility,equipment, property,or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Green Will Conservancy Inc. Program Name: Hui Mana'o ii. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). � I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. t �,�� .2 11 1 /24/2019 Signature of Auth'drized Person (see checklist, 2nd item) Date 4 /9/-te- t.,(--, P(‘— g e' ' / Title/Position of Authorized Person n,2-) .i.-ap— 5 efryt 401.1.t fn.vi /7 - --1/14)r''''' '41. / ,: Te:e...0 4, EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Green Will Conservancy Inc. Program Name: Hui Mana'o 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 12 Behavioral Mental Health Professionals Professional Training X 25 Behavioral Mental Health Professionals trained in Trauma Consultation Professional Consultation Units of Direct Community Service 400 Units Client Fund Raising $1,000 Pre-vocational individualized skill sets X 10 clients Individualized skill sets TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 0 Professional Fees $2,000 Operations $2,500 Supplies $3,000 Equipment 0 Other: Software Requirements $ 1,500 Other: Student Stipends/Honorariums $3,500 Other: Food $4,000 Other: Online Web Learning Site development $ 1,000 Other: TOTAL $ 17,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Habitat for Humanity Hawaii Island Together We Build 73 ORIGINAL County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Habitat for Humanity Hawaii Island Program Name: Together We Build Agency Director: Patrick F. Hurney Phone No.: (808) 331 — 8010 Contact Person: Lisa Santana Phone No.: (808) 331 — 8010 Mailing Address: Address: P.O.Box 4619 Address: City,ST,Zip Kailua-Kona, Hawaii 96745 Facility Address: Address: 73-4161 Ulu Wini Place, Bay 1 Address: City,ST,Zip Kailua-Kona, Hawaii 96740 Email Address: lisa@habitathawaiiisland.org Fax No.: (808 ) 331 — 8020 Accountant/CPA: Chris Patulski Phone No.: (808 ) 331 — 8010 Firm (if applicable): N/A Mailing Address: Address: P.O. Box 4619 Address: City,ST,Zip Kailua-Kona, Hawaii 96745 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑✓ North Kona ❑✓ South Hilo ✓❑ North Kohala ❑✓ South Kona ❑✓ North Hilo ✓❑South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) [' Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ✓❑Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Habitat for Humanity Hawaii Island Program Name: Together We Build 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $12,500 $0 $19,300 2. Agency Mission Statement: Our Vision As an affiliate of Habitat for Humanity International, Habitat for Humanity Hawaii Island shares the global vision of;a world where everyone has a decent place to live. Our Mission Seeking to put God's love into action, Habitat for Humanity brings people together to build homes, communities, and hope. 3. Program Description: Habitat Hawaii Island is the only provider of affordable housing that addresses the needs of the lower-income population on the Big Island.A Habitat mortgage is designed so that no family is paying more than 30%of their monthly income on housing. To ensure that families become sustainable homeowners,and to break the cycle of poverty,the family support component of the Habitat program provides ongoing assistance with budgeting,financial literacy, house repair and maintenance. Since 2002, Habitat Hawaii Island has been dedicated to creating a Hawaii where everyone has a safe and affordable place to live by building 60 homes for over 100 deserving residents, many of whom have young children or elderly adults. The Habitat model provides home ownership opportunities for families earning between 30%and 80%AMI on a no-interest, no-profit basis. Habitat homeowners have a low monthly mortgage payment($350-$550)and have money left over for other necessities such as health care,transportation and recreational activities. Each family served has a unique story and one that strengthens the notion that these are hardworking, local families that are both qualified and deserving of a"forever"home. To date, Habitat for Humanity has built 60 new homes and provided 48 to alleviate health and safety concerns across Hawaii Island,and each year strives to increase its capacity to serve more families in need of affordable housing. But the need continues to grow, and becomes more chronic with each passing year. With this success,the Habitat Board of Directors has set an annual goal of completing 20 new homes per year and a priority of 10 homes to be constructed on the east side of the Big Island assisting victims of the Kilauea Volcano eruption. 4. Total Budget& Position Count: Total Program Budget: $2,994,000 Total Program Position Count: 5 Total Agency Budget: $1,909756 Total Agency Position Count: 22 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Habitat for Humanity Hawaii Island Program Name: Together We Build 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii: Non-Profit Grant($50,000)+HOME ($450,000)Pending $500,000 Hawaii Community Foundation $137,000 State of Hawaii GIA/CIP Grant Pending $500,000 Habitat Revenue(In-kind, Restore,Fund for Humanity, Events, Donations, Sponsorships) $190,000 Construction Funds-DHHL(NHHBG) $1,497,000 United Way $20,000 HEI Foundation Pending $150,000 TOTAL: $2,994,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Habitat Hawaii Island's resource development plan includes increasing funds through individual donors,fundraising events, Local,State and Federal grants as well as Foundation grants and corporate donations.This multi-sector approach is successful and will help Habitat to leverage other contributions of public and private funding to support this important project. Habitat Hawaii Island's Board of Directors has endorsed a 5 year Strategic Plan that is reviewed annually. It is aimed at increasing Habitat's capacity to provide more homeownership opportunities,as well as to maximize its potential to support all of its programs through the strategic solicitation of funds, investment in human resources,and acquisition of land.The Habitat model also provides for all mortgages to be put into a revolving"Fund for Humanity",which is then used to build additional homes every year,and which allows each Habitat family to"pay it forward". The affiliate also operates three ReStores,located in Kailua-Kona,Waimea and Hilo, Hawaii which sell gently used products to the community at greatly reduced prices.The revenue from these three ReStores has been increasing annually, and helps to cover salaries and general administration costs,allowing contributions and sponsorships from other organizations to go straight to the homebuilding program and hardworking low-income families in need. 7. Program Objectives Using County Nonprofit Grant Program Funds: Habitat West Hawaii recognizes the importance of homeownership,and works hard to help as many people as possible.This project will provide safe and affordable housing for 20 low-income families(100+individuals. By funding this project,the County can achieve a priority goal of the County Consolidated Plan-affordable homes for 20 local families. To achieve this goal Habitat Hawaii Island has outlined the following objectives: 1. Increase monetary and in-kind resources to meet the costs of building 20 new homes in FY 2019-2020. 2. Develop partnerships and collaborate with foundations,corporations, local businesses and county,state and federal agencies to build safe, new,affordable single-family homes for low-income families on the Island of Hawaii. 3. Recruit and coordinate teams of volunteers to assist with the construction of the 20 homes. 4. Identify 20(qualified)low-income families(Family Selection Committee)earning between 30%-80%of the AMI for Habitat homes to be constructed. 5. Habitat families,staff,contractors,teams of volunteers work together to build 20 new affordable homes. 6.All 20 Habitat families close on their respective homes, move into new,safe homes and begin paying an affordable mortgage. This project's overall outcome is:20 low-income families on a path to financial and housing stability leading to prosperity by building their own affordable homes with Habitat staff and caring volunteers. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Habitat for Humanity Hawaii Island Program Name: Together We Build 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of families served 20 Number of individuals served 100+ Number of children served 60 Number of volunteer participants 1,300 Volunteer work hours donated 130,000 hours Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies $967,000 $1,994,000 $35,000 Equipment Other: Civil/Site Work $50,000 $100,000 Other: Subtrades $238,000 $560,000 Other: Site Supervisor $70,000 $100,000 Other: General Requirements $88,000 $240,000 $15,000 Other: TOTAL $1,413,000 $2,994,000 $50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Habitat for Humanity Hawaii Island Program Name: Together We Build 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Patrick F. Hurney POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor n The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: N/A ❑✓ If no conflicts exist, check here. • January 17, 2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Habitat for Humanity Hawaii Island Program Name: Together We Build 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai i Nonprofit Grant Application FY2019-20 Agency Name: Habitat for Humanity Hawaii Island Program Name: Together We Build 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. _ January 17, 2019 Signature of Authorized Person (see checklist, 2nd item) Date XC rI117.0 Dt f2CfeiZ Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7.of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Habitat for Humanity Hawaii Island Program Name: Together We Build 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of families served 20 Number of individuals served 100+ Number of children served 60 Number of volunteer participants 1,300 Volunteer work hours donated 130,000 hours TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees Operations Supplies $35,000 Equipment Other: Civil/Site Work Other: Subtrades Other: Site Supervisor Other: General Requirements $15,000 Other: TOTAL $50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hamakua Harvest, Inc Program Support 76 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Harvest, Inc. Program Name: Program Support Agency Director: Lori Beach Phone No.: (808) 775 — 8209 Contact Person: Lori Beach Phone No.: ( ) — Mailing Address: Address: P.O. Box 621 Address: City,ST,Zip Honokaa, Hawaii 96727 Facility Address: Address: 44-2600 Mamalahoa Hwy. Address: City,ST,Zip Honokaa, Hawaii 96727 Email Address: info@hamakuaharvest.org Fax No.: ( ) — Accountant/CPA: Schumacher Tax&Accounting, P.C. Phone No.: (928) 772 — 5878 Firm (if applicable): Mailing Address: Address: P.O.Box 395 Address: City,ST,Zip Dewey,AZ 86327-0395 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑✓ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona. ❑✓ North Hilo ❑South Kohala ❑Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns Youth 9 Victims of Crimes 9 Culture and the arts 9 Aged 9 Victims of Health or Social Crises 9 Needs of the poor 9 Physical/Emotional Disabilities 9 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Harvest, Inc. Program Name: Program Support 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $4,750 $8,675 2.Agency Mission Statement: Hamakua Harvest's(HH)mission is to promote and advance Hamakua agriculture by supporting local farmers,enriching the region's social fabric, and promoting healthy rural lifestyles for the benefit of Hamakua's communities,economy, and environment. HH was conceived in direct response to the community's desire to maintain its rural lifestyle and sustainable family farms/ranches as a foundation for its economic and social structure. We are a multi-faceted agricultural hub that serves as a community-based platform for collaboration,education,and innovation to incentivize and facilitate farming in order to increase local food security and vitalize the rural economy of the Hamakua region Our focus is on sustainable agriculture, access to healthy foods for all income groups,supporting local entrepreneurship, education and creating a safe,family-friendly space for the community to gather. 3. Program Description: We currently provide: 1. A Weekly Farmers'Market offering only locally produced products that currently enjoys approximately 600 visitors weekly. We are the only direct market outlet available to area farmers and the only Farmers'Market in the area that accepts SNAP/EBT benefits. 2. Our Keiki Learning Garden provides a free after-school and summer program to area youth serving more than 500 youth in the last year. 3. Our 3-acre Demonstration Orchard is a diversified farming system that models sustainable practices for specific economically and environmentally viable crops suited to Hamakua's unique climate and soils.The Orchard is designed to teach and inspire local farmers through hands-on training and educational programs which is not otherwise available in the area. 4. Practical Ag,a professional development program for area farmers with a diverse curriculum that includes a monthly lecture as well as a hands-on workshop with agriculture experts from within and outside the community. 5. The Annual Farm Festival held in May of each year that features 40 vendors selling only locally produced goods,an all-day schedule of educational events, local entertainers and draws almost 2,000 people annually. It is a free community event that brings community and agriculture together and"kicks off'Honoka'a town's historic Western Week activities. 4.Total Budget&Position Count: Total Program Budget: 112,000 Total Program Position Count: 5 Total Agency Budget: 43,000 Total Agency Position Count: 5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Harvest, Inc. Program Name: Program Support 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate State of Hawaii Department of Agriculture Contract for Services $35,000 Hawaii Tourism Authority Grant $6,000 County of Hawaii Non Profit Grant 2017-18 (Balance of Funds) $4,337 Farmers Market Vendor Fees $26,000 Keiki Garden Sales $3,000 Practical Ag Class Fees $6,000 Merchandise Sales $3,000 TOTAL: $72,537 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our individual programs are moving towards self-sufficiency as follows:The Farmers'Market is very close to being self-sufficient and we only need a few more regular vendors to meet this goal. We are actively recruiting vendors and continue to see their numbers increase. In the next year the Keiki Learning Garden will be focusing on planting a section of the garden as a production model. Produce grown in the garden will be sold at the Farmers' Market to offset the cost of the program. The Demonstration Orchard will begin producing within the next few years and the fruits will be harvested and sold at the Farmers' Market to offset the cost of the program. The Practical Ag program currently charges a minimal,$10 fee,for the classes and we anticipate that at least 30 people will attend each class which should cover most of our costs for this program. In addition,we are in process of amending our Special Use Permit with the County of Hawaii to allow us to provide agritourism activities as well as hold community events at our site. Farm to Table Dinners,Orchard Tours,additional activities and fees charged for other groups to use our site will provide additional revenue and move us towards self-sufficiency.These activities will also draw both residents and tourists and additional attention to the market increasing the number of customers and sales for our local producers. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Farmers'Market will be held weekly and we will continue to attract new vendors raising our average from 19 vendors to at least 25 vendors weekly. We will continue to actively promote the market and anticipate at least a 10%increase in our attendance from an average of almost 600 per week to 660 per week. The Keiki Learning Garden will continue to offer free after-school program with at least a 10%increase in the number of children, parents and teachers participating(from 500 last year to 550 this year). We will increase the size of the garden with a section for production crops to accommodate produce being sold at the Farmers'Market to assist in funding the program. The Demonstration Orchard will be maintained and used for training and education purposes and agritourism activities for residents and visitors will be initiated upon approval of the amendment to our Special Use Permit. The Practical Ag classes will continue to be held regularly. We will continue to attract at least 20 participants per session. We will pursue finalizing the amendment to our Special Use Permit which will allow us to hold additional activities at the site in order to improve our revenue stream. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Harvest, Inc. Program Name: Program Support 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) See Attached Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 1849 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 84,156 93,550 10,000 Professional Fees 520 520 Operations 12,517 11,547 Supplies 8,932 8,450 Equipment Other: Maintenance 16,372 16,715 5,000 Other: Promotion 5.620 5,750 Other: Program expenses 12,844 17,545 5,000 Other: Site Improvements 4,051 1,500 Other: TOTAL 145,786 155,057 20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name.: Hamakua Harvest, Inc. Program Name: Program Support 'a. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: ❑,/ If no conflicts exist, check here. /- a-t9 Si ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Harvest, Inc. Program Name: Program Support 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract,or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express,and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Harvest, Inc. Program Name: Program Support 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. _ „ „ Signatur- of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Harvest, Inc. Program Name: Program Support 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 10,000 Professional Fees Operations Supplies Equipment Other: Maintenance 5,000 Other: Promotion Other: Program expenses 5,000 Other: Site Improvements Other: TOTAL 20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hamakua Harvest— Program Support PROGRAM PERFORMANCE MEASURES and Applicant Projected Results Current programs will continue and be improved as follows: Farmers'Market: Weekly Market attendance will increase from 600/wk to 660/wk. Total number of vendors will be increased from 19 to 25. Total number of vendors accepting SNAP/EBT will increase accordingly. Keiki Learning Garden: Number of attendees will increase from 500 to 550 annually. 100 pounds of produce harvested from the Keiki Learning Garden will be sold at the Farmers' Market. Practical Ag Classes: At least 20 attendees will attend each monthly Ag session. Exit surveys will be used to quantify success. Demonstration Orchard will be maintained and used for farmer education in conjunction with our Practical Ag Classes. Farm Festival will be held annually Amendment to the Special Use Permit will be submitted to the County and upon approval additional activities will be initiated. Hamakua Youth Foundation, Inc. Hamakua Teen Center 77 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation, Inc Program Name: Hamakua Teen Center Agency Director: Mahealani Maikui Phone No.: (808) 775 — 0976 Contact Person: Mahealani Maikui Phone No.: (808) 775 — 0976 Mailing Address: Address: PO Box 381 Address: City,ST,Zip Honokaa, HI 96727 Facility Address: Address: 45-3396 Mamane St, Address: City,ST,Zip Honokaa, HI 96727 Email Address: hamakuayouthcenter@gmail.com Fax No.:, ( ) — Accountant/CPA: Bonnie Bibeault Phone No.: (808 ) 968 — 1002 Firm (if applicable): Carbonaro CPAs&Management Group Mailing Address: Address: 136 kinoole St Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ✓❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ✓❑Youth ❑Victims of Crimes ✓❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 • County of Hawaii Nonprofit Grant Application ' FY2019-20 Agency Name: Hamakua; Youth Foundation, Inc Program Name: Hamakua Teen Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $9,500 $18,637.50 . $9,675.00 2.Agency Mission Statement: Hamakua Youth Foundation, Inc.(HYF)is a community based organization dedicated to creating a nurturing youth service program for ages 10-18 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 social service agencies. Hamakua Youth Center(HYC)provides low-cost after-school programs open daily,during intersessions,occasional weekends and summer breaks to school age youth in Hamakua. HYC continually strives to instill life skills that are are guided by traditional values-Kuleana,Aloha, Laulima,&Mahalo. HYC offers safe,adult supervised programs and activities and youth to youth mentoring through homework assistance and leadership training. We"provide experiential learning in music and the arts with studio production capability as well as traditional Hawaiian and contemporary arts and crafts and holiday themed activities. HYC is currently the only facility in the Hamakua District that focuses primarily on programs for elementary through high school youth. After-school alternatives for youth are limited and our'youth are considered at risk for unhealthy behaviors based on the family demographics in our community. Our general objectives are to expand the scope of programs to provide more alternatives for youth;offer additional training to staff;assist volunteers and parents in enabling them to identify and correct unhealthy behaviors in both youth and families;design programs that build self-concept, mutual respect and teamwork, and expand learning capacity. • 3. Program Description: For several years now the Hamakua Youth Foundation(HYF)has held the intention to expand our program to reach more youth and,in particular,to expand the ages we serve to include teens. This has not been possible in our present rented facility. However,almost two years ago an unexpected opportunity arose and we are now planning to purchase the historic Okada Building in Honokaa. During 2019 we will renovate the center.The building offers two separate wings,one for youth and the other for teens.The building that connects the two wings houses a kitchen that can become a certified kitchen in the future that will serve the entire community as well as the Youth Center.The property also provides a large yard that we will use for gardening and outdoor play.The new center will feature an arts/craft room,'music studio, multimedia room,teen lounge,and student study center,game and meeting rooms.' HYC is currently the only facility in the Hamakua District that focuses primarily on programs for middle and high school youth. After-school alternatives for teens are limited and our teens are considered at risk for unhealthy behaviors based on the family demographics in our community. Our general objectives include additional training to staff;assist volunteers and parents in enabling them to identify and correct unhealthy behaviors in both teens and families;design programs that build self-concept, mutual respect and teamwork, and expand learning capacity. Based on the results of the 2016 needs assessment survey of Honokaa students and community adults,the HYF Board is committed to expand the programs that will be offered at the new center,as well as increase the total participation levels,especially for the under-served and at-risk teens. Results from the survey indicated students want, in order of popularity,1)culinary arts,2)music;3)cultural classes,4)agriculture, and 5)arts. Consequently our curriculum is expanding to include teaching culinary skills,play ukulele,exploring additional cultures within our community,gardening and animal care;and expanding photographic skills. 4.Total Budget& Position Count: Total Program Budget: $ 74,000 Total Program Position Count: 8 Total Agency Budget: $253,750 Total Agency Position Count: 21 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County • • of Hawai Nonprofit Grant Application FY2019-20 0. 19-20 Agency Name: Hamakua Youth Foundation, Inc Program Name: Hamakua Teen Center 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii-Non Profit grant 15,000 State of Hawaii-Grant in Aid 25,000 Private grant 20,000 Community Support 5,000 Fundraising 7,000 Program Fees • 2,000 TOTAL: ' $74,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increaserevenues to support this program: Hamakua Youth Foundation, Inc.will schedule and host community fundraising events throughout the year, including our annual Hula Festival. HYF will strive to build community partnerships that include joint funding agencies and collaboration with other community organizations throughout Hawaii to ensure our keiki learn the value of utilizing the many Hawaiian (&other cultural)specialists, community artists,and kupuna that our island has to offer. Currently,we are strengthening our grant writing team so that we can increase our capabilities for receiving foundation,state and federal'government support. We promote three fundraising events each year that emphasis creation of a long term benefactors to provide sustainability. One of the events has been the HYF Hula Festival. While this is primarily a major community cultural event, it is also a fund-raiser for us and provides greater community awareness of our programs.' We are exploring additional grants and plan to expand the number of grants we apply for and hopefully increase the funding we receive through grants. To improve our fiscal credibility,we are preparing and budgeting for an audit to be accomplished during our next fiscal year. This will help in our eligibility for larger grants requiring'an audit and generally help with our fiscal transparency to attract additional donors. We are in the process of creating a teen advisory group of experienced community members who have worked with teens. This group will include the principal and member of the counseling staff of the Honokaa school. 7. Program Objectives Using County Nonprofit Grant Program Funds:, 1.To provide and expand an compelling, experiential and developmentally relevant after-school program to our teens 2.To continually promote an environment of Kuleana,Aloha, Laulima,&Mahalo 3.To strengthen life and leadership skills of our teens in a way that support's them making healthy choices,succeed in their academic studies and become an informed member of the Hamakua Community. 4.To help our teens build self-awareness and respect for the multi-culture nature of Hamakua and strengthen their self identity by knowing how they and their cultural roots fit within our community. 5.Specifically for teens to explore the various cultures of Hamakua;including Hawaiian/Polynesian, Micronesian/Marshallese, Samoan/Tongan,Japanese, Filipino, Chinese, Korean, Portuguese, European/American,Latino and African American. 6.To tangibly incorporate Blue Zone philosophy in regard to food,exercise,stress reduction and community involvement so to encourage practices that lead to healthier, happier and longer lives. 7.To expand our program for youth and teens in a way that financially and operationally sustains Hamakua Youth Center operations,as we move from the present limited facilities to the new center at the Okada,Building. 8.Specifically to expand our existing staff, board,volunteers and collaboration with other community organizations through improved fundraising,fiscal management&transparency in the community ' EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application ' FY2019-20 Agency Name: Hamakua Youth Foundation, Inc Program Name: Hamakua Teen Center 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 18 volunteers working to produce for youth center participants 18 new community volunteers involved 6 workshops to examine music,food&history of 6 different cultures of HamakuaWorkshops involve center teens in cultures Teen involved in inter-generational events while learning cultural differences 90 teen involved in training Teen center increases reach into community events and participants 40 new teen involved in HYC Create a teen advisory group Increase in teen programs for the new center Initiate partnerships with Honokaa Hongwanji Buddhist Temple and Honokaa HS 3 partnerships supporting teen development Initiate teen program in collaborations with Hamakua Harvest New program provided for Hamakua teen Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req_ Salary and Wages $49,700 $9,000 Professional Fees 0 0 20,300 4,000 Operations Supplies 1,000 500 Equipment 0 0 Other: Food and Beverage 2,000 1,000 Other: Travel 1,000 500 Other: Other: Other: TOTAL $74,000 $15,000 IfI' I app scab e EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application . FY2019-20 Agency Name: Hamakua Youth• Foundation, Inc Program Name: Hamakua Teen Center 10. ORGANIZATION CONFLICT DISCLOSURE FOR=';; Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in factor appearance,any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. s�� ?tz- Jan 25; 2019 Sign ture of A/ thorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation, Inc Program Name: Hamakua Teen Center 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds toNonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving our County Nonprofit Grant submittal, and that we have full responsibilityto ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.'gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card.; 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),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,'using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020, Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation, Inc Program Name: Hamakua Teen Center 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days ofJune 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. Jan 25, 2019 Sign ture of Authorized Person (see checklist, 2nd item) ` Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation, Inc Program Name: Hamakua Teen Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 18 volunteers working to produce 6 multi-cultural workshops for youth center participants n8o1e d ommunityvolunteers 6 workshops to examine music,food&history of 6 different cultures of Hamakua workshopsteensincultures involve center Youth involved in inter-generational events while learning cultural differences 90 "involved in training Youth center increases reach into community events and participants 40 new teen involved m Hvc Each cultural traininginvolves 4 separate sessions of over 3 hours each In°reaseinteen programs for P the new center Strengthen partnerships with Honokaa Hon wan i Buddhist Temple and Honokaa HS 3ddepvrtonpemrsehnipts supporting teen Strengthenyouth programsprovided byHamakua Youth Center New program provided for 9 P 9 Hamakua teen TABLE II: PROGRAM EXPENDITURES FV 19-20 Grant Council Request Award Salary and Wages $9,000 Professional Fees Operations 4,000 Supplies 500 Equipment p Other: Food and Beverage 1,000 Other: Travel 500 Other: Other: Other: TOTAL ' $15,000 Additional Council directives regarding award:' , • EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hamakua Youth Foundation, Inc. Hamakua Youth Center 78 1 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center Agency Director: Mahealani Maikui Phone No.: (808) 775 — 0976 Contact Person: Mahealani Maikui Phone No.: (808) 775 — 0976 Mailing Address: Address: PO Box 381 Address: City,ST,Zip Honokaa, HI 96727 Facility Address: Address: 45-3396 Mamane St Address: City,ST,Zip Honokaa, HI 96727 Email Address: hamakuayouthcenter@gmail.com Fax No.: ( ) — Accountant/CPA: Bonnie Bibeault Phone No.: (808 ) 968 — 1002 Firm (if applicable): Carbonaro CPAs&Management Group Mailing Address: Address: 136 Kinoole St Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000 Geographical Areas To Be Served: (One or more can be checked) [' Puna ❑✓ Hamakua ❑ North Kona ❑South Hilo [' North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Kali Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ✓❑Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑Aged ❑Victims of Health or Social Crises [' Needs of the poor [' Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020, Page 1 of 8 • • County of'Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 9,500.00 18,637.50 9,675.00 • 2.Agency Mission Statement: Hamakua Youth Foundation, Inc. (HYF)is a community based organization dedicated to creating a nurturing youth service program for ages 6-18 during non-school hours, engaging youth in environmental sustainability and stewardship, providing Hawaiian culture and arts education, multicultural awareness,developing youth leadership and connecting youth and their families with social service agencies. Hamakua Youth Center(HYC)provides low-cost after-school programs open daily,,during intersessions, occasional weekends and summer breaks to school age youth in Hamakua. HYC continually strives to instill life skills that are are guided by traditional values-Kuleana,Aloha, Laulima,&Mahalo. HYC offers safe,adult supervised programs and activities and youth to youth mentoring through homework assistance and leadership training. We provide experiential learning in music and the arts with studio production capability as well as traditional Hawaiian and contemporary arts and crafts and holiday themed activities. HYC is currently the only facility in the Hamakua District that focuses primarily on programs for elementary through high school youth. After-school alternatives for youth are limited and our youth are considered at risk for unhealthy behaviors based on the family demographics in our community. Our general objectives are to expand the scope of programs to provide more alternatives for youth;offer additional training to staff;assist volunteers and parents in enabling them to identify and correct unhealthy behaviors in both youth and families;design programs that build self-concept, mutual respect and teamwork, and expand learning capacity. • 3. Program Description: Hamakua Youth Foundation is planning to renovate the historic Okada Hospital in Honokaa. The building offers two separate wings,one for youth and the other for teens. The building that connects the two wings will become a certified kitchen. The property also provides a large yard that we will use for gardening and outdoor play. The expansion of our after-school facility will fulfill the long held youth center's dream to include teens. The new center will feature an arts/craft room, music studio, multimedia room,teen lounge,student study center,game and meeting rooms. ' HYC staff and board are committed to a comprehensive tutorial program for youth of all ages to support their academic goals as well as expand specialized classes of outdoor agricultural and recreational activities, multicultural awareness and internship programs. Our goal is to increase the total participation levels,especially for the under-served and at-risk teens. Results from the 2016 comprehensive needs assessment survey indicate students want, in order of popularity, 1)culinary arts,2)music,3) cultural classes,4)agriculture,and 5)arts. Therefore,' curriculum will expand to include teaching how to cook meals, play musical instruments,additional cultures within our community and world,gardening and animal care;and photography and other art forms. This list is not conclusive,but represents a significant step to attract our under-served youth in relevant and engaging classes. 4.Total Budget& Position Count: Total Program Budget: $153,700 Total Program Position Count: 18 Total Agency Budget: $253,750 Total Agency Position Count: 21 • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 • County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation, Inc: Program Name: Hamakua Youth Center 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate State of Hawaii - Grant-In-Aid 55,000 County of Hawaii - Non Profit grant _ 40,000 Private Grant Revenue 40,000 Community Support _ 9,000 Fundraising 3,000 Program Fees 7,000 TOTAL: $ 154,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HYF will schedule and host community fundraising events throughout the year, including Ka Hamakua Makahiki,special dinners and fundraising mailings. HYF will strive to build community partnerships that include both joint proposal and funding agencies.Our goal is to collaborate with other community organizations throughout Hawaii to ensure our keiki learn the value of utilizing the many Hawaiian (&other cultural)specialists,community artists,and kupun'a that the islands have to offer. We promote three fundraising events each year that emphasis creation of,a long term benefactors to provide sustainability. One of the events is the annual Ka Hamakua Makahiki,which will allow opportunities to collaborate with other Hamakua area organizations and schools. We have expanded the variety and number of grants we apply for and that has increased the funding we receive through grants. To improve our fiscal credibility,we are preparing and budgeting for an audit to be accomplished in the near future. This will help in our eligibility for larger grants requiring an audit and generally help with our fiscal transparency to attract additional donors. In addition,the students will;from time to time, engage in fund-raising at community events,selling merchandise such as t-shirts and food cooked and prepared by them in a certified kitchen. We have strengthened our grant writing team so that we can increase our capabilities for receiving foundation,state and federal government support. We are also researching government programs that will help our families subsidize monthly costs for our after-school program. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1.To expand our program for youth and teens in a way that financially and operationally sustains Hamakua Youth Center operations, as we move from the present limited facilities to the new center at the Okada Building. 2.Specifically to expand our existing staff, board,volunteers and collaboration with other community organizations through improved fundraising,fiscal management,transparency and recognition in the community. 3.To continue to provide and expand a compelling,experiential and developmentally relevant after-school program to our youth 4.To continually promote an environment of Kuleana,Aloha, Laulima,&Mahalo 5.To strengthen life and leadership skills of our youth in a way that supports them making healthy choices,succeed in their academic studies and become an informed member of the Hamakua Community., 6.To tangibly incorporate Blue Zone philosophy in regard to food,exercise,stress reduction and community involvement so to encourage practices that lead to healthier, happier and longer lives 7. To increase the proportion of county funding and look into attracting federal funds to continue the long term sustainability of the center. 8. To expand and deepen intergenerational experiences for youth in a multicultural setting. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 8.TABLEI: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Establish a new center,expanding our youth and teen programs Add 25 teens&10 youth involved in HYC Open renovated facility for youth and teens in Honokaa : Operate&staff expanded facility Youth involved in inter-generational events while learning cultural differences 60 youth involved in experience Youth center increases visibility into community events and participants 30 new families involved in HYC Expand and strengthen youth programs provided by Hamakua Youth Center 3 new program provided for Hamakua youth Strengthen partnerships with Honokaa Elementary&Honokaa High& Intermediate School 3 school/HYF supported programs Increase staff positions for teen center 3 additional employees Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual*. Total Budget Grant Re. Salary and Wages 83,500 89,700 20,000 Professional Fees 2,750 0 0 Operations 21,450. 40,900 13,000 Supplies 4,600 7,000 4,000 Equipment 0 0 0 Other: Food & Beverage 2,600 7,500 2,000 Other: Travel 2,600 3,000 1,000 Other: Admin 0 5,600 0 Other: Other: TOTAL 117,500 153,700 40,000 *If •applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation, Inc.. Program Name: Hamakua Youth Center 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in factor appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. ,, -�- 7 srde�-t I J 25, 2019 ignature Authorized Person (specify title)' ; Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the,County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for`a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit theifinal report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned:to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impactthe evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 75)-eith._ Jan 25 2019 Signature of Authorized Person (see checklist, 2nd item) ' Date F Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit ;Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth.Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Add 25 teens&10 youth involved in HYC Operate&staff expanded facility • 60 youth involved in experienc= 30 new families involved in • HYC • 3 new program provided for Hamakua youth 3 school/HYF supported • programs • 3 additional employees TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 20,000 Professional Fees 0 Operations 13,000 Supplies • 4,000 Equipment 0 Other: Food &Beverage 2,000 Other: Travel 1,000 Other: Admin 0 Other: Other: ; TOTAL 40,000 Additional Council directives regarding award:'` EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hamakua Youth Foundation, Inc, Multicultural Awareness Prog 79 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation - Inc; • Program Name: Multicultural Awareness Program Agency Director: Mahealani Maikui Phone No.: (sos) 775 - 0976 Contact Person: Mahealani Maikui Phone No.: (808) 775 - 0976 Mailing Address: Address: PO Box 381 • Address: City,ST,Zip Honokaa,`HI 96727 Facility Address: Address: 45-3396 Mamane St Address: City,ST,Zip Honokaa, HI 96727 Email Address: hamakuayouthcenter@gmail.com Fax No.: , ( ) — Accountant/CPA: Bonnie Bibeault Phone No.: (808 ) 968 - 1002 Firm (if applicable): Carbonaro CPAs&Management Group Mailing Address: Address: 136 kinoole St Address: City,ST,Zip Hilo,'HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or'more'can be checked) ❑ Puna ❑✓ Hamakua 0 North Kona ❑South Hilo ❑ North Kohala ' ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more canbe checked) ❑✓ Educational concerns ✓❑Youth • ❑.Victims of Crimes ❑✓ Culture and the arts ❑Aged' ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ; ❑ Public Health and Welfare ofthe'People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION • FY 2019 ;2020 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 • Agency.Name: Hamakua Youth Foundation, Inc Program Name: Multicultural Awareness Program 1. Prior Year Award of County Nonprofit Grant Program Funds: . FY 16-17 FY 17-18 FY 18-19 $9,500 • $18,637.50 $9,675.00 2. Agency Mission Statement: Hamakua Youth Foundation, Inc. (HYF)is a community based organization dedicated to creating'a nurturing youth service program for ages 10-18 during non-school hours, engaging youth in environmental sustainability and stewardship, providing Hawaiian culture and arts education,developing youth leadershipand,connecting youth and their families with social service agencies. Hamakua Youth Center(HYC)provides low-cost after-school programs open daily,'during intersessions,occasional weekends and summer breaks to school age kids in Honokaa. HYC continually,strives to instill life skills that are are guided by traditional values-Kuleana,Aloha, Laulima,&Mahalo. HYC offers safe,adult supervised programs and activities and youth to youth mentoring through homework assistance and leadership training. We provide experiential learning in music and the arts with studio production capability as well as traditional Hawaiian and contemporary arts and crafts and holiday themed activities. HYC is currently the only facility in the Hamakua District that focuses primarily on programs for elementary through high school youth. After-school alternatives for youth are limited and our youth are considered at risk for unhealthy behaviors based on the family demographics in our community. Our general objectives are'to expand the scope of programs to provide more alternatives for youth;offer'additional training to staff;assist volunteers and parents in enabling them to identify and correct unhealthy behaviors in both youth and families;design programs that build self-concept, mutual respect and teamwork,and expand learning capacity. 3. Program Description: During the last year of HYF's Multi-cultural Awareness Program(MAP)four cultures represented along the Hamakua coast will have been studied,each over an eight-week period.These immersions.included the Japanese, Filipino, Portuguese and European/American Cultures. For the third'year of the program(2019-2020)we will schedule approximately 240 hours of activities focusing on four more cultures important to our district–Korean;Chinese,Samoan/Tongan and once again Hawaiian/Polynesian-with each culture being explored during an eight to ten week segment. We will be focusing again on the Hawaiian/Polynesian Culture, since it is the host culture for all of the.Center's activities. Other cultures that will be studied in the future include Micronesian/Marseilles, Hispanic/Latino and African American'. Since there is so much to be learned from every immersion and our youth group varies from year to year,we also plan to'repeat some of the immersions as our program continues and deepens. As before, MAP will make use of elders and inter-generational experts who will focus on their culture's music,food and history, particularly in regard to settling on th'e Big'Island. We not only want to'explore the individual cultures but how each of them have helped to develop the integrated mixed culture we know in'Hawaii today,especially along the Hamakua Coast. For example,the historical significance of the Polynesian's to the discovery of Hawaii,as well as the introduction of Asians for the agricultural industry,and the current influx of Latinos will be emphasized during the program. For each culture studied,the youth will focus on a farm-to-table food experience: Each segment will include the growing and reparation of food and an experiential introduction to music relevant to teenagers here and in the culture's home country. For example, in the first year of the program the youth explored Japanese/Hawaiian cuisine from the garden to a complete meal, and what Japanese teenagers are listening to in Japan as well as an introduction to historical'Japanese music.There will be field trips to cultural locations around the island.`Each segment will culminate in a celebration-hoike-including a full meal and musical event. '- 4.Total Budget& Position Count: Total Program Budget: $18,000 ' Total Program Position'Count: 2 Total Agency Budget: $253,750 Total Agency Position Count: 21 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation, Inc Program Name: Multicultural Awareness Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii-Non Profit grant 10,000 _ Private grant 6,000 Community Support 2,000 TOTAL: $18,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hamakua Youth Foundation, Inc.will schedule and host community fundraising events throughout the year, including our annual Hula Festival. HYF will strive to build community partnerships;that include joint funding'agencies and collaboration with other community organizations throughout Hawaii to ensure our keiki learn the value of utilizing the many Hawaiian (&other cultural)specialists,community artists,and kupuna that our island has to offer.. Currently,we are strengthening our grant writing team so that we can increase our capabilities for receiving foundation,state and federal government support. We promote three fundraising events each year that emphasis'creation of a long term benefactors to provide sustainability. One of the events is the annual HYF Hula Festival. While this is primarily a major community cultural event, it is also a fund-raiser for us and provides greater community awareness of our programs. We are exploring additional grants and plan to expand the number. of grants we apply for and hopefully increase the funding we receive through grants. To improve our fiscal credibility,we are preparing and budgeting for an audit to be accomplished during our next fiscal year. This will help in our eligibility for larger grants requiring an audit and generally help with our fiscal transparency to attract additional donors. • In addition,the program has begun to collate information and materials to create a"Keiki Cookbook"which will consist of favorite recipes and documentation of the learning activities experienced by the students. Sales of the book in the community will be used to support the Multi-cultural Awareness Program. The students'will,from time to time,engage in fund-raising at community events,selling merchandise such as t-shirts and food cooked and prepared by them in a'certified kitchen. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1.To continue to provide and expand an experiential,compelling and developmentally relevant after-school program to our youth 2.To continually promote an environment of Kuleana,Aloha, Laulima,&,Mahialo ' 3.To strengthen life and leadership skills of our youth in a way that supports them making healthy choices,succeed in their academic studies and become an informed member of the Hamakua Community. 4.To help our youth build self-awareness and respect for the multi-culture nature of Hamakua and strengthen their self identity by knowing how they and their cultural roots fit within our community and their world. 5.Specifically to explore the various cultures of Hamakua, including Hawaiian/Polynesian,Micronesian/Marshallese, Samoan/Tongan,Japanese, Filipino,Chinese, Korean, Portuguese, European/American, Latino and African American. 6.To tangibly incorporate Blue Zone philosophy in regard to,food,exercise,stress reduction and,community involvement so to encourage practices that lead to healthier,happier and longer lives.; 7.To expand our program for youth and teens in a way that financially and operationally sustains Hamakua Youth Center operations,as we move from the present limited facilities to the new center at th'e Okada Building. 8.Specifically to expand our existing staff,board,volunteers and collaboration with other community organizations through improved fundraising,fiscal management&transparency in the community 1' EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation, Inc Program Name: Multicultural Awareness Program 8.TABLE I: ' What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) : ', 18 volunteers working to produce 6 multi-cultural workshops for youth center participants 18 new community volunteers involved 6 workshops to examine music,food&history of 6 different cultures of Hamakua • Workshops involve center youths in cultures Youth involved in inter-generational events while learning cultural differences 90 youth involved in training Youth center increases reach into community events and participants 40 new youth involved in HYC Each cultural training involves 4 separate sessions of over 3 hours each Provide in-depth cultural training Strengthen partnerships with Honokaa Hongwanji Buddhist Temple and Honokaa HS 3 partnerships supporting youth development Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES ' FY 18-19 FY 19-20 FY 19-20 ;Actual* Total Budget Grant Re Salary ansiWages ' 3,216 $6,500 $2,000 Professional Fees 0 0 0 Operations 2,164, 2,500 1,000 Supplies 135 1,000 1,000 Equipment 0, 0 0 Other: Food and Beverage 1,195, . 2,000 2,000 Other: Travel 750 1,000 1,000 Other: Contract labor 4,540 5,000 3,000 Other: Other: TOTAL $12,000 . $18,000 $10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with the County of Hawail.Only those listed below need to be disclosed. One form per person with a conflict is needed. If no:conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a confli4t or potential conflict of interest, including any familial relationship,with any of the following(check aIl that apply): • MeMber or members of the Council Staf appointed by a member of the Council O The Mayor Th Managing Director O The Director of Finance 0 The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Cotnsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid,in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. Jan 25 2019 Sig ature of Au orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit;Grant Application FY2019-20 Agency Name: Hamakua Youth Foundation, Inc: Program Name: Multicultural Awareness Program 11. Certification'of Understanding (gage a of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of.Finance, designated Council representative, or expending/oversight agency)full,free;,and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. . I (we) hereby certify that information supplied herein, including allsupportingdocuments, is correct and that I (we) have the authority and ability to fully administer the programs) 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"p'ersonnel receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov,`complete the easy step-by-step process, and pay the annual registration fee online using a'credit'card If awarded a grant from the County of Hawaii, I (we)understand and will comply with the requirement to submit a ear-end resort to the Count Council within 60 da s after June 30 of the contractual ear for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),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'using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 • Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2019-20: Agency Name: Hamakua Youth Foundation; Inc. Program Name:. Hamakua Youth Center = ii. Certification of Understanding (Page 2 of:2) If:awarded a grant.from,the County-of Hawaii;I (we) understand that a current Certificate of Liability ($1,000,000 general•liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and:explicitly indicates that.the County'of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to"submit the final report'within 60 days`of June 30th shall result in loss of all grant funds received during the grant'period(must be refunded to County)and exclusion from future grant participation for a minimum of one yearor until a written report is submitted to,and. accepted by,the council. I(we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://wwwhawaiicounty gov/fn-nonprofit grant-forms/on or about May 30 of the year the final:report:is.due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for''alministrative.and overhead. costs. Any funds-unused by June 30, :2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signingbelow,youare acknowledging that you.have read and understood these requirements.. Jan 25; 2019. Signature of Auth rized Person(see checklist,29d item) Date. /Poe-4 1+.1) p--- Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 , Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name:. Hamakua Youth Foundation, Inc Program Name: Multicultural Awareness'Program Al. COUNCIL' WARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 18 volunteers working to produce 6 multi-cultural workshops for yoUth center participants ilnavoniezdcommunityvolunteers • 6 workshops to examine music,food&history of 6 different cultures of Hamakua' workshops involve center youths in cultures Youth involved in inter-generational events while learning cultural differences 90youth involved in training Youth center increases reach into community events and participants • 40 new youth involved in HYC • Each cultural training involves 4 separate sessions of over 3 hours each : Provide in-depth cultural Strengthen partnerships with Honokaa Hongwanji Buddhist Temple end Honokaa HS youth devieop sup orting Strengthen youth programs provided by Hamakua Youth Center TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES : r Request Award Salary and Wages $2000. Professional Fees 0 Operations 1 000 • , Supplies 1 000 Equipment '0, , Other: Food and Beverage 2,000 Other: Travel 1,000 Other: Contract labor 3,000 Other: Other: TOTAL $10,000 Additional Council directives regarding award is i r EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020' Page 8 of 8 • Hawaii Institute of Pacific Agriculture K-20 Agricultural Resiliency & Nutrition Educational Pipeline 81 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Institute of Pacific Agriculture Program Name: K-20 Agricultural Resiliency & Nutrition EducationAl Pipeline Agency Director: Dash Kuhr Phone No.: (808) 889 — 6316 Contact Person: Lauren Ruotolo Phone No.: (808) 333 — 8664 Mailing Address: Address: PO Box 497 Address: City,ST,Zip Kapaau, HI 96755 Facility Address: Address: 53-378 Pratt Rd Address: City,ST,Zip Kapaau, HI 96755 Email Address: institute@hipagriculture.org Fax No.: ( ) — Accountant/CPA: Patty Schumacher Phone No.: (808 ) 345 — 7900 Firm (if applicable): Schumacher Tax&Accounting P.C. Mailing Address: . Address: PO Box 395 Address: City,ST,Zip Dewey, AZ 86327 • YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ❑ South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ['Youth ['Victims of Crimes ❑✓ Culture and the arts ['Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Institute of Pacific Agriculture Program Name: K-20 Agricultural Resiliency & Nutrition Educational Pipeline 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 • FY 18-19 $0 $4,500.00 $7,125.00 2.Agency Mission Statement: The Hawaii Institute of Pacific Agriculture's(HIP Ag) mission is to practice and teach ecologically conscious agriculture, empowering individuals and communities to cultivate alternative systems of living that restore human and environmental health. To achieve this we provide agriculture and nutrition education to students grades K-20. Established in 2008, HIP Ag provides programs primarily in Kohala. HIP Ag's work is to train new farmers, educate youth, support Farm to School initiatives and develop replicable curriculum. HIP Ag has a track record of offering successful programming to Kohala schools and ongoing partnerships to build upon our success. Over the past ten years, we have provided our community with educational'programming which includes farm field trips, in- school workshops, infield farmer training, and community events. We have added to our offerings over the past two years by developing a High School Agricultural Mentorship and Internship program,.a one year post-secondary Farm Apprenticeship program, and have been actively supporting'Aina Polio in creating a successful Farm to School Pilot(F2S)and Garden to Cafeteria Programs Pilot(G2C) at the Kohala Complex in Hawaii'.We also have a small farm that serves as our classroom for our educational programming and an.avenue to supply F2S in Kohala with fresh fruits and vegetables. HIP Ag believes that education is key to increasing the number of future farmers along with healthy and conscious consumers. By expanding this job sector within our state, it will also advance rural economic development and Hawaii's overall health and food security. 3. Program Description: . , Main Objective: Expand learning,awareness and skills in agriculture and nutrition to K-20 at.the-Kohala Complex and with post secondary students looking to pursue a career in agriculture.We provide K-8 students with in-school workshops on farm-to-fork,. garden and nutrition,and pa'i'ai. High school students are reached through the HS mentorship program,which serves all of the natural resource classes as well as intro to engineering and career technical education(CTE)classes.The school farm serves at the class room for this program. High School students also have the opportunity to participate in a six-week summer farm internship. Post-secondary students are served through a year long farm apprenticeship at HIP Ag. Our goal is to increase students' understanding and connection to regenerative food systems and healthy lifestyle choices through the followin 1)IK-5 In-class Workshops:We will serve all classes at the Kohala Elementary School with three series of woiihops including: Farm to Fork:A nutrition class incorporates a"farm to table"lesson that uses school garden produce and otrk local ingredients. This connects students to food being served in the cafeteria and to crops that students are growing in their cpus gardens. Garden&Nutrition: In the Spring,we follow the cooking demos with an in-depth garden and nutrition lesson on canoe crops, plant medicine remedies, beekeeping,soil investigations,bamboo building, and plant propagation. Pa'i'ai Pounding:We offer pa'i'ai(poi) pounding workshops during the last month of school.This activity highlights Hawaiian tools,traditional kalo preservation, and why kalo was such an important staple food crop.2)9-12 High School Mahi'ai Mentorship&Internship: mentors Kohala High School (KHS)students grades 9-12 on gardening,farming,cooking,and leadership skills. Mentorship primarily takes place at KHS farm, but incorporates other farm site visits.We are working with teachers to build replicable curriculum and infrastructure for on-campus exposure to agriculture and farmer training.We also host a 6-week Summer Internship with a stipend to students who participate in the Mentorship Program.3)Farm Apprenticeship:We provide an opportunity for post-secondary students to serve on HIP Ag's farm for one year.We are working to build this program to so that it becomes more attractive to graduating local seniors serving those interested in exploring a career in agriculture locally. 4.Total Budget & Position Count: • Total Program Budget: $197,772.00 Total Program Position Count: 4 Total Agency Budget: $382,454.00 Total Agency Position Count: 5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Institute of Pacific Agriculture Program Name: K-20 Agricultural Resiliency & Nutrition Educational Pipeline 5. Program Funding Sources (identify all sources of funding applied to this program):' • FY19-20 Revenue Source Estimate GIAS Grant $50,000.000 Atherton Grant $41,570.00 HCF Career Connected Learning Grant $41,570.00 HMSA FoundationGrant $40,000.00 TOTAL: $173,140.00 Attach additional pages,if needed. • 6. Explain what plans your agency or program has to increase revenues to-support this program: We are establishing more resilient financial systems through: Building programs that can eventually pay for themselves, implementing a more robust grant schedule,fulfilling more youth education contracts,filling paid program enrollment and by increasing our individual donors. After 2020,sustaining the Agriculture Initiatives in time will be met as the program builds capacity. While our youth education programs are a'free service funded through'grants,the need to educate the youth on nutrition and agriculture will continue to be a needed service.The youth education will sustain due to the community's commitment to the next generation's health,well-being,and need for future farmers. Eventually,we would like the HS Farm ManagerQe hired by the DOE or to grow enough food that is purchased through the Farm to School program and community markets to cover a wage. In two years, after the Mentorship Program has been fully developed and trialed,we will propose to the DOE that they adothe program and curriculum and fund it within their budget overtime.Last year we have increased our fundraising capacity through hiring a Development Director.She is guiding our core fundraising strategy and planning,to work in tandem with our executive leadership team. For individual donors we use targeted appeals to existing and new potential donor groups as part of an effort to develop a more robust annual fund and major gift program.We maintain regular communication with prospects will allow us to increase awareness and in turn support for our programs.We will also target new individuals who support education, our community and our work.We are doing this through personalized major donor asks,a newly developed donor ask card and envelope, plus adding a donation widget to our website and newsletter.We will increase grant and foundation support by focusing on a broader pool of foundation prospects that support K-20 education,environmental work and increasing request amounts from current funders. Lastly,we will increase tuition based programs that generate a steady source of revenue for operations. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)K-5 In-class Workshops:We will serve all classes at the Kohala Elementary School(340 students)with three series of workshops to increase students'fondness and familiarity to foods by at least 50%, Enhance student experience by 50%through hands on, place-based learning 2)HS Mahi'ai Mentorship:Two HIP Ag educators work with students during classes 4 days a week providing lectures, hands on Project Based Learning, reflection talking circles,and core agriculture education curriculum with five different classes in the CTE(50 students). Host a minimum of four guest teachers from various fields of agriculture.We give post-surveys to gauge learning objectives and likability.Take students on at least two Farm Field Trips to visit other farms in Hawaii.We give post surveys to measure student experience. Distribute annual pre and post surveys to students to measure our target outcomes. Host a minimum of two cooking classes where students learn to cook with the food being grown on the school farm. Increase student rate in growing food by 50%. Increase student rate of interest in careers in farming by 30% 3)Mahi'ai Summer Internship: HIP Ag hosts a minimum of five HS students for 6-weeks,where students engage in land and project based learning alongside the HIP Ag Farm Team. Conduct bi-weekly check-ins to gauge their comprehension'engagement, personal needs, and the program's goals. 4)Farm Apprenticeship:staff provides training&mentorship to Apprentices segmented into the following 8 w rotating management modules: Food Safety Management, Nursery Management,Amendment Management, Irrigation Management,-Bee Management, and Communications.Apprentices receive a survey after each module to evaluate the module and share what they learned. Farm Managers receive a survey to evaluate the progress of the apprentice whom they mentored throughout the module.Increase Apprentices subject knowledge by 75%and interest in careers in farming by 50%. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application F 2019-20 Agency Name: Hawaii 'Institute of Pacific Agriculture Program Name: K-20 Agricultural Resiliency & Nutrition Educational Pipeline 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of K-5 students reached, number of contact hours K-5 340 students/3 hrs per student(1020 hrs) Numher of 9-12 students reached , number of contact hours 9-12 50 students/126 per student(6,300 hrs total) Number of 9-12 Summer Farm Interns, number of contact hours 6 HS Interns/150 hrs per student(900 hrs otal Number of post-secondary 1-year Apprentices' number of contact hours 6 post-secondary apprentices/1800 hrs pe• apprentice(10,800 hrs total) *Attached Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $81,073.15 $94,765.84 $10,000.00 Professional Fees $16,212.31 $17 979 28 $2,000.00 Operations $25,051.47 $26,245.00. $0 Supplies $8,449.19 $9,720.00 $1,000.00 Equipment $3,711.17 - $5,000.00 $0 Other: Transport $4,472.54 $5,612.00 • $0 Other: Marketing $400.00 $450:00 $0 Other: HS Farm Internship Stipends $7,500.000 $9,000.00 $2,000.00 Other: Post-Secondary 1-year Apprenticeship Stipends $18,000.00 $28,800.00 $10,000.00 Other: TOTAL $164,869.83 $1417,772.12 $25,000.00 *If applicable • • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Institute of Pacific Agriculture Program Name: K-20 Agricultural Resiliency & Nutrition Educational Pipeline so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only thosellisted below need to be disclosed. One form per person with a conflict is needed. If no conflicts exit, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council ❑ The Mayor n The Managing Director ❑ The Director of,Finance_ n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing ingeneral to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: MIf no conflicts exist, check here. • .;, - . . Development 30 January 2019 Signat re of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of FHawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Institute of Pacific Agriculture Program Name: K-20 Agricultural Resiliency & Nutrition Educational Pipeline 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 C iapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 rcntractual year for which the grant was awarded.The report, using the template provided, shall inclujle an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Institute of Pacific Agriculture Program Name: K-20 Agricultural Resiliency & Nutrition Educational Pipeline 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prier to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th sha!I result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand thereis no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the Courity of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these revirements. "of /ye,. 30 January 2019 ?or, V�re of A orized Person (see checklist, 2nd item) Date Director of Development Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of FIawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Institute of Pacific Agriculture Program Name: K-20 Agricultural Resiliency & Nutrition Educational Pipeline tfr 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result • TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Reque ,; Award • Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: • Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hawaii Institute of Pacific Agriculture #8.Program Performance Measures Program: Increasing Agriculture &Nutrition Experience within K-20 Main Objective: Expand learning,awareness and skills in agriculture and nutrition to K-20 at the Kohala Complex and with post secondary students looking to pursue a career in agriculture.We provide K-8 students with in-school workshops on farm-to-fork,garden and nutrition,and pa'i'ai.High school students are reached through the HS mentorship program,which serves all of the natural resource classes as well as intro to engineering and career technical education(CTE) classes.The school farm serves at the class room for this program.High School students also have the opportunity to participate in a six-week summer farm internship.Post-secondary students are served through a year long farm apprenticeship at HIP Ag. Our goal is to increase students'understanding and connection to regenerative food systems and healthy lifestyle choices through the following: 1)K-5 In-class Workshops: We will serve all classes at the Kohala Elementary School with three series of workshops including: A.Farm to Fork:A nutrition class incorporates a"farm to table"lesson that uses school garden produce and other local ingredients.This connects students to food being served in the cafeteria and to crops that students are growing in their campus gardens. We believe this is important lesson since 68%of the students are on free or reduced lunch,meaning that the majority are eating lunch from the cafeteria within the Kohala complex. • Crops to be highlighted are: taro,banana,poi,taro leaf,vegetables,fruit,breadfruit,and cocoyams. • We aim to increase students'fondness and familiarity to foods by at least 50%. • These classes will be offered throughout the Fall semester,with emphasis in October during Farm to School month. • Youth Program Director will give"Farm to Fork"class for all Discovery Garden classes,grades K-5 (serving 340 students),using Kokua Hawaii Foundation'Aina in Schools curriculum at its core. B. Garden &Nutrition: In the Spring,we follow the cooking demos with an in-depth garden and nutrition lesson on canoe crops,plant medicine remedies,beekeeping,soil investigations,bamboo building,and plant propagation to all 340 students in K-5 classes at KES. • Kindergarten: Pollinators &Beekeeping-60 students will learn about the ecological importance of pollinators while looking at their anatomy under the microscope and watching bees in our observation hive. • 1st Grade: Seed saving and planting seeds -60 students will learn about heirloom seeds that are easily saved and replanted.A tactile activity to include shucking seeds,sorting for quality,and drying for planting in the future. • 2nd Grade: IMO potions-60 students will create indigenous microorganism potions to help increase soil fertility while learning about the benefits of IMOs for soil and plant health. • 3rd Grade: Nutrition and Wellness -"Taste the Rainbow" -60 students have a taste of various fruits, veggies,and herbs while learning about how the shapes and colors relate to powerful nutritional and healing properties.With access to a food prep space,we will also work with the students,in groups, to prepare or cook their tastings. • 4th Grade: Canoe crops(kalo, `ulu,`uala,niu,ti) -40 students will gain knowledge on I‘Iawaiian canoe crops,their uses,and how to propagate these. • 5th Grade: Bamboo building,hau rope making-60 students work with bamboo and hau to create garden trellises. • All students are given pre and post surveys. • All students are given an educational coloring book after the workshop. Hawaii Institute of Pacific Agriculture C.Pa'i'ai Pounding: We offer pa'i'ai (poi)pounding workshops to all 340 students during the last month of school.We bring cooked kalo,boards,and stones to share the traditional tastes and experience of pounding pa'i'ai.Students are much more willing and excited to eat poi or kalo when they have been apart of creating the finished product.This activity highlights Hawaiian tools,traditional kalo preservation,and why kalo was such an important staple food crop.We utilize pre and post surveys to gauge whether or not we are achieving our intended outcomes,such as: • Increase knowledge of pa'i'ai by 80% (including knowledge of Hawaiian terms,how kalo is grown, and how to make pa'i'ai). • Increase student desire to eat more kalo by 50%. • Increase Enhance student experience by 50%through hands on,place-based learning; introduce new experiential learning by 50%. • All students are given pre and post surveys. 2.9-12 High School Mahi'ai Mentorship &Internship: Mahi'ai mentorship program megtors Kohala High School (KHS) students grades 9-12 on gardening,farming,cooking,and leadership las. Mentorship primarily takes place at KHS farm,but incorporates other farm site visits.We are working with teachers to build replicable curriculum and infrastructure for on-campus exposure to agriculture and farmer training.We have been supporting the revitalization of the Career Technical Education (CTE) line and its connection to the farm.Starting this year the HS will be participating in the new State pilot program Garden to Cafeteria(G2C).We will be working with students,faculty,and the administration to provide food grown at the HS farm to the Kohala Complex cafeteria.We also host a 6-week Mahi'ai Summer Internship with a stipend to students who participate in the Mentorship Program. A.Mahi'ai Mentorship: • Two HIP Ag educators work with students during classes 4 days a week providing lectures,hands on Project Based Learning,reflectiontalking.circles,and core agriculture education curriculum. • HIP Ag currently works with five different classes in the CTE.In 2019-2020,we will work to add at least six additional CTE classes to the program with the principal's support,to create the farm as the focus of learning. • Host a minimum of four guest teachers from various fields of agriculture.We give post-surveys to gauge learning objectives and likability. • Take students on at least two Farm Field Trips to visit other farms in Hawaii.We give post surveys to measure student experience. • Distribute annual pre and post surveys to students to measure our target outcomes. • Host a minimum of two cooking classes where students learn to cook with the food being grown on the school farm. • Increase student rate in growing food by 50%. • Increase student rate of interest in careers in farming by 30%. • Increase student rate of interest in growing food by 50%. • Increase student self-rate of health and physical stamina by 50% B.Mahi'ai Summer Internship: • HIP Ag hosts a minimum of five HS students for 6-weeks,where students engage in land and project based learning alongside the HIP Ag Farm Team. • Distribute pre and post surveys to HS interns. • Conduct bi-weekly check-ins to gauge their comprehension,engagement,personal needs,and the program's goals. • Increase student rate of interest in careers in farming by 50%. Hawaii Institute of Pacific Agriculture • • Increase student rate of interest in growing food by 50%. • Increase student self-rate of health and physical stamina by 50%. C.Garden to Cafeteria • Providing one food safety training to Elementary and High School Ag Teachers and related staff. • Further improve the in-field packing shed at the High School for harvesting produce going to the cafeteria. • Support crop planning that will direct food being grown at KES and KHS into the cafes..:ria. • Increase the percentage of food grown by the students that is diverted to the cafeteria by at least 20%. • Increase the likelihood of students eating at the cafeteria by at least 10%. • Host a minimum of two community volunteer days to support the school gardens. 5.Farm Apprenticeship: We provide an opportunity for post-secondary students to serve on HIP Ag's farm for one year. We are working to build this program to so that it becomes more attractive to graduating local seniors serving those interested in exploring a career in agriculture locally.This year we will be expanding our island outreach for apprenticeship in hopes of increasing the number of Hawaii residents that apply to the program.The overarching goal of the program is to give a more in-depth farmer training to provide students who are pursuing a career in agriculture and want to increase their knowledge and technical skills.Students learn through hands-on engagement,readings,and weekly educational sessions.Each apprentice receives food safety training,in-depth training on market gardening,permaculture,Korean natural farming,agroforestry,beekeeping,crop design,planting, harvesting,herbal medicine making,and value-added food processing.Apprentices leave the program with an agricultural certificate,which can leverage to attain a job within the agricultural sector or to access ag loans to start their own operation. • Distribute pre and post surveys to Apprentices. • HIP Ag staff provides training and mentorship to Apprentices throughout the year segmented into the following 8 week rotating management modules such as: Food Safety Management,Nrsery Management,Amendment Management,Irrigation Management,Bee Management,and Communications. Apprentices receive a survey after each module to evaluate the module and share what they learned.Farm Managers receive a survey to evaluate the progress of the apprentice whom they mentored throughout the module. • Increase Apprentices subject knowledge by 75%. • Increase Apprentices rate of interest in careers in fanning by 50%. • Increase Apprentices rate of interest in food by 75%. • Increase Apprentices self-rate of health and physical stamina by 75% • Partner with a college that is able to provide college credit to the apprentices. • At least two out of five Apprentices are local youth from Hawaii for the 2019-2020 cohort. • 3 Hawaii Island Adult Care, Inc. Adult Day Care Center 82 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Center Agency Director: Marcie Saquing Phone No.: (808 ) 961 — 3747 Contact Person: Marcie Saquing Phone No.: (808 ) 961 — 3747 Mailing Address: Address: 561 Kupuna Place Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 561 Kupuna Place Address: City,ST,Zip Hilo, HI 96720 Email Address: msaquing@hawaiiislandadultcare.org Fax No.: (808 ) 961 — 3740 Accountant CPA: Ann Fukuhara, CPA, CGMA,MBA / Phone No.: (808 961 — 5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address:P.O. Box 6691 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona ❑✓ North Hilo n South Kohala n Ka`O Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑✓ Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $13,750 $22,500 $14,000 2. Agency Mission Statement: "To provide high-quality day care for elders aqnd challenged adults and support for their families in order to ensure continued living at home-aging in place." 3. Program Description: Our adult day care center provides safe and socially active daytime programs for our kupuna and challenged adults.The program provides a structured daily schedule six days a week which includes movement and exercise(chair yoga,xigong)to aide in mental and physical stimulation.We have an in-house artist who teaches water color,ceramics and other creative projects.We offer games,singing, dancing, meals and snacks.The greatest benefit from attending adult day care is the socialization that occurs with our participant Attending adult day care meets our mission and goals to keep kupuna living at home as long as possible-aging in place. Day care allows them to keep their dignity and independence and prevent premature institutionalization.Additionally, our program supports the caregiver/families with time-off through respite,educational opportunities and the ability to remain employed. Hawaii Island Adult Care, Inc. received CARF International accreditation in 2014 through 2017, at which time,we were re-certified through March 2020.With this recognition, CARF recognizes Hawaii Island Adult Care as an adult day services provider meeting high standards for quality of service and continuous improvement. Perhaps the most critical aspect of adult day care is the rapid increase of need in our community that we serve. Kupuna are living longer,the so called"Silver Tsunami"of Baby Boomers are already hitting our shores.We have seen our new participant levels jump 200%in the last month alone. 4. Total Budget & Position Count: Total Program Budget: 2,055,900 Total Program Position Count: 34 Total Agency Budget: 2,071,800 Total Agency Position Count: 34 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Center 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Day Care Tuition & Fees 1,374,500.00 State/Federal (Medicaid) 320,000.00 County Of Hawaii Assistance Request(Grant) 50,000.00 Hawaii Island United Way 24,000.00 Friends of HIAC/Golf Tourney TA Fund 7,000.00 Other Tuition Assistance Grants 105,000.00 See attachment A 175,400.00 TOTAL: 2,055,900.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our tuition assistance program supports those kupuna who require daytime supervision and socialization.We assist those who are above the Medicaid income levels and do not qualify for Medicaid-paid services,yet cannot pay full-time cost tuition rates out of pocket to attend adult day care. To increase revenues,we implement an annual service fee increase that goes into effect each spring on daily tuition, transportation and other fee rates.We also work closely with the Hawaii County Office of Aging to provide additional financial and resource supports for participants and their families. However,the most critical way to assist those kupuna and their ohana is to provide financial assistance for this low-income gap group by writing multiple tuition assistance grants each year. Many families do not prepare for the situation of an aging loved one who suddenly requires daytime supervision.Thus,through this grant,we are able to assist those in need at any point in time of their need for day care services. Again,allowing for the employed caregiver to remain gainfully employed knowing that his/her loved one can attend adult day care. We also hold our annual golf tournament(13 years)as our primary fund raiser.A portion of the funds raised are used for tuition assistance. II 7. Program Objectives Using County Nonprofit Grant Program Funds: The objective of this grant request is to provide tuition assistance for the low income kupuna who require adult day care;who are financially ineligible for Medicaid benefits due to the income/asset levels,yet cannot afford to pay full costs to attend adult day care. In 2018,we served over 160 participants at our centers. 70%of our participants fall in the low to poverty level income brackets. These individuals need to attend day care either because of their doctor's order or family concerns about socialization and the lack of safety being at home alone all day long.Additionally, many of the caregivers are employed and would need to leave their jobs if their loved ones did not have the opportunity to attend adult day care.Tuition assistance funding helps close the gap and allows all our kupuna to attend adult day care regardless of their ability to pay. This tuition assistance program is offered on a cost-share basis and each applicant is reviewed for income, expenses and savings to determine their eligibility and need as well as define their monthly cost-share portion.We also maximize the number of participants who can receive assistance.An application is completed by the participant in need and their information is reviewed, with their income verified against the USDA application (each participant is required to complete this form annually).Those applicants with large savings/assets more than their own home are usually not eligible. Each tuition assistance applicant will pay some cost share based on their income and expenses(their personal, not caregiver/family). EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 Hawaii Island Adult Care, Inc. Hawaii County Human Services Grant for Fiscal Year 2019-20 Page 3, Attachment A Additional Program Funding Sources r USDA Lunch Reimbursement 76,650.00 Donations, lunch, Christmas, etc. 6,000.00 Donations, Tuition Assistance 5,000.00 Fundraising 39,000.00 Equipment/Other Grants (not for Tuition Assistance) 48,000.00 PIN Management Fees/misc 500.00 Interest Income 250.00 Total: 175,400.00 Please note: We disburse Persons-In-Need(PIN)grants for the community at large (through referrals), and thus the fee is allowed by the grantor. County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Center 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of participants to attend day care 50-60 Total#units(months)of funding assistance 150-200 Number of elders who maintained/improved their self care 50-60 Number of elders who are able to remain living at home 50-60 Number of elders who increased their self-esteem 50-60 Number of familes/caregivers who received respite 50-60 Number of carmiles/caregivers who are able to continue employment 30-40 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 1,239,700 1,437,699 Professional Fees 18,000 19,300 Operations 310,000 292,901 Supplies Equipment Other: Tuition Assistance for Adult Day Care 120,000 120,000 50,000 Other: 150,000 136,000 Other: 14,000 50,000 Other: Other: ' hass"r On Jed-L•rn'r. an-4-6.;0.14,e dog* TOTAL 4-1,851,700 2,055,900 50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Center 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor ❑ The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. �XEtu7�vE 2flgeCAD_ //� /S' Signature of Authori ers•0 (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Center 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Adult Care, Inc. Program Name: g Adult Day Care Center 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. ‘t4°- //XI 47 Signature of Authorized rson (see checklist, 2nd item) Date Fre D can �� ire -Tark._ Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Participants able to attend day care 50-60 Total#Units(months)of funding assistance 150-200 Number of elders who maintained/improved their self-care 50-60 50-60 Number of elders who are able to remain living at home 50-60 Numbers of elders who increase self-esteem 50-60 Number of families/caregivers who received respite 30-40 Number of families/caregivers who are able to continue employment TABLE II: PROGRAM EXPENDITURES FY 19-20 Grant Council Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Tuition Assistance for Adult Day Care 50,000 Other: Other: Other: Other: TOTAL 50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hawaii Island Business Plan Competition (HIplan) Hiplan Business Plan Competition 83 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Business Plan Competition (Hiplan) Program Name: Hiplan Business Plan Competition Agency Director: Jason Ueki Phone No.: (808) 494 — 4031 Contact Person: Jason Ueki Phone No.: (808) 494 — 4031 Mailing Address: Address: PO Box 1095 Address: City,ST,Zip Kurtistown, HI 96760 Facility Address: Address: NA Address: City,ST,Zip Email Address: jason@hiplan.biz Fax No.: ( ) — Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna Hamakua ❑✓ North Kona ❑✓ South Hilo North Kohala ❑✓ South Kona ❑✓ North Hilo ✓❑South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑Youth ['Victims of Crimes ❑ Culture and the arts ❑Aged ['Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Business Plan Competition (Hlplan) Program Name: Hiplan Business Plan Competition 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 NA NA NA 2.Agency Mission Statement: Hawaii Island Business Plan Competition (trade name:Hlplan)is an educational 501(c)(3) non-profit with the mission of educating and informing Hawaii Island entrepreneurs in business planning and communication skills. Hlplan undertakes various activities on a year round basis to educate entrepreneurs with a goal of stimulating development of an entrepreneurial ecosystem on Hawaii Island leading to job creation and diversified sustainable economic development.A more supportive and friendlier environment for entrepreneurs will lead to job creation and diversified sustainable economic development. The entrepreneurs most in need of support from the Hawaii Island entrepreneurial ecosystem are the startups and micro-businesses(fewer than 20 employees). Of all small businesses in the United States,micro-businesses make up 90% and of these,there are 23 million owner operators who have no employees. The startup and early stage businesses face many hurdles including knowledge/education and access to capital. Many of these businesses will not qualify for commercial lending programs. Of the businesses who do qualify for commercial loans,50%are rejected due to poorly written business plans and the inability to clearly articulate their visions. Small business owners often fill many roles in their company and inevitably have many more questions than answers. Entrepreneurs in this situation will benefit greatly from networking with other entrepreneurs in the community. It is common for entrepreneurs to believe that their problems are unique to themselves,when in reality,businesses share more in common than not. In stimulating development of the entrepreneurial ecosystem,Hlplan's initiatives will lead to job creation and development of a diverse,stable and sustainable economy on Hawaii Island. 3. Program Description: Hlplan currently engages in two main initiatives throughout the year and will launch a new initiative in the Spring of 2020. Hlplan's events are intended to provide an educational/learning experience and increase the ability for Hawaii Island businesses to gain access to capital and encourage peer/community support. Using a$25,000 cash prize as enticement, Hlplan attracts entrepreneurs to our annual business plan competition where we educate and encourage them in the process of developing a solid business plan.Our 3-round competition requires a 7-page written plan,a 2-minute pitch and a 12-minute detailed presentation. Highly qualified judges score each plan in each round and the highest scores in each round move on to the subsequent round. Our process is intended to get entrants functional in three modes of communication required for financing and success in a startup. Over the first three years, 123 qualified entrants have participated in the Hlplan business plan competition. Hiplan has awarded$125,000 in cash and prizes over the first 3 years. The monthly Entrepreneur Meetup Groups in Hilo and Kona launched in March 2018 attracted over 380 attendees last year. These free events feature a guest speaker,the opportunity for each person to introduce themselves and time to network. In the Spring of 2020, Hlplan will launch a new initiative targeting University of Hawaii at Hilo and the Hawaii Community College students. This new initiative is a Hackathon,a two-day project based learning program that uses cash prizes as an incentive to participate. The Hackathon will consist of student based teams using creative problem solving to find and present app-based solutions with commercialization potential for real world problems found on Hawaii Island. The winning teams will be chosen by a panel of expert judges. 4.Total Budget&Position Count: Total Program Budget: $207,500 Total Program Position Count: 1 Total Agency Budget: $207,500 Total Agency Position Count: 1 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 ISI County of Hawai`i Nonprofit Grant Application FY2019-20 Name: Hawaii Island Business Plan Agency NaCompetition (HIplan) HI( p Program Name: HIplan Business Plan Competition 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate State of Hawaii GAI (pending) 135,000 Hawaii County Nonprofit Grant(pending) 45,000 Ulupono Initiative(pending) 5000 Hawaii Strategic Development Corporation (pending) 5000 Hawaii Technology Development Corporation (pending) 2500 Natural Energy Laboratories of Hawaii Authority(NELHA- HOST Park) (pending) 5000 First Hawaiian Bank Foundation (pending) 10,000 TOTAL: $207,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HIplan recently(December 2018)received official 501(c)(3)status from the Internal Revenue Service. HIplan is now able to apply for funds from larger charitable institutions that require tax exempt status for funding consideration. In particular,grant opportunities though Hawaii Community Foundation and financial institutions such as the local banks. Sponsorship through multi-tiered program will be implemented in 2019. As most grants, including government will not allow funds to be used as cash prizes, HIplan will seek cosporate sponsorship to expand the number of cash prizes awarded in the annual business plan competition. Currently,there is a grand prize of$25,000 to the winner. Moving forward,the goal is to provide a second and potentially a third place cash award. 7. Program Objectives Using County Nonprofit Grant Program Funds: The general objective of HIplan is to encourage development of the Entrepreneurial Ecosystem on Hawaii Island. The ecosystem includes but is not limited to,increasing access to capital,providing knowledge/education,developing a culture of risk taking and cultivating support from the community. The HIplan business plan competition develops entrepreneurs in planning and communication which are vital for access to capital through investors and lenders. While there is only one grand prize,every participant gains through the process of the competition. In a reverse education system business model, Hlplan's objective is to offer a cash incentive to participants to educate and develop their business planning and communication skills. There are no losers in this sense. The Entrepreneur Meetup Groups are intended to provide a free informal venue for entrepreneurs to network. While there are other networking groups in the community,they often require membership,a fee to attend and require participation. The EMGs are free and open to the public. The objective of the EMGs are to encourage entrepreneurs to help one another solve problems. While every business needs more sales,they also must continue to solve new problems on an ongoing basis. The ability to connect and help each other is vital to growth as seen by cohorts in accelerators and incubators. The goal of the Hackathon is to encourage the youth and next generation of entrepreneurs to view research and problem solving with the specific goal of commercialization. Cultivating this mindset is vital to our future economic growth on Hawaii Island. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Business Plan Competition (Hlplan) Program Name: Hlplan Business Plan Competition 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of participants in the Hlplan Business Plan Competition year 2019 50 Number of participants in the EMGs year 2019 450 Number of participants in Hackathon year 2020 36 Cash Prizes for Biz Plan Competition and Hackathon $50,000 Scholarship Value to UH Hilo and Hawaii Community College $45,000 Advertising Award through Pacific Media Group $5,000 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $0 $50,000 $15,000 Professional Fees 3500 1000 Operations 145,500 26,000 Supplies 4500 1000 Equipment Other: Travel 4000 1000 Other: Food and Refreshments 3600 1000 Other: Other: Other: TOTAL $207,100 $45,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Business Plan Competition (Hlplan) Program Name: Hlplan Business Plan Competition 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓0 If no conflicts exist, check here. Q. 01 /30/2019 Sign.' ure of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Business Plan Competition (Hlplan) Program Name: Hiplan Business Plan Competition 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Business Plan Competition (HIplan) Program Name: Hiplan Business Plan Competition 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. v - ture of Authorized Person (see checklist, 2nd item) 01 /30/2019 Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Business Plan Competition (HIplan) Program Name: HIplan Business Plan Competition 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of participants in the HIplan Business Plan Competition year 2019 50 Number of participants in the EMGs year 2019 450 Number of participants in Hackathon year 2020 36 Cash Prizes for Biz Plan Competition and Hackathon $50,000 Scholarship Value to UH Hilo and Hawaii Community College P5,000 Advertising Award through Pacific Media Group $5,000 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $15,000 Professional Fees 1000 Operations 26,000 Supplies 1000 Equipment Other: Travel 1000 Other: Food and Refreshments 1000 Other: Other: Other: TOTAL $45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hawaii Island HIV/AIDS Foundation Client Transportation 84 Countyof Hawaii Nonprofit Grant Application FY2019-20 • Agency Name: Hawaii Island HIV/AIDS Foundation ORIGHIK g Pro ram Name: Client Transportation Agency Director: Bruce Merrell Phone No.: (808) 331 — 8177 Contact Person: Teri Hollowell Phone No.: (808) 331 — 8177 Mailing Address: Address: Palani Court Address: 74-5620 Palani Road Suite 101 City,ST,Zip Kailua Kona, Hawaii 96740 Facility Address: Address: Shipman Industrial Park Address: 16-204 Melekahiwa Place Suite 1 City,ST,Zip Kea'au, Hawaii 96749 Email Address: hihaf@hihaf.org Fax No.: (808 ) 331 — 0762 Accountant/CPA: Carbonaro CPA and Associates Phone No.: (808 ) 930 — 6850 Firm (if applicable): Mailing Address: Address: PO Box 4372 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑J Hamakua [' North Kona ❑✓ South Hilo ❑✓ North Kohala South Kona ❑✓ North Hilo ❑✓ South Kohala ❑Q Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑Victims of Crimes n Culture and the arts n Aged n Victims of Health or Social Crises El Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019®20 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Client Trans sortation 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $6,625 $6,500 $7,425 2.Agency Mission Statement: The Hawaii Island HIV/AIDS Foundation is a nonprofit organization dedicated to assisting those affected by HIV/AIDS to maximize their quality of life and to ending the spread of HIV.We also utilize the lessons learned in the HIV epidemic to care and advocate for others in the fight against related diseases. 3. Program Description: Continuing the Ciient Transportation Grant will allow HIHAF to make sure our disabled clients are driven to health appointments and linked to care, or provided a travel companion volunteer for medical specialty services on Oahu or Maui.We have trained a small dedicated core of volunteers for linkage transportation work this year and have plans to expand our volunteer base with help from the NonProfit Learning Center through our membership with Volunteer Match to be able to help more people in 2019-2020. Recently one of our clients who was released from prison and in transitional recovery housing had a medical emergency. Legally,he could not fly without a companion to have his surgery done on Oahu, so when we told his probation officer that-with the help of the County of Hawaii-HIHAF could take care of the travel companion and transport to the medical facility, the probation officer was really excited!This is just one of the small but important success stories for Big Island residents that this program provides. This program pays for staff support to locate, background check,train and manage volunteers for companion travel and linkage transportation work in our Hilo and Kona offices. Now that Uber is becoming more established on the Big Island,and wait times are not so excessive,staff will be working with Uber's Community branch to create ride share opportunities for our clients to medical appointments. With the rising price of ground and air ambulance rides,HIHAF-with the help of the County of Hawaii-will work to contain medical costs for our 265 clients on the Big Island-getting them to their routine doctor and hospital appointments-averting high emergency transport costs. 4.Total Budget & Position Count: Total Program Budget: $20,000 Total Program Position Count: 7 Total Agency Budget: $1,878,000 Total Agency Position Count: 18 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Client Transportation 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Ryan White HIV/AIDS Program (transportation &some salaries) $5000.00 Neighbor Island Housing Program (gas cards) $2000.00 Hawaii Department of Health Integrated Prevention and Care Grant(some salaries) $12000.00 Visitor Industry Charity Walk(gas cards) $500.00 TOTAL: $19,500.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continue to find and write grants even as we recieve much needed funding.Transportation is an ongoing concern for our agency on the Big Island.We also fundraise for cllient services during our Big Island AIDS Walk every year in Hilo. Come join us this April 13th! 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHAF's Program Objective is to strengthen our valuable linkage to care programs with our 265 clients. Continuation of this grant will allow us to provide assisted medical transportation and companion travel volunteers. HIHAF's key objectives: 1. Provide a needed travel companion volunteer for medical specialty services on Oahu or Maui for physically and/or mentally challenged clients on a case by case basis. 2. Provide taxi or ride share payments so that clients who lack transportation get transport to medical doctors, pharmacies,social services,our Foundation office, and various other appointments to stay healthy and in care. 3.Continue to strengthen HIHAF's volunteer base with a trained,assured,and background verified volunteer maximum staff of six(3 per office)to drive clients to medical doctors, pharmacies,social services,our Foundation office, and various other appointments to stay in care. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 • County of Hawai6 i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Client Trans•ortation 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) disabled client flies to Oahu or Maui for medical/dental treatment w/companion 12 RT flights with a companion volunteer client without transportation provided ride to health appointment to be linked to care 40 linkage to care transports locating,vetting,training of volunteers for companion,linkage transportation work 6 more volunteers volunteers and staff will attend webinar training from NonProfit Learning Center one webinar a quarter-show certification Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $23,500 $11,500 Professional Fees 0 0 Operations $2,500 $2,500 Supplies $800 $800 0 0 Equipment Other: volunteer mileage (.17 a mile) $200 $200 Other: taxi/ride share payments $2,000 $2,000 Other: companion airline tickets $3,000 $3,000 Other gas cards $2,500 0 Other air transport for clients $5,000 0 TOTAL $39,500 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Client Transportation 10i ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Bruce Merrell POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director H The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: • n If no conflicts exist, check here. V� 01/30/2019 tree 4. Signature of Authorized Person (specify title) %r Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Client Trans•ortation 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will notbe accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http:/Jvendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Client Trans sortation 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. Failure to return thesefunds 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 01/30/2019 Signature of Authorized Person (see checklist, 2nd item) Date e . �— � vee Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Client Transportation 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result disabled client flies to Oahu or Maui for medical/dental treatment w/companion co Ramon volunteer client without transportation provided ride to health appointment to be linked to care 40 linkage to care transports locating,vetting,training of volunteers for companion,linkage transportation work 6 more volunteers volunteers and staff will attend webinar trainingfrom NonProfit LearningCenter onewebinaraquarter•show certification TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $11,500 Professional Fees 0 Operations $2,500 Supplies $800 Equipment 0 Other: volunteer mileage (.17 a mile) $200 Other: taxi/ride share payments $2,000 Other: companion airline tickets $3,000 Other: gas cards 0 Other: air transport for clients 0 TOTAL $20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hawai'i Island HIV/AIDS Foundation Sexually Transmitted Disease Education and Testing 85 County of Hawaii Nonprofit Grant Application FY2019-20 I Agency Name: Hawaii Island HIV/AIDS FoundationOR E Program Name: Sexually Transmitted Disease Education and Testing Agency Director: Bruce Merrell Phone No.: (808) 331 — 8177 Contact Person: Teri Hollowell Phone No.: (808) 331 — 8177 Mailing Address: Address: 74-5620 Palani Rd., Ste 101 Address: City,ST,Zip Kailua-Kona, HI 96740 Facility Address: Address: Same as Above Address: City,ST,Zip Email Address: bmerrell@hihaf.org Fax No.: (808 ) 331 — 0762 Accountant/CPA: Carbonaro CPA and Associates Phone No.: (808 ) 930 — 6850 Firm (if applicable): Mailing Address: Address: PO Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ['Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Sexually Transmitted Disease Education and Testing 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $5,500 $6,500 $5,300 2. Agency Mission Statement: The Hawaii Island HIV/AIDS Foundation is a nonprofit organization dedicated to assisting those affected by HIV/AIDS to maximize their quality of life and to ending the spread of HIV.We also utilize the lessons learned in the HIV epidemic to care and advocate for others in the fight against related diseases. 3. Program Description: HIHAF continues to work on the front lines testing for HIV, Hepatitis C, Syphilis ,and educating the at-risk population in Big Island high schools , colleges, and Health Fairs across the island about screening and prevention.As you are aware,there are great challenges to being seen by a health care professional and treated quickly for STD testing at community health centers or Department of Health, especially if you are a resident in West Hawaii. HIHAF's program will help address the need to be at an equivalent level across the island. Now that our offices have certified phlebotomists-we are able to do the confirmatory testing for Hepatitis, HIV and Syphilis, so that the lab referral for blood draws are unnecessary. Once the confirmatory test is done,we can refer for linkage to medical care and medicine. Now with increased awareness about Hepatitis C and the medication to be cured of this dangerous virus, HIHAF can do the multilevel testing and case management. Through county funding for this program,we will also begin implementation for testing for Gonorrhea and Chlamydia with the support and training from Department of Health's Department of Harm Reduction Services Branch.We will also use county funding to continue important STD Education through social media websites, high schools and colleges, public forums and community meetings across the Big Island. Hawaii Department of Health 2015 Summary of reported cases of notifiable disease in the State of Hawaii: AIDS 35 people Hepatitis C 16,000 people Syphylis 163 people Gonorrhea 1,252 people Chlamydia 7,109 people 4. Total Budget& Position Count: Total Program Budget: 25,000 Total Program Position Count: 7 Total Agency Budget: 1,878,000 Total Agency Position Count: 18 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Sexually Transmitted Disease Education and Testing 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Department of Health Integrated Care and Prevention Grant 10,000 Visitor Industry Charity Walk 4,000 TOTAL: 14,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continue to find and write grants even when we receive much needed funding.We have been working with CMS and exploring avenues to open up direct billing with Medicare and insurance agencies to provide HIHAF with program sustainability. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our program objectives are to provide early diagnosis for Sexually Transmitted Diseases, so that public health doesn't have to foot the bill for expensive treatment later on.We must continue to educate the public about prevention and transmission-as well as the severe health consequences of not getting tested and subsequent treatment. CDC estimates that nearly 20 million new sexually transmitted infections occur every year in this country-half among young people aged 15-24. Our mission is to educate our youth"where they are at"-whether it be social media, radio, print or the classroom.We will do what it takes to educate,test treat and refer all people on the Big Island that need our services. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Sexually Transmitted Disease Education and Testing 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Syphilis testing offered to all people testing for HIV and Hepatitis C 130 tests provided Confirmation, case management and treatment arranged for positive tests 100%positive tests Advertisement of STD services via HIHAF website, Facebook, and other Social Media 3-4 updates or new messages/month STD prevention out-reach activities at heath fairs, businesses and public events. 6-7 events/year STD prevention at local Secondary Schools and Universities/Colleges for students 7-8 events/year Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 25,000 15,000 Professional Fees Operations 2,500 2,500 Supplies 7,500 3,500 Equipment Other: Staff Mileage 1,000 1,000 Other: Advertisement 2,000 2,000 Other: Training 1,000 1,000 Other: Other: TOTAL 39,000 25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Sexually Transmitted Disease Education and Testing 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. e---e_ � �•/,. I, January 31 , 2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Sexually Transmitted Disease Education and Testing 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Sexually Transmitted Disease Education and Testing 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. January 31 , 2019 Signature of Authorized Person (see checklist, 2nd item) Date ey_e_ v :e 4a-Cia—e-- Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island HIV/AIDS Foundation Program Name: Sexually Transmitted Disease Education and Testing 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Syphilis testing offered to all people testing for HIV and Hepatitis C 130 tests provided Confirmation, case management and treatment arranged for positive tests 100%positive tests Advertisement of STD services via HIHAF website, Facebook, and other Social Media 3-4 updates or newmessages/ STD prevention out-reach activities at heath fairs, businesses and public events. 6-7 events/year STD prevention at local Secondary Schools and Universities/Colleges for students -8 events/year TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 15,000 Professional Fees Operations 2,500 Supplies 3,500 Equipment Other: Staff Mileage 1,000 Other: Advertisement 2,000 Other: Training 1,000 Other: Other: TOTAL 25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hawaii Island Home for Recovery, Inc. HIHR Food Pantry Outreach 86 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Food Pantry Outreach Agency Director: Rita Sandi Palma Phone No.: (808) 649 - 9442 Contact Person: Rita Sandi Palma Phone No.: (808) 934 - 7852 Mailing Address: Address: Address: 440 Kapiolani St. City,ST,Zip Hilo,HI.96720-3937 Facility Address: Address: Same as above Address: City,ST,Zip Email Address: rpalma111@yahoo.com Fax No.: (808 ) 935 - 7894 Accountant/CPA: Alex J.Smith Phone No.: (808) 257 - 6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: City,ST,Zip Honolulu,HI.96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $12,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna 0✓ Hamakua 0 North Kona 0 South Hilo 0 North Kohala 0 South Kona 0 North Hilo Q✓ South Kohala 0 Kalil Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns 0 Youth 0 Victims of Crimes 0 Culture and the arts 0 Aged 0✓ Victims of Health or Social Crises 0 Needs of the poor 0 Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Food Pantry Outreach 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 N/A $7,375.00 $7,925.00 2.Agency Mission Statement: HIHR Programs Mission is to Serves the Single Adult Homeless Population with mental illnesses,substance abuse disorders, dual diagnosis with physical,health and other disabilities,prioritizing the Chronically Homeless Individuals. The programs help focus homeless individuals to achieve specific goals that includes but is not limited to:obtaining and maintaining Transitional Housing,Supportive Permanent Housing and long term Permanent Housing,improving their life's and general skills,increasing personal income,enhancing self-determination for pursuing life goals and dreams. HIHR will continue to provide Housing Services with Evidence-Based and Low Barrier Service Models,as well as Coordinated Data Entry System VI-SPDAT and the Housing First Model Approached. 3. Program Description: HIHR has provided Homeless Shelter Services since 2002.Adding the Food Pantry Service increases the well-being of all residents,an independent healthier living residency facility that serves the Single Adult Homeless Population with mental illnesses,substance abuse disorders,dual diagnosis with physical,health and other disabilities,prioritizing the Chronically Homeless Individuals.HIHR utilizes quick books software for financial tracking,which is subcontracted,to a professional bookkeeper and an independent auditing firm conducts financial audits and tax returns. HIHR has a successful experience with a high level of expertise in assisting homeless and chronically homeless individuals to overcome and or better handle their multiple barriers,including primarily mental illnesses,substance abuse disorders,dual diagnosis, physical disabilities and general health problems in order to help them become Housed and or Permanent Housing ready for their self-sufficiency. HIHR has trained staff that provides care coordination creating the needed infrastructure to implement our service goals,asses and creates Individualized Service Plans(ISP)including case management,job training,job placement,substance abuse/mental health treatment,healthcare,living skills,financial training,education,housing resources, entitlements,parenting,domestic violence services,recreational activities,holistic,spiritual and other social services.These Service Plans may also include individual and group skills development services,vocational and employment,services at HIHR main facility with optional link to additional services and resources coordinate with multiple local community service providers, and in some instances with Island wide,State,and Nationwide public and private services providers. HIHR provides these range of Services and Individualized Service Plans to address the significant unmet needs of our homeless population in the Big Island,a caring living environment that helps restores some individuals to a sounder more balance mind,body and spirit,to live independently becoming contributing members to their communities. 4.Total Budget& Position Count: Total Program Budget: $16,000.00 Total Program Position Count: 2 @ 0.5 Total Agency Budget: $709,510.00 Total Agency Position Count: 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Food Pantry Outreach 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate HIHR Food Pantry Outreach $1,000.00 Hawaii Island United Way $3,000.00 County of Hawaii Non-Profit Grants $12000.00 TOTAL: $16,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HIHR actively search all other potential or possible sources of additional grants,funds and general resources available among others like Federal,State,County, Institutional,public and or Private Entities. HIHR secured additional funding FY18-19 and FY19-20 with Hawaii Island United Way national campaign for their Emergency Food Shelter Program EFSP Phases 34 and 35 respectable. 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR works to achieve all program goals,as stated above in the Mission Statement and Program Description,promoting and strengthening the ability of the Homeless and Chronically Homeless to live healthier in balance and independently. HIHR wholesome living environment promotes and encourages the reestablishing of adult individuals to a sound and unblemished mind,body and spirit. HIHR program goals greatly increase the success of residents when complemented with additional benefits like the Food Pantry Service at our facility. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Food Pantry Outreach 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Provide Hot Serve meals as per funds to Program Residents 100% Provide Bag meals as per funds to Program Residents 100% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $4,000.00 $4,000.00 $2,000.00 Professional Fees Operations $1,500.00 $1,500.00 $1,000.00 Supplies $7,425.00 $10,500.00 $9,000.00 Equipment Other: Other: Other: Other: Other: TOTAL $12,925.00 $16,000.00 $12,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Food Pantry Outreach 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted: Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. EXECUTIVE DIRECTOR 4 G? 2019/01 /29 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Food Pantry Outreach 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Food Pantry Outreach is. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 2019/01 /29 Signature of Authorized Person (see checklist, 2nd item) Date EXECUTIVE DIRECTOR Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Food Pantry Outreach 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Provide Hot Serve meals as per funds to Program Residents. 100% Provide Bag meals as per funds to Program Residents. 100% TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $2,000.00 Professional Fees Operations $1,000.00 Supplies $9,000.00 Equipment Other: Other: Other: Other: Other: TOTAL $12,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hawaii Island Home for Recovery, Inc. HIHR Permanent Supportive Housing Program #1 87 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #1 Agency Director: Rita Sandi Palma Phone No.: (808) 649 - 9442 Contact Person: Rita Sandi Palma Phone No.: (808) 934 - 7852 Mailing Address: Address: Address: 440 Kapiolani St. City,ST,Zip Hilo,HI.96720-3937 Facility Address: Address: Same as above Address: City,ST,Zip Email Address: rpalma111@yahoo.com Fax No.: (808 ) 935 - 7894 Accountant/CPA: Alex J.Smith Phone No.: (808) 257 - 6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: City,ST,Zip Honolulu,HI.96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $39,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna Q✓ Hamakua ✓❑ North Kona ✓�South Hilo p✓ North Kohala ✓0 South Kona p✓ North Hilo Q✓ South Kohala El Ka1.1 Services or Activities To Be Provided: (One or more can be checked) p Educational concerns ❑Youth ❑✓ Victims of Crimes ❑Culture and the arts Q✓ Aged 0✓ Victims of Health or Social Crises Q✓ Needs of the poor Ei Physical/Emotional Disabilities [I Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #1 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $14,500.00 $11,250.00 $7,613.00 2.Agency Mission Statement: y HIHR Programs Mission is to Serves the Single Adult Homeless Population with mental illnesses,substance abuse disorders, dual diagnosis with physical,health and other disabilities,prioritizing the Chronically Homeless Individuals. The programs help focus homeless individuals to abhieve specific goals that includes but is not limited to:obtaining and maintaining Transitional Housing,Supportive Permanent Housing and long term Permanent Housing,improving their life's and general skills,increasing personal income,enhancing self-determination for pursuing life goals and dreams. HIHR will continue to provide Housing Services with Evidence-Based and Low Barrier Service Models,as well as Coordinated Data Entry System VI-SPDAT and the Housing First Model Approached. 3. Program Description: HIHR has been providing Homeless Shelter Services since 2002,adding Transitional Housing Shelter Services since 2006,and Permanent Supportive Housing Services since 2011,an independent healthier living residency facility that serves the Single Adult Homeless Population with mental illnesses,substance abuse disorders,dual diagnosis with physical,health and other disabilities,prioritizing the Chronically Homeless Individuals. HIHR utilizes quick books software for financial tracking,which is subcontracted,to a professional bookkeeper and an independent auditing firm conducts financial audits and tax returns. HIHR has a successful experience with a high level of expertise in assisting homeless and chronically homeless individuals to overcome and or better handle their multiple barriers,including primarily mental illnesses,substance abuse disorders,dual diagnosis,physical disabilities and general health problems in order to help them become Housed and or Permanent Housing ready for their self-sufficiency.HIHR has trained staff that provides care coordination creating the needed infrastructure to implement our service goals,asses and creates Individualized Service Plans(ISP)including case management,job training,job placement,substance abuse/mental health treatment,healthcare,living skills,financial training,education,housing resources, entitlements,parenting,domestic violence services,recreational activities,holistic,spiritual and other social services.These Service Plans may also include individual and group skills development services,vocational and employment,services at HIHR main facility with optional link to additional services and resources coordinate with multiple local community service providers, and in some instances with Island wide,State,and Nationwide public and private services providers. HIHR provides these range of Services and Individualized Service Plans to address the significant unmet needs of our homeless population in the Big Island,a caring living environment that helps restores some individuals to a sounder more balance mind,body and spirit,to live independently becoming contributing members to their communities. 4.Total Budget&Position Count: Total Program Budget: $291,137.00 Total Program Position Count: 4 Total Agency Budget: $709,510.00 Total Agency Position Count: 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #1 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate HUD-CoC Grant/Administer by State Of Hawaii-DHS-HPO $184,304.00 HIHR-Program Fees $60,243.00 Hawaii Island United Way $6,000.00 Other Funds $1,500.00 County of Hawaii $39,000.00 TOTAL: $291,137.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HIHR actively search all other potential or possible sources of additional grants,funds and general resources available among others like Federal,State,County, Institutional,public and or Private Entities. HIHR active searching history clearly shows the development and expansion of our agency programs like Permanent Supportive Housing which was made possible in part with Federal Grants via HUD and its program initiative Continuum of Care COC, administrated by HPO of DHS of the State of Hawaii. HUD-COC funding was afforded for the period Nov 2011-Oct 2015,and lately additional funding for the current fiscal period of Nov 2015-Oct 2020 with an annual contract renewal agreement,concurrently HIHR has secure with HUD-COC an extended designation of service provider for a 15 years period form Nov 2015-2030. More Importantly as of July 27,2018 Hawaii Island Home for Recovery, Inc.(HIHR)was Designated Approved as a Direct Recipient by HUD_COC,ending many years of contracting as Sub-recipients under HPO of DHS of the State of Hawaii. 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR works to achieve all program goals,as stated above in the Mission Statement and Program Description,promoting and strengthening the ability of the Homeless and Chronically Homeless to live healthier in balance and independently. HIHR wholesome living environment promotes and encourages the reestablishing of adult individuals to a sound and unblemished mind,body and spirit. As participants are assessed,the Case Manager coordinates HIHR resources and community based programs that will help to manage the obstacles that interfere with resident's ability to meet the obligations of housing and other needs they may have. Case Manager promotes the participation in a variety of programs that improves housing stability. HIHR Case Manager/Care Coordinator maintains bi-weekly meetings to process and follow-up activities,also conduct team meetings with providers including probation officers,mental health,substance abuse and medical case managers as part of the support system to follow-up with the goals and objectives of the Individualized Service Plan(ISP)enhancing their well-being. Most chronically homeless population deals with dual diagnosis(substance abuse/mental health)as well as physical conditions that limit them to have the ability to secure employment,HIHR makes referrals to job development agencies as well as General Assistance,Social Security benefits,or other mainstream services to increase income and stability. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 Countyof Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Su sportive Housing Program #1 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Case Manager,Comprehensive Assessment,and Individual Service Plan(ISP). 100% Health/Mental Health/Substance Abuse Treatment Services. 100% Life Skills Trainings in HIHR Programs and or Other Community Providers. 90% Maintain Housing and at exit of program to obtain and Maintain Permanent Housing. 70% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $94,673.00 $112,060.00 $25,000.00 professional Fees $15,700.00 $15,700.00 Operations $98,944.00 $121,844.00 $9,000.00 Supplies - $27,190.00 $41,533.00 $5,000.00 Equipment Other: Other: Other: Other: Other: TOTAL $236,507.00 $291,137.00 $39,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #1 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. EXECUTIVE DIRECTOR al2019/01 /29 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #1 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #1 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of allgrant funds received duringthegrantperiod (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 2019/01 /29 Signature of Authorized Person (see checklist, 2nd item) Date EXECUTIVE DIRECTOR Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #1 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Case Manager,Comprehensive Assessment,and Individual Service Plan(ISP). 100% Health/Mental Health/Substance Abuse Treatment Services. 100% Life Skills Trainings in HIHR Programs and or Other Community Providers. 90% Maintain Housing and at exit of program to obtain and Maintain Permanent Housing. 70% TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $25,000.00 Professional Fees Operations $9,000.00 Supplies $5,000.00 Equipment Other: Other: Other: Other: Other: TOTAL $39,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hawaii Island Home for Recovery, Inc. HIHR Permanent Supportive Housing Program #2 88 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #2 Agency Director: Rita Sandi Palma Phone No.: (808) 649 - 9442 Contact Person: Rita Sandi Palma Phone No.: (808) 934 - 7852 Mailing Address: Address: Address: 440 Kapiolani St. City,ST,Zip Hilo, HI.96720-3937 Facility Address: Address: Same as above Address: City,ST,Zip Email Address: rpalma111@yahoo.com Fax No.: (808 ) 935 - 7894 Accountant/CPA: Alex J.Smith Phone No.: (808) 257 - 6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: City,ST,Zip Honolulu,HI.96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $12,000 Geographical Areas To Be Served: (One or more can be checked) 0✓ Puna Hamakua North Kona []✓ South Hilo ✓0 North Kohala 0 South Kona North Hilo 0 South Kohala 0✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns 0 Youth 0 Victims of Crimes 0 Culture and the arts Q Aged 2 Victims of Health or Social Crises ✓l Needs of the poor El Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #2 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 N/A $5,625.00 $6,300.00 2.Agency Mission Statement: HIHR Programs Mission is to Serves the Single Adult Homeless Population with mental illnesses,substance abuse disorders, dual diagnosis with physical,health and other disabilities,prioritizing the Chronically Homeless Individuals. The programs help focus homeless individuals to achieve specific goals that includes but is not limited to:obtaining and maintaining Transitional Housing,Supportive Permanent Housing and long term Permanent Housing,improving their life's and general skills,increasing personal income,enhancing self-determination for pursuing life goals and dreams. HIHR will continue to provide Housing Services with Evidence-Based and Low Barrier Service Models,as well as Coordinated Data Entry System VI-SPDAT and the Housing First Model Approached. 3. Program Description: HIHR has been providing Homeless Shelter Services since 2002,adding Transitional Housing Shelter Services since 2006,and Permanent Supportive Housing Services since 2011,an independent healthier living residency facility that serves the Single Adult Homeless Population with mental illnesses,substance abuse disorders,dual diagnosis with physical,health and other disabilities,prioritizing the Chronically Homeless Individuals. HIHR utilizes quick books software for financial tracking,which is subcontracted,to a professional bookkeeper and an independent auditing firm conducts financial audits and tax returns. HIHR has a successful experience with a high level of expertise in assisting homeless and chronically homeless individuals to overcome and or better handle their multiple barriers,including primarily mental illnesses,substance abuse disorders,dual diagnosis,physical disabilities and general health problems in order to help them become Housed and or Permanent Housing ready for their self-sufficiency. HIHR has trained staff that provides care coordination creating the needed infrastructure to implement our service goals,asses and creates Individualized Service Plans(ISP)including case management,job training,job placement,substance abuse/mental health treatment,healthcare,living skills,financial training,education,housing resources, entitlements,parenting,domestic violence services, recreational activities,holistic,spiritual and other social services.These Service Plans may also include individual and group skills development services,vocational and employment,services at HIHR main facility with optional link to additional services and resources coordinate with multiple local community service providers, and in some instances with Island wide,State,and Nationwide public and private services providers. HIHR provides these range of Services and Individualized Service Plans to address the significant unmet needs of our homeless population in the Big Island,a caring living environment that helps restores some individuals to a sounder more balance mind,body and spirit,to live independently becoming contributing members to their communities. 4.Total Budget&Position Count: Total Program Budget: $$64,641.00 Total Program Position Count: 2 Total Agency Budget: $709,510.00 Total Agency Position Count: 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #2 S. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate HUD-CoC Grant/Administer by State Of Hawaii-DHS-HPO $42,341.00 HIHR-Program Fees $10,300.00 County of Hawaii $ 12,000.00 TOTAL: $64,641.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HIHR actively search all other potential or possible sources of additional grants,funds and general resources available among others like Federal,State,County, Institutional,public and or Private Entities. HIHR active searching history clearly shows the development and expansion of our agency programs like Permanent Supportive Housing which was made possible in part with Federal Grants via HUD and its program initiative Continuum of Care COC, administrated by HPO of DHS of the State of Hawaii. HUD-COC funding was afforded for the period Nov 2011-Oct 2015,and lately additional funding for the current fiscal period of Nov 2015-Oct 2020 with an annual contract renewal agreement,concurrently HIHR has secure with HUD-COC an extended designation of service provider for a 15 years period form Nov 2015-2030. More Importantly as of July 27,2018 Hawaii Island Home for Recovery, Inc.(HIHR)was Designated Approved as a Direct Recipient by HUD_COC,ending many years of contracting as Sub-recipients under HPO of DHS of the State of Hawaii. 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR works to achieve all program goals,as stated above in the Mission Statement and Program Description,promoting and strengthening the ability of the Homeless and Chronically Homeless to live healthier in balance and independently. HIHR wholesome living environment promotes and encourages the reestablishing of adult individuals to a sound and unblemished mind,body and spirit. As participants are assessed,the Case Manager coordinates HIHR resources and community based programs that will help to manage the obstacles that interfere with resident's ability to meet the obligations of housing and other needs they may have. Case Manager promotes the participation in a variety of programs that improves housing stability. HIHR Case Manager/Care Coordinator maintains bi-weekly meetings to process and follow-up activities,also conduct team meetings with providers including probation officers,mental health,substance abuse and medical case managers as part of the support system to follow-up with the goals and objectives of the Individualized Service Plan(ISP)enhancing their well-being. Most chronically homeless population deals with dual diagnosis(substance abuse/mental health)as well as physical conditions that limit them to have the ability to secure employment, HIHR makes referrals to job development agencies as well as General Assistance,Social Security benefits,or other mainstream services to increase income and stability. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #2 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Case Manager,Comprehensive Assessment,and Individual Service Plan(ISP). 100% Health/Mental Health/Substance Abuse Treatment Services. 100% Life Skills Trainings in HIHR Programs and or Other Community Providers. 90% Maintain Housing and at exit of program to obtain and Maintain Permanent Housing. 70% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $26,066.00 $27,766.00 $8,000.00 Professional Fees $2,700.00 $2,700.00 Operations $18,508.00 $24,508.00 $3,000.00 Supplies $6,366.00 $9,667.00 $1,000.00 Equipment Other: Other: Other: Other: Other: TOTAL $53,640.00 $64,641.00 $12,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #2 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director O The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result In measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. EXECUTIVE DIRECTOR , al 2019/01 /29 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #2 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov,complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #2 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. le a t 2019/01 /29 Signature of Authorized Person (see checklist, 2nd item) Date EXECUTIVE DIRECTOR Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #2 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Case Manager,Comprehensive Assessment,and Individual Service Plan(ISP). t00 Health/Mental Health/Substance Abuse Treatment Services. 100% Life Skills Trainings in HIHR Programs and or Other Community Providers. 90% Maintain Housing and at exit of program to obtain and Maintain Permanent Housing. 70% TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $8,000.00 Professional Fees Operations $3,000.00 Supplies $1,000.00 Equipment Other: Other: Other: Other: Other: TOTAL $12,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hawaii Island Home for Recovery, Inc. HIHR Permanent Supportive Housing Program #3 89 County of.JIawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #3 Agency Director: Rita Sandi Palma Phone No.: (808) 649 — 9442 Contact Person: Rita Sandi Palma Phone No.: (808) 934 — 7852 Mailing Address: Address: Address: 440 Kapiolani St. City,ST,Zip Hilo, HI.96720-3937 Facility Address: Address: Same as above Address: City,ST,Zip Email Address: rpalma111@yahoo.com Fax No.: (808 ) 935 — 7894 Accountant/CPA: Alex J.Smith Phone No.: (808) 257 — 6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: City,ST,Zip Honolulu,HI.96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $18,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna 0✓ Hamakua ✓0 North Kona 0 South Hilo []✓ North Kohala 0 South Kona ✓0 North Hilo 0 South Kohala ✓Q Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓0 Educational concerns D Youth El Victims of Crimes 0 Culture and the arts 0 Aged 0 Victims of Health or Social Crises ✓0 Needs of the poor 0 Physical/Emotional Disabilities 0✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #3 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 N/A $5,625.00 $6,300.00 2.Agency Mission Statement: HIHR Programs Mission is to Serves the Single Adult Homeless Population with mental illnesses,substance abuse disorders, dual diagnosis with physical,health and other disabilities,prioritizing the Chronically Homeless Individuals. The programs help focus homeless individuals to achieve specific goals that includes but is not limited to:obtaining and maintaining Transitional Housing,Supportive Permanent Housing and long term Permanent Housing, improving their life's and general skills,increasing personal income,enhancing self-determination for pursuing life goals and dreams. HIHR will continue to provide Housing Services with Evidence-Based and Low Barrier Service Models,as well as Coordinated Data Entry System VI-SPDAT and the Housing First Model Approached. 3. Program Description: HIHR has been providing Homeless Shelter Services since 2002,adding Transitional Housing Shelter Services since 2006,and Permanent Supportive Housing Services since 2011,an independent healthier living residency facility that serves the Single Adult Homeless Population with mental illnesses,substance abuse disorders,dual diagnosis with physical,health and other disabilities, prioritizing the Chronically Homeless Individuals. HIHR utilizes quick books software for financial tracking,which is subcontracted,to a professional bookkeeper and an independent auditing firm conducts financial audits and tax returns. HIHR has a successful experience with a high level of expertise in assisting homeless and chronically homeless individuals to overcome and or better handle their multiple barriers,including primarily mental illnesses,substance abuse disorders,dual diagnosis,physical disabilities and general health problems in order to help them become Housed and or Permanent Housing ready for their self-sufficiency. HIHR has trained staff that provides care coordination creating the needed infrastructure to implement our service goals,asses and creates Individualized Service Plans(ISP)including case management,job training,job placement,substance abuse/mental health treatment,healthcare,living skills,financial training,education,housing resources, entitlements,parenting,domestic violence services, recreational activities, holistic,spiritual and other social services.These Service Plans may also include individual and group skills development services,vocational and employment,services at HIHR main facility with optional link to additional services and resources coordinate with multiple local community service providers, and in some instances with Island wide,State,and Nationwide public and private services providers. HIHR provides these range of Services and Individualized Service Plans to address the significant unmet needs of our homeless population in the Big Island,a caring living environment that helps restores some individuals to a sounder more balance mind,body and spirit,to live independently becoming contributing members to their communities. 4.Total Budget& Position Count: Total Program Budget: $ 101,660.00 Total Program Position Count: 2 Total Agency Budget: $ 709,510.00 Total Agency Position Count: 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #3 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate HUD-CoC Grant/Administer by State Of Hawaii-DHS-HPO $70,660.00 HIHR-Program Fees $13,000.00 County of Hawaii $ 18,000.00 TOTAL: $101,660.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HIHR actively search all other potential or possible sources of additional grants,funds and general resources available among others like Federal,State,County, Institutional,public and or Private Entities. HIHR active searching history clearly shows the development and expansion of our agency programs like Permanent Supportive Housing which was made possible in part with Federal Grants via HUD and its program initiative Continuum of Care COC, administrated by HPO of OHS of the State of Hawaii. HUD-COC funding was afforded for the period Nov 2011-Oct 2015,and lately additional funding for the current fiscal period of Nov 2015-Oct 2020 with an annual contract renewal agreement,concurrently HIHR has secure with HUD-COC an extended designation of service provider for a 15 years period form Nov 2015-2030. More Importantly as of July 27,2018 Hawaii Island Home for Recovery,Inc. (HIHR)was Designated Approved as a Direct Recipient by HUD_COC,ending many years of contracting as Sub-recipients under HPO of OHS of the State of Hawaii. 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR works to achieve all program goals,as stated above in the Mission Statement and Program Description,promoting and strengthening the ability of the Homeless and Chronically Homeless to live healthier in balance and independently. HIHR wholesome living environment promotes and encourages the reestablishing of adult individuals to a sound and unblemished mind,body and spirit. As participants are assessed,the Case Manager coordinates HIHR resources and community based programs that will help to manage the obstacles that interfere with resident's ability to meet the obligations of housing and other needs they may have. Case Manager promotes the participation in a variety of programs that improves housing stability. HIHR Case Manager/Care Coordinator maintains bi-weekly meetings to process and follow-up activities,also conduct team meetings with providers including probation officers,mental health,substance abuse and medical case managers as part of the support system to follow-up with the goals and objectives of the Individualized Service Plan(ISP)enhancing their well-being. Most chronically homeless population deals with dual diagnosis(substance abuse/mental health)as well as physical conditions that limit them to have the ability to secure employment, HIHR makes referrals to job development agencies as well as General Assistance,Social Security benefits,or other mainstream services to increase income and stability. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #3 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (Le.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Case Manager,Comprehensive Assessment,and Individual Service Plan(ISP). 100% Health/Mental Health/Substance Abuse Treatment Services. 100% Life Skills Trainings in HIHR Programs and or Other Community Providers. 90% Maintain Housing and at exit of program to obtain and Maintain Permanent Housing. 70% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $37,925.00 $42,625.00 $11,000.00 Professional Fees $3,500.00 $3,500.00 Operations $30,004.00 $40,204.00 $5,000.00 Supplies $9,575.00 $15,331.00 $2,000.00 Equipment Other: Other: Other: Other: Other: TOTAL $81,004.00 $ 101,660.00 $18,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #3 so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. EXECUTIVE DIRECTOR c5 /� 2019/01 /29 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #3 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #3 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. a 2019/01 /29 Signature of Authorized Person (see checklist, 2nd item) Date EXECUTIVE DIRECTOR Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Permanent Supportive Housing Program #3 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Case Manager,Comprehensive Assessment,and Individual Service Plan(ISP). 100% Health/Mental Health/Substance Abuse Treatment Services. 100% Life Skills Trainings in HIHR Programs and or Other Community Providers. 90° Maintain Housing and at exit of program to obtain and Maintain Permanent Housing. 70% TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $11,000.00 Professional Fees Operations $5,000.00 Supplies $2,000.00 Equipment Other: Other: Other: Other: Other: TOTAL $18,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hawaii Island Home for Recovery, Inc. HIHR Transitional Housing Program 90 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Transitional Housing Program Agency Director: Rita Sandi Palma Phone No.: (808) 649 - 9442 Contact Person: Rita Sandi Palma Phone No.: (808) 934 - 7852 Mailing Address: Address: Address: 440 Kapiolani St. City,ST,Zip Hilo, HI.96720-3937 Facility Address: Address: Same as above Address: City,ST,Zip Email Address: rpalma111@yahoo.com Fax No.: (808 ) 935 - 7894 Accountant/CPA: Alex J.Smith Phone No.: (808) 257 - 6484 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: City,ST,Zip Honolulu, HI.96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $39,000 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna ❑✓ Hamakua 0 North Kona ✓p South Hilo ❑✓ North Kohala ❑✓ South Kona ✓❑ North Hilo ['South Kohala p Ka`u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ❑Youth ✓❑Victims of Crimes ❑Culture and the arts p Aged ✓❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Transitional Housing Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $13,750.00 $8,750.00 $7,425.00 2.Agency Mission Statement: HIHR Programs Mission is to Serves the Single Adult Homeless Population with mental illnesses,substance abuse disorders, dual diagnosis with physical,health and other disabilities,prioritizing the Chronically Homeless Individuals. The programs help focus homeless individuals to achieve specific goals that includes but is not limited to:obtaining and maintaining Transitional Housing,Supportive Permanent Housing and long term Permanent Housing, improving their life's and general skills,increasing personal income,enhancing self-determination for pursuing life goals and dreams. HIHR will continue to provide Housing Services with Evidence-Based and Low Barrier Service Models,as well as Coordinated Data Entry System VI-SPDAT and the Housing First Model Approached. 3. Program Description: HIHR has been providing Homeless Shelter Services since 2002,adding Transitional Housing Shelter Services since 2006,an independent healthier living residency facility that serves the Single Adult Homeless Population with mental illnesses,substance abuse disorders,dual diagnosis with physical,health and other disabilities,prioritizing the Chronically Homeless Individuals. HIHR utilizes quick books software for financial tracking,which is subcontracted,to a professional bookkeeper and an independent auditing firm conducts financial audits and tax returns. HIHR has a successful experience with a high level of expertise in assisting homeless and chronically homeless individuals to overcome and or better handle their multiple barriers,including primarily mental illnesses,substance abuse disorders,dual diagnosis,physical disabilities and general health problems in order to help them become Housed and or Permanent Housing ready for their self-sufficiency. HIHR has trained staff that provides care coordination creating the needed infrastructure to implement our service goals,asses and creates Individualized Service Plans(ISP)including case management,job training,job placement,substance abuse/mental health treatment,healthcare,living skills,financial training,education,housing resources, entitlements,parenting,domestic violence services,recreational activities,holistic,spiritual and other social services.These Service Plans may also include individual and group skills development services,vocational and employment,services at HIHR main facility with optional link to additional services and resources coordinate with multiple local community service providers, and in some instances with Island wide,State,and Nationwide public and private services providers. HIHR provides these range of Services and Individualized Service Plans to address the significant unmet needs of our homeless population in the Big Island,a caring living environment that helps restores some individuals to a sounder more balance mind,body and spirit,to live independently becoming contributing members to their communities. 4.Total Budget& Position Count: • Total Program Budget: $237,072.00 Total Program Position Count: 3.5 Total Agency Budget: $709,510.00 Total Agency Position Count: 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Transitional Housing Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate State Of Hawaii-DHS-HPO $157,252.00 Hawaii Island United Way $8,000.00 HIHR-Program Fees $30,320.00 Other Funds $2,500.00 County of Hawaii $39,000.00 TOTAL: $237,072.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HIHR actively search all other potential or possible sources of additional grants,funds and general resources available among others like Federal,State,County, Institutional,public and or Private Entities. HIHR active searching history clearly shows the development and expansion of our agency programs like Transitional Housing Services which was supported in part,with funding from DHS-HPO of the State of Hawaii from Aug 2007-July 2011,with renewal funding from Aug 2011-July 2015 and with annual contract agreement renewals,including additional supplemental extensions up to the early 2017.And lately HIHR secured additional funding for the current fiscal period of Feb 2017-July 2021 with an annual contract renewal agreement. 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR works to achieve all program goals,as stated above in the Mission Statement and Program Description,promoting and strengthening the ability of the Homeless and Chronically Homeless to live healthier in balance and independently. HIHR wholesome living environment promotes and encourages the reestablishing of adult individuals to a sound and unblemished mind,body and spirit. As participants are assessed,the Case Manager coordinates HIHR resources and community based programs that will help to manage the obstacles that interfere with resident's ability to meet the obligations of housing and other needs they may have. Case Manager promotes the participation in a variety of programs that improves housing stability. HIHR Case Manager/Care Coordinator maintains bi-weekly meetings to process and follow-up activities,also conduct team meetings with providers including probation officers,mental health,substance abuse and medical case managers as part of the support system to follow-up with the goals and objectives of the Individualized Service Plan(ISP)enhancing their well-being. Most chronically homeless population deals with dual diagnosis(substance abuse/mental health)as well as physical conditions that limit them to have the ability to secure employment,HIHR makes referrals to job development agencies as well as General Assistance,Social Security benefits,or other mainstream services to increase income and stability. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Transitional Housing Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Case Manager,Comprehensive Assessment,and Individual Service Plan(ISP). 100% Health/Mental Health/Substance Abuse Treatment Services. 100% Life Skills Trainings in HIHR Programs and or Other Community Providers. 90% Maintain Housing and at exit of program to obtain and Maintain Permanent Housing. 70% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 1849 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $97,342.00 $114,917.00 $25,000.00 Professional Fees $17,600.00 $17,600.00 Operations $65,054.00 $74,054.00 $9,000.00 Supplies $25,501.00 $30,501.00 $5,000.00 Equipment Other: Other: Other: Other: Other: TOTAL $205,497.00 $237,072.00 $39,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Transitional Housing Program so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the"No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): • Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor The Managing Director ❑ The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist,check here. EXECUTIVE DIRECTOR /&2 c5a42144Zihtd. 2019/01 /29 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Transitional Housin. Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Transitional Housing Program i.1. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 2019/01 /29 Signature of Authorized Person (see checklist, 2nd item) Date EXECUTIVE DIRECTOR Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Island Home for Recovery, Inc. (HIHR) Program Name: HIHR Transitional Housing Pro.ram 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Case Manager,Comprehensive Assessment,and Individual Service Plan(ISP). 100% Health/Mental Health/Substance Abuse Treatment Services. 100% Life Skills Trainings at HIHR Programs and or Other Community Providers. 90% Maintain Housing and at exit of program to obtain and Maintain Permanent Housing. 70% TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $25,000.00 Professional Fees Operations $9,000.00 Supplies $5,000.00 Equipment Other: Other: Other: Other: Other: TOTAL $39,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 • Hawai'i Wildfire Management Organization Hawai'i Island Wildfire Prevention 91 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Wildfire Management Organization Program Name: Hawaii Island Wildfire Prevention Agency Director: Elizabeth Pickett Phone No.: (808) 885 — 0900 Contact Person: Elizabeth Pickett Phone No.: ( ) — Mailing Address: Address: 65-1279 Kawaihae Rd.Ste 211 Address: City,ST,Zip Kamuela, HI 96743 Facility Address: Address: 65-1279 Kawaihae Rd. Ste 211 Address: City,ST,Zip Kamuela, HI 96743 Email Address: elizabeth@hawaiiwildfire.org Fax No.: (n/a ) — Accountant/CPA: Patricia Schumaker Phone No.: (480 ) 584 — 4344 Firm (if applicable): Schumaker Tax and Accounting P.C. Mailing Address: Address: PO Box 395 Address: City,ST,Zip Dewey,AZ 86327 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 44,000 Geographical Areas To Be Served: (One or more can be checked) • Puna 0 Hamakua 0 North Kona 0 South Hilo 0 North Kohala 0 South Kona O North Hilo 0 South Kohala 0 Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ❑Victims of Crimes ❑Culture and the arts 0 Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 ' County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Wildfire Management Organization Program Name: Hawaii Island Wildfire Prevention 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $7,175.00 2. Agency Mission Statement: Hawaii Wildfire Management Organization's(HWMO) mission is to assist the people and places of Hawaii toward becoming wildfire-safe and wildfire-ready,to serve as a hub of wildfire prevention, hazard reduction,and fire planning activities in the region, and to lead proactive,cross-jursidiction, and forward-thinking wildfire-related projects that fill in existing agency gaps in service. Background: HWMO is a 501(c)(3) nonprofit organization that has been providing Hawaii Island with nationally recognized wildfire prevention and preparedness activities since 2000. We began focused in West Hawaii. Our early work helped protect Waikoloa from the largest fires in state history via fuel breaks and community education,we developed federally compliant community wildfire protection plans that made West Hawaii eligible for federal wildfire funds, and we increased firefighting capacity by installing helicopter water dip tanks across Northwest Hawaii Island.These successes led to people in all districts of Hawaii Island (and across the state)to request our assistance. In other states,the services HWMO provides are performed by government agencies but this is not the case in Hawaii. Hence,the need for what we do is often overlooked, but is essential to a wildfire-safe island and state. HWMO has become the hub of wildfire-related information and prevention projects. Hawaii Island is our hub and home-focus,and we also provide services across the state. Focal areas include: 1)Community-based wildfire preparedness outreach and education, including assisting communities in becoming nationally recognized Firewise Communities. 2) Hazard reduction projects to protect residential,commercial, and natural areas. 3) Improving firefighting capacity through training, equipment,water infrastructure, planning, and mapping. 4)Serving as a nonprofit arm for local firefighting and forestry agencies to implement collaborative,cross-boundary projects. 3. Program Description: Wildfire risk in increasing in all districts on Hawaii Island (even windward areas)due to changing climate, invasive species, and dense, unmanaged combustable vegetation. The National Weather Service just announced that the coming year will be an El Nino year,which will see much of Hawaii Island remaining at high fire risk well beyond the typical fire season. Again,this is true for all districts mauka to makai, not just for leeward lowland areas.The conditions that are setting up for 2019-20 are those that existed during all of Hawaii's most severe wildfire seasons. Firefighting is the last line of defense, is the most costly form of action,and does little to limit fire's impact on public health and safety, drinking water,forests, soils, and nearshore sedimentation that smothers coral reefs and destroys fisheries. Conversely, prevention education has been proven to significantly reduce wildfire occurrence, save money, limit the severity of wildfire impacts,and save lives and homes. HWMO has maintained a wildfire prevention program over the years that has included working with firefighters, natural resource managers, educators, and others across the island and state on projects that are regionally specific. For the 2019-20 program, we will ramp up community education and preparedness across Hawaii, particularly as fire risk is higher than usual. The program will develop and offer workshops, make and distribute materials that encourage and inform wildfire readiness, run frequent radio prevention ads, provide classroom materials to schools, and target several underrepresented groups, such as non-English speakers and those with disabilities to learn about how they can take action to protect their home,family, and community.Targeting these underrepresented groups as well as the general public and youth will be necessary for residents to be adequately informed and adequately motivated to take personal preparedness actions. The broader program goals and overall budget is for the entire state, but specific goals and budgets for each county have been developed. Detailed in this proposal are the objectives specific to Hawaii County that were collaboratively developed by local fire,forestry, and community partners. 4.Total Budget& Position Count: Total Program Budget: 180,500 Total Program Position Count: 3 Total Agency Budget: 344,000 Total Agency Position Count: 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Wildfire Management Organization Program Name: Hawaii Island Wildfire Prevention 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate USDA Forest Service 73.5K secured Firefighter Chili Cookoff Fundraiser 5K anticipated County of Hawaii Nonprofit Grant Program 42K this request State Grant-In-Aid 60K proposed TOTAL: 180,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HWMO has applied for State Grant-In-Aid funds to aid in our statewide wildfire prevention and preparedness education efforts, with$60,000 that will specifically go toward our efforts on Hawaii Island. HWMO has also secured funds through the USDA Forest Service for our larger statewide prevention program,$73,500 of which will be used toward efforts on Hawaii Island. In 2017 and 2018, we held our signature fundraising event-a firefighter chili cookoff,from which we were able to apply funds to both our overhead operational needs and our Hawaii Island outreach and education programs. We intend to hold another similar fundraising event in 2019 to again assist this program. Additionally,we have launched a fee-for-service initiative, wherein we are offering wildfire safety/Firewise home and yard assessments to homeowners as well as wildfire safety consulting services for land-use planning firms that we anticipate will bring in additional funds,that we can use toward our operational and program expenses. 7. Program Objectives Using County Nonprofit Grant Program Funds: HWMO is requesting operational funds to provide wildfire prevention and preparedness education across Hawaii Island, with the specific goal of immediately increasing public action toward the following: •Preventing wildfire ignitions. (98%of wildfires in Hawaii are started by people, 75%by accident— meaning 75%of fires are preventable if people know to take precautions). •Reducing the ability of wildfire to spread across lands and homes through vegetation management strategies. •Working proactively as neighborhoods/communities to reduce wildfire risk beyond the individual household level. In order to accomplish these larger goals for reducing wildfires across the island, it is imperative that: 1.The public receives multiple exposures to wildfire information to promote awareness and prevention. HWMO's objective is to accomplish this with an island-wide radio and print educational campaign coordinated to strategically take place at the start of wildfire season. 2. Provide information to accommodate and reach diverse people groups, especially those that are underrepresented in current materials. Hawaii Island has no wildfire preparedness information for people with disabilities and people needing language translations. HWMO's objective is to work with Hawaii Fire Department and other fire agencies working on the island(Army, National Park Service,State Forestry)to develop content for resources for these people groups, in addition to printing and providing materials for youth and the general public. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 ' County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Wildfire Management Organization Program Name: Hawaii Island Wildfire Prevention 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Radio and print wildfire preparedness education campaign for two months Populations in all districts exposed to wildfire Translate Wildfire Lookout!materials into a minumum of 4 languages, post, print,distribute Non-English residents wildfire-safe Develop wildfire prevention and preparedness materials for people with disabilities People w/disabilities wildfire-safe Print and provide wildfire preparedness info resources to all relevant county and state (cont'd from above)offices and fire stations where public can pick up Wide public access to wildfire safety materials Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 126,077 64,000 16,000 Professional Fees 576 2,500 500 Operations 43,802 34,000 12,500 Supplies 4,826 4,000 2,000 Equipment Other: Language translation services(contracted) 24,000 6,000 Other: Printing of wildfire preparedness informational resources 2,228 18,000 4,500 Other: Radio ads for island-wide coverage 2,500 10,000 2,500 Other: Other: TOTAL 177,509 180,500 44,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 ' County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Wildfire Management Organization Program Name: Hawaii Island Wildfire Prevention 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Elizabeth Pickett POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ ' Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. January 17, 2019 Signature-df Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 ' County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Wildfire Management Organization Program Name: Hawaii Island Wildfire Prevention 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 ' County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Wildfire Management Organization Program Name: Hawaii Island Wildfire Prevention 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. C4-C � January 17, 2019 Signature of Authorized Person (see checklist, 2nd item) Date 641cu.kv-e Ye Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hawaii Wildfire Management Organization Program Name: Hawaii Island Wildfire Prevention 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Radio and print wildfire preparedness education campaign for two months Populations in all districts P Pexposed to wildfire safety info Translate Wildfire Lookout!materials into a minumum of 4 languages, post, print,distribute Non-English residents wildfire-safe Develop wildfire prevention and preparedness materials for people with disabilities People w/disabilities wildfire-sa Print and provide wildfire preparedness info resources to all relevant county and state cont'd from above offices and fire stations where ublic canpick upWide public access to wildfire P safety materials TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 16,000 Professional Fees 500 Operations - 12,500 Supplies 2,000 Equipment Other: Language translation services (contracted) 6,000 Other: Printing of wildfire preparedness informational resources 4,500 Other: Radio ads for island-wide coverage 2,500 Other: Other: TOTAL 44,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Heart Ranch Heart Ranch 92 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Heart Ranch Program Name: Heart Ranch Agency Director: Anthony Harris Phone No.: (808 ) 640 —2232 Contact Person: Fronda Harris Phone No.: (808 ) 937 —9717 Mailing Address: Address: 380 Akolea Rd. Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 380 Akolea Rd. Address: City,ST,Zip Hilo, HI 96720 Email Address: tony@heartranch.org Fax No.: (808 )969 —7409 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) Puna I Hamakua ❑ North Kona ®South Hilo ❑ North Kohala ❑South Kona WI North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ® Educational concerns l Youth ®Victims of Crimes ❑Culture and the arts ❑Aged lI Victims of Health or Social Crises Needs of the poor Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Heart Ranch Program Name: Heart Ranch 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $4,500 $13,000 $10,250 2. Agency Mission Statement: The Heart Ranch Mission is: "To Build Confidence, Develop Leadership, and Encourage Personal Growth in children and families." The goals are measured by: 1) Build Confidence The demonstration of each participants body posture,open communication,and response to the animals. 2)Develop Leadership The practices by participants in approaching horses pro-actively, making decisions and not allowing the horse to dominate and lead;and by implementing the practice of slowly and fairly building phases of pressure from as light as possible to as much as necessary. 3)Encouraging Personal Growth in children and families Family attendance to sessions,events,and demonstrating involvement in the participant's experience by taking pictures,giving encouraging feedback,and asking questions at the end of sessions. 3. Program Description: The mentorship program was born out of the Harris'personal faith and has adopted the basic tenants of love and care.Each child is paired with a horse where life lessons such as,"do unto others",is taught first hand,and where care and concern breeds mutual love and respect. Self-confidence and leadership are developed by mastering control of a 1,000 pound animal-the horse;which provides the ultimate test of both as the horse naturally seeks its own boundaries. Horses require and seek leadership in order to have a successful partnership with a human.The child is faced with the decision to take the lead. If they do not,the horse will. One-on-one mentorship guides the child through this process with positive reinforcement, challenges, and encouragement for the child to take control. Mentors are one of a variety of volunteers at Heart Ranch,and there are no paid employees to date. Responsibility,work ethic,and life skills are reinforced in the chore phase.This is the time where many children start to build their relationship with their mentor;talking about life's challenges and observing their mentor as a positive role model who interacts with children and animals in a positive way. In addition,the horses,goats, dogs,and a bunny are all cared for.There are small garden projects and other self sustaining chores that children participate in. It is during this time that responsibility, work ethic,caring for the land,and daily life skills are learned. The session continues to the care of the horse. It is here that hygiene,animal stewardship,caring for others and animals, and having safe self boundaries flourish. Children learn the correct way to approach the horse,the cost of taking care of a horse,the anatomy of a horse, and the proper way to care for and handle the horse. (Continued on additional page) 4.Total Budget& Position Count: Total Program Budget: 46,500 Total Program Position Count: 44 Total Agency Budget: 46,500 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Heart Ranch Program Name: Heart Ranch S. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Private Donors 20,200 Hawaii County Grant 15,000 PTSD Health and Research Center-Veterans Program 7,200 EAP programs 1,500 Additional Club Grants 1,000 Fundraising 1,600 TOTAL: 46,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Private Donations continue to be the majority of the revenue. This year some of the private donors created fundraising on behalf of Heart Ranch. MoiMoiMarket.com for example has a mission pledge to give back 5%of their profits to Heart Ranch. Moi Moi additionally created an opportunity for our Impact Youth Volunteers to make bracelets,sold on their website and market booths,to bring more funds and awareness to Heart Ranch. Another volunteer hosted a Go Fund Me to raise funds for Heart Ranch. Another Volunteer hosted a Santa Surf Event on the Kona side,to both raise awareness and funds for Heart Ranch. Hurricane Lane did a great deal of damage to our arena,the road and additional feed costs were incurred. Approximately$3,000.was donated by several donors,to help repair the damage. The Annual Christmas Caroling Event has been held now for 6 years. Donations are sought from community members and clubs to give gifts for Heart Ranch children and families that attend. Donors have included Hawaii Horse Owners Club, Mirandas Country Store,Waiakea Lions Club, Lilio'ukalani Trust, KTA,HPM,Ben Franklin,Safeway,Walmart,Target, Dels,and Ironman, as well as private donors. Public Speaking-The founders have spoken to groups such as Kiwanis Service Club, CRU College group as well as a local church. They will schedule addiitional speaking appointments with service clubs and other groups as available and time allows. Fundraisers-Sales of shirts and hats also provide some potential for raising funds. Grant writing is attempted, like this one. PTSD Health and Research Center dontates to Heart Ranch as a service provider for each Veterans group. 7. Program Objectives Using County Nonprofit Grant Program Funds: Animal feed costs remain the biggest budgetary item each year.With the low quality,nutrition in the grass in our area,all of our animals need to be subsidized daily with additional feed.This includes hay and grain for our horses and goats.Along with feed costs,we purchase medicines,stall shavings,and supplements for the animals used in the program. Volunteering is at the center of what makes Heart Ranch,and we are completely dependent on the devoted volunteers. Our volunteer team loves to be here and to provide a safe environment of encouragement and love. Our Youth Volunteer Program is gives youth an opportunity to give back.Youth volunterers are mostly past participants of the program desiring an opportunity to build additional skills in working with horses and give back to others. Periodic retreats,camping,and activities in additioin to their weekly service time are scheduled to guide and nurture these youth with a special servant's heart,to a deeper and more consistent level. Financial costs to assist in supporting these activities is necessary to provide the mentorship.They are the future and are worthy of our time and commitment. In April of 2018,we redesigned the Youth Volunteer Program. It now includes 2 additional monthly group meetings, led by a Youth Volunteer Coordinator. These meetings are usually a dinner and games and include a talk about servant leadership. Riding meetings have been held at the end of each term with opportunities to work on personal horsemanship skills.This youth program is called"Impact". EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Heart Ranch Program Name: Heart Ranch 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) In 2018 we served 137 kids,with a total of 480 Individual Sessions and Self Confidence,Leadership,Personal Growth 31 Group Sessions. Heart Ranch has just completed its 7th year,with over 3500 total Self Image,Boundaries,Work Ethic,Respect sessions.We currently have 32 Adult and 12 Youth Volunteers.The EAP Program for Animal and Environment Care Veterans with PTSD, utilizes pre and post assessments to evaluate the quality and efficacy Development of a Servant's Heart of services received and to evaluate the program as a whole. Decreased PTSD symptoms including,anger, depressions,nightmares,and social isolation Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees 421 500 Operations 1540 1800 Supplies 29,329 30,000 15,000 Equipment 4,899 7,500 Other: Travel/Education 715 2,500 Other:Veterinarian 950 1,200 Other: Insurance 1,214 1,200 Other: COG 2,875 1,800 Other: TOTAL 41,943 46,500 15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 Countyof Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Heart Ranch Program Name: Heart Ranch 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: V/ If no conflicts exist,check here. • . �C0.2141 / 1-7 I Sigr$ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 • Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Heart Ranch Program Name: Heart Ranch 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Heart Ranch Program Name: Heart Ranch 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (see checklist, 2nd item) Date ?If e Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Heart Ranch Program Name: Heart Ranch 12. COUNCIL AWARD WORKSHEET TABLE I: • PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Self Confidence,Leadership, Personal Growth Self Image,Boundaries,Work Ethic,Respect Animal and Environment Care Development of a Servant's Heart Decreased PTSD symptoms ncluding,anger, iepressions,nightmares,and social isolation TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 0 Professional Fees Operations - Supplies 15,000 Equipment Other: Travel/Education Other: Veterinarian Other: Insurance Other: COG Other: TOTAL 15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Heart Ranch Program Name: Heart Ranch • 3. Program Description Continued: Finally,the children go into the riding portion of the session where their confidence to lead the horse is put into play.This time also teaches awareness and the importance of following direction. Reading and interpreting behavior in addition to appropriate responses and trust are just some of the things that children are able to learn and develop during the riding portion of their session. Our enclosed family area allows family involvement to be a big part of the Heart Ranch experience, because family life is such an integral part of personal development during these formative years, our program supports and encourages the family as well. Heart Ranch takes a holistic approach in the development of youth and family.This is where families can spend time with siblings of participants and observe mentors modeling positive interaction with their child and others. Any child, aged 8-18,who wants to participate in the program is eligible and welcome. The program is FREE of charge for all participants.Typically, opportunities with horses are reserved for privileged higher economic children. In our program,the primary group is underprivileged youth, with most participants coming from disadvantaged socio-economic backgrounds. We serve children with various special circumstances, including those with ADD/ADHD, Autism,Asperger's Syndrome, and family crisis such as divorce, abuse, and abandonment. Many of our participants are foster children, newly adopted, and referrals from therapists as well as Hawaii County and private mental health agencies. Participants also come from families where a parent, or in some cases both, has passed away, and/or are incarcerated. No special circumstance is required, however,to participate. It is our thinking that adolescence is a difficult and challenging phase of life, no matter how idyllic the family life might seem. If we, (human leaders, horses, ranch environment, and other animals), can be a support and encouragement by mentoring through this process, through love and encouraging words, our goals are being achieved. County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Heart Ranch Program Name: Heart Ranch 3. Program Description Continued from additional page: We added an E.A.P. (Equine Assisted Psychotherapy), program for Veterans with P.T.S.D. in 2017. This program is also FREE to its participants and coordinated with the Vet Center and Veterans Therapist.The delivery method is different than the youth "mentorship", as this program is"therapy" driven. Time is spent after each horse exercise/activity, in processing what went on for the participant emotionally and mentally, and how that can be translated in their own lives. It is a blessing to get to work with these fantastic guys who have given so much for our freedom. County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Heart Ranch Program Name: Heart Ranch 2019 Schedule includes: • Five 6-week terms (4 days/week)for the youth mentorship program • Annual Christmas Caroling Event • VA Grad group • Veterans PTSD new groups (Two 8-week Groups) • 2 EAP/EAL Clinics for VA Staff • EAP Clinics with Private Psychotherapist clients t.b.a. • 16 Youth Volunteer Meetings "Impact" • 5 Youth Volunteer"Impact" Riding Meetings HOPE Services Hawaii, Inc. West Hawaii Emergency Housing 95 County of Hawaii Nonprofit Grant Application FY2019-20 • Agency Name: HOPE Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program Agency Director: Brandee Menino Phone No.: (808 ) 938 -3050 Contact Person: Brandee Menino Phone No.: (808 ) 930 -3050 Mailing Address: Address: 357 Waianuenue Avenue Address: City,ST,Zip Hilo, HI, 96720 Facility Address: Address: 357 Waianuenue Avenue Address: City,ST,Zip Hilo, HI, 96720 Email Address: bmenino@hopeserviceshawaii.org Fax No.: (808 )935 -3794 Accountant/CPA: Shelly Toledo Phone No.: (808 )933 -6008 Firm (if applicable): Mailing Address: Address:357 Waianuenue Avenue Address: City,ST,Zip Hilo, HI, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) n Puna 171 Hamakua North Kona n South Hilo North Kohala [71 South Kona n North Hilo 7]South Kohala 71 Ka'11 Services or Activities To Be Provided: (One or more can be checked) ri Educational concerns n Youth • ❑Victims of Crimes • n Culture and the arts Aged [71 Victims of Health or Social Crises Needs of the poor Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: HOPE Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $20,000.00 $ 15,500.00 $0(funding not requested) 2.Agency. Mission Statement: HOPE Services Hawaii, Inc.delivers on its mission to"Bring to life the gospel values of justice,love,compassion and hope through service,empowerment and advocacy"through a continuum of housing-focused programs for families and individuals at imminent risk of and experiencing homelessness. Programs include:Homeless Outreach,an initial and ongoing engagement with families and individuals living unsheltered to meet their immediate needs by connecting them to food,clothing,shelter, health care and housing;Emergency and transitional shelter provides a temporary place to stabilize and begin the journey to securing a more permanent place to call home;Housing Navigation and Case Management help participants search for housing in the private rental market,assist with leases, move in-costs,and support during the transition from homelessness to housed; Diversion helps households who are at imminent risk of homelessness remain housed; Representative Payee Services ensure that our community members unable to manage their finances independently are not left vulnerable to homelessness;Advocacy efforts are carried out by championing evidence-based best practices with local and state legislatures,and by enhancing public awareness;Since May 2018, HOPE has led the Housing Recovery Effort for those displaced by the Puna lava eruptions through Rental Assistance and Emergency Sheltering,and played a key role in establishing the Hawaii Island Disaster Response and Recovery Team,ensuring that when disaster strikes our most vulnerable community members are not left behind. 3. Program Description: The West Hawaii Emergency Housing Program(WHEHP)offers short-term temporary housing for men and women who are experiencing homelessness in West Hawaii.At initial intake,an individualized housing plan is developed with the each participant.An assessment is conducted to determine current housing and employment challenges,from which goals are established to promote and strengthen housing and financial sustainability. Residents are provided with life skills trainings, including basic budgeting and tenant readiness,housing search, placement and rent assistance.Staff also connect participants to other community resources including Supplemental Nutrition Assistance Program(SNAP)and health insurance enrollment, healthcare,mental health services,substance abuse treatment,and employment readiness and training.With a targeted stay of 90 days,service plans and goals are reviewed with participants bi-monthly.The ultimate goal for all participants is to move into permanent housing as rapidly as possible,while delivering services in a person-centered away-trauma-informed to each participants'strengths,challenges,and opportunities.The Shelter offers the first step to feeling stabilized and secure,and HOPE staff work together with participants to remain housing-focused. 4.Total Budget& Position Count: Total Program Budget: $424,360.31 Total Program Position Count: 12 Total Agency Budget: $6,007,482.19 Total Agency Position Count: 58 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: HOPE Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate State of Hawaii-Department of Human Services $309,090.12 Foundation grants $42,281.15 Fundraising (unsecured) $57,989.04 County of Hawaii-Non-profit grant(unsecured) $15,000.00 TOTAL: $424,360.31 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The West Hawaii Emergency Housing Program assesses fees when able of no greater than 30/o of a participant's income,and up to a maximum of$250.00 per month. People experiencing unsheltered homelessness are never turned away for lack of ability to pay.Thus this program relies on government,private,and philanthropic support.While we did not request funding support 'from the County of Hawaii Nonprofit Grant Program in FY18-19,we did receive funding support in the two previous years. WHEHP is the only low-barrier to entry shelter for all single men and women experiencing homelessness in West Hawaii. It is a critical resource in West Hawaii,particularly as unsheltered homelessness has persisted across the island's communities.We will continue to search and apply for government and private grants through foundations,the philanthropic community,and fundraising events to help sustain this program. 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from the County of Hawaii will support personnel costs(salary&benefits)to provide critical support to single men and women experiencing unsheltered homelessness through the West Hawaii Emergency Housing Program.The outcomes, objectives and value of support provided through these services is measurable by the number of program participants,the rate of participants who exit to permanent housing,and the rate at which participants remain housed. Through the West Hawaii Emergency Housing Program: 1)Participants will resolve living in unsheltered homelessness,entering into secure emergency sheltering 2)Participants will receive one-on-one assistance in becoming document-ready to enter into a traditional lease 3)Participants will gain permanent housing,thus ending their homeless episode 4)Participants will receive critical supports through case management to ensure their success in remaining housed. 5)Participants risk of entering into or returning to homelessness will be greatly reduced,thus ensuring that vulnerable households receive critical support in maintaining stability and dignity EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: HOPE Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of participants who end their episode of unsheltered homelessness 120 Exit rate to permanent housing 30% Rate of success in remaining housed 75% Attach additional pages as necessary. 9.TABLE 11: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $247,802.49 $255,236.56 $15,000.00 Professional Fees Operations $86,191.02 $88,776.75 Supplies $14,900.00 $15,347.00 Equipment Other: Security Services $144,003.16 $65,000.00 Other: Other: Other: Other: TOTAL $492,896.67 $424,360.31 $15,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: HOPE Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council ❑ The Mayor The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. f/�� " ` CEO / r�. 01/31/2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: HOPE Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: HOPE Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. yyttmiL___ 01/31/2019 Signature of Authorized Person (see checklist, 2nd item) Date Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application. FY2019-20 Agency Name: HOPE Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 120 Number of participants who end their episode of unsheltered homelessness Exit rate to permanent housing 30% Rate of success in remaining housed 75% TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $15,000.00 Professional Fees Operations Supplies Equipment Other: Security Services Other: Other: Other: Other: TOTAL $15,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hope Services Hawaii, Inc. Representative Payee Services Program 96 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: HOPE Services Hawaii, Inc. Program Name: Representative Payee Services Program Agency Director: Brandee Menino Phone No.: (808) 938 - 3050 Contact Person: Brandee Menino Phone No.: (808) 938 - 3050 Mailing Address: Address: 357 Waianuenue Avenue Address: City,ST,Zip Hilo, HI,96720 Facility Address: Address: 357 Waianuenue Avenue Address: City,ST,Zip Hilo, HI 96720 Email Address: bmenino@hopeserviceshawaii.org Fax No.: (808 ) 935 - 3050 Accountant/CPA: Shelly Toledo Phone No.: (808 ) 933 - 6008 Firm (if applicable): Mailing Address: Address: 357 Waianuenue Avenue Address: City,ST,Zip Hilo, HI, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) [' Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ['Youth ❑✓ Victims of Crimes ❑ Culture and the arts Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: HOPE Services Hawaii, Inc. Program Name: Representative Payee Services Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $ 17,500.00 $8,000.00 $4,800.00 2. Agency Mission Statement: HOPE Services Hawaii,Inc.delivers on its mission to"Bring to life the gospel values of justice, love,compassion and hope through service,empowerment and advocacy"through a continuum of housing-focused programs for families and individuals at imminent risk of and experiencing homelessness.Programs include:Homeless Outreach,an initial and ongoing engagement with families and individuals living unsheltered to meet their immediate needs by connecting them to food,clothing,shelter, health care and housing; Emergency and transitional shelter provides a temporary place to stabilize and begin the journey to securing a more permanent place to call home; Housing Navigation and Case Management help participants search for housing in the private rental market,assist with leases, move in-costs,and support during the transition from homelessness to housed; Diversion helps households who are at imminent risk of homelessness remain housed; Representative Payee Services ensure that our community members unable to manage their finances independently are not left vulnerable to homelessness;Advocacy efforts are carried out by championing evidence-based best practices with local and state legislatures,and by enhancing public awareness;Since May 2018, HOPE has led the Housing Recovery Effort for those displaced by the Puna lava eruptions through Rental Assistance and Emergency Sheltering,and played a key role in establishing the Hawaii Island Disaster Response and Recovery Team,ensuring that when disaster strikes our most vulnerable community members are not left behind. 3. Program Description: The Representative Payee Services Program aids individuals with severe and persistent mental illnesses who receive Supplemental Security Income(SSI)benefits, but who are unable to independently manage their finances. Referrals are received from the Social Security Administration,Department of Health Adult Mental Health Division,and/or community mental health case managers. Participants served by this program are often victims of financial abuse from family members or peers who embezzle or coerce their finances,leaving them destitute or financially compromised. In partnership with the participant, the Representative Payee(HOPE staff)develops a monthly budget to ensure that basic needs of food,clothing, housing, and healthcare needs,including medication costs,are met.The Representative Payee makes rent payments directly to the landlord or property manager,ensuring that rent is paid in full and on time.This decreases the risk of imminent and actual return to homelessness.After all expenses are paid,the Representative Payee works closely with the participant to assist in saving a portion of their discretionary funds,preferably in an interest-bearing bank account,for future emergencies or larger expenditures.All remaining funds are then distributed to the participant as an allowance on a daily,weekly or monthly basis, depending on the participant's functioning level.Representative Payee staff complete accounting reports that show how each individuals income is spent and saved,and report changes in participant circumstances that could affect benefit eligibility (including income,resources,change of address,living arrangements,return to work,etc.)to the Social Security Administration, thus decreasing the vulnerability of mentally ill individuals at risk of homelessness.At program capacity of 200 participants,the Representative Payee distributes more than 1,200 checks annually and provides over 80 hours of financial and money management counsel each month. 4.Total Budget& Position Count: Total Program Budget: $164,345.76 Total Program Position Count: 2 Total Agency Budget: $6,007,482.19 Total Agency Position Count: 58 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: HOPE Services Hawaii, Inc. Program Name: Representative Payee Services Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Adult Mental Health Division (secured) $98,550.00 State of Hawaii -Department of Human Services (secured) $16,282.67 TOTAL: $114,832.67 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: As this program is offered at no-cost to program participants,it relies on government,private,and philanthropic support. We will continue to search and apply for government and private grants through foundations,the philanthropic community,and fundraising events to help sustain this program.While funding support for this program from the County of Hawaii Nonprofit Grant Program has decreased in the past three years,we continue to seek revenue support as this program serves among our counties most vulnerable households.The Representative Payee Program provides a critical support to those with severe and persistent mental disorders who are at higher risk of entering into or returning to homelessness. 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from the County of Hawaii will support personnel costs(salary&benefits)to provide critical support through the Representative Payee Services Program.The outcomes,objectives and value of support provided through these services is measurable by the number of program participants,the hours spent providing budget counseling,and the rate at which participants remain housed. Through the Representative Payee Services Program: 1)Participants,together with the Representative Payee,will establish a reasonable and adaptable budget to afford fixed and variable livings costs,and work toward establishing a savings account 2)Participants fixed living costs will be paid in full in a timely,consistent manner,thus promoting responsible tenancy and reducing the risk of eviction and/or service interruption due to non-payment 3)Participants basic needs, including food and clothing,will be prioritized during budgeting 4)Participants critical healthcare costs, including medications and necessarily medical devices,will be prioritized and paid on time,promoting the health and well-being of the participant,and regular,uninterrupted use of needed medications. 5)Participants risk of entering into or returning to homelessness will be greatly reduced,thus ensuring that vulnerable households receive critical support in maintaining stability and dignity EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i.Nonprofit Grant Application FY2019-20 Agency Name: HOPE Services Hawaii, Inc. Program Name: Representative Payee Services Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of individuals served 175 Hours of budget counseling provided 1,000 Rate of participants who remain housed and do not return to homelessness 90% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $42,972.77 $110,076.57 $20,000.00 Professional Fees Operations $9,923.08 $30,000.00 Supplies $2,169.35 $4,000.00 Equipment $100.00 $2,100.00 Other: Administrative Fee $11,086.88 $18,169.19 Other: Other: Other: Other: TOTAL $66,252.08 $164,345.76 $20,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: HOPE Services Hawaii, Inc. Program Name: Representative Payee Services Program so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai`i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): 0 Member or members of the Council f 1 Staff appointed by a member of the Council (l The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. /14-40;_, //)//// • Signat e of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: HOPE Services Hawaii, Inc. Program Name: Representative Payee Services Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: HOPE Services Hawaii, Inc. Program Name: Representative Payee Services Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30t"shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. A.AAJO At0/1/,‘_. 40/7.24/6 Signature of Authorized Person (see checklist, 2nd item) Date Brrws.cice, A4-as htd Gid Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: HOPE Services Hawaii, Inc. Program Name: Representative Payee Services Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of individuals served 175 Hours of budget counseling provided 1,000 Rate of participants who remain housed and do not return to homelessness 90% TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $20,000.00 Professional Fees Operations Supplies Equipment Other: Administrative Fee Other: Other: Other: Other: TOTAL $20,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hui Kahu Malama (HKM) UH Internal Medicine Residency Program Rural Health Elective 97 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Kahu Malama (HKM) Program Name: UH Internal Medicine Residency Program Rural Health Elective Agency Director: Sydney Tatsuno, M.D. (President HKM) Phone No.: (808) 969 — 1671 Contact Person: Sydney Tatsuno, M.D. Phone No.: (808) 969 — 1671 Mailing Address: Address: 868 Ululani St Address: Suite 102 City,ST,Zip Hilo, HI 96720 Facility Address: Address: Address: City,ST,Zip Email Address: sydtatsuno@gmail.com Fax No.: (808 ) 969 — 7557 Accountant/CPA: Necelyn Yamashiro Phone No.: (808 ) 935 — 5404 Firm (if applicable): Taketa Iwata Hara&Associates Mailing Address: Address: 101 Aupuni St Address: Suite 139 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka'u . Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑Youth ❑ Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Kahu Malama (HKM) Program Name: UH Internal Medicine Residency Program Rural Health Elective 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 0 2.Agency Mission Statement: The County of Hawaii,as well as the State of Hawaii, has been experiencing an increasing physician shortage which is becoming a critical issue as our population ages and expands,and as more of its established physicians reach retirement age. This is particularly true of our primary care physician population. For this County, it is estimated that the current shortage of primary care physicians alone is 36 full-time equivalents. In an attempt to help alleviate this situation,the UHIMRP Rural Health Elective was created for the Big Island as an elective within the John A Burns School of Medicine(JABSOM)and the University of Hawaii Internal Medicine Residency Program (UHIMRP). Medical residents,as well as medical students, are encouraged to come to the Big Island to participate in this four week elective program.They rotate through private physicians'offices to learn outpatient internal medicine, as well as how to run a successful medical practice. With this positive experience it is hoped that these physicians will return to the Big Island to practice. Because of the costs(e.g.travel, rental car,and housing)incurred by the medical residents and students, Hui Kahu Malama (HKM)was established in 2017 as a nonprofit organization to financially assist the medical residents and students participating in the Rural Health Elective. Please visit our website:www.huikahumalama.org 3. Program Description: The UHIMRP Rural Health Elective for 2018 had 5 medical residents and 1 medical student participate. They all spent time rotating through private physicians'offices; all of whom are volunteer faculty. The emphasis is on primary care internal medicine. We have tried to offer a quality elective that is both educational and fun, and thus far have received a 5 out of 5 rating(highest possible)from all of our students and residents. One of our residents who participated in the Rural Health Elective is determined to return to the Big Island to practice. In addition to the Rural Health Elective,the board members of Hui Kahu Malama are taking a broader perspective to help address this physician shortage. We are hoping that one of our members will be asked to join the admissions committee of the John A Burns School of Medicine. This will involve travel costs from Hilo to Honolulu. There are a number of other meetings that we have been participating in, including the Hawaii Medical Education Council(HMEC)which is chaired by the Dean of the School of Medicine. These meetings were established to help address the physician shortage. We also have expanded our Board to include individuals from Oahu. Again, all of this involves travel costs. Finally,we realize that students from the Big Island are more likely to return than students from other locations to practice. We are hoping to help our premedical students here at UH Hilo and students from the Big Island studying elsewhere prepare in the medical school admission processes(e.g. with their medical school admissions tests). 4.Total Budget& Position Count: Total Program Budget: 1 Total Program Position Count: 11 Total Agency Budget: 1 Total Agency Position Count: 11 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hui Kahu Malama (HKM) Program Name: UH Internal Medicine Residency Program Rural Health Elective 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Shippers Wharf Grant $6,000 County of Hawaii Nonprofit Grant $20,000 TOTAL: $26,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We are in the process of applying for non-County grants and donations. 7. Program Objectives Using County Nonprofit Grant Program Funds: See above(#3)but in summary: Continue to have medical residents and medical students participate in the UHIMRP Rural Health Elective so that some of them return to the Big Island to practice. Have one of our board members sit on the admission committee at JABSOM to learn more about the admission process. Continue to engage and educate our state leaders and other stakeholders about the critical physician shortage that is only getting worse on the Big Island and throughout the State.There are solutions to this problem but it takes innovation, initiative, perseverance, and leadership. To help our premedical students with their medical school admission processes. The members of Hui Kahu Malama would be happy to sit down with the grant committee members and discuss our program in detail. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Kahu Malama (HKM) Program Name: UH Internal Medicine Residency Program Rural Health Elective 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) To continue to have medical students and medical residents participate in the UHIMRP Have physicians return here to practice Rural Health Elective offered here on the Big Island To continue to participate with meetings held at John A Burns School of Medicine and with Have one of our Board members sit on the our elected state officials to address/stress the critical physician shortage here sit on the admissions committee at JABSOM To provide educational assistance to our premedical students to help them prepare for Have more of our students from the Big Island the medical school admission process admitted to medical schools especially JABSOM Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages Professional Fees $1,000 1,000 Operations $500 500 Supplies $500 500 Equipment Other: Housing,rental car, airline tickets for the residents/medical students $14,000 14,000 Other: Travel expenses(airline tickets, rental car)for HKM board members $5,000 5,000 Other: Educational expenses for premedical students $5,000 5,000 Other: Other: TOTAL $26,000 26,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Kahu Malama (HKM) Program Name: UH Internal Medicine Residency Program Rural Health Elective so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. tee, (t',e£yi ,., — 30 Jan 2019 Signature of Auth ized Person (s ec' title) r 32 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Kahu Malama (HKM) Program Name: UH Internal Medicine Residency Program Rural Health Elective 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 . Page 6 of 8 t ' County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Kahu Malama (HKM) Program Name: UH Internal Medicine Residency Program Rural Health Elective 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. r-D 30 Jan 2019 Signature of Authorized Person (see checklist, 2nd item) Date Pe tat k"tt..._ 11404sekt.AL Title/Position of Authorized Person rody2-fir V/7, EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Kahu Malama (HKM) Program Name: UH Internal Medicine Residency Program Rural Health Elective 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result To continue to have medical students and medical residents participate in the UHIMRP to p acitesicians return here Rural Health Elective offered here on the Big Island To continue to participate with meetings held at John A Burns School of Medicine and with Have one of our Board member our elected state officials to address/stress the critical physician shortage here sit on the admissions committee at JABSOM To provide educational assistance to our premedical students to help them prepare for Have more Islandt einnts from the Big Island being the medical school admission process admitted to medical schools especially JABSOM TABLE II: PROGRAM EXPENDITURES FY 19-20 Grant Council Request Award Salary and Wages Professional Fees 1,000 Operations 500 Supplies 500 Equipment Other: Housing,rental car, airline tickets for the residents/medical students 14,000 Other: Travel expenses(airline tickets, rental car)for HKM board members 5,000 Other: Educational expenses for premedical students 5,000 Other: Other: TOTAL 26,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hui Malama Ola Na 'Oiwi Community Relations Program - Ladies Night Out & Kane 2019 98 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Community Relations Program - Ladies Night Out & Kane 2019 Agency Director: Louis Hao, Executive Director Phone No.: (808) 969 — 9220 Contact Person: Lisa Canale, Project Analyst Phone No.: (808) 969 — 9220 Mailing Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, HI,96720 Facility Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, HI,96720 Email Address: lisa@hmono.org Fax No.: (808 ) 961 — 4794 Accountant/CPA: Phone No.: (808 ) 531 — 1040 Firm (if applicable): CW Associates, CPAs Mailing Address: Address: 700 Bishop Street,Suite 1040 Address: City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua p✓ North Kona ❑✓ South Hilo 0 North Kohala Z✓ South Kona ❑✓ North Hilo ❑✓ South Kohala Q✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑Youth ❑Victims of Crimes ❑✓ Culture and the arts ✓❑Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ✓❑ Physical/Emotional Disabilities I✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out & Kane 2019 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $2,250 $4,375 $5,925 2.Agency Mission Statement: Mission Statement: 'O Hui Malama Ola Na'Oiwi makou-We are the group that takes care of the health of Hawaiian people, Eia ke kuleana: Ho'oulu ola o ka lahui Hawaii-Our mission is to uplift the health of the Hawaiian nation. Malama is Moku o Keawe-We will take care of Hawai'i Island, Malama i na kua'aina-country and rural areas, Malama i kou olakino-your physical,spiritual,and mental body, Malama i na mea Hawaii-and Hawaiian culture and practices. E ho'oikaika a ola ka lahui Hawaii-We envision a strong and healthy Hawaiian nation. Values: Hui Malama Ola Na'Oiwi, its Board of Directors,Administration,and Staff are guided and directed by Na Kupuna(our elders) with wisdom and skill received from our ancestors.We are Hawaiian.We embrace the following basic values: •Ke Akua Mana: Existence of a higher power •Lokahi: Harmony, parity and balance •'Ohana: Family-core, intermediate, extended •Po'okela: Excellence •Ho'omau:Life-long learning with guaranteed life for generations to come •Koho'ia:To be chosen; a responsibility given to one to carry forward the wisdom,skill and knowledge that guarantees the continued existence of Hawaiians. 3. Program Description: The Hui Malama Ola Na'Oiwi Ladies Night Out is an annual wellness event for Hawai'i island women in need.This flagship community event promoting self-care and positive self-esteem,occurs annually because more than 300 compassionate community volunteers and service provider professionals come together to contribute to an evening of hope and healing for this vulnerable population. Hui Malama Ola Na'Oiwi works with Hawai'i island community agencies servicing underprivileged women to distribute guest tickets to female clients,18-years of age or older,who would not normally afford to partake in self-care or"pampering"activities,and who might benefit from an 3-hour evening of free health and wellness attention.These women are greeted by a beautifully decorated and welcoming venue with an abundance with health and wellness stations,art and craft activities,and a buffet of healthy foods and beverages.The honored guests quickly indulged themselves in their choice of whole-person services and are entertained by Hawaiian music and dance performances. The Ladies Night Out offerings range from vision, blood pressure,glucose,and bone health education and screenings;foot, hand,and chair massage as well as Lomilomi massage; haircuts,mini-manicures,and facials; gifting of new and gently used clothing and footwear.The art-and-crafting fun include the making of bracelets,ornaments, postcards,earrings,and luggage tags. Door prizes,the table centerpieces,and gift bags containing wellness information and health goodies are also given to the guests.Additionally,guests are registered or renewed as Hui Malama Ola Na'Oiwi clients to avail themselves to the free health and wellness advocacy services for diabetes, heart disease, cancer navigation and support,health education and fitness classes,and its signature Traditional Health program.This year, Hui Malama Ola Na'Oiwi will pilot a similar,but separate and smaller,event for Kane. It will also offer health screenings,self-care, and wellness activities. Connecting with these vulnerable populations is a critical goal of Hui Malama Ola Na'Oiwi and the events are an entry into receiving ongoing health and wellness services. 4.Total Budget& Position Count: Total Program Budget: $ 40,533 Total Program Position Count: 35 Total Agency Budget: $3,384,836 Total Agency Position Count: 37 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out & Kane 2019 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Health Resources Services Administration (HRSA) 30,033 County of Hawaii 10,000 Restricted donation for the event(cash) 500 TOTAL: 40,533 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hui Malama Ola Na'Oiwi will seek financial support from private foundations as well as continued allocation of Health Resources Services Administration(HRSA)to support the Hui Malama Ola Na'Oiwi Ladies Night Out(LNO)health and wellness event. Monetary donations,and in-kind materials and services,will continue to support the event as well. The ability of the Community Relations planning committee members to tap into local resources for in-kind contributions has been one of the most successful means to leverage program event delivery and minimizing cost associated with carrying out the event.The planning committee will also work to identify and submit applications for grants for women-in-need programs as well as community event grant opportunities.Much of the success for completing this event is attributable to in-kind services, in-kind materials,and volunteerism.The planning committee is committed year after year to increase in-kind services and goods to bring down cost to implement the event. Through increased Radio,Television, Internet,Social,and Print-Media, Hui Malama Ola Na'Oiwi capacity to help the public become aware of the Ladies Night Out event for under-resourced women will greatly increase as well as bring a greater awareness of the need for monetary,in-kind,or in-service contributions to ensure a successful event. 7. Program Objectives Using County Nonprofit Grant Program Funds: The program objective for use of County funds will focus on logistical line items in program event supplies such as copy paper, food and water and food service products,decoration supplies,signage,wrist bands,supplies needed for community providers, and miscellaneous small item purchases. In addition,tables,chairs,and other event equipment to comfortably sit 500 guest women plus 200 services providers is a requirement for the size and type of event. Professional fee allocation of County funding will support event security and professional sound system to ensure a safe and welcoming event venue. County funds will support an event that brings community providers together for one purpose in taking care of women ages 18 and older with pampering and health and wellness services that if not for this event,they would struggle to afford. In addition,the County funds will support a small pilot Kane event that will offer health screenings and wellness services to men. For both events,all activities promote positive self-esteem and self-care and proactive wellness such as health screenings for vision, blood pressure,and glucose in a one-stop shop setting.The funding request supports the values instilled in our island community of"giving"and providing opportunity for less fortunate women and men. Attendees will be registered or be renewed as clients to avail themselves to the Hui Malama Ola Na'Oiwi free health and wellness advocacy services for diabetes, heart disease,healthy pregnancy and positive parenting,health-related non-emergency para-transportation,health education,fitness classes,Traditional Hawaiian health classes and workshops. In addition,Behavior Health,Nutrition,and Medical services are available to Hui Malama Ola Na'Oiwi patients. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Community Relations Program - Ladies Night Out & Kane 2019 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of women provided with health and wellness pampering activities at LNO 500 Number of community providers and volunteers providing services for the LNO event 300 Number of men provided with health and wellness activities at the Kane event 50 Number of tickets provided to persons-in-need[women:600&men:75] 675 Percentage of attendees partaking in health screenings(blood pressure,blood sugar. height and weight,and/or vision) 100% self-care or"pampering"activities 100% Attach additional pages as necessary. 9.TABLE II: • PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 18,300 22,206 0 Professional Fees 506 2,300 1,300 Operations 1,057 0 Supplies 5,002 7,900 5,900 Equipment Other: Facilities, Clean-up, Tables&Chairs rental 1,358 4,270 1,700 Other: Marketing 1,428 2,800 1,100 Other: Other: Other: TOTAL 26,594 40,533 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Community Relations Program - Ladies Night Out & Kane 2019 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. Executive Director 30 January 2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out & Kane 2019 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests: EXHIBITA NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out & Kane 2019 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 30 January 2019 W;-/) Signature of Authorized Person (see checklist, 2nd item) Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Community Relations Program - Ladies Night Out & Kane 2019 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of women provided with health and wellness pampering activities at LNO 500 Number of community providers and volunteers providing services for the LNO event 300 Number of men provided with health and wellness activities at the Kane event 50 Number of tickets provided to persons-in-need[women:600&men:75] 675 Percentage of attendees partaking in health screenings(blood pressure, blood sugar. height and weight,and/or vision) 100% self-care or"pampering"activities 100% TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 0 Professional Fees 1,300 Operations 0 Supplies 5,900 Equipment Other: Facilities, Clean-up, Tables &Chairs rental 1,700 Other: Marketing 1,100 Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hui Malama Ola Na 'Oiwi Diabetes Program - Education, Keiki &Adult Support Groups 99 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Diabetes Program - Education, Keiki & Adult Support Groups Agency Director: Louis Hao, Executive Director Phone No.: (808) 969 — 9220 Contact Person: Lisa Canale, Project Analyst Phone No.: (808) 969 — 9220 Mailing Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, HI,96720 Facility Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, HI,96720 Email Address: lisa@hmono.org Fax No.: (808 ) 961 — 4794 Accountant/CPA: Phone No.: (808 ) 531 — 1040 Firm (if applicable): cW Associates, CPAs Mailing Address: Address: 700 Bishop Street,Suite 1040 Address: City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $23,505 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ✓❑ North Kohala ❑✓ South Kona ✓0 North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ✓❑Youth ❑Victims of Crimes ✓❑Culture and the arts ✓❑Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 tea County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Diabetes Program - Education, Keiki & Adult Support Groups 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $5,500 $10,750 $7,800 2.Agency Mission Statement: Mission Statement: 'O Hui Malama Ola Na'Oiwi makou-We are the group that takes care of the health of Hawaiian people, Eia ke kuleana: Ho'oulu ola o ka lahui Hawaii-Our mission is to uplift the health of the Hawaiian nation. Malama is Moku o Keawe-We will take care of Hawaii Island, Malama i na kua'aina-country and rural areas, Malama i kou olakino-your physical,spiritual,and mental body, Malama i na mea Hawai'i-and Hawaiian culture and practices. E ho'oikaika a ola ka lahui Hawai'i-We envision a strong and healthy Hawaiian nation. Values: Hui Malama Ola Na'Oiwi, its Board of Directors,Administration,and Staff are guided and directed by Na Kupuna(our elders) with wisdom and skill received from our ancestors.We are Hawaiian.We embrace the following basic values: •Ke Akua Mana: Existence of a higher power •Lokahi:Harmony,parity and balance •'Ohana: Family-core,intermediate,extended •Po'okela: Excellence •Ho'omau: Life-long learning with guaranteed life for generations to come •Koho'ia:To be chosen; a responsibility given to one to carry forward the wisdom,skill and knowledge that guarantees the continued existence of Hawaiians. 3. Program Description: The Hui Malama Ola Na'Oiwi Diabetes Program provides diabetes education through awareness and prevention campaigns, free Diabetes Management Education courses taught by registered nurses(RN), invitational presentations,and Hilo-based Diabetes Support Groups.This year Hui Malama Ola Na'Oiwi will also offer a Children with Diabetes Support Group.These services are in alignment with the best practices for Diabetes Education as stated by the Centers for Disease Control and Prevention(CDC)*as well as the Hawaii State Department of Health 2014-2020 Hawaii Coordinated Chronic Disease Framework.** The Hui Malama Ola Na'Oiwi Diabetes Program also conducts diabetes awareness and prevention outreach efforts through its newsletter and social media avenues and at community wellness events across the county. In addition,the Hui Malama Ola Na'Oiwi Diabetes Program arranges glucose(blood sugar)readings,diabetes clinical screenings at health fairs,and offers one-on-one sessions with a Hui Malama Ola Na'Oiwi medical staff. According to the CDC Behavioral Risk Factor Surveillance System***,6.9%of the Hawai'i Island population is living with diabetes.There are also the subpopulation of those with prediabetes and those at risk of diabetes.With the assistance of funding from the County of Hawaii,the Hui Malama Ola Na'Oiwi Diabetes Program can reach a broader base of residents in need of diabetes management education and support,as well as expand its diabetes awareness and diabetes prevention outreach endeavors. *https://www.cdc.gov/diabetes/managing/education.html **http://health.hawaii.gov/chronic-disease/files/2014/09/CDFrameworkLR.pdf ***https://www.cdc.gov/diabetes/atlas/obesityrisk/15/atlas.html 4.Total Budget& Position Count: Total Program Budget: $87,622 Total Program Position Count: 15 • Total Agency Budget: $3,384,836 Total Agency Position Count: 37 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Diabetes Program - Education, Keiki & Adult Support Groups 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Health Resources Services Administration (HRSA) 64,117 County of Hawai'i 23,505 TOTAL: 87,622 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The primary means of funding for Hui Malama Ola Na'Oiwi is from the U.S. Department of Health and Human Services, Health Resources Services Administration (HRSA).This funding supports several positions as well as the operational costs to actualize the Hui Malama Ola Na'Oiwi diabetes program which consists of screenings,health education materials,self-management courses,support group meetings,speakers,and wellness events outreach.Community partners continue to support the Hui Malama Ola Na'Oiwi Diabetes Program efforts.The University of Hawaii at Hilo Daniel K Inouye College of Pharmacy outreach team provides clinical blood glucose and HbA1 c screening.Additionally,the School of Nursing provides our clients with health education materials through their Community Health Practicum. Hui Malama Ola Na'Oiwi is also launching a medical service site with behavioral health and nutrition services which will enable patients with pre-diabetes or diabetes diagnosis to easily receive appropriate management education and support. Through increased Radio,Television, Internet,Social,and Print Media,the capacity of Hui Malama Ola Na'Oiwi to help the public become aware of diabetes prevention and management will continue to grow and also bring a greater awareness of the need for monetary, in-kind,or in-service contributions to ensure an expanded reach to the community. In addition, Hui Malama Ola Na'Oiwi will be offering a medical clinic that,once sustainable,should also be able to supplement the cost of the educational programs. Meanwhile,the organization will research the medical billing potential of its 10-week Diabetes Management Education course.And,finally, Hui Malama Ola Na'Oiwi is always seeking additional funding opportunities to supplement the cost of its programs. 7. Program Objectives Using County Nonprofit Grant Program Funds: With the County of Hawaii funding,the Hui Malama Ola Na'Oiwi Diabetes program can offer multiple strategies to help residents of Hawaii County to become aware of diabetes,prevent the onset of diabetes,and manage diagnosed diabetes.The Diabetes Awareness Campaign will consist of six invitational speaking engagements reaching 150 people,social media postings,Aunty's Health Message in the Olakino newsletter,and Health-Minutes aired during drive-time radio.Through the Diabetes Awareness Campaign and by working directly with doctors and nurses,community health centers,the Hui Malama Ola Na'Oiwi medical clinic,and hospitals for referrals, Hui Malama Ola Na'Oiwi will enroll diagnosed diabetes patients into its Diabetes Management Education Course.The Hui Malama Ola Na'Oiwi Diabetes Management Education Course,led by a registered nurse,teaches patients with diabetes how to manage the disease and how to reduce the risk of diabetes-related complications through behavioral changes.By the end of the six-hour course(three 2-hour sessions, held once a week for 3 consecutive weeks)the participants understand diabetes,are able to determine strategies to reduce risk of diabetes complications,and know how to manage the condition while leading a healthy life.The course is free and offered 20 times annually,once every quarter, in Districts of South Hilo, Ka'u, North Kohala,South Kona,and Puna for a total of 200 participants(10 per course).To assist with immediate adoption and the continuous application of the behavioral health strategies presented in the course,graduates will also be encouraged to join a Hui Malama Ola Na'Oiwi Diabetes Support group.There will be two offered,one for adults and one for children.The Diabetes Support groups will also be open to caregivers,those with prediabetes,and those wanting to learn more about diabetes.The Adult Diabetes Support group will meet twice a month and the Children's Diabetes Support group will meet once a month.Average attendance for the supports groups is expected to be 10 participants. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Diabetes Program - Education, Keiki & Adult Support Groups 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Diabetes Management Course(5 per quarter; 3-sessions,2-hrs per session for 6-hrs) 20 courses;120 hours of instruction by a RN Hilo(4),Waimea(4), Kona(4), Ka'u (4),and Puna(4)w/average attendance of 10 200 participants Diabetes Support Group(3 per month with an average attendance of 10) 360 people via 36 meetings Adult Support Group(2 meetings per month) 24 meetings Youth Support Group(1 meeting per month) 12 meetings Diabetes Invitational Speaking Engagements(1 at each location) 6 presentations Hilo, Puna, Kohala, Pahala, Na'alehu, Kona)w/average attendance of 25 150 participants Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 60,435.62 61,047 0 Professional Fees 130.00 13,800 13,800 Operations -- 844.33 3,070 0 Supplies 6,185 6,185 Equipment 536.92 0 0 Other: Facilities rental 3,520 3,520 Other: Other: • Other: Other: TOTAL 62,946.87 87,622 23,505 *If applicable • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 A County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Diabetes Program - Education, Keiki & Adult Support Groups 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. i (;//z,e,c____04::, 24, 30 January 2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Diabetes Program - Education, Keiki & Adult Support Groups 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Diabetes Program - Education, Keiki & Adult Support Groups g 9 PP 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss • of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai`i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 30 January 2019 Signature of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 F. ' County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Diabetes Program - Education, Keiki & Adult Support Groups 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Diabetes Management Course(5 per quarter;3-sessions,2-hrs per session for 6-hrs) in eruction;120 hours of instruction by a RN Hilo(4),Waimea(4),Kona(4),Ka'0(4),and Puna(4)w/average attendance of 10 200 participants Diabetes Support Group(3 per month with an average attendance of 10) 360 people via 36 meetings Adult Support Group(2 meetings per month) 24 meetings Youth Support Group(1 meeting per month) 12 meetings Diabetes Invitational Speaking Engagements(1 at each location) 6 presentations Hilo, Puna,Kohala, Pahala, Na'alehu, Kona)w/average attendance of 25 150 participants TABLE II: PROGRAM EXPENDITURES FY 19-20 Grant Council Request Award Salary and Wages 0 Professional Fees 13,800 Operations 0 Supplies 6,185 Equipment 0 Other: Facilities rental 3,520 Other: Other: Other: Other: TOTAL 23,505 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hui Malama Ola Na 'Oiwi Fitness Program - Makahiki Games Expansion 100 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Fitness Program - Makahiki Games Expansion Agency Director: Louis Hao, Executive Director Phone No.: (808) 969 — 9220 Contact Person: Lisa Canale, Project Analyst Phone No.: (808) 969 — 9220 Mailing Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, HI,96720 Facility Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, HI,96720 Email Address: lisa@hmono.org Fax No.: (808 ) 961 — 4794 Accountant/CPA: Phone No.: (808) 531 — 1040 Firm (if applicable): CW Associates, CPAs Mailing Address: Address: 700 Bishop Street,Suite 1040 Address: City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $28,332 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona ❑✓ North Hilo ❑South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ['Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Fitness Program - Makahiki Games Expansion 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 n/a n/a $5,050 2.Agency Mission Statement: Mission Statement: 'O Hui Malama Ola Na'Oiwi makou-We are the group that takes care of the health of Hawaiian people, Eia ke kuleana:Ho'oulu ola o ka lahui Hawaii-Our mission is to uplift the health of the Hawaiian nation. Malama is Moku o Keawe We will take care of Hawaii Island, Malama i na kua'aina-country and rural areas, Malama i kou olakino-your physical,spiritual,and mental body, Malama i na mea Hawai'i-and Hawaiian culture and practices. E ho'oikaika a ola ka lahui Hawai'i-We envision a strong and healthy Hawaiian nation. Values: Hui Malama Ola Na'Oiwi,its Board of Directors,Administration,and Staff are guided and directed by Na Kupuna(our elders) with wisdom and skill received from our ancestors.We are Hawaiian.We embrace the following basic values: •Ke Akua Mana: Existence of a higher power •Lokahi: Harmony,parity and balance •'Ohana:Family-core, intermediate,extended •Po'okela: Excellence •Ho'omau:Life-long learning with guaranteed life for generations to come •Koho'ia:To be chosen;a responsibility given to one to carry forward the wisdom,skill and knowledge that guarantees the continued existence of Hawaiians. 3. Program Description: Through the Hui Malama Ola Na'Oiwi Fitness Program's E Malama I Ke Olakino 0 Na Keiki Makahiki Games project, Hawaii youth attending public or public-charter elementary, intermediate,and high schools in the rural districts will be(re) introduced to Traditional Hawaiian games of the Makahiki season such as'ulu maika(bowling),moa pahee(dart sliding), 'o'o the(spear-throwing), hukihuki(tug of war), haka moa(one-arm,one-leg wrestling match), pa uma(hand wrestling),and kukini (swift running.)The youth will learn about Makahiki-game fitness skills,physiology of muscle,and exercise strategies to train for the events.The youth will also learn the mo`olelo(stories)of Makahiki legends to deepen their understanding of these sports and their appreciation of Hawai'i.The specific strategy to deliver the Fitness education and the'Ike Hawai'i(Hawaiian knowledge)will be developed in conjunction with the administrators of each school as it may occur in the classroom,at recesses,or after school,depending on the needs of the school as determined at each grade level. Hui Malama Ola Na'Oiwi will seek to develop the program to support ongoing partnerships to co-host multi-school Makahiki games in January and additional partners to co-host a kukini(swift running)Rainbow 5k Fun Walk/Run in early May. The Hui Malama Ola Na'Oiwi Fitness Program's E Malama I Ke Olakino 0 Na Keiki Makahiki Games pilot project is currently running with great reviews by the participating schools and will be evaluated at the end of the Department of Education School Year 2018/19 to determine how to better support the goals of the school and the program while determining how best to to replicate the efforts at additional public schools. If the 2nd year pilot is successful and replicable,and if funding for staffing exists, Hui Malama Ola Na'Oiwi will expand island-wide and offer the program at a variety of schools. 4.Total Budget& Position Count: Total Program Budget: $83,770 Total Program Position Count: 2.0 Total Agency Budget: $3,384,836 Total Agency Position Count: 37 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Fitness Program - Makahiki Games Expansion 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Health Resources Services Administration (HRSA) $55,438 County of Hawaii $28,332 OHA Culture grant(in review) TOTAL: $83,770 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The U.S. Department of Health and Human Services, Health Resources Services Administration(HRSA)would be the major funder of the Fitness Program: E Mama I Ke Olakino 0 Na Keiki Makahiki Games expansion project with additional funding support from the County of Hawaii. Hui Mama Ola Na'Oiwi has a pending grant application with OHA which would be used to expand the programming. Hui Mama Ola Na'Oiwi will actively recruit in-kind donations and volunteer support to reduce some of the projected costs. Hui Mama Ola Na'Oiwi is also searching for youth fitness, combating childhood obesity,and Hawaiian culture grant opportunities as well as grants directly supporting the health and wellness of Hawai'i youth. 7. Program Objectives Using County Nonprofit Grant Program Funds: The County of Hawaii funding will support the Hui Mama Ola Na'Oiwi Fitness Program: E Mama I Ke Olakino 0 Na Keiki Makahiki games expansion project to enable Hawaii island youth attending public or public-charter elementary, intermediate, and high schools in the rural districts,to be(re)introduced to Traditional Hawaiian games of the Makahiki season such as'ulu maika(bowling),moa pahee(dart sliding), 'o'o the(spear-throwing), hukihuki(tug of war),haka moa(one-arm,one-leg wrestling match), pa uma(hand wrestling),and kukini(swift running.)A portion of the funds will also assist with the further development of the E Mama I Ke Olakino 0 Na Keiki Makahiki Game curriculum as well as fund the Makahiki-game training sessions where youth learn fitness skills,physiology of muscle,and exercise strategies to train for the events. Hui Mama Ola Na'Oiwi will co-host Makahiki games at the participating schools, as well as gather baseline health information for each participating student. The training sessions and games will be free to the participants. If funding allows,each participate will receive a Makahiki game booklet and the participating school will receive a set of Makahiki game equipment to use after the program ends. Evaluation of the Hui Mama Ola Na'Oiwi Fitness Program: E Mama I Ke Olakino 0 Na Keiki initiative is paramount to determining the ongoing success of this nascent project.There will be a pre-and post-survey of the youths'knowledge about the Makahiki games as well as general fitness,nutrition,and hydration.The pre-and post-surveys will also capture current levels of fitness activities,attitude toward exercise,and eating habits.Youth appropriate Body-Mass Index will be calculated at the beginning and at the end of the program.The County of Hawai'i funding will also be used to determine if the project was successful and if it is feasible to replicate the initiative at additional public schools. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Fitness Program - Makahiki Games Expansion 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Makahiki training sessions held(40 weeks annually,6 schools) 240 Unduplicated number of youth who entered training (40 per school) 240 Unduplicated number of youth who completed training (35 per school) 210 Number of na keiki or'opio that increased their level of proficiency of a valuable activity 240 Number of na keiki or'opio that increased their frequency of practice of a valuable activity 210 Number of Memorandum of Agreements with DOE school for Makahiki Games education 6 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 20,685.15 69,638 18,000 Professional Fees 8,322.52 0 0 Operations 2785.71 3,800 0 Supplies 866.84 2,729 2,729 Equipment 7,603 7,603 Other: Other: Other. Other: Other: TOTAL $32,660.22 $83,770 $28,332 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Fitness Program - Makahiki Games Expansion 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director ❑ The Director of Finance H The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: H If no conflicts exist, check here. Executive Director 30 January 2019 Signature o Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Fitness Program - Makahiki Games Expansion is. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Fitness Program - Makahiki Games Expansion 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. o‘e."/A3 �►' � 30 January 2019 Signature of Authorized Person (see checklist, 2nd item) Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Fitness Program - Makahiki Games Expansion 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Makahiki training sessions held(40 weeks annually,6 schools) 240 Unduplicated number of youth who entered training (40 per school) 240 Unduplicated number of youth who completed training(35 per school) 210 Number of nä keiki or'opio that increased their frequency of practice of a valuable activity 240 Hours of hypertension education and hula fitness per participant 210 Number of Memorandum of Agreements with DOE school for Makahiki Games education 6 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 18,000 Professional Fees 0 Operations 0 Supplies 2,729 Equipment 7,603 Other: Other: Other: Other: Other: TOTAL $28,332 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hui M\ lama Ola Na 'Oiwi Transportation Program - Kokua Hall Specialty ParaTransit 101 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Mama Ola Na 'Oiwi Program Name: Transportation Program - KOkua Hali Specialty ParaTransit Agency Director: Louis Hao, Executive Director Phone No.: (808) 969 — 9220 Contact Person: Lisa Canale, Project Analyst Phone No.: (808) 969 — 9220 Mailing Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, HI,96720 Facility Address: Address: 1438 Kilauea Avenue Address: City,ST,Zip Hilo, HI,96720 Email Address: lisa@hmono.org Fax No.: (808 ) 961 — 4794 Accountant/CPA: Phone No.: (808 ) 531 — 1040 Firm (if applicable): CW Associates, CPAs Mailing Address: Address: 700 Bishop Street,Suite 1040 Address: City,ST,Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $55,000 Geographical Areas To Be Served: (One or more can be checked) ❑J Puna Hamakua ❑✓ North Kona ❑✓ South Hilo ✓❑ North Kohala ✓❑South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 • Agency Name: Hui Malama Ola Na `Oiwi Program Name: Transportation Program - KOkua Hali Specialty ParaTransit 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 • $16,625 $20,250 $13,500 2.Agency Mission Statement: Mission Statement: 'O Hui Malama Ola Na'Oiwi makou-We are the group that takes care of the health of Hawaiian people, Eia ke kuleana: Ho'oulu ola o ka lahui Hawai'i-Our mission is to uplift the health of the Hawaiian nation. Malama is Moku o Keawe-We will take care of Hawai'i Island, Malama i na kua'aina-country and rural areas, Malama i kou olakino-your physical,spiritual,and mental body, Malama i na mea Hawaii-and Hawaiian culture and practices. E ho'oikaika a ola ka lahui Hawaii-We envision a strong and healthy Hawaiian nation. Values: Hui Malama Ola Na'Oiwi,its Board of Directors,Administration,and Staff are guided and directed by Na Kupuna(our elders) with wisdom and skill received from our ancestors.We are Hawaiian.We embrace the following basic values: •Ke Akua Mana: Existence of a higher power •Lokahi: Harmony,parity and balance •`Ohana: Family-core, intermediate,extended •Po'okela: Excellence •Ho'omau:Life-long learning with guaranteed life for generations to come •Koho'ia:To be chosen; a responsibility given to one to carry forward the wisdom,skill and knowledge that guarantees the continued existence of Hawaiians. 3. Program Description: The Hui Malama Ola Na'Oiwi Kokua Hall Specialty Transportation program is a paratransit initiative helping Hawai'i islanders, who have no other means of transportation and are unable to walk without assistance of durable medical equipment(DME) (e.g.,wheelchairs,walkers,crutches,canes)or visually-impaired clients requiring a blind walking stick,arrive safely and on-time to their health-related appointment and also return home safely. The Hui Malama Ola Na'Oiwi Transportation Specialist,trained in First Aid and Standard CPR,schedules the transportation. appointment,selects and drives the appropriate paratransit vehicle,accompanies and assists the client from time of pickup to drop-off to ensure safe and on-time departure and arrival.The Transportation Specialist has a fleet of two wheel-chair accessible vehicles:one with gurney-capable lift and the other with 4-wheel drive.Both vehicles can accommodate large types of durable medical equipment(DME)that would otherwise be impossible or challenging for a regular type of vehicle. The Hui Malama Ola Na'Oiwi KOkua Hali Specialty Transportation services are free of charge to the transported. Due to limited resources,all KOkua Hali Specialty Transportation services must be to,and from,an agency, person(s),or business whose purpose is to provide medical-related services(e.g., pharmacy,laboratory, physical&occupational therapy,traditional healing practitioner,dental appointment, physician visit). 4.Total Budget& Position Count: Total Program Budget: 68,196 Total Program Position Count: 1 Total Agency Budget: $3,384,836 Total Agency Position Count: 37 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na `Oiwi Program Name: Transportation Program - KOkua Hali Specialty ParaTransit 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Health Resources Services Administration (HRSA) $13,196 County of Hawaii $55,000 TOTAL: $68,196 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hui Malama Ola Na'Oiwi has relied on federal funding from Health Resources Services Administration(HRSA)to cover most of the costs associated with the KOkua Hali Specialty Transportation Program. Historically, HRSA funding provides personnel costs and most of the non-personnel costs, however,this revenue source remains in jeopardy as medical transportation is not a named mandate of the Native Hawaiian Health Care Improvement Act even though this need exists and providing transportation reduces a barrier to receiving health support. Hui Malama Ola Na'Oiwi continues to develop its own tariff for non-emergency medical transportation.Once the tariff is completed,officially submitted with an application,and approved,the Public Utilities Commission license will enable collection of billed revenue from Aloha Care and other medical insurance carriers such as HMSA. Reimbursement from Medicaid or Program of All-Inclusive Care for the Elderly(PACE)is also a possibility once the PUC licensing is established. Hui Malama Ola Na'Oiwi is always seeking opportunities to update our paratransit fleet and supplement the cost of the program with grant funding sources and monetary donations.Also,through Radio,Television, Internet,Social,and Print-Media, Hui Malama Ola Na'Oiwi capacity to reach the public and create awareness of the Kokua Hali Specialty Transportation Program's paratransit services is increasing and this may be a pathway to bring greater awareness of the need for support of the vital service. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Kokua Hali Specialty Transportation is offered island-wide, however most clients are from the Districts of Puna and Hilo. The program serves clients that are either non-ambulatory(unable to walk)and,therefore,wheelchair bound or have limited mobility with the use of DME.The paratransit service of these clients demands a longer loading and unloading time reducing the number of clients that can be transported in a given day. In addition, many of the paratransit clients have multiple health concerns resulting in a high frequency of trips per client served.Most of the clients are elderly and physically very fragile. Through funding from County of Hawai'i, Hui Malama Ola Na'Oiwi can continue its non-emergency medical paratransit program, reestablish services in Ka'u and North Hawaii,expand services in Kona,and strengthen the island-wide services through hiring a designated transportation specialist. Hui Malama Ola Na'Oiwi would also like to recruit and train a substitute driver for the KOkua Hali Specialty Transportation program to ensure no gaps in service. Both drivers would receive the appropriate emergency response training. Paratransit services will be provided in a caring and timely manner. This funding would ensure paratransit services to existing and new clients island-wide, reaching those with barriers to access adequate medical care,especially those whom reside in rural areas where transportation has been a recurrent barrier toward attending regular scheduled appointments with their medical provider and achieving a continuum of care.These services will also help address the amount of stress placed on clients that have no other means and may have been labeled as non-compliant.With the County's assistance,the Hui Malama Ola Na'Oiwi paratransit program can better serve more clients. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Transportation Program - KOkua Hali Specialty ParaTransit 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Designated Transportation Specialist 1-FTE 1 Hilo residents receiving paratransit for health-related services 70 Ka'u residents receiving paratransit for health-related services 20 Kona residents receiving paratransit for health-related services 35 Puna residents receiving paratransit for health-related services 35 North Hawai'i residents receiving paratransit for health-related services 30 Number of transportation"stops" annually 700 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 17,555.96 41,100 27,904 Professional Fees 0 0 Operations 3,071.87 25,096 25,096 Supplies 2,000 2,000 Equipment 0 0 Other: Other: Other: Other: Other: TOTAL 20,627.83 $68,196 $55,000 *If applicable • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Transportation Program - KOkua Hall Specialty ParaTransit 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. Executive Director 30 January 2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Transportation Program - Kokua Hall Specialty ParaTransit 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Transportation Program - Kokua Hali Specialty ParaTransit 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. JA 30 January 2019 Signature of Authorized Person (see checklist, 2nd item) Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Transportation Program - KOkua Hali Specialty ParaTransit 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Designated Transportation Specialist 1-FTE Hilo residents receiving paratransit for health-related services 70 Ka'G residents receiving paratransit for health-related services 20 Kona residents receiving paratransit for health-related services 35 Puna residents receiving paratransit for health-related services 35 North Hawaii residents receiving paratransit for health-related services 30 Number of transportation"stops" annually 700 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 27,904 Professional Fees 0 Operations 25,096 Supplies 2,000 Equipment 0 Other: Other: Other: Other: Other: TOTAL $55,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Hui Pono Holoholona Low Cost Spay/ Neuter Clinics 102 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spay/ Neuter Clinics Agency Director: Frances P. Pueo Phone No.: (808) 968 — 8279 Contact Person: Frances P. Pueo Phone No.: (808) 769 — 1128 Mailing Address: Address: PO Box 943 Address: City,ST,Zip Mt.View HI 96771 Facility Address: Address: 11-3436 Hibiscus Street Address: City,ST,Zip Mt.View HI 96771 Email Address: paws@hphhawaii.org Fax No.: (NA ) - Accountant/CPA: Vivian Toellner Phone No.: (808) 345 — 2753 Firm (if applicable): Mailing Address: Address: PO Box 6894 Address: City,ST,Zip Hilo,HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $76,500 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna Hamakua ❑North Kona ❑✓ South Hilo ❑ North Kohala 0 South Kona ❑✓ North Hilo ❑South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns 2 Youth ❑Victims of Crimes ❑Culture and the arts ✓❑Aged ❑Victims of Health or Social Crises Q Needs of the poor 0 Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawail Nonprofit Grant Application FY2019-20 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spay/ Neuter Clinics 1.Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $18,875.00 $11,750.00 6,300.00&6,550.00412,850.00 2.Agency Mission Statement: Hui Pono Holoholona-HPH founded in 2007 as a 501c3 nonprofit,united with dedicated volunteers seeking to decrease animal overpopulation,animal abandonment,and high euthanasia of healthy animals,by making available low cost/no cost spay/neuter for dogs and cats within our community. Our organization has provided low cost/no cost spay/neuter clinics for over 5,500 animals,a service vitally needed. Our islanders love and care for their pets,tell us over and over that they are not able to afford the high cost of a private Veterinarian office appointment to spay/neuter which averages over$100. The cost of living in Hawai'i is difficult because of low paying jobs,high rent,food,and medical,which leaves little,or nothing left. Statistically,(horrifically high kill numbers)70+percent of animals entering local Humane Societies and across our nation are euthanized.The scientifically proven solution to decrease that high kill percentage is to make available spay/neuter clinics, which substantially decrease unwanted litter births. We also provide support to pet owners,caregivers and other loosely formed individuals and groups caring for lost,stray,abandoned,abused,and neglected animals. FYI-Hui Pono Holoholona 20 acres sanctuary called P.A.W.S-Pono Animal Way Sanctuary,took in 75 feline volcano rescues from Pahoa during the 2015-16 eruption,and from May 4,2018 over 100 more feline volcano rescues coming from Leilani Estates,Kapoho,Lanipuna Gardens and other areas. 3.Program Description: HPH advertises free Spay/Neuter clinics. We work directly with the community,by loaning traps/pet carriers,arrange transportation and offer other assistance when necessary. We also have phone contact and maintain lists of people in need of assistance. We have spayed/neutered cats from the 2015&2018 Pahoa Lava rescue,Transfer Stations,Parks and other areas.These grant funds we are requesting will be used to maintain and increase our efforts as our operation is outgrowing our donations. Vaccination,microchip,wellness review,and flea treatment are offered at our clinics. We encourage ear tipping for outdoor cats.Our clinics welcome visitors and volunteers. We support the TNRM-Trap Neuter Return and Management of cat colonies.TNRM prevents uncontrolled breeding of abandoned cats. From 2007 until the end of 2018 we have spay/neutered over 5,500 dogs and cats. Hui Pono Holoholona—HPH schedules the clinics,prepares the clinic location,promoting the clinics, providing supplies including microchips,flea treatment and medications and more.HPH schedules the veterinarian staff for clinics. Recruits local volunteers to support clinics including;trapping efforts,admitting,flea treatment,ear tip,vaccination and microchipping,recovery watch and checkout.A Patient Registration Form is filled out at intake for each cat.Each cat is numbered,and the form goes with the animal into the clinic.Each Patient Registration Form is kept in our files. We have monitored the HIHS monthly animal intake statistical reports and have noted a reduction in euthanasia.The effectiveness of clinics,shows a dramatic drop in HIHS intake number,thus indicating S/N is saving lives.The June 2017 Kea'au HIHS intake of strays/feral cats was 415,by comparison the July intake dropped to 297.This was a decrease of 118 cats being turned in and without doubt as a direct result of our hosting a 6-day clinic saving lives via S/N by preventing unwanted litter births.Those participating tell us,how much they appreciate helping the community and animals with this humane solution to animal control. 4.Total Budget&Position Count: Total Program Budget: $90,000 Total Program Position Count: 12 Total Agency Budget: $13,500 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spay/ Neuter Clinics 5.Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Spay/Neuter Participants 10,500.00 Mail Donations 2,500.00 Donation Boxes 500.00 TOTAL: 13,500.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hui Pono Holoholona's sustainability of the Spay/neuter clinics relies on grants from national animal Organizations,Hawai'i County,private donations,and having various fundraising activities and campaigns.Increasing number of Donation boxes placed at the counters of places of business in the community. Social media fundraising campaigns and local activities help raise additional funds. Grants Hui Pono Holoholona has applied for in 2019: State of Hawaii GIA-Grant in Aid for spay/neuter Petco Foundation Grant for spay/neuter Rotary Club of South Hilo Foundation grant for spay/neuter Our clinics do not charge a fee, Participants are asked to donate what they can to help continue this service to more and more cats.No one is turned away. We loan out traps and pet carriers for bringing cats into the clinics. Hui Pono Holoholona officers are volunteers,donating much of their time,expenses and services. The average clinic expense per cat is around$60.00. Cats sterilized at regular veterinarian clinics cost HPH an average of $115 each. Each year we exceed the number of cats funded for sterilization by this grant and below budget! This shows a very good use of taxpayer's funds and the community's support for this service. 7.Program Objectives Using County Nonprofit Grant Program Funds: 1-Sponsor monthly low cost Spay/Neuter clinics for the public. 2-Purchase medical supplies&clinic supplies for the Spay/Neuter clinic. 3-Transport Animals to and from Spay/Neuter appointments. 4-Transport traps/pet carriers at no charge. 5-Encourage UHH Pre-Veterinary students and High School students interested in animal husbandry to attend our clinics. 6-Encourage community support in the humane non-kill reduction of animal overpopulation. HPH's goal is to reduce the number of stray,feral and abandoned animals,humanely in Hawaii Island lava evacuation zones,parks and communities.Current numbers of euthanasia on Hawai'i Island are staggering as reported from the HIHS monthly stats. Yet many animals in our community are abandoned and go uncounted. Unwanted litter births lead to animal abandonment and cruelty. Over decades rounding up to kill has proven unsuccessful, and overall more costly. Success in addressing animal overpopulation is through holding free spay/neuter clinics. A bigger push for large spay/neuter clinics is needed. HPH provides sterilization,microchip,health check,flea treatment,deworming and vaccination. We support TNR as a humane and compassionate response to pet overpopulation and we encourage pet adoptions which decrease euthanasia. Every animal is precious to us,whether privately owned or from a TNRM colony,and by providing spay/neuter keeps these animals generally healthier and safer from wondering off to mate or fight. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Ilawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spar/ Neuter Clinics 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Kilauea Vet.Services/Dr.Seeske 20 Aloha Veterinary Center/Dr.Rodrigues 30 Clinic Veterinarian-Dr Katie Spaulding-Kauai-Petco 450 Clinic Veterinarian-Dr Eric Jayne&Molokai Team 1000 Total 1500 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 0 Professional Fees 0 Operations 25,000 58,000 50,000 Supplies 20,000 30,000 25,000 Equipment 3,000 2,000 1,500 Other: Other: Other: Other: Other: TOTAL 48,000 90,000 76,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spay/ Neuter Clinics 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director n The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. ck ignature of Authorized Person specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spay/ Neuter Clinics 11.Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express,and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spay/ Neuter Clinics is. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Si nature of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spay/ Neuter Clinics 12.COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Kilauea Vet.Services/Dr.Seeske 20 Aloha Veterinary Center/Dr.Rodrigues 30 Clinic Veterinarian-Dr Katie Spaulding-Kauai-Petco 450 Clinic Veterinarian-Dr Eric Jayne&Molokai Team 1000 1500 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 0 Professional Fees 0 Operations 50,000 Supplies 25,000 Equipment 1,500 Other: Other: Other: Other: Other: TOTAL 76,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Innovations Public Charter School Foundation Na Kalai Ola - Life Navigators-Wellness Program 103 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program Agency Director: Jennifer Hiro Phone No.: (808 ) 331 —3130 Contact Person: Lee Nelson Phone No.: (boa ) 756 — 5492 Mailing Address: Address: 75-5815 Queen Ka'ahumanu Hwy. Address: City,ST,Zip Kailua-Kona, HI 96740 Facility Address: Address: 75-5815 Queen Ka'ahumanu Hwy. Address: City,ST,Zip Kailua-Kona, HI 96740 Email Address: Fax No.: (808 ) 331 —3140 Accountant/CPA: Gretchen Kremeyer, CPA Phone No.: (808 ) 930 — 6850 Firm (if applicable): Carbonaro CPAs&Management Company Mailing Address: Address: 1885 Main Street Ste 408 Address: City,ST,Zip Wailuku, HI 96793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona n South Hilo n North Kohala n South Kona ❑ North Hilo ❑South Kohala n Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth n Victims of Crimes ❑✓ Culture and the arts n Aged ❑Victims of Health or Social Crises [' Needs of the poor n Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 • $3,125.00 0 $7,850.00 2.Agency Mission Statement: The mission of Innovations Public Charter School Foundation is to provide support to the Innovations Public Charter School and the West Hawaii Community by helping nurture the bodies,minds and spirits of the children of West Hawaii. Innovations Foundation provides facilities for Innovation Public Charter School and Community Non-Profits such as boys scouts and after school programs. Additionally,the Foundation raises funds,has numerous outreachactivities and after-school and in-school support activities for Innovations Public Charter School. Innovations Foundation strives to teach students to make responsible choices that will lead to developing strong bodies,minds and spirits. The goal of the Foundation is to support the school in nurturing children so that they may grow into responsible young adults that are community contributors and life long learners. Innovations Foundation supports on campus community gardens, sustainability initiatives(recycling/composting),art programs, fine art mentorship experiences and technologyintegration in education. 3. Program Description: "Na Kalai Ola-Life Navigators"is the metaphor for Innovations. Through a grant from the State Foundation of Culture and Arts,artist Stuart S Nakamura Studio is installed a prominent feature of artwork including the iconic"lobster claw"sails of the Makali'i to depict our students as life navigators.Students study the culture and skills of navigators and relate them to the modern day culture and skills that they are developing to be successful in life. This program funds after school and in school art,drama,garden and sustainability programs. Over 60 mentors throughout the community are involved with student navigators. The students engage in expanding current indigenous and endemic gardens. With the push for common core achievement,and low per pupil funds,there is little funds available for the arts,music,garden and sustainability programs. These healthy types of activities are paramount to the overall development of our youth. Innovations Foundation is seeking support for the Na Kalai Ola program so that there are funds for after and in-school culture, arts,sustainability and garden programs to engage students in their Aina and prepare for their life journeys. 4.Total Budget& Position Count: Total Program Budget: 73,000 Total Program Position Count: 2 Total Agency Budget: 10,000 Total Agency Position Count: .5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $3,125.00 0 $7,850.00 2.Agency Mission Statement: The mission of Innovations Public Charter School Foundation is to provide support to the Innovations Public Charter School and the West Hawaii Community by helping nurture the bodies,minds and spirits of the children of West Hawaii. Innovations Foundation provides facilities for Innovation Public Charter School and Community Non-Profits such as boys scouts and after school programs. Additionally,the Foundation raises funds,has numerous outreach activities and after-school and in-school support activities for Innovations Public Charter School. Innovations Foundation strives to teach students to make responsible choices that will lead to developing strong bodies, minds and spirits. The goal of the Foundation is to support the school in nurturing children so that they may grow into responsible young adults that are community contributors and life long learners. Innovations Foundation supports on campus community gardens,sustainability initiatives(recycling/composting),art programs, fine art mentorship experiences and technology integration in education. 3. Program Description: "Na Kalai Ola-Life Navigators"is the metaphor for Innovations. Through a grant from the State Foundation of Culture and Arts,artist Stuart S Nakamura Studio has installed a prominent feature of artwork including the iconic"lobster claw"sails of the Makali'i to depict our students as life navigators.Students study the culture and skills of navigators and relate them to the modern day culture and skills that they are developing to be successful in life. This program funds after school and in school art,drama,garden and sustainability programs. Over 60 mentors throughout the community are involved with student navigators. The students engage in expanding current indigenous and endemic gardens. With the push for common core achievement,and low per pupil funds,there is little funds available for the arts,music,garden and sustainability programs. These healthy types of activities are paramount to the overall development of our youth. Innovations Foundation is seeking support for the Na Kalai Ola program so that there are funds for after and in-school culture, arts,sustainability and garden programs to engage students in their Aina and prepare for their life journeys. 4.Total Budget& Position Count: Total Program Budget: $90,000 Total Program Position Count: 2 Total Agency Budget: $10,000 Total Agency Position Count: .5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Bill Healy Foundation 8,000 FarmCorps - Pending-In Kind 22,000 Innovations School Ohana 27,000 County of Hawaii Grant 10,000 Rotary Club- In Kind Time and Supply Donations 3,000 Kohanaiki Ohana- In Kind Hawaiiana Educational Programs 10,000 Mentor In-Kind Grant 10,000 TOTAL: 90,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: "Na Kalai Ola-Life Navigators"is a program that ties all of our extracurricular community outreach and art,music,garden and sustainability programs together. Life Navigators key component is community involvement. Innovations relies heavily on support from the community. All seventy-two of our 7th and 8th grade students are paired with mentors in the community each Friday. This is the outreach mentorship learning part of our life navigators program. This year we have students at the following businesses more than 4 hours per week: Holy Donuts, Dolphin Quest, Humane Society, Icicles Hair Salon,Miranda's Pets, Paws,3 Ring Ranch, Roth Kimura Architecture Firm,Scandinavian Shave Ice, Keauhou Vet,Shane Dorian, Kamehameha Preschool,Aoki Plumbing,Sea Paradise, Diamond Auto, Oasis Skate Shop, Kona Vet, Island Naturals, Roy Lambrechts Woodworkers,Daylight Mind,Torpedo Tours, Miller's Surf,Yoga Hale, Holualoa El., Kealakehe El.,Soundwave Music,Sakata Archery Supplies, Inc.,Creative Day and Kona Coffee and Tea Company. In addition,we have had local Rotary Support, Pohakuloa Marines, Kohanaiki Ohana and Kaiser Permanent all donate countless volunteer hours in our gardens or with health and wellness programs for our keiki.These in-kind businesses and mentors have really made a huge impact on our students and it has connected them in our community. Growing in the community will have a long-term snowball affect for our students that will lead us to increased revenue and support as our community becomes more invested in our programs each year. 7. Program Objectives Using County Nonprofit Grant Program Funds: The County of Hawaii Grant Program will go exclusively for our garden/sustainability and arts programs on campus. Part of life navigation for our students is learning to treat their bodies,minds and the Aina in a healthy and respectful manner. The garden/ sustainability and arts program is key to the health of our keiki. All school events are zero waste and we practice"farm to fork" practices with garden class. Students not only learn to grow kale,spinach,eggplant and tomatoes, but also how to prepare vegetables for a healthy future. Students will engage in music,art and drama in order to nuture their creative talents. Unfortunately,lack of adequate funds for life programs such as art, music drama and garden/sustainability, Innovations Foundation must fundraise and seek grants to continue these vital programs. We,therefore respectfully request,that the County of Hawaii support our Life Navigators program so that we can navigate our students into a healthy and sustainable future. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators -Wellness Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Community Mentors to help our young student navigators in the life voyage 60 Documented Community Mentorships Volunteer Planting and Community Gardening Days 4 full days-250 in attendance Curriculum Shares Incorporating Art, Music, Drama,Sustainability 5-250 in attendance per tour Community Garden,Sustainability Tours 5-200 in attendance per tour All Students Served with Weekly Garden,Art, Music,and Sustainability Lessons 240 students per week Community Zero Waste Music and Local Grown Fruit/Pancake Breakfasts 3-300 attendance per event Full Culminating Performance of After School Dram Program at Aloha Theatre 900 in attendance over 3 days Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 36800 35,000 10,000 Professional Fees Operations Supplies 8,987 10,000 Equipment Other: In-Kind Mentors 10,000 10,000 Other: In-Kind Rotary 3,000 Other: In-Kind Kohanaiki 10,000 Other: In-Kind Farmcorps 22,000 Other: TOTAL 55787 90,000 10,000 *If applicable • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. ( 112C 5xndc►it Secretari 1 /23/2019 Sig ture o-Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Innovations Public Charter School Foundation g Y Program Name: Na Kalai Ola - Life Navigators - Wellness Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. • ion+ (.))-1;1,b 1/23/2019 Signature of Authorized Person (see checklist, 2nd item) Date 'IRS Found c I o, 3e cxvi'tai Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 60 Documented Community Community Mentors to help our young student navigators in the life voyage Mentorships Volunteer Planting and Community Gardening Days 4 full days-250 in attendance Curriculum Shares Incorporating Art, Music, Drama,Sustainability 5-250 in attendance per tour Community Garden,Sustainability Tours 5-200 in attendance per tour All Students Served with Weekly Garden,Art, Music,and Sustainability Lessons 240 students per week 3-300 attendance per event Community Zero Waste Music and Local Grown Fruit/Pancake Breakfasts 900 in attendance over 3 days Full Culminating Performance of After School Dram Program at Aloha Theatre TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 10,000 Professional Fees Operations Supplies Equipment Other: In-Kind Mentors Other: In-Kind Rotary Other: In-Kind Kohanaiki Other: In-Kind Farmcorps Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Island of Hawaii YMCA, The Family Visitation Center (FVC) 104 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) Agency Director: Wendy Botelho-Cortez Program Director, FVC , CEO Phone No.: (so ) 464 -4020 Contact Person: Wendy Botelho-Cortez Phone No.: (8os ) 464 -4020 Mailing Address: Address: The Island of Hawaii YMCA Address: 300 W. Lanikaula St. City,ST,Zip Hilo, HI 96720 Facility Address: Address: (same) Address: City,ST,Zip Email Address: daniellej@islandofhawaiiymca.org Fax No.: ( ) — Accountant/CPA: Carbonaro CPAs&Management Group Phone No.: (808 )930 -6850 Firm (if applicable): Mailing Address: Address:P.O.Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna ® Hamakua © North Kona ©South Hilo © North Kohala ©South Kona © North Hilo ©South Kohala ® Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ©Youth ®Victims of Crimes ['Culture and the arts ❑Aged ©Victims of Health or Social Crises © Needs of the poor © Physical/Emotional Disabilities ® Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 , County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $12,000 $27,625 $28,925 2. Agency Mission Statement: As described on the YMCA's national website, all YMCA's share three areas of focus: Our Areas of Focus The Y is a cause-driven organization that is for youth development,for healthy living and for social responsibility.That's because a strong community can only be achieved when we invest in our kids, our health and our neighbors. Defining our areas of focus: YOUTH DEVELOPMENT:Nurturing the potential of every child and teen. HEALTHY LIVING:Improving the nation's health and well-being. SOCIAL RESPONSIBILITY:Giving back and providing support to our neighbors. Opportunities for All The Y is for everyone.Our programs,services and initiatives enable kids to realize their potential,prepare teens for college, offer ways for families to have fun together,empower people to be healthier in spirit, mind and body;prepare people for employment,welcome and embrace newcomers and help foster a nationwide service ethic.And that's just the beginning. 3. Program Description: What is the Family Visitation Center(FVC)? It is a safe, nurturing place within the YMCA facility where child visitations and exchanges can occur.The Center helps children and parents who are experiencing difficulties with domestic violence,divorce,separation or custody disputes. The Family Visitation Center can help when: Children need to go from one parent to another without their parents meeting each other. Children's visits with a parent are required to be supervised. Children's visits are court-ordered but their parents are not able to make the arrangements for visits. A parent is concerned about the safety of the children during visits with the other parent. Assistance is needed for children to visit with other adults and/or children. What services does the Family Visitation Center offer? SUPERVISED EXCHANGES-Children can go from one parent to the other without the parents meeting each other.The exchange of the children is supervised and occurs at the Center. SUPERVISED VISITATION-Center staff supervise visits between children and parents in a stable and supportive environment. Different levels of supervision are available, including full direct, intermittent,and beginning&ending supervision. Homeless parents are offered change of clothes and a warm shower before the visit with the child. SUPERVISED TELEPHONE VISITS-Center staff monitor telephone calls between children and parents.Children come to the FVC with their custodial parent, and the"visiting parent"calls the center. Face Time Visits over the Internet is possible. To arrange visits at the Center,you need a court order or an agreement of all the adults involved. 4.Total Budget& Position Count: Total Program Budget: $78,000 Total Program Position Count: 6 Total Agency Budget: $357,000 Total Agency Position Count: 18 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Hawaii County Council-Contingency Fund(expected from Council members) $1,000 Visitation fees paid by participants(usually the visiting parent) $24,000 TOTAL: $25,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: FVC visitation fees expected have more than doubled from last year to this year. (Last year the amount expected was$10,000.) Some donations to the YMCA that would have been used for overall YMCA facilities maintenance and improvement can now be diverted to program operations,such as the FVC,due to financial support from the State government's Grant In Aid. Physical improvements now in progress include expanded restroom facilities for children. Ongoing search and applications to grants and other funding sources continue year round. It should be noted that while the additional revenue search goes on, FVC employees have volunteered when there were gaps in funded services. 7. Program Objectives Using County Nonprofit Grant Program Funds: This application for County Nonprofit Grant Program Funds would be used to maintain approximately the current level of service at its Hilo facility. No long-term steady source of income is currently available. Continuation of the Family Visitation Center provides an invaluable resource for the judicial and social services systems on our island,significantly relieving pressures in society that could lead to further abuse,neglect, violence, and perhaps even deaths.To put it bluntly,the Center probably also reduces expenses that would have been spent on social work, police,court,prison, and other services if dysfunctions in the families instead continued and worsened. The County Nonprofit Grant Program funds would be used to maintain the Hilo facility operations. If other sufficient long-term funds become available from whatever sources,the YMCA's Family Visitation Center would like to start a West Hawaii(Kona) branch center. Participants from the West Hawaii area and other areas outside Hilo have valued this program so much that they have travelled to Hilo to participate.This compounds the emotional and financial stresses they are under due to the travel time and travel expenses involved. Further, if sufficient long-term funds become available,additional staff and days of service per week is desired for Hilo and Kona. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) adults to be served 350 family units to be served 175 children and teens under 18 years old to be served 480 volunteers-- State DHS, First To Work volunteers/Judiciary Community Service 4 (3,840 hours)/16 (1,200 hours) Alu Like/DECA high school club/community members 1 (960 hours)/1 (480 hours)/6(1,080 hours) FVC Employee volunteer hours 6(1,260) YMCA Board of Directors volunteers 6(576) Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $33,000 $78,000 $53,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $33,000 $78,000 $53,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential • conflicts of interest: ✓❑ If no conflicts exist, check here. V, Signature of Authorized Person (specify title) (L( c Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii:gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your proaram's or agency's future fundina requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information ' and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes statedin the application,except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report.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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. r/ jig Signature of Authorized Person (see checklist, 2nd item) Date f1eCL& Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 A County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Island of Hawaii YMCA Program Name: Family Visitation Center (FVC) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 350 175 480 4(3,840 hours)/16(1,200 hours) 1(960 hours)/1(480 hours)/ 6(1,080 hours) 6(1,260) 6(576) TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $53,000 Professional Fees Operations Supplies Equipment Other; Other: Other: Other: Other: TOTAL $53,000 . Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 A' ;.'''' IFF , ,1, :>:.:;-1' ' : - v � -;;; ' , the Yi , 1,1 x a 9alasal4 rWerectu111 e47aaallyq/eaeratYea 300 71MSOO Viat Zdadada Sower it4, r?4awau 96720 80l 935-3721 Dam* l08 464-4020 1/29/2019 Please add in to the County of Hawaii Grant Application: #3 Program Description: (Additional Details) What is the Family Visitation Center? It is the most home like environment away from home that allows the children to feel at home, safe and happy to see the other parent. It is a place where Aloha is found within the walls of the YMCA facility. It is a place where the children can come, watch TV with their parents, celebrate their birthday with their family, eat snacks, meals and goodies and have fun in a supervised, safe place. The FVC is a place where children fall down, scrape their knees, and laugh, tell stories, and attend parties held and hosted by the FVC. The FVC has visitation rooms, set up like a living room, toys, foosball table, bikes, trikes, balls, games and books for the children and parents to enjoy their time together. The YMCA FVC provides two annual events sponsored by the YMCA free of charge to the children and the visiting child. The Saturday, following the 4th of July Holiday, is a splash party with chili, hotdogs, corn on the cob and cupcakes. The pool is set up and water slides are set up for the children to enjoy. The YMCA also provides a Christmas get together with Santa and gifts to all the children with the visiting parents. At this event a Christmas snowflake tree is set up with all of the children's first manes on the snowflake. Members of the YMCA choose names and purchase a gift for the child. Those members are invited to attend the party. Santa gives the gifts to the children from Santa. Games are played and a traditional Christmas dinner food is served (Turkey, Ham, stuffing, mashed potatoes). The Family Visitation Center also offers Supervised Face Time Visits over the internet. These visits can be fully supervised or intermittent visits, lasting up to one hour. t r We offer Intermittent Visits, where the children and visiting parent is left but checked on every 10 minutes, however, never out of the eye's view of the Visitation Associates or FVC Security Officers. The FVC assists visiting parents with snacks as needed. The FVC utilizes the Food Basket Services and lets the parents do the selections and preparations. The FVC assists the parents who are homeless with change of clothes and a warm shower before the visit with the child. Thus, building the confidence of the parents, and allowing to child to have a proud moment with the visiting parent, causing positive memories at the visits. The FVC provides updated letters for court hearings, and general updates as needed or as incidents occur that the court and attorneys need to be informed. FVC will recommend to change to different levels of supervision for the visits progress as the situation is monitored and documented. The goal of the FVC is to work hard to close cases where the "Supervision" is no longer needed. The FVC provides the needed paperwork trail for verification of parents and children's behaviors. #4 Total Budget and Position Count: Long range dream budget Total Position Count: 10 FVC Director: Full time $48,000.00 ($25/hr) FVC Supervisor Full time $30,720.00 ($16/hr) FVC Specialist Part time $11 ,520.00 ($12/hr) FVC Specialist Part time $11,520.00 ($12/hr) FVC Specialist Part time $11 ,520.00 ($12/hr) FVC Specialist Part time $11 ,520.00 ($12/hr) FVC Support Staff Part time $10,080.00 ($10.50/hr) FVC Security Part time $11 ,520.00 ($12/hr) FVC Security Part time $11 ,520.00 ($12/hr) FVC Security Part time $11 ,520.00 ($12/hr) TOTAL SALARIES: $169,440.00 Office supplies: $4,000.00 Food: $1 ,000.00 Training: $5,000.00 Office space $12,000.00 Utilities $ 6,000.00 TOTAL MISC: $28,000.00 PAD IN $10,000.00 FOR EMPLOYEE BENEFITS TOTAL NEEDED: $207,440.00 (TOTAL AGENCY BUDGET) #6 Explain what plans your agency has to increase revenues to support this program: Please add in : The staff at the YMCA continues to think of creative ways to offer financial support to the FVC. The Staff and Board members put together quarterly "Dance Parties" hosted by local bands to raise funds to supplement and offer scholarships to the families who need to utilize the family Visitation Center. At these Dance Parties, the community is invited to attend, dance the night away and eat pupu's. A donation is collected for the pupu's and an entry fee is collected at the door. All of the YMCA staff volunteer that evening. I . c Vlt the � .Y } a Outtersto,cant 95729109 Td ( s?'a«aa ?'11th 74.,A*V altatlaws Lata 300 Wag"a"4. 4 Setae We, Wa.a& 96720 102-935-3721 Deud: 101464-4020 1/29/2019 Please add in to the County of Hawaii Grant Application: #8 Table 1: Adults to be served: Adults involved in Domestic Violence: 350 Family Units: 175 Children and teens under 18 years old: 480 Volunteer hours/sources: State of Hawaii, Department of Human Services, First to Work Volunteers: 4 Number of First to Work Volunteer hours: 3,840 Alu like Adult Job Training funded position: 1 position Total number of hours: 960 State of Hawaii Judiciary Community Service: 16 individuals Total Number of hours: 1,200 Note: Not a direct service, assisted with set up, clean up, maintenance, upkeep answering the phones and painting the building. DECCA, Distributive Education Clubs of America Waiakea High School: 1 Number of Volunteer hours: 480 Community Members/Walk- ins: 6 Number of Volunteer hours: 1,080 FVC Employee Volunteer hours: 6 Number of volunteer hours: 1,260 YMCA Board of Directors Volunteers for FVC: 6 Total number of volunteer hours: 576 Ka'u Rural Health Community Association, Inc. Ka'u Community "Healthy Hearts" Pilot program 105 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kau Rural Health Community Association Inc. Program Name: Kau Community "Healthy Hearts" Pilot program Agency Director: Jessanie Marques Phone No.: (808) 928 — 0101 Contact Person: Jessanie Marques Phone No.: (808) 928 — 0101 Mailing Address: Address: P.O.Box 878 Address: City,ST,Zip Pahala,Hawaii 96777 Facility Address: Address: 96-3126 Puahala Street Address: City,ST,Zip Pahala,Hawaii 96777 Email Address: krhcai@yahoo.com Fax No.: ( ) — Accountant/CPA: • Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: • Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑Puna ❑Hamakua ❑North Kona ❑South Hilo ❑North Kohala ❑South Kona ❑North Hilo ❑South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kau Rural Health Community Association Inc. Program Name: Kau Community "Healthy Hearts" Pilot program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $11,875 $10,375 2.Agency Mission Statement: Kau Rural Health Community Association Inc.(KRHCAI)Mission "To Do What It Takes to Keep Kau Healthy"best describes our commitment to support and promote community empowerment,capacity building,collaborative partnership an a health community through education,information and community outreach. 3. Program Description: KRHCAI is seeking$25,000 to develop a"Kau Community Healthy Hearts"(KCHH) Pilot to improve the quality of life for individuals diagnosed with chronic disease i.e.hypertension,diabetes,cardiovascular conditions;through training,education and outreach;in collaboration with the Dept.of Health Community Health Worker Outreach/Kau Telehealth Virtual Clinic Demonstration project; UHM/JABSOM Family Medicine and Community Health Pacific,Regional Comprehensive Cancer Control program; Dept.of Health Chronic Disease Prevention&Health Promotion Division, Kau Critical Access Hospital; and HMSA Telehealth Online Care. Funds will be used to 1)facilitate education/training to individuals diagnosed with Chronic Disease i.e.hypertension, diabetes,and/or cardiovascular conditions; 2)coordinate certification of Community Health Workers/Certified Nurse Aides in Blood Pressure Measurement Train-the-Trainers Training;3)facilitate/coordinate Chronic Disease Self Management support groups in Pahala,Naalehu and Oceanview; 4)educate,engage and enroll individuals with HMSA/Kau Online Telehealth program/s and 5)enhance CHWs/CNAs professional workforce development skills and experience. (Reference Sources:)The UHM/Center on Kau Family Profile stated"Kau's people are faced with substantial number of economic,social and educational hardships,have the highest rate of poverty,welfare,food stamps and Medicaid recipients, poverty linked to the high cost of healthcare because of lack of access to healthcare,education,employment,vocational training and social services. Recognizing the substantial economic,social and educational hardships,KRHCAI created this"place based"pilot program to help improve the quality of life for it's people,through education,training,outreach and sustainable opportunities 4.Total Budget&Position Count: Total Program Budget: $46,187 Total Program Position Count: 7 Total Agency Budget: $191,037 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kau Rural'Health Community Association Inc. Program Name: Kau Community "Healthy Hearts" Pilot program 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Dept.of Health Telehealth Virtual Clinic(FY2018-19) $10,000.00 County of Hawaii CHW/Telehealth WFD Demonstration Project(FY2018-19) 5,187.00 UHM/JABSOM Family Medicine and Community Health Pacific Region(FY2018-21) 6,000.00 TOTAL: $21,187 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: KRHCAI operating budget depends on membership dues,donations,fundraising and grants. Upon completion of CHW/Workforce development,telehealth,outreach demonstration program/s; and Kau Community Healthy Hearts Pilot, KRHCAI plans to negotiate placement fees for each trained CHW/CNA that is hired or matriculates; a"finder's fee"and reimbursement for each new patient or encounter that results in a successful clinic visit via telehealth. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Educate individuals diagnosed with Chronic Disease i.e.hypertension,diabetes and/or cardiovascular disease on prevention and self management. 2) Increase access to individuals who have limited/or no health education/prevention support. 3)Establish a certification Blood Pressure Measurement Train-the-Trainers program with CHW/s and CNAs. 4)Facilitate/coordinate Chronic Disease Self Management support groups in Pahala,Naalehu and Hawaiian Oceanview. 5)Inform,educate,engage and enroll individuals in HMSA/Kau Online Telehealth program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kau Rural Health Community Association Inc. Program Name: Kau Community "Healthy Hearts" Pilot program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Develop Blood Pressure Measurement Train-the-Trainers program Certification of 5 CHWs/CNAs Establish Chronic Disease Self Management Support groups in Pahala,Naalehu,OV 3 groups with 12-15 participants Engage individuals diagnosed with chronic disease i.e.hypertension,diabetes,CVD 100 participants Provide Blood Pressure devices to individuals who participate in KCHH Pilot 50-100 participants Establish a community health needs assessment tool 100 participants Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages Professional Fees 9,000 5,000 Operations 4,000 1,000 Supplies Equipment 5,187 5,000 Other: Other: Utilities 3,000 1,000 Other: Staff Development&Training 5,000 3,000 Other: Stipends 10,000 5,000 Other: Mileage 10,000 5,000 TOTAL 46,187 25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kau Rural Health Community Association Inc. Program Name: Kau Community "Healthy Hearts" Pilot program so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): D Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor The Managing❑ g g Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. qt, h14 ,� January 30, 2019 nature of Authoriz Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kau Rural Health Community Association Inc. Program Name: Kau Community "Healthy Hearts" Pilot program 11.Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express,and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov,complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kau Rural Health Community Association Inc. Program Name: Kau Community "Healthy Hearts" Pilot program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in thea application,except for a maximum tenpercent(10%)for administrative and overhead pp � p costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report.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. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. il-kteArd/?1 erik7) 3o) / Signature of Authorized Person (see checklist, 2nd item) Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kau Rural Health Community Association Inc. Program Name: Kau Community "Healthy Hearts" Pilot program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Certification of 5 CHWs/CNAs 3 groups with 12-15 participants 100 participants 50-100 participants 100 participants TABLE II: • FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees 5,000 Operations 1,000 Supplies Equipment 5,000 Other: Other: Utilities 1,000 Other: Staff Development&Training 3,000 Other: Stipends 5,000 Other: Mileage 5,000 TOTAL 25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Keaukaha One Youth Development Hokualaka'i Restoration Project 106 k . County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project Agency Director: Shadd Keahi Warfield Phone No.: (808) 895 — 8666 Contact Person: Naomi Ahu Phone No.: (sob) 756 — 5859 Mailing Address: Address: 67 Keokea Loop Address: City,ST,Zip Hilo, Hawaii, 96720 g�® Facility Address: Address: same as above ORiGI AL Address: City,ST,Zip Email Address: naomi.koyd.rise@gmail.com Fax No.: ( ) — Accountant/CPA: Carbonaro CPA's&Management Group Phone No.: (808 ) 930 — 6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street Address: PO Box 4372 City,ST,Zip Hilo, Hawaii, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) n Puna n Hamakua n North Kona ❑✓ South Hilo n North Kohala n South Kona n North Hilo n South Kohala n Kali Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns n Youth ❑Victims of Crimes n Culture and the arts Ti Aged n Victims of Health or Social Crises n Needs of the poor n Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0.00 $7,625.00 $8,800.00 2. Agency Mission Statement: • The mission of Keaukaha One Youth Development(KOYD)is to contribute toward the development of youth leadership in Keaukaha/Panaewa Hawaiian Homestead and East-Hawaii County communities.Through the cultural heritage of a Hawaiian warriorship model and ocean based activities surrounding the Hawaiian canoe,these cultural vessels of learning will promote: (1)the stress of physical fitness; (2) instructional use and maintenance of voyaging and 1 &6 man canoes; (3)waterman competence and perfection of swimming skills; (4)training Hawaiian youth to become qualified crew members of the Hokualaka`i double hulled sailing canoe;and (5)out of school educational opportunities to reveal individual strengths and passions for lifelong learning and efficacy. 3. Program Description: In November 2015,the Hokualaka'i double-hulled voyaging canoe owned and built by`Aha Punana Leo was graciously donated to KOYD and the community of Keaukaha.As the new caretakers,we decided to make Keaukaha its permanent home having been over-challenged with the restoration demands it requires.We envision this donation as another learning domain to further solidify our goals of creating cultural learning places for youth and their families to contribute their talents and learning engagements through our Polynesian voyaging heritage and to teach our youth to become qualified voyaging members of the Hokualaka`i. 4. Total Budget& Position Count: Total Program Budget: $25,000.00 Total Program Position Count: 4 Total Agency Budget: $555,000.00 Total Agency Position Count: 4 EXHIBITA NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 � a County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii (reflects current request) $25,000.00 TOTAL: $25,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Hokualaka'i Restoration Project continues to rely on contributions and grants from the public and private sector.We strive for community support to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Hokualaka'i Restoration Project will strive to reach the following objectives: 1)Restore the Hokualaka'i double-hulled voyaging canoe back to seaworthiness. 2)Teach the values of team work, goal setting, commitment, physical, mental, and spiritual well-being, and cultural identity through the restoration process and use of the voyaging canoe. 3)Create more cultural learning places for youth and their families to contribute their talents and learning engagements through our Polynesian voyaging heritage. 4)To inspire and teach our youth to become cultural experts in the arts of kalai wa'a(canoe restoration)and ho'okele wa'a (voyaging)through the use of Hokualaka`i. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Hawaii County youth served 150 youth Volunteer hours of 12 people 5,760 hours Hokualaka'i Restoration Completed by June 2020 ***See attachment Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $2,500.00 $2,500.00 Professional Fees Operations Supplies $8,800.00 $15,000.00 $15,000.00 Equipment $7,500.00 $7,500.00 Other: Food/snacks for youth &volunteers Other: Travel Other: Gen'I Liability Insurance Other: Other: TOTAL $8,800.00 $25,000.00 $25,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 ,7 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ri If no conflicts exist, check here. i Eztlntre-- III 42,491q Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 - Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 I County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. llrsl20/9 l -- Signature of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Hokualaka`i Restoration Project 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Hawaii County youth served 150 youth Volunteers hours of 12 people 5,760 hours HOkOalakal Restoration Completed by June 2020 ***See attachment TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $2,500.00 Professional Fees Operations Supplies $15,000.00 Equipment $7,500.00 Other: Food/snacks for youth &volunteers Other: Travel Other: Gen'! Liability Insurance Other: Other: TOTAL $25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 1 County of Hawaii Non-Profit Grants Program —Attachment Fiscal Year 2019-20 Keaukaha One Youth Development (KOYD) Hokualaka`i Restoration Project Total Grant Request = $25,000.00 Reference to Page 4, Question 8: Table I—What are the intended measurable outputs or outcomes that would be achieved with this funding? Reference to Page 8, Question 12: Table I— Council Award Worksheet Program Performance Measures Applicant Projected Results 1) Number of Hawaii County youth served Approximately 150 youth 2) Volunteer hours of 12 people: Executive Approximately 5,760 hours (see breakdown Director, Cultural Practitioner, and 10 below): Keaukaha Hawaiian Homestead kupuna * 40 hours per month x 12 months =480 hours per person x 12 people= 5,760 hours 3) Hokualaka`i restoration Restoration completed by June 2020 Reference to Page 4, Question 9: Table II—Program Expenditures for County Grant Request Reference to Page 8, Question 12: Table II— Council Award Worksheet Program Expenditures Additional Details Budget Salaries &Wages: Portion of Executive Director $2,500.00 Salary Equipment: Outdoor power $7,500.00 tools/equipment Supplies: Misc. materials/supplies for $15,000.00 Hokualaka`i reconstruction and site maintenance 1 Keaukaha One Youth Development Ho'ola Hou - Hawaiian Warriorship Program 107 r ' h County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Ho'ola Hou - Hawaiian Warriorship Program Agency Director: Shadd Keahi Warfield Phone No.: (808) 895 — 8666 Contact Person: Naomi Ahu Phone No.: (808) 756 — 5859 Mailing Address: Address: 67 Keokea Loop Address: City,ST,Zip Hilo, Hawaii, 96720 ati1G1 ; Facility Address: Address: same as above Address: City,ST,Zip Email Address: naomi.koyd.rise@gmail.com Fax No.: ( ) — Accountant/CPA: Carbonaro CPA's&Management Group Phone No.: (808 ) 930 — 6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street Address: PO Box 4372 City,ST,Zip Hilo, Hawaii, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna 0 Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona ❑✓ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Ho'ola Hou - Hawaiian Warriorship Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0.00 $0.00 $8,800.00 2. Agency Mission Statement: The mission of Keaukaha One Youth Development(KOYD)is to contribute toward the development of youth leadership in Keaukaha/Panaewa Hawaiian Homestead and East-Hawai'i County communities.Through the cultural heritage of a Hawaiian warriorship model and ocean based activities surrounding the Hawaiian canoe,these cultural vessels of learning will promote: (1)the stress of physical fitness; (2)instructional use and maintenance of voyaging and 1 &6 man canoes; (3)waterman competence and perfection of swimming skills; (4)training Hawaiian youth to become qualified crew members of the Hokualaka'i double hulled sailing canoe; and(5)out of school educational opportunities to reveal individual strengths and passions for lifelong learning and efficacy. 3. Program Description: The Ho'ola Hou system was founded by the late Lohe Ka'aloa to promote the warrior traditions,values, and practices of a Hawaiian martial order. Ho'ola Hou incorporates three necessary stages of learning: 1)Ho'ola hou`revitalization of the individual'; 2)Ola hou`to live revitalized'; and 3) Kia`i'to safeguard and protect'. The Ho'ola Hou system is a martial art that incorporates various martial techniques of many traditions. Its unique style is based upon the strength and movement of our Pacific waters, and the spirit of Aloha identifies its philosophy.While effective techniques of self-defense are part of the essential training, character building and understanding the true spirit of Aloha are of greater importance. 4. Total Budget& Position Count: Total Program Budget: $25,000.00 Total Program Position Count: 4 • Total Agency Budget: $555,000.00 Total Agency Position Count: 4 EXHIBITA NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Ho'ola Hou - Hawaiian Warriorship Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii (reflects current request) $25,000.00 TOTAL: $25,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Ho'ola Hou-Hawaiian Warriorship Program will rely on contributions and grants from the public and private sector.We strive for community support to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Ho'ola Hou-Hawaiian Warriorship Program will strive to reach the following objectives: 1)Provide an environment suitable for youth learning about ones self and character through peer interaction. 2) Develop strong youth leaders based on native Hawaiian practices and applied values. 3)Develop confidence, self-identity, and enhanced self-esteem for efficacy. 4)Develop and deepen the competence of practitioners in Ho'ola Hou. EXHIBITA NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Ho'ola Hou - Hawaiian Warriorship Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Hawaii County youth served 75 youth Volunteer hours of four people 1920 hours ***See attachment • Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $2,500.00 $2,500.00 Professional Fees Operations Supplies $6,000.00 $4,500.00 $4,500.00 Equipment $10,000.00 10,000.00 Other: Food/snacks for youth &volunteers $800.00 $3,000.00 $3,000.00 Other: Travel $2,000.00 $5,000.00 $5,000.00 Other: Gen'l Liability Insurance Other: Other: ga TOTAL $8,800.00 $25,000.00 $25,000.00 *If applicable EXHIBIT A • NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Ho'ola Hou - Hawaiian Warriorship Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. i L-N)1 Eer �� am litAr (11 /20 9 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Ho'ola Hou - Hawaiian Warriorship Program ii. Certification of Understanding (Page sof 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Ho'ola Hou - Hawaiian Warriorship Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. f X16/2 9 Signature of Authorized Person (see checklist, 2nd item) Date 1 Ti VE C)'/& V(— PACS./PENT Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Ho'ola Hou - Hawaiian Warriorship Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Hawaii County youth served 75 youth Volunteers hours of 12 people 1920 hours Hokualaka`i Restoration ***See attachment TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $2,500.00 Professional Fees Operations Supplies $4,500.00 Equipment 10,000.00 Other: Food/snacks for youth &volunteers $3,000.00 Other: Travel $5,000.00 Other: Gen'I Liability Insurance Other: Other: TOTAL $25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 County of Hawaii Non-Profit Grants Program — Attachment Fiscal Year 2019-20 Keaukaha One Youth Development (KOYD) Ho`ola Hou — Hawaiian Warriorship Program Reference to Page 4, Question 8: Table I—What are the intended measurable outputs or outcomes that would be achieved with this funding? g Reference to Page 8, Question 12: Table I— Council Award Worksheet Program Performance Measures Applicant Projected Results 1) Number of Hawaii County youth served Approximately 75 youth 2) Volunteer hours of four people: Executive Approximately 1920 hours (see breakdown Director, Executive Assistant, below): Fiscal/Administrative Coordinator, and * 40 hours per month x 12 months =480 hours Cultural Expert per person x 4 people = 1920 hours Reference to Page 4, Question 9: Table II—Program Expenditures for County Grant Request Reference to Page 8, Question 12: Table II—Council Award Worksheet Program Expenditures Additional Details Budget Salaries &Wages: Portion of Executive Director $2,500.00 Salary Supplies: Misc. training supplies $4,500.00 Equipment: Misc. training equipment $10,000.00 Food: Snacks/other food supplies $3,000.00 Travel: Intra-island travel expenses $5,000.00 for staff professional development 1 Keaukaha One Youth Development PISCES-VEX IQ Robotics Program 108 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: PISCES - VEX IQ Robotics Program Agency Director: Shadd Keahi Warfield Phone No.: (808) 895 — 8666 Contact Person: Naomi Ahu Phone No.: (808) 756 — 5859 Mailing Address: Address: 67 Keokea Loop Address: City,ST,Zip Hilo, Hawaii, 96720 Facility Address: Address: same as above iOIGNAL Address: City,ST,Zip Email Address: naomi.koyd.rise@gmail.com . Fax No.: ( ) — Accountant/CPA: Carbonaro CPA's&Management Group Phone No.: (808 ) 930 — 6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street Address: PO Box 4372 City,ST,Zip Hilo, Hawaii, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑ North Kona ['South Hilo ❑ North Kohala ❑South Kona n North Hilo n South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ri Youth ❑Victims of Crimes n Culture and the arts ❑Aged n Victims of Health or Social Crises n Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: PISCES - VEX IQ Robotics Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0.00 $0.00 $0.00 2. Agency Mission Statement: The mission of Keaukaha One Youth Development(KOYD)is to contribute toward the development of youth leadership in Keaukaha/Panaewa Hawaiian Homestead and East-Hawai'i County communities.Through the cultural heritage of a Hawaiian warriorship model and ocean based activities surrounding the Hawaiian canoe,these cultural vessels of learning will promote: (1)the stress of physical fitness; (2)instructional use and maintenance of voyaging and 1 &6 man canoes; (3)waterman competence and perfection of swimming skills; (4)training Hawaiian youth to become qualified crew members of the Hokualaka'i double hulled sailing canoe; and(5)out of school educational opportunities to reveal individual strengths and passions for lifelong learning and efficacy. 3. Program Description: In September 2017,through a new collaboration with the Pacific International Space Center for Exploration Systems (PISCES), the PISCES-VEX IQ Robotics Program was established to provide opportunities of innovation, design, competition and future interest in science,technology, engineering, and math(STEM)fields. Students engage with two UH-Hilo interns that help train them to conduct computer programming and construction of robots engineered to perform specific tasks to overcome challenges and game like gauntlets such as those seen in the annual Waiakea-Hilo-Honokaa(WHH)VEX IQ League which they participated in for the first time during the 2018-19 school year. 4. Total Budget& Position Count: Total Program Budget: $25,000.00 Total Program Position Count: 4 Total Agency Budget: $555,000.00 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: PISCES - VEX IQ Robotics Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii (reflects current request) $25,000.00 TOTAL: $25,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The PISCES-VEX IQ Robotics Program continues to rely on contributions and grants from the public and private sector.We strive for community support to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: The PISCES-VEX IQ Robotics Program will strive to reach the following objectives: 1) Provide opportunities of innovation, design, competition and future interest in science,technology,engineering, and math (STEM)fields. 2)Promote valuable skills such as critical thinking and problem solving to overcome life challenges. 3)Create more opportunities to utilize STEM in KOYD's current and future culture-based programs. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: PISCES - VEX IQ Robotics Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Hawaii County youth served 30 youth Volunteer hours of four people • 575 hours VEX IQ Robotics League Six(6)competitive events ***See attachment Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $2,500.00 $2,500.00 Professional Fees Operations Supplies $8,000.00 $8,000.00 Equipment $5,000.00 $5,000.00 Other: Food/snacks for youth &volunteers $2,000.00 $2,000.00 Other: Travel $7,500.00 $7,500.00 Other: Gen'l Liability Insurance Other: Other: TOTAL $0.00 $25,000.00 $25,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: PISCES - VEX IQ Robotics Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council I I Staff appointed by a member of the Council n The Mayor The Managing Director The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. /91 PRV ft/ C�,1� Iles/201q I Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: PISCES - VEX IQ Robotics Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai`i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: PISCES - VEX IQ Robotics Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. d I I S1 / Signature of Authorized Person (see checklist, 2nd item) Date X rA-n v-: OiReCZ / Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: PISCES - VEX IQ Robotics Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Hawaii County youth served 30 youth Volunteers hours of four people 575 hours VEX IQ Robotics League Six(6)competitive events "**See attachment TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $2,500.00 Professional Fees Operations Supplies $8,000.00 Equipment $5,000.00 Other: Food/snacks for youth &volunteers $2,000.00 Other: Travel $7,500.00 Other: Gen'l Liability Insurance Other: Other: TOTAL $25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 County of Hawaii Non-Profit Grants Program — Attachment Fiscal Year 19-20 Keaukaha One Youth Development (KOYD) PISCES — VEX IQ Robotics Program Total Grant Request = $25,000.00 Reference to Page 4, Question 8: Table I—What are the intended measurable outputs or outcomes that would be achieved with this funding? Reference to Page 8, Question 12: Table I— Council Award Worksheet Program Performance Measures Applicant Projected Results 1) Number of Hawaii County youth served Approximately 30 youth 2) Volunteer hours of four people: Executive Approximately 575 hours (see breakdown Director, Program Assistant, Two (2) Program below): Interns * 4 two hour robotics training days per month x 12 months = 96 hours x 4 volunteers = 384 hours * 6 eight hour Saturday robotics competition events x 4 volunteers = 192 hours Reference to Page 4, Question 9: Table II—Program Expenditures Reference to Page 8, Question 12: Table II— Council Award Worksheet Program Expenditures Additional Details Budget Salaries &Wages: Portion of Executive Director $2,500.00 Salary Equipment & Supplies: Various robotics equipment $13,000.00 and supplies Other: Travel Costs (State Robotics $7,500.00 Competion) Snack/other food supplies $2,000.00 1 Keaukaha One Youth Development Rise 21st Century After School Program 109 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program Agency Director: Shadd Keahi Warfield Phone No.: (808) 895 — 8666 Contact Person: Naomi Ahu Phone No.: (808) 756 — 5859 Mailing Address: Address: 67 Keokea Loop Address: City,ST,Zip Hilo, Hawaii, 96720 ���� Facility Address: Address: same as above ""� ORIGINAL Address: City,ST,Zip Email Address: naomi.koyd.rise@gmail.com Fax No.: ( ) — Accountant/CPA: Carbonaro CPA's&Management Group Phone No.: (808 ) 930 — 6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street Address: PO Box 4372 City,ST,Zip Hilo, Hawaii, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) 0 Puna 0 Hamakua ❑ North Kona 0 South Hilo ❑ North Kohala ❑South Kona 0 North Hilo ❑South Kohala - ❑ Kati) Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns ['Youth ❑Victims of Crimes 0 Culture and the arts ❑ Aged ❑Victims of Health or Social Crises 0 Needs of the poor ❑ Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $6,750.00 $8,250.00 $9,050.00 2. Agency Mission Statement: The mission of Keaukaha One Youth Development(KOYD)is to contribute toward the development of youth leadership in Keaukaha/Panaewa Hawaiian Homestead and East-Hawai'i County communities.Through the cultural heritage of a Hawaiian warriorship model and ocean based activities surrounding the Hawaiian canoe,these cultural vessels of learning will promote: (1)the stress of physical fitness; (2)instructional use and maintenance of voyaging and 1 &6 man canoes; (3)waterman competence and perfection of swimming skills; (4)training Hawaiian youth to become qualified crew members of the Hokualaka'i double hulled sailing canoe; and(5)out of school educational opportunities to reveal individual strengths and passions for lifelong learning and efficacy. 3. Program Description: The RISE 21st Century After School Program was established in 2011 by Keahi Warfield and Naomi Ahu to serve as a community resource bank for underprivileged, Native Hawaiian youth ages 8-18 in the Hilo district.The main focus is to aid in revealing their individual strengths and passions for future career and academic success.A variety of mediums are used to build Individual Student Success Plans(ISSP)such as but not limited to: apprenticeships, Hawaiian cultural practice, internships, multimedia, performing arts, project exhibitions, student exchange, and work study initiatives. RISE also provides opportunities to support physical well-being, cultural identity, and leadership. By implementing this mission, RISE envisions that when the youth participants graduate from high school,they will have a clear and stronger idea of what their future career and academic pursuits will be. The relationships they have gained through our program will help motivate and encourage them to become valuable contributors to the well-being and sustainability of the Hilo community. 4. Total Budget& Position Count: • Total Program Budget: $455,000.00 Total Program Position Count: 4 Total Agency Budget: $555,000.00 Total Agency Position Count: 4 EXHIBITA NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 • Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii (reflects current request) $25,000.00 Hauoli Mau Loa Foundation- HOPE for Kids Elua (pending) $80,000.00 Hawaii Community Foundation -Career Connected Learning (pending) $50,000.00 Kamehameha Schools-Community Investing (pending) $300,000.00 TOTAL: $455,000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The RISE 21st Century After School Program continues to rely on contributions and grants from the public and private sector. We strive for community support to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our key objectives for youth success are the following: 1)To reveal the strengths and passions of youth participants to contribute toward overall student engagement and confidence. 2)To help youth participants develop Individual Student Success Plans(ISSP)to track monthly goals and expectations and to contribute toward building responsible, respectful and reliable students. 3)To implement Hawaiian cultural practices such as the art of ho'ola hou(restoration discipline)and ho'okele/hoe wa'a(canoe voyaging/paddling)to teach values and encourage discipline, balance, and leadership for physical, mental, and spiritual well-being. 5)To incorporate STEM (science,technology,engineering, and mathematics)principles in the cultural/place-based learning domains we have access to. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application. FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Hawaii County youth served 75 youth Volunteer hours of 13 people 2160 hours Implementation of Individual Student Success Plans(ISSP) Implement ***See attachment Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $100,000.00 $2,500.00 Professional Fees $15,000.00 $1,500.00 Operations $4,050.00 $30,000.00 $5,000.00 Supplies $5,000.00 $200,000.00 $7,000.00 Equipment $40,000.00 $6,000.00 Other: Food/snacks for youth &volunteers $20,000.00 $3,000.00 Other: Travel $35,000.00 Other: Gen'I Liability Insurance $15,000.00 Other: Other: TOTAL $9,050.00 $455,000.00 $25,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 Countyof Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the Council n The Mayor n The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. ._%0/14/A) fit'ffainfrE //94 /0if 1E/26/91 Signature of Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. a ifis/20/9 Signature of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Hawaii County youth served 75 youth Volunteers hours of 13 people 2160 hours Implementation of Individual Student Success Plans(ISSP) Implement ***See attachment TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $2,500.00 Professional Fees $1,500.00 Operations $5,000.00 Supplies $7,000.00 Equipment $6,000.00 Other: Food/snacks for youth &volunteers $3,000.00 Other: Travel Other: Gen'I Liability Insurance Other: Other: TOTAL $25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 County of Hawaii Non-Profit Grants Program — Attachment Fiscal Year 2019-20 Keaukaha One Youth Development (KOYD) Revealing Individual Strengths for Excellence (R.I.S.E.) Total Grant Request = $25,000.00 Reference to Page 4, Question 8: Table I—What are the intended measurable outputs or outcomes that would be achieved with this funding? Reference to Page 8, Question 12: Table I— Council Award Worksheet Program Performance Measures Applicant Projected Results 1) Number of Hawaii County youth served Approximately 75 youth 2) Volunteer hours of three people: Executive Approximately 2160 hours (see breakdown Director, Executive Assistant, and below): Fiscal/Administrative Coordinator * 60 hours per month x 12 months = 720 hours per person x 3 people = 2160 hours 3) Number of volunteer mentors and hours 10 volunteers, 360 hours (see breakdown served below): 10 volunteers x 3 hours = 30 hours per month x 12 months = 360 hours 4) Implementation of Individual Student Evidence of beginning stages of Success Plans (ISSP) for youth participants implementation such as goal setting and recorded support from mentors and parents Reference to Page 4, Question 9: Table II—Program Expenditures for County Grant Request Reference to Page 8, Question 12: Table II— Council Award Worksheet Program Expenditures Additional Details Budget Salaries &Wages: Portion of Executive Director $2,500.00 Salary Administrative/Professional CPA—Year End Financial $1,500.00 Fees: Statement Generation Maintenance: Monthly Interior/Exterior $5,000.00 Grounds Maintenance Equipment Program/office supplies $7,500.00 Monthly 4G data plan + $2,000.00 portable wifi device for (2) RISE staff iPad's Xerox machine expenses $3,500.00 Food: Snacks/other food supplies $3,000.00 1 Keaukaha One Youth Development Youth Paddling Program 110 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program Agency Director: Shadd Keahi Warfield Phone No.: (808) 895 — 8666 Contact Person: Naomi Ahu Phone No.: (808) 756 — 5859 Mailing Address: Address: 67 Keokea Loop Address: City,ST,Zip Hilo, Hawaii, 96720 i I I AL Facility Address: Address: same as above Address: City,ST,Zip Email Address: naomi.koyd.rise@gmail.com Fax No.: ( ) — Accountant/CPA: Carbonaro CPA's&Management Group Phone No.: (808 ) 930 — 6850 Firm (if applicable): Mailing Address: Address: 136 Kinoole Street Address: PO Box 4372 City,ST,Zip Hilo, Hawaii, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) n Puna n Hamakua n North Kona n South Hilo n North Kohala n South Kona PI North Hilo n South Kohala n Ka'u Services or Activities To Be Provided: (One or more can be checked) I-1 Educational concerns n Youth n Victims of Crimes n Culture and the arts n Aged n Victims of Health or Social Crises Fl Needs of the poor ❑ Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $6,750.00 $7,750.00 $8,875.00 2. Agency Mission Statement: The mission of Keaukaha One Youth Development(KOYD) is to contribute toward the development of youth leadership in Keaukaha/Panaewa Hawaiian Homestead and East-Hawaii County communities.Through the cultural heritage of a Hawaiian warriorship model and ocean based activities surrounding the Hawaiian canoe,these cultural vessels of learning will promote: (1)the stress of physical fitness; (2) instructional use and maintenance of voyaging and 1 &6 man canoes; (3)waterman competence and perfection of swimming skills; (4)training Hawaiian youth to become qualified crew members of the Hokualaka'i double hulled sailing canoe; and (5)out of school educational opportunities to reveal individual strengths and passions for lifelong learning and efficacy. 3. Program Description: The Youth Paddling Program was established in 2006 to offer Hawaii County youth ages 8-18 Native Hawaiian cultural opportunities that reconnect them to historic ocean experiences such as the Hawaiian canoe. 4. Total Budget& Position Count: Total Program Budget: $25,000.00 Total Program Position Count: 4 Total Agency Budget: $555,000.00 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii (reflects current request) $25,000.00 TOTAL: $25,000.00 Attach additional pages,if needed. • 6. Explain what plans your agency or program has to increase revenues to support this program: The Youth Paddling Program continues to rely on contributions and grants from the public and private sector.We strive for community support to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Youth Paddling Program will strive to reach the following objectives: 1)Teach the values of team work, goal setting, commitment, physical, mental, and spiritual well-being, and cultural identity through the use of the Hawaiian Canoe. 2) Utilize the Hawaiian Canoe to present the metaphoric message of ones journey through life: "you steer your own waa(life), but not without the help of others(KOYD and our extended communities)." 3) Help offset the high risks of drug and alcohol exposure/abuse among our Hawaii County youth through fostering after school canoe paddling practices and weekend regatta races, a healthier alternative for the utilization of their time. 4)Teach the values and processes necessary for the maintenance of Keaukaha Canoe Club's historic koa canoes and other equipment for current and future generations. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program ---- - 111 /1\1- 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of Hawaii County youth served - 120 youth Volunteer hours of four people 850 hours ***See attachment Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $2,500.00 $2,500.00 Professional Fees $500.00 $500.00 Operations $6,000.00 $6,000.00 Supplies $6,500.00 $6,500.00 $6,500.00 Equipment $2,000.00 $2,000.00 Other: Food/snacks for youth &volunteers Other: Travel $2,375.00 $7,500.00 $7,500.00 Other: Gen'l Liability Insurance Other: Other: TOTAL $8,875.00 $25,000.00 $25,000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the Council n The Mayor n The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. nirE Age:- -.1eMbe21:-Air 03/2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%),for administrative and overhead costs. Any funds unused by June 30, 2019, must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 11I /2o/ C7 Signature of Authorized Person (see checklist, 2nd item) Date Ex -ve- vi�cu,f pc&i - Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of Hawaii County youth served 120 youth Volunteers hours of four people 850 hours ***See attachment TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $2,500.00 Professional Fees $500.00 Operations $6,000.00 Supplies $6,500.00 Equipment $2,000.00 Other: Food/snacks for youth &volunteers Other: Travel $7,500.00 Other: Gen'I Liability Insurance Other: Other: TOTAL $25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 County of Hawaii Non-Profit Grants Program —Attachment Fiscal Year 19-20 Keaukaha One Youth Development (KOYD) Youth Paddling Program Total Grant Request = $25,000.00 Reference to Page 4, Question 8: Table I—What are the intended measurable outputs or outcomes that would be achieved with this funding? Reference to Page 8, Question 12: Table I—Council Award Worksheet Program Performance Measures Applicant Projected Results 1) Number of Hawaii County youth served Approximately 120 youth 2) Volunteer hours of four people: Youth Approximately 850 hours (see breakdown Division Head Coach, two Youth Division below): Assistant Coaches, and one Youth Division * 16 two hour practices per month x 5 months Program Assistant (March-July) = 160 hours x 3 coaches =480 hours * 9 ten hour Saturday regattas x 3 coaches = 270 hours * 20 hours per month for Program Assistant x 5 months = 100 hours Reference to Page 4, Question 9: Table II—Program Expenditures Reference to Page 8, Question 12: Table II— Council Award Worksheet Program Expenditures Additional Details Budget Salaries &Wages: Portion of Executive Director $2,500.00 Salary Professional Fees: CPA- Year End Financial $500.00 Statement Generation Equipment: Paddle and canoe repair $5,500.00 Various paddling equipment $5,500.00 and supplies Escort boat repair and $1,500.00 maintenance Portable toilet rental for $2,000.00 program site Other: Travel Costs (bus rentals, $7,500.00 gasoline expenses, airfare, etc.) 1 Kohala Animal Relocation and Education Service (KARES) Canine Spay and Neuter Program for Community Pets 111 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay & Neuter Program for Community Pets Agency Director: Deborah M. Cravatta, President& Founder Phone No.: (808) 333 — 6299 g Y Contact Person: Deborah M. Cravatta Phone No.: (808) 333 — 6299 Mailing Address: Address: Kohala Animal Relocation and Education Service(KARES) Address: P.O. Box 44670 City,ST,Zip Kamuela, Hawaii 96743 Facility Address: Address: Kohala Animal Relocation and Education Service(KARES) Address: 59-241 Kipa Mai Place City,ST,Zip Kamuela, Hawaii 96743 Email Address: KAREShawaii@gmail.com Fax No.: (808 ) 880 — 1925 Accountant/CPA: Marilyn J. Gagen Phone No.: (808) 220 — 3087 Firm (if applicable): Marilyn J. Gagen, CPA LLC Mailing Address: Address: Address: 59-398 Ka Nani Drive City,ST,Zip Kamuela, Hawaii 96743 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 4-4-37-- $1713 /512 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ✓❑ Hamakua ❑ North Kona n South Hilo ❑✓ North Kohala n South Kona ❑ North Hilo ❑✓ South Kohala 171 Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑Youth Fl Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai6i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay & Neuter Program for Community Pets 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $20,000 $15,000 $5,500 2.Agency Mission Statement: The widespread interest to create an organization adhering to a"no kill" philosophy gave birth to the Kohala Animal Relocation &Education Service(KARES)which serves the entire Big Island of Hawaii. The mission of KARES is to rescue and relocate abused, abandoned and stray domestic animals,to provide temporary housing for them through our foster care network and to facilitate adoptions into caring permanent homes. KARES focuses on community education to promote responsible pet ownership and to prevent animal cruelty. KARES raises awareness about the causes of animal overpopulation and advocates alternative humane solutions for population control including spay and neuter. KARES makes possible free spay/neuter services. KARES emphasis is on reaching community residents who do not have the financial resources to provide these surgeries for their companion pets,especially the elderly and economically-troubled residents. 3. Program Description: Summary:The KARES Canine Spay&Neuter Program for 2019-2020 with the assistance of the County of Hawaii NP Grant, will provide free spay and neuter(SIN)surgeries for 400 owned dogs. KARES will conduct up to 14 S/N clinics in community locations,bringing this service directly to our residents,will provide pet transportation as needed and will provide pet preventative health care. No other resource on Hawaii Island offers the accessibility and extended services of the KARES Canine S/N Program. The KARES S/N Program initiated in late 2010 with realization that 1)there existed and still does, a serious overpopulation of dogs on the island,2)a humane means of controlling and reducing the number of dogs was essential and 3)for many island residents the cost of sterilizing their pets was either too costly or not easily available.To date KARES has provided SIN surgeries to 4,568 dogs, all free to pet owners.The majority of grateful recipients have been low income families including our older residents living on fixed incomes who could never afford this service for their pet(s). KARES S/N Program functions with a veterinary team,volunteers,surgical equipment and supplies that can be easily set up in community centers for S/N clinics. KARES veterinarian and volunteer vet tech assistants can perform S/N surgeries on up to 50 dogs per clinic. In each clinic we offer wellness health care(veterinary examination,treatment for fleas, mites and intestinal worms).The KARES clinic may be the first and only time the dog is seen by a veterinarian. Depending on funding we can host one large clinic each month,and smaller clinics for up to 15 dogs,as needed.Another important feature of KARES'program is transportation of pets to and from clinics,needed for residents who do not have cars/trucks or money for gasoline.Typically we transport about 75%of all pet patients to clinics.The benefit to our Hawaii residents is that KARES S/N Program will prevent the birth of unwanted or unplanned litters of puppies, perhaps as many as 4,200 puppies(average 6 pups/litter; range 4-12 for large breeds)per year, litters that will otherwise become a burden to our community. 4.Total Budget& Position Count: Total Program Budget: $60,000 Total Program Position Count: 12 Total Agency Budget: $100,000 Total Agency Position Count: 30 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay & Neuter Program for Community Pets 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Applications To Be Submitted for 2019-20; anticipated but not guaranted Corporate Foundations(Petco Foundation, Bissell Pet Foundation) $10,000 Community Foundation and/or County of Hawaii $10,000 Private Foundation and Individual Donors(estimated based on past years) $5,000 TOTAL: $25,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: KARES programs of rescue with medical care-adoption and canine spay/neuter surgeries run efficiently and effectively with 5% or less allocated to administrative costs. KARES will continue to maximize efforts of applying for corporate and private foundation grants and exploring new funding sources. This year we will add the Hawaii Community Foundation FLEX grants to our lists of applications. Part of our sustainability funding comes from fees for adoptions($100 per dog)less expenses for S/N, microchip,vaccinations and possible medical expenses associated with a rescue situation however,often not much money remains from this fee. The work of KARES is becoming more visible throughout the island and we have first-time donors,island residents and Mainland visitors,who have met our volunteers at adoption events, in S/N clinics or during rescues. We hope to expand the base of private donations assuring donors that 100%of their charitable donation goes toward good works for the benefit of the residents and animals of the island. By necessity expenses for rescue and medical/surgical rehabilitation come first. We will provide as many free S/N surgeries to owned pets as possible depending on the availability of funding. Our dedication to this important work has no limitations. 7. Program Objectives Using County Nonprofit Grant Program Funds: KARES Canine S/N Program objectives using County of Hawaii funds will directly benefit the people of Hawai'i by 1) Providing free S/N surgeries and wellness care for 400 dogs owned by indigent and elderly residents,an expense most cannot possibly afford. 2) Bringing our MASH-style S/N surgical unit into communities that have no available affordable S/N services or resources too distant for those without transportation. 3) Hosting at least 14 SIN clinics per year in community locations.'. 4) Providing free transportation of pets to and from S/N clinics. 5) Preventing the birth of unplanned puppy litters for which residents cannot cover the costs of food and veterinary care;allowing families to keep the pets that they have without the additional economic burden of unwanted puppies. 6) Reducing the number of free-roaming(stray)dogs which cause damage to property and livestock and could cause potential health risks due to bites and the spread of disease. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of flawai i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay & Neuter Program for Community Pets 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Provide spay/neuter(S/N)surgeries to sterilize companion dogs with grant funds 400 dog spay&neuter surgeries in 12 months Provide FREE S/N procedures for dogs owned by low income and elderly residents Assistance to at least 350-400 families Conduct at least one or more S/N clinics per month in community locations Conduct 12-14 clinics/year Provide FREE transport of pets for owners without vehicles or cannot afford gasoline Transport-300 dog to and from SIN clinics Provide FREE wellness care for all dogs in SIN clinics Treat for fleas,mites,worms,give pain meds Reduce number of deaths of otherwise healthy dogs in shelters Prevent overpopulation of feral&owned dogs Reduce damage to property,livestock&police nuisance calls caused by stray/feral dogs SIN provides humane dog population control Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18- FY 19-20 FY 19-20 Actual* Total Budget Grant Re 0 0 0 Salary and Wags `p $26e/d ,500 $45,000 $32,000 Professional Fees. veftvtmmu(S'tut 6 0 Lec r'Spivi1M!ii-f 0 0 Operations0 0 0 Supplies 0 Equipment 0 0 Other: S/N clinics supplies-anesthesia gases, syringes&needles, gloves $500 $600 $500 Other: Surgical instrument ultrasound cleaning &autoclav sterilizations $400 $650 $400 Other: S/N procedure medications-pain medications, antibiotics $400 $650 $450 Other: Wellness care (vaccines, antiparasitic and deworming medications) $6,000 $7,000 $6,000 Other: Vehicle expenses(surgery van and animal transport)for S/N clinics $5,900 $6,100 $3,800 TOTAL $39,700 $60,000 $43,150 *lf applicable .-4( 1cM.Es ` t is 461.ntiLvi, i 1 k c 0 a\6 e4.. 3 i EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 r J County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay & Neuter Program for Community Pets 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council n Staff appointed by a member of the Council The Mayor The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. /fri ./A/19 Signature of Authorized Person .- ify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay & Neuter Program for Community Pets 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the-easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay & Neuter Program for Community Pets 1a. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai`i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. / Signature of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person , s EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Fawai6i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay & Neuter Program for Community Pets 12. c UNCil AWA*re i,ORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Provide spay/neuter S/N sur surgeries to sterilize companion dogs withgrant funds 400 dog spay&neuter ( ) 9 Psurgeries in 12 months Provide FREE S/N procedures for dogs owned by low income and elderly residents Assistance to at least 350-400 families Conduct at least one or more S/N clinics per month in community locations Conduct 12-14 clinics/year Provide FREE transport ofpets for owners without vehicles or cannot afford gasoline Transport—300 dog to and P from SIN clinics Provide FREE wellness care for all dogs in S/N clinics Treat for fleas,mites,worms, give pain meds&antibiotics Reduce number of deaths of otherwise healthy dogs in shelters &rowned dosopulation of feral 9 Reduce damage to property, livestock&police nuisance calls caused by stray/feral dogs populationconVol humane dog TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 0 Professional Fees—VL�'CVtd1uVi� }eeS -i/ i t Sp tui 4t�l��c¢�Jl gulfg04I(/% $32,000 Operations .l J 0 Supplies 0 Equipment 0 Other: S/N clinics supplies-anesthesia gases, syringes& needles, gloves $500 Other: Surgical instrument ultrasound cleaning&autoclav sterilizations $400 Other: S/N procedure medications-pain medications, antibiotics $450 Other: Wellness care(vaccines, antiparasitic and deworming medications) $6,000 Other: Vehicle expenses(surgery van and animal transport)for S/N clinics $3,800 TOTAL $43,150 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Kohala Institute 'Aina-based Learning in the 'Tole Ahupua'a 112 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Institute Program Name: `Aina-based Learning in the `lobe Ahupua'a Agency Director: D. Noelani Kalipi Phone No.: (808) 889 — 5151 Contact Person: Katie Schwind Phone No.: (808) 889 — 5151 Mailing Address: Address: PO Box 344 Address: City,ST,Zip Kapa'au, HI 96755 Facility Address: Address: 53-580 lole Rd Address: City,ST,Zip Kapa'au, HI, 96755 Email Address: grants@kohalainstitute.org Fax No.: ( ) — Accountant/CPA: Allison DeGuzman Phone No.: (808 ) 935 — 5404 Firm (if applicable): Taketa, Iwata, Hara, &Associates, LLC Mailing Address: Address: 101 Aupuni St., Suite 139 Address: City,ST,Zip Hilo, HI, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $16,500 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona [' South Hilo ❑✓ North Kohala ['South Kona [' North Hilo [' South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ['Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Institute Program Name: Aina-based Learning in the `tole Ahupua'a 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0 none for this program none for this program 2. Agency Mission Statement: Kohala Institute's mission is to inspire the discovery and deepening of human connection and collaboration for a sustainable world. Kohala Institute's vision is to be a leading learning center that cultivates wholehearted leadership and collaboration through connection with the land, universal values and the spirit of Aloha. Kohala Institute accomplishes this mission through customized learning experiences, applied research, and collaborative convening supported by the GRACE Center facilities and 2,400-acres of land it manages.The GRACE Center is a multi-purpose meeting and education center in the newly renovated six-building Historic Kohala Girls School campus, built in 1874, which is a part of the Nationally Registered Bond Historic District;it includes a 40-bed dormitory, numerous program spaces, dining hall with certified kitchen, and ten new cabins.The 2,400 acres of land includes 3 gulches,the entire'tole ahupua'a from mauka to makai, and these lands serve ranchers, farmers, edu-tourism activities, and much more. KI's programs within this exceptional environment often yield transformative experiences resulting in broadened world views and a deeper appreciation for the collective good. 3. Program Description: KI Tours:'Aina-Based Excursions and Workshops(KI Tours)welcomes groups for hands-on experiences that integrate Hawaiian culture, history, arts, natural resources, science,values, and more. KI Tours is based at the Kauhale outdoor classroom consist of 1/2 acre of lo`i kalo, surrounded by 2.5 acres of native botanicals.The site was created to preserve the history of the two large lo`i kalo (over 8 acres combined),famed as favorites of Kamehameha the Great,that once existed at `tole. Other significant sites within the'tole ahupua'a, like Kamehameha Springs and 'auwai, are featured as well, and the whole integrated ahupua'a system of management supports discussions of sustainability and learning from the past to create a better future for people and the planet. KI aims to bridge the old and new,traditional and modern, indigenous and non-indigenous in a 21st century ahupua'a system. Kauhale classroom is a space for community that grows by the hands of the people who come to'tole;every plant and feature on the site was added by students and adults engaged in'aina-based learning. School and community groups have been a part of this site from the start through service learning projects. Some examples of curriculum and activities that we have co-created with educators include:Social Studies and History Units- Looking into the past while gaining deeper understanding of the present and potential for the future by studying land and water practices during different time periods(traditional Hawaiian, missionary, plantation, and post-plantation);Migration patterns and influences that have shaped Hawaii. Science and Ecology Units- Island and ecosystem cycles like rain shadow effect, and water and nutrient cycles; Invisible forces of nature,the science of observation; Intersection of science and traditional knowledge. Hawaiian Culture Units-Hawaiian cultural practices:arts, language, mo`olelo, and more;Traditional Hawaiian and contemporary methods of sustainable agriculture. 4.Total Budget & Position Count: Total Program Budget: 76,000 Total Program Position Count: 1 FT, 2 PT •Total Agency Budget: 1,548,947 Total Agency Position Count: 10 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Institute Program Name: Aina-based Learning in the `tole Ahupua'a 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Hawaii Tourism Authority 28,000 Kamehameha Schools Community Investing Program 23,000 Giving Tuesday Donations to support field trips 3,000 Hawaii County Request 16,500 KI contribution 5,500 TOTAL: 76,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Once we have established momentum and efficiency in our recruitment, planning, and implementation of school field trips and -other community organizations,we will begin to expand our outreach into the visitor market in quarter 3 of 2019.The goal for this program has always been that income from the tourism-based experiences will fund the educational programs for our Hawai'i community. We reduced the fees for schools, youth groups, and other community organizations, but we have maintained the fees for visitor groups, businesses, and organizations that can afford the fees. We are looking to create closer working partnerships with Hawaii Island Visitors Bureau and Hawaii Tourism Authority to accomplish this. Additionally, our Giving Tuesday Fundraising efforts usually go to support'aina-based education for youth.This will be an ongoing revenue source to support these experiences, and as our community impact and presence grows,we anticipate that the success of fundraising efforts will too! 7. Program Objectives Using County Nonprofit Grant Program Funds: The objective of this program is to provide meaning, impactful, and educational experiences to students and adults on Hawaii Island that deepen their understanding and recall through memorable hands-on experiences. KI offers a wide variety of learning modules supported by the variety of agricultural practices past and present, rich natural environment, and history of'tole. We customize every excursion to meet the specific learning objectives of each class and group that visits. The program grew from—250pp1 in 2016 to over 900 in 2018.The end of 2018 culminated with a successful push to support and encourage more school field trips through outreach to educators, reduction or waiving of program fees, and funding support for school bus costs. For public and charter schools in particular,these costs inhibit our local students from learning beyond the classroom and learning from Hawaii's natural environment, so we worked to remove that barrier. With the addition of a new Kauhale Educational Coordinator and Programs Director, both of whom have substantial experience in'aina-based learning, we expect to increase participation to exceed 800 students and 400 adults, while also deepening the content and improving the quality of experiences at'tole. Kumu Hula Ryan McCormack, Programs Director brings his expertise in'aina-based learning as an educator and cultural practitioner. This team works with educators to design the curriculum and 'aina-based activities that allow students to tactilely engage with subjects,create memories and experiences that improve their recall and retention of the associated lessons. It also creates an opportunity for keiki and adults to deepen their sense of place,their appreciation for this incredible island, and their understanding of our shared history,which allows our community to build bridges towards a thriving future for our home. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Institute Program Name: Aina-based Learning in the `tole Ahupua`a 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of keiki who experience'aina-based learning 800 Number of adults who experience'aina-based learning 400 Number of community workshops to Level of satisfaction from participants 85%satisfied Number of different classes that take a field trip to Kohala Institute 25 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 51,000 63500 12,500 Professional Fees 2000 1000 1000 Operations Supplies 10800 6000 2000 Equipment Other: Flus funding to support Held trips 1200 3000 Marketing and outreach 2800 500 Other: Other: Indirect 3300 2000 1000 Other: Other: TOTAL 71,000 76,000 16,500 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Institute Program Name: Aina-based Learning in the lole Ahupuaa 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Davelyn Noelani Kalipi POSITION: Senior Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. 10 /1 //. / / /j / 1/30/2019 Signature o` A:uthorized Person ( cify ti e) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Institute Program Name: Aina-based Learning in the lole Ahupuaa 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Institute Program Name: Aina-based Learning in the lole Ahupuaa 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. $ i 1 ;� et t l / 1/30/201 Signature .Authorized Person ee ecklist, 2nd item) Date LCem[0x, DI rue/toy__ Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Institute Program Name: Aina-based Learning in the `tole Ahupua'a 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of keiki who experience'aina-based learning BOO Number of adults who experience'aina-based learning 400 Number of community workshops 10 Level of satisfaction from participants 85i satisfied Number of different classes that take a field trip to Kohala Institute 25 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 12,500 Professional Fees 1000 Operations Supplies 2000 Equipment Other: Bus funding to support field trips Other: Marketing and outreach Other: Indirect • 1000 Other: Other: TOTAL 16,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Kohala Institute GRACE Leadership Journey 113 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Institute Program Name: GRACE Leadership Journey Agency Director: D. Noelani Kalipi Phone No.: (808) 889 — 5151 Contact Person: Katie Schwind Phone No.: (808) 889 — 5151 Mailing Address: Address: PO Box 344 Address: City,ST,Zip Kapa'au, HI 96755 Facility Address: Address: 53-580 lole Rd Address: City,ST,Zip Kapa'au, HI, 96755 Email Address: grants@kohalainstitute.org Fax No.: ( ) — Accountant/CPA: Allison DeGuzman Phone No.: (808 ) 935 — 5404 Firm (if applicable): Taketa, Iwata, Hara, &Associates, LLC Mailing Address: Address: 101 Aupuni St., Suite 139 Address: City,ST,Zip Hilo, HI, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000 Geographical Areas To Be Served: (One or more can be checked) [' Puna ❑✓ Hamakua ❑✓ North Kona [' South Hilo ❑✓ North Kohala [' South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Institute Program Name: GRACE Leadership Journey 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0 12,000 4,800 2. Agency Mission Statement: Kohala Institute's mission is to inspire the discovery and deepening of human connection and collaboration for a sustainable world. Kohala Institute's vision is to be a leading learning center that cultivates wholehearted leadership and collaboration through connection with the land, universal values and the spirit of Aloha. Kohala Institute accomplishes this mission through customized learning experiences, applied research, and collaborative convening supported by the GRACE Center facilities and 2,400-acres of land it manages.The GRACE Center is a multi-purpose meeting and education center in the newly renovated six-building Historic Kohala Girls School campus, built in 1874,which is a part of the Nationally Registered Bond Historic District;it includes a 40-bed dormitory, numerous program spaces, dining hall with certified kitchen, and ten new cabins.The 2,400 acres of land includes 3 gulches,the entire'Tole ahupua'a from mauka to makai, and these lands serve ranchers, farmers, edu-tourism activities,and much more. KI's programs within this exceptional environment often yield transformative experiences resulting in broadened world views and a deeper appreciation for the collective good. • 3. Program Description: In the local, national, and international arenas,there has been a breakdown of communication increasing polarization that divides communities and makes attempts at communication, reconciliation, and collaboration futile. Reaction to any proposal draws immediate opposition, often based on mistrust of motives, instead of analysis of substance. Even in day-to-day conversation the trend is disengagement, distrust, and misuse of facts to serve individual stance rather than collective benefit. How do we reverse that trend?How do we reengage in the civic process and create a solutions-based, not obstructionist, mentality. Our answer is to work with future leaders to: (1) recognize the value of relationships and opportunities to build those through shared experiences as a precursor to facilitated discussions focused on collaborative solutions and (2) by providing future leaders with tools, skills, and practical experience to deal with difficult conversations,to seek to better understand the emotional and historical context of issues, and to pro-actively identify and implement solutions that benefit the collective. This 12-month program begins with a one-week retreat employing academic sessions, guest instructors, place-based learning, physical challenges, and practical application of skills being discussed and studied. Each month, students return for one weekend—Friday evening:"Conversation with a Leader";Saturday:place-based activity, practical application of leadership skills and processes and communication techniques using a highly charged issue;Sunday:assessment of application.The relationships formed and the practical application of skills are vital tools that participants will learn to use to regularly resolve challenging issues in ways that are proactive, inclusive, and yield results to benefit communities collectively. GLJ brings together best processes and scholarship to equip youth to build a culture of collaboration and proactive participation in community. Educators, administrators, and parents have already shared positive changes they have witnessed in cohort 1. 4. Total Budget & Position Count: Total Program Budget: $150,000 Total Program Position Count: 3 (partial) Total Agency Budget: $1,548,947 Total Agency Position Count: 10 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Institute Program Name: GRACE Leadership Journey 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate KI Contributions+ program fees ($1,000 -$2,000) $40,000 Hawaii County Council - Non-profit grants $12,000 First Hawaiian Bank $20,000 Atherton Family Foundation $15,000 HEI Foundation $8,000 Kamehameha Schools Community Giving $40,000 TOTAL: $135,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The fees for GRACE Leadership program will never support the program costs because we intentionally cost to participants low to ensure that financial resources are not a barrier to participation.The program fee is$200/participant/year.All program materials,food and beverage, lodging, and activities are covered by the program. For the duration of the program, it also provides each participant with an iPad that is loaded with all the program materials so that participants have equal access to technology and program materials.The intensive nature of this program makes it costly per student, but the transformation in each student that can be achieved with the in depth and prolonged approach makes the investment well worth it. As the program has demonstrated its substantial benefit to the next generation of our island youth, KI anticipates an increase in sponsorship and fundraising for the program. Though there have been delays in getting KI's revenue generating projects to full operation, our strategic plan focuses on the development of revenue generating projects to support the programs that are not intended to be profitable, but are for community benefit.These projects- Fish Farm,Tours, GRACE Center are getting closer to yielding the revenue necessary for long-term financial sustainability and support of the programs. 7. Program Objectives Using County Nonprofit Grant Program Funds: The goal of GRACE Leadership Journey is to provide future leaders with the skills, knowledge, and experience to bring people together for positive action that benefits the collective when faced with challenges and controversy.At the most basic level it seeks to shift the mindset from"not my problem"to"if not me,then who? If not now,then when?"from"no can"to"How can?"by empowering 15 high school juniors with the knowledge, experiences, skills, and relationships to lead the way to making collaboration the"new normal."After five years,—70 future leaders will have shared experiences and common understanding of techniques to help navigate difficult conversations and problem solving. GLJ does this through practical application and place-based experiences, and providing the foundational skills for future leaders to seek collaboration as a common and realistic outcome to challenges. KI has already received testimony on the ability of the cohort 1 students to apply the skills with their peers and within their schools.This program is a subset of Collaboration For Solutions, an innovative method of community engagement focusing on building relationships between stakeholders prior to challenging discussions and focusing on benefiting the collective. GLJ works with students to (1) build relationships with others from different geographic locations and backgrounds that they otherwise would not interact with; (2) navigate difficult and challenging discussions with others, particularly when discussing emotionally laden issues, by providing them with the specific communications tools; (3)seek to"step up"rather than letting someone else take care of"it", (4) learn about different perspectives and the multiple contexts that inform decision-making processes, (5) learn about different leadership skills and styles and adapting those skills for different situations, (6) learn about their specific strengths, leadership styles, communications skills, (7) learn through the experiences of others via mentors/guests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Institute Program Name: GRACE Leadership Journey 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of applications 30 applications Number of students who complete the program, and attendance rate 12 students;85%attendance Pre-program compared to post program survey from participants 75%improvement in review/self-assessement Post-program feedback from family or counselor/teacher/coach 80%report improvement in student Number of mentors experts and,professionals contributing to the program 15 throughout the program Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages TBD 55,000 4,000 Professional Fees The program 1,000 Operations ends in June Supplies 10,000 Equipment Other: hood and beverage (1 week + 11 weekends) 30,000 5,000 Other: Lodging and tacllltles 22,500 2,000 Other I ravel for participants/facilitators/experts 7,500 1,500 Other: Administrative costs 10,000 1,500 Other: TOTAL 135,000 15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Institute Program Name: GRACE Leadership Journey 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: bavekp 1 Kioe-l.{hi l'<alipi POSITION: Son to- D ?C,(-ir May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑.• If no conflicts exist, check here. d' '1em(or Dire-G-1- 1/30/2019 Signatur- of Authorized Pe o (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Institute Program Name: GRACE Leadership Journey 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived'from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Institute Program Name: GRACE Leadership Journey 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. `r 11 ,AI�l.' r/i �` 1/30/2019 , , Signature of Authorized Person (see checklist, 2nd item) Date CS" 14— ])) Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kohala Institute Program Name: GRACE Leadership Journey 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of applications 30 applications Number of students who complete the program, and attendance rate 12 students;85%attendance Pre-program compared to post program survey from participants 75%improvement in review/se Post-program feedback from family or counselor/teacher/coach s0%report improvement in student Number of mentors, experts, and professionals contributing to the program 15 throughout the program TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 4,000 Professional Fees 1,000 Operations Supplies Equipment Other: Food and Beverage (1 week + 11 weekends) 5,000 Other: Lodging and facilities 2,000 Other: Travel for participants/facilitators/experts 1,500 Other: Administrative costs 1,500 Other: TOTAL 15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 1 Kona Adult Day Center, Inc. Adult Day Care 114 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Adult Day Center, Inc. Program Name: Adult Day Care Agency Director: Rowena L.Tiqui Phone No.: (808) 322 — 7977 Contact Person: Rowena L. Tiqui Phone No.: (808) 322 — 7977 Mailing Address: Address: P 0 Box 1360 Address: City,ST,Zip Kealakekua HI 96750 Facility Address: Address: 81-989 Halekii Street Address: City,ST,Zip Kealakekua HI 96750 Email Address: kadcrowena@hawaii.rr.com Fax No.: (808 ) 322 — 0614 Accountant/CPA: Meleana Smith Phone No.: (808 ) 929 — 8000 Firm (if applicable): Kau Business Services LLC Mailing Address: Address: P 0 Box 6239 Address: City,ST,Zip Ocean View HI 96737 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ❑South Hilo ❑ North Kohala ❑✓ South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ✓❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor) ✓❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Adult Day Center, Inc. Program Name: Adult Day Care 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $8750.00 $8437.50 $0 2.Agency Mission Statement: "Our mission is to provide social and recreational programs and activities that enable impaired adults to experience feelings of belonging,friendship, acceptance,accomplishment and independence in a caring and secure social environment. 3. Program Description: Kona Adult Day Center, Inc. is a community, non-profit organization,providing impaired adults,their families and other caregivers with an alternative to premature institutionalization. Currently, in the thirty-first year of operation ,the Center has an enrollment of 30 adults. Since opening in December 1988,service has been provided to over 750 families. A comprehensive program provides a variety of social and related support services to groups of adult clients in a protective setting during any part of a day, but less than 24 hours. Day care fosters caregivers continued participation in the work force. Day care provides a less restrictive setting and a more cost effective program than other types of care,such as home care or nursing facility. Financial access to services includes utilization of available funding sources through the Department of Human Services, Hawaii Island United Way and County of Hawaii. The geographic area to be served includes the north and south judicial districts. Services will be provided at the Kona Adult Day Center,centrally located in Kealakekua. Participants travel to KADC from Kealia(south)to Kona Palisades(north). KADC is the only adult day care in West Hawaii. Adult DayCare is viewed as a promisinglongterm care option because itprovides regular and reliable respite to informal P 9 P caregivers. Persons eligible for KADC services are those adults 18 years and older, but particularly those 60 and older having eitherr aa physical or cognitive disability, requiring supportive care. 4.Total Budget& Position Count: Total Program Budget: 413130.61 Total Program Position Count: 7.50 Total Agency Budget: 413130.61 Total Agency Position Count: 7.50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Adult Day Center, Inc. Program Name: Adult Day Care 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Tuition 115000.00 Fees 35000.00 Adult Food Care 15000.00 Donation/Membership Drive 11000.00 Other grantrs 7000.00 Fund raising sales 6000.00 In-Kind Revenue 9000.00 TOTAL: 198000.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Look for more grants.Add 300 more names to our membership drive. Increase advertising for fundtraiser. Increase ticket sales for fundraising. Increase census to increase tuition. • 7. Program Objectives Using County Nonprofit Grant Program Funds: To be used for salaries which is our biggest expense. 7.5 staff. 1.5 months EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Adult Day Center, Inc. Program Name: Adult Day Care 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) This will pay for 1.5 months of salaries for 7.50 staff. 1.5 months salaries.7.5 staff. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $0 15000.00 15000.00 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL 15000.00 15000.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Adult Day Center, Inc. Program Name: Adult Day Care so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Rowena L. Tiqui POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: FP If no conflicts exist, check here. dowil air c—___ January 11 , 2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Adult Day Center, Inc. Program Name: Adult Day Care 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai CountyCode, relatingto Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Adult Day Center, Inc. Program Name: Adult Day Care 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. January 11 2019 Signature of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Adult Day Center, Inc. Program Name: Adult Day Care 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Salaries for 7.5 staff/1.5 months 1.5 months salaries.7.5 staff. TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 15000.00 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL 15000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 1 Kona Historical Society Experiencing Kona's Traditions 115 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Historical Society Program Name: Experiencing Kona's Traditions Agency Director: Joy Holland Phone No.: (808) 323 — 3222 Contact Person: Joy Holland Phone No.: (808) 323 — 3222 Mailing Address: Address: P.O. Box 398 Address: City,ST,Zip Captain Cook, HI 96704 Facility Address: Address: 81-6551 Mamalahoa Hwy Address: City,ST,Zip Kealakekua, HI 96750 Email Address: joy@konahistorical.org Fax No.: (808 ) 323 — 2398 Accountant/CPA: Renee Sherman Phone No.: (808 ) 238 — 8972 Firm (if applicable): Mailing Address: Address: P.O. Box 398 Address: City,ST,Zip Captain Cook, HI 96704 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑ North Kohala ❑✓ South Kona ❑ North Hilo ❑South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ['Victims of Crimes Aged❑Culture and the arts ❑ Victims of Health or Social Crises ❑ ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Historical Society Program Name: Experiencing Kona's Traditions 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $6,125 $5,875 $6,750 2.Agency Mission Statement: The Kona Historical Society preserves the history of Kona to enrich, inspire, and inform our community and visitors.We do this through collecting, preserving, researching, interpreting, and disseminating the history of Kona,with a special emphasis on the period from 1830 to the present.The Kona Historical Society connects past,current, and future generations to Kona and Hawaii's history and inspires an appreciation of its heritage. Our purpose is to collect, preserve, interpret, and disseminate that history in a variety of programs and to maintain a climate controlled library, archives and research facility to be used to support public exhibits and community research, house historical documents, photographs, and other important resources,which are held in trust for the people of Hawaii. 3. Program Description: The Kona Historical Society, a non-profit museum, archive, and steward of historic sites, has,over several decades, provided public space,free or deeply discounted school and other educational programs and lectures throughout the year, exhibits, historic field trips,cultural festivals, access to unique and significant Hawaii collections and artifacts. KHS provides stewardship and financial care of two State of Hawaii and Nationally registered historic sites and structures, and approximately 10 acres of publicly accessible State of Hawaii Legacy Land reserves, including endemic native forest.Among these varied and culturally important public offerings, KHS's Living History Programs provide interactive experiences to nearly 18,000 participants annually through regular weekly programming. In 2019-20 Kona Historical Society will continue to add new stimulating content to its award winning Living History Programs, and to serve more Hawaii Island schools and keiki. H.N. Greenwell Store Museum (1890's):Visitors enter the lava stone building constructed ca. 1870,where imported and exported goods from the late 19th century are displayed and explained.Visitors are offered opportunities to touch and experience the objects.Trained and costumed interpreters discuss subjects including ranching, dairying, land use, ethnic groups, and trade with the outside world, highlighting the importance of Hawaii's contributions to the Pacific's commercial role. In June a special public exhibit will be installed in the Store,offering visitors access to archival treasures not usually seen. •Portuguese Stone Oven (1860's): Patrons visiting on Thursdays engage in rolling and panning the fresh dough as part of an authentic bread-baking program, and are rewarded with a sample when it emerges from the hot oven.An important learning outcome is a better understanding of Portuguese traditions and history, including how sweetbread became part of Hawaii's culture.About 100 loaves of bread are baked and sold each week to local and visiting customers, broadening their appreciation of Kona's culture with fresh-baked bread. Special bakes were offered on holidays such as Christmas and Easter. CONTINUED ON ATTACHED PAGE 9 4.Total Budget& Position Count: Total Program Budget: TBD Total Program Position Count: 20 Total Agency Budget: 692,951 Total Agency Position Count: 27 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Historical Society Program Name: Experiencing Kona's Traditions 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Tour Income 127,352 Portuguese Bread Sales 25,000 Coffee Sales 30,000 Sales of Gifts& Publications 10,000 Grants 10,000 Fundraising/Donations 5,000 County of HI Request 17,300 TOTAL: 224,652 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In 2019-20 Kona Historical Society plans to continue to increase social media promotion,which has proven to be effective in the past two years, as KHS visitation numbers remained steady during a very tough tourism period for Hawaii Island.We were pleased to experience an uptick in the last part of the year in the number visitors to the Living History programs.Additional media releases and targeted publicity, as well as feature articles in widely distributed media such as Hana Hou magazine (the Hawaiian Airlines publication) and Ke Ola magazine will continue to be an important component of KHS's marketing strategy.We will also continue to work to increase the level of corporate sponsorships, particularly for special events,and will continue to pursue matching grant support for Living History Programs and the planned new activities within these programs in 2019-20. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Continue to provide unique and authentic programs at landmark historic sites that connect visitors to their own history and experiences;2)Through hands on cultural activities and engaging programs, enlighten students and visitors about the diverse characteristics of Kona and Hawaii's history in order to foster understanding and appreciation;3) Demonstrate important themes of sustainability,family values, cooperation, and independence to visitors and students;4)continue to provide unique and engaging Living History activities, such as interacting at the Kona Coffee Living History Farm with the period-dressed farm wife preparing bentos for the children to take to school,while the farmer explains coffee processing;or delighted school children trade goat skins for"money"at H.N. Greenwell Store.These activities that strike a chord with the cultural interests and heritage of our community;5) Expand school group appropriate curriculum in a"hands-on"living history model,such as English floral arranging and rawhide braiding;6)Continue efforts to develop curriculum in collaboration with schools and an educational professional to adapt 10-12 activities to incorporate state standards with local curriculum. 7) Provide additional discounted or free to the community festival, holiday, and special event opportunities at living history sites. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Historical Society Program Name: Experiencing Kona's Traditions 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Living History School Group Participants 1,400 Farm Independent Travelers 10,000 Farm Adult Escorted Tours 3,000 H.N. Greenwell Store Visitors 2,000 Portuguese Bread Program Visitors 2,740 Portuguese Bread Sales 4,200 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 153,793 161,888 10,000 Professional Fees 0 0 0 Operations 18,648 19,629 700 Supplies 11,682 12,297 800 Equipment 5,554 5,847 0 Other: Employee Benefits and Payroll Taxes 6,990 7,358 3,000 Other: General Liability Insurance 9,953 10,477 900 Other: Repairs and Maintenance 1,820 1,916 1,000 Other: Marketing & Public Relations 4,978 5,240 900 Other: TOTAL 213,418 224,652 17,300 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Historical Society Program Name: Experiencing Kona's Traditions 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential _ conflicts of interest: 0 If no conflicts exist, check here. i73453/ !it9 Signature of A th ;rized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Historical Society Program Name: Experiencing Kona's Traditions 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Historical Society Program Name: Experiencing Kona's Traditions 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that.a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in thea application, except for a maximum tenpercent (10%)for administrative and overhead pp P costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. a:, \/3;c://1 Si natur_ of uthh rized Person (see checklist, 2nd item) Date g = � 1 P Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Historical Society Program Name: Experiencing Kona's Traditions 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Living History School Group Participants 1,400 Farm Independent Travelers 10,000 Farm Escorted Tours 3,000 H.N. Greenwell Store Visitors 2,000 Portuguese Bread Program Visitors 2,740 Portuguese Bread Sales 4,200 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 10,000 Professional Fees 0 Operations 700 Supplies 800 Equipment 0 Other: Employee Benefits and Payroll Taxes 3,000 Other: General Liability Insurance 900 Other: Repairs and Maintenance 1,000 Other: Marketing & Public Relations 900 Other: TOTAL 17,300 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Kona Historical Society, Page 9 County of Hawaii Non-Profit Grant PROGRAM DESCRIPTION (Continued) 2019-20 LIVING HISTORY PROGRAMS •Kona Coffee Living History Farm (1920 `s-1940's):Patrons visiting this site are inspired by the lives of pioneer coffee farmers. Following the scent of burning wood,they enter the kitchen where a housewife is cooking rice on a traditional open hearth stove. Costumed interpreters demonstrate Japanese cooking using traditional implements and a wood-burning stove, show how coffee is processed at the mill (kuriba), invite visitors to participate in picking coffee, and, at the donkey pasture, explain the important role of the donkey in coffee farming. Visitors leave the site with an appreciation of the critical role of children in the success of the coffee farm, and the contrast between their own modern life and the family of 1920's Kona mauka. •The Kona Coffee Living History Farm has provided expanded cultural activities and plans to do more of this in 2019-20,when we will feature new activities including coffee harvesting, coffee land games, and languages of the coffee land; increased accessible content for school programs; and additional special events. The cultural activities program allows visitors and residents to experience traditional crafts,trades, and foodways that were typical of an early 20th century Kona coffee farm, such as lauhala weaving, Japanese pickling, and Ikebana(Japanese flower arranging).Participants leave the farm with a lauhala fish to hang, a recipe for pickles to make at home, or a lovely flower arrangement. These takeaways enhance the visitor experience, provide a sense of accomplishment, and foster appreciation for the Island's heritage. •Education Programs: In addition to adult visitors, every year KHS serves thousands of students. In collaboration with schools from preschool to college age,the programs provide unique learning that tie students to their communities and culture through interactive experiences and group feedback activities. Interactive activities supplement traditional living history engagement, and school programs provide rare opportunities for field trips to Hawaii Island and neighbor island children. In 2018 an educational professional was hired to collaborate with KHS management to adapt 10-12 activities to incorporate state standards with local curriculum. From 2014 to the present,KHS served nearly 7000 students from schools around the State. -In 2019-20,new interactive cultural activities are planned for visitors to the Kalukalu Living History programs site,where the H.N. Greenwell Store and Portuguese Stone Oven are located. These activities may include English flower arranging, rawhide braiding, and other historic ranching oriented crafts. KHS is currently the only museum of its type offering the array of activities that it does. Overall, in 2019-20 the broad array of enhanced Living History Programs will continue to offer plentiful opportunities for culturally enriching experiences for adults, students, and children of all ages, from Hawaii and around the globe. Thank you for your consideration. 1/30/19 11:34 AM dss Kona Historical Society Kona Akau to Kona Hema: KHS Community Outreach Program 116 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Historical Society Program Name: Kona Akau to Kona Hema: KHS Community Outreach Program Agency Director: Joy Holland Phone No.: (808) 323 — 3222 Contact Person: Joy Holland Phone No.: (808) 323 — 3222 Mailing Address: Address: PO Box 398 Address: City,ST,Zip Captain Cook, HI 96704 Facility Address: Address: 81-6551 Mamalahoa Hwy Address: City,ST,Zip Kealakekua, HI 96750 Email Address: joy@konahistorical.org Fax No.: (808 ) 323 — 3298 Accountant/CPA: Renee Sherman Phone No.: (808 ) 238 — 8972 Firm (if applicable): Mailing Address: Address: PO Box 398 Address: City,ST,Zip Captain Cook, HI 96750 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $16,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna Hamakua ❑✓ North Kona ✓❑ South Hilo ❑✓ North Kohala ❑✓ South Kona ✓❑ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Youth ❑Victims of Crimes ✓❑ Culture and the arts ❑✓ Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Historical Society Program Name: Kona Akau to Kona Hema: KHS Community Outreach Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 6125 5875 6275 2.Agency Mission Statement: The Kona Historical Society(KHS)preserves the history of Kona to enrich, inspire, and inform our community and visitors.We do this through collecting, preserving, researching, interpreting,and disseminating the history of Kona,with a special emphasis on the period from 1830 to the present.The Kona Historical Society connects past, current, and future generations to Kona and Hawaii's history and inspires an appreciation of its heritage. Our purpose is to collect, preserve, interpret, and disseminate that history in a variety of programs and to maintain a climate controlled library, archives and research facility to be used to support public exhibits and community research, and to house historical documents, photographs, and other important resources,which are held in trust for the people of Hawaii. 3. Program Description: Kona Historical Society has developed a strategic outreach program that encourages the community to experience historical programming and living history programs on two sites on National and State Historic Registries that KHS stewards.The outreach program also brings the stories of Kona to more of the community through award-winning lectures,excursions, pop-up exhibits,performances and partnerships with other organizations coordinated at various venues throughout the county. Over the past year, our regular programs have been enriched by our outreach activities, including several pop-up exhibits,with two at the West Hawaii Community Health Center, and another that celebrated canoe builders of Kona and the homecoming of Hokule'a;sponsorship of Hawaii's celebrated actor Moses Goods'one-man performance of'Opukaha'ia;and a display of Kona's Christmases of the past at the Kainaliu Kalikimaka Stroll. In addition, our annual free-to-the-community event, Farm Fest, attracted more patrons to our site than an any previous year.This coming year,we will continue to coordinate history theatre programs in partnership with Hawaii Mission Houses and Daughters of Hawaii, including performances of the Hawaiian patriot Emma Nawahi, and the statesman Curtis laukea;we'll be hosting lectures from world-renown archaeologist Patrick Kirch, Smithsonian curator John Troutman, and Marsonaut Michaela Musilova as part of our Hanohano'0 Kona Lecture Series; we'll be expanding our hands-on activity program at the Kona Coffee Living History Farm from 3 days a week to 4 days a week with activities that include mochi pounding, sashiko stitching and ikebana;we will continue to host our Farm Fest event with cultural performances,food tastings,cooking demonstrations and cultural workshops for free to the community;and we will be representing our sites and building relationships with our fellow community groups by participating in local events like the Waikoloa Dry Forest Initiative,the Kona Coffee Cultural Festival,the Kainaliu Kalikimaka Stroll, University of Hawaii job fairs and other school and community outreach. 4.Total Budget & Position Count: Total Program Budget: 78,922 Total Program Position Count: 8 Total Agency Budget: 702,862 Total Agency Position Count: 27 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Historical Society Program Name: Kona Akau to Kona Hema: KHS Community Outreach Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Earned Income (Tours/Sales/Memberships) 21,260 Contributed Income : Donations 5,000 Sponsorships (Hanohano, Farm Fest& Exhibits) 11,500 Grants (SFCA& Foundation Grants) 20,162 Auction Sales 5,000 COH Requested 16,000 TOTAL: 78,922 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: KHS will solicit sponsorships from community businesses, and individuals to support expanded free public program offerings such as exhibits,community preservation and cultural heritage workshops, Ha'ilono publication, and the Hanohano o Kona Lecture Series. Donations and membership drives will complement the sponsorship campaigns and we will continue to seek grant funding from a variety of sources. 7. Program Objectives Using County Nonprofit Grant Program Funds: Provide expanded free community offerings including pop-up and installed exhibits,community workshops on preservation and cultural heritage, publication projects,website historical content,festival days,school and community outreach, and the Hanohano o Kona lecture series.These activities further KHS's mission to preserve and interpret the history of Kona. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Historical Society Program Name: Kona Akau to Kona Hema: KHS Community Outreach Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Hanohano o Kona Lecture Series 1000 Exhibits(Pop-up and Installed) 7300 Ha ilono Publication 2050 Hailono Digital/Web Publication 3000 Community Workshops 75 Kona Coffee Living History Farm Annual Farm Fest 600 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 50,894 11,034 Professional Fees 4,450 1,240 Operations 8,715 2,057 Supplies 2,770 1,009 Equipment 7,150 550 Other: Equipment Rental (AN) 600 110 Other: Print Advertisements/Announcements 4,343 0 Other: Other: Other: TOTAL 78,922 16,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020' Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Historical Society Program Name: Kona Akau to Kona Hema: KHS Community Outreach Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no,conflicts exist, check here. 1 /131011 (31 'I Signatu e os"Au horized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Historical Society Program Name: Kona Akau to Kona Hema: KHS Community Outreach Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Kona Historical Society Program Name: Kona Akau to Kona Hema: KHS Community Outreach Program ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. I I/ )01.1, C/ Signature • uth rized Person (see checklist, 2nd item) Date \4)vPi Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: . Kona Historical Society Program Name:. Kona Akau to Kona Hema: KHS Community Outreach Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Hanohano o Kona Lecture Series 1000 . Exhibits(Pop-up and Installed) 7300 Ha ilono Publication 2050 Ha'ilono Digital/Web Publication 3000 Community Workshops 75 Kona Coffee Living History Farm Annual Farm Fest 600 TABLE II: • FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 11,034 Professional Fees 1,240 Operations 2,057 Supplies 1,009 Equipment 550 Other: Equipment Rental (NV) 110 Other: Print Advertisements/Announcements 0 Other: Other: Other: TOTAL 16,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Ku'ikahi Mediation Center Community Conflict Prevention & Resolution Services 117 r , County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services Agency Director: Julie Mitchell, Executive Director Phone No.: (808 ) 935 -7844 Contact Person: same Phone No.: ( ) — Mailing Address: Address: 101 Aupuni Street Address: Suite PH 1014 B-2 City,ST,Zip Hilo, HI 96720 Facility Address: Address: same Address: City,ST,Zip Email Address: info@hawaiimediation.org Fax No.: (808 )961 9727 Accountant/CPA: Bonnie Gibeault, CPA Phone No.: (808 )968 -1002 Firm (if applicable): Carbonaro CPAs&Management Group Mailing Address: Address:PO Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) VI Puna 1736 Hamakua ❑ North Kona • South Hilo ❑ North Kohala ❑South Kona • North Hilo ❑South Kohala I Ka'u Services or Activities To Be Provided: (One or more can be checked) VI Educational concerns ®Youth Victims of Crimes ❑Culture and the arts I1 Aged II Victims of Health or Social Crises • Needs of the poor ❑ Physical/Emotional Disabilities VI Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 1 � County of Hawai`i Nonprofit Grant Application FY2019-20 _—__ ____Agency_Name:__Ku'ikahi Mediation Center _ Program Name: Community Conflict Prevention & Resolution Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $7,250 $10,500 $9,750 2. Agency Mission Statement: OUR MISSION We empower people to come together--to talk and to listen,to explore options,and to find their own best solutions. To achieve this mission,we offer mediation,facilitation, and training to strengthen the ability of diverse individuals and groups to resolve interpersonal conflicts and community issues. OUR VISION A peaceful community where people routinely seek common ground. OUR VALUES Communication/Collaboration/Confidentiality/Courtesy/Competence OUR HISTORY Ku'ikahi is the sole nonprofit mediation center serving East Hawaii and 1 of only 5 in the state. Our agency helps individuals, families,organizations,businesses,schools,and others to find creative solutions to challenging situations. Founded in 1983 as a program of the island of Hawaii YMCA,and becoming an independent organization in 2006,Ku'ikahi has a 36 year track record providing mediation,facilitation,and training to further alternative dispute resolutions in the County of Hawaii. Our purpose is"Finding Solutions, Growing Peace." 3. Program Description: Mediation resolutions tend to be long lasting and help to improve relationships, promote understanding, and ultimately strengthen our community. Mediations are provided on an affordable sliding scale,with no one turned away for lack of funds. Between 50% to 60%of our mediation clients have annual household incomes of under$20,000. According to The Mediation Centers of Hawa!i Economic Impact and Social Return on Investment Analysis for the Fiscal Year 2017,"for every$1 invested in these mediation programs,they deliver$8 in immediate and long-term consequential financial benefits to the citizens of Hawaii. In the areas of facilitation and training,we serve the public,private, and non-profit sectors. Unique opportunities include: 1) neutral facilitators for small and large groups,2) Free Brown Bag Lunch Series of monthly talks,3)public and private trainings in communication and transforming conflict,4)free in-house continuing education for volunteer mediators;and 5)peer mediation training for elementary students. For example, Ku'ikahi's executive director assisted the County of Hawaii Civil Defense Agency by collaboratively redesigning and facilitating some of the Pahoa Community Meetings in 2018 following the eruption. CLIENT SUCCESS STORY: "I'm already using the skills gained from the Basic Mediation Training in my one-to-one conversations with students in crisis or helping students resolve conflicts with faculty,staff,and/or other students.The Division of Student Affairs is already seeing a return on the investment. These skills are so incredible and valuable!"-Karishma Kamath, UH-Hilo 4.Total Budget&Position Count: Total Program Budget: $288,672 Total Program Position Count: 3.5 Total Agency Budget: $328,222 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Direct contributions $20,000 Foundation/trust grants $89,250 United Way contributions $7,500 County of Hawaii nonprofit grant $15,000 Hawaii state&county contracts $62,402 Program fees (mediation, facilitation &workshops/trainings) $36,700 Special events ($55,000)+Other($2,820) $57,820 TOTAL: $288,672 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 1)Offer 8 community workshops/trainings that are tuition based. Also,target market private,customized trainings for businesses and organizations. 2) Hold our seventh annual fund drive to solicit direct contributions, including from major donors(individuals and businesses). On our 990 from FY2017-18,we reported$116,575 under"all other contributions,gifts,grants, and similar amounts." This amount is in addition to income from federated campaigns,fundraising events,government grants,and program service revenue. 3)Market our services more to local businesses and community groups. This includes workplace mediation opportunities, facilitation of sensitive issues and sticky situations,and workshops/trainings(see#1 above). 4) Research and apply for new and continuing grants from foundations, locally and nationally. In FY 2017-18,we received $104,570 from foundations, up 50%from$69,930 received in FY 2016-17, as per our CPA prepared financial statements. 5) Explore new partnership opportunities at the county and state levels for program and fund development. These may include applying for county and state RFPs,such as with County R&D, State Grants-in-Aid,Victims of Crime Act(VOCA),etc. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Provide low-or no-cost mediation and facilitation services to self-,community-, and court-referred clients. Mediations are provided on an affordable sliding scale,with no one turned away for lack of funds. 2)Offer a critical alternative to litigation,especially for poor and indigent populations who cannot afford legal counsel and/or have a hard time navigating the legal system as self-represented litigants. Local non-profit legal services and court self-help centers receive more inquiries than they can process. Mediation is integral to Hawai'i's"Access to Justice"framework,which strives to ensure that all people have access to civil processes. 3) Provide conflict prevention and resolution education to community members and volunteer mediators in East Hawaii. Volunteer mediators may attend any educational program for free. Economically challenged community members may apply for scholarships to encourage attendance by diverse populations. Our educational programs have also attracted people/businesses in West Hawai'i,the neighbor islands,and the continental U.S. We strive to serve all sectors:public,private,and non-profit. 4)Utilize 40+professionally trained volunteer mediators to provide primary service delivery. Annually',we offer Basic Mediation Training,from which we recruit volunteers to join a year-long apprenticeship program. Subsequently,these apprentices are graduated to mediator status and given continuing education to better serve the needs of the community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 __________Agency--Name: _Kulkahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) #of mediation&facilitation cases opened 400 #of mediation&facilitation clients served(in cases closed) 900 #of mediation&facilitation sessions held 250 #of mediator volunteer hours donated 1,100 % of mediated cases that resulted in agreement 65% %of clients who are satisfied with mediation 95% %of clients who felt mediation saved them time and/or money 75% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $182,000 $184,130 $10,000 Professional Fees $20,000 $21,600 $2,000 Operations $49,000 $50,592 $2,000 Supplies $4,000 $4,350 $1,000 Equipment $2,000 $3,000 Other: Special events $24,050 $25,000 Other: • Other: Other: PLEASE NOTE: FY 18-19 figures are estimates Other: since we are only 7 months into the FY TOTAL $281,050 $288,672 $15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 8.TABLE I (additional page): What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) #of free brown bag lunch talks held 12 #of brown bag lunch talk attendees served 240 of brown bag lunch talk attendees report learning something new& useful 95% #of trainings&workshops held 8 #of training&workshop attendees served 160 of training&workshop attendees report learning something new& useful 95% • • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2018-2019 Page 4 of 8(continued) County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Aaron Brown POSITION: Director & Assistant Treasurer, Ku'ikahi Board of Directors May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): wi Member or members of the Council n Staff appointed by a member of the Council n The Mayor ❑ The Managing Director n The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Aaron Brown is the Deputy County Clerk and,as such,interacts regularly with all Hawaii County Council Members. To avoid any conflicts or potential conflicts of interest,Mr.Brown will recuse himself from any and all decision-making regarding Ku'ikahi Mediation Center contracts and grants with the County of Hawaii. ❑ If no conflicts exist, check here. / / / b / I ) Sign ure of Author ed Person (specify title) *ecr"-- Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 ____Agenc_y_Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services i1. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). • I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructionshttp://www.hawaiicounty.gov/fn-nonprofit-grant-forms/are available at http://www.hawancounty.gov/fn nonprofit grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 mustbe returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. ti 01/30/2019 Si ature of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 _____________igencyName: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result 400 #of mediation&facilitation cases opened 900 #of mediation&facilitation clients served(in cases closed) #of mediation&facilitation sessions held 250 1,100 #of mediator volunteer hours donated 35% %of mediated cases that resulted in agreement 25% %of clients who are satisfied with mediation 75% %of clients who felt mediation saved them time and/or money TABLE II: FY 19-20 Grantl Council PROGRAM EXPENDITURES Request Award Salary and Wages $10,000 Professional Fees $2,000 Operations \' $2,000 Supplies $1,000 Equipment Other:_Special events Other: Other: Other: PLEASE NOTE: FY 18-19 figures are estimates Other: since we are only 7 months into the FY TOTAL $15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Prevention & Resolution Services 12. COUNCIL AWARD WORKSHEET TABLE I (additional page): PROGRAM PERFORMANCE MEASURES Applicant Council Projected Proposed Results Projected Result #of free brown bag lunch talks held 12 #of brown bag lunch talk attendees served 240 of brown bag lunch talk attendees report learning something new& useful 95% #of trainings&workshops held 8 #of training&workshop attendees served 160 of training&workshop attendees report learning something new& useful 95% • EXHIBIT B' NONPROFIT GRANT APPLICATION FY 2018-2019 Page 8 of 8 (continued) Ku`ikahi Mediation Center Youth Peer Mediation Program 118 i 1 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program Agency Director: Julie Mitchell, Executive Director Phone No.: (808 ) 935 -7844 Contact Person: same Phone No.: ( ) — Mailing Address: Address: 101 Aupuni Street Address: Suite PH 1014 B-2 City,ST,Zip Hilo, HI 96720 Facility Address: Address: same Address: City,ST,Zip Email Address: info@hawaiimediation.org Fax No.: (808 )961 -9727 Accountant/CPA: Bonnie Gibeault, CPA Phone No.: (808 )968 -1002 Firm (if applicable): Carbonaro CPAs&Management Group Mailing Address: Address:PO Box 4372 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) WI Puna Hamakua ❑ North Kona South Hilo ❑ North Kohala ❑South Kona North Hilo ❑South Kohala E1 Ka'u Services or Activities To Be Provided: (One or more can be checked) ▪ Educational concerns V]Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION PL CATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency__Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0 $5,000 $7,050 2.Agency Mission Statement: OUR MISSION We empower people to come together--to talk and to listen,to explore options, and to find their own best solutions. To achieve this mission,we offer mediation,facilitation, and training to strengthen the ability of diverse individuals and groups to resolve interpersonal conflicts and community issues. OUR VISION A peaceful community where people routinely seek common ground. OUR VALUES Communication/Collaboration/Confidentiality/Courtesy/Competence OUR HISTORY Ku'ikahi is the sole nonprofit mediation center serving East Hawaii and 1 of only 5 in the state. Our agency helps individuals, families,organizations,businesses,schools,and others to find creative solutions to challenging situations. Founded in 1983 as a program of the Island of Hawaii YMCA, and becoming an independent organization in 2006, Ku'ikahi has a 36 year track record providing mediation,facilitation,and training to further alternative dispute resolutions in the County of Hawai'i. Our purpose is"Finding Solutions,Growing Peace." • 3. Program Description: In 2010,the Hawaii Department of Education(DOE)Safe Schools Community Advisory Committee established several recommendations to address conflict in the schools,including establishing a school community culture that creates and encourages an environment of safety and respect. To support this directive,we launched a youth peer mediation program in East Hawaii in 2015. Peer mediation is both a program and a process where students of the same age group facilitate resolving disputes between 2 or more people. Students in conflict can request mediation or be referred by staff or other students. Mediators work in pairs and help disputants reach and-document-agreements that are fair,safe,and doable. Peer mediation training focuses on the nature of conflict,communication and problem solving skills,and understanding and respecting differences. Through peer mediation and conflict resolution,students learn to work effectively with their schoolmates to facilitate positive outcomes. This process has proven effective in schools around the United States and in the state of Hawaii. In the past 4 years, Ku'ikahi's peer mediation program has reached 7 schools and trained 444 youth. Our 2019-20"Youth Peer Mediation Program"will focus on deepening the successful peer mediation programs at 3 elementary schools in the Ka'u-Kea'au-Puna Complex Area(Keonepoko,Mountain View,and Volcano),as well as seeking out new partners. In addition, we will develop curriculum to expand peer mediation into middle schools(slated to pilot in Volcano)and create stand-alone conflict resolution workshops for kids to offer at libraries,schools, and other youth programs. PEER MEDIATOR QUOTE:"I am proud to be a Peer Mediator because I can make the world better. I have learned in peer mediation to follow the'ground rules'and let the students solve their own problems."-Caleilah-Estelle,grade 5 4.Total Budget& Position Count: Total Program Budget: $39,550 Total Program Position Count: .5 Total Agency Budget: $328,222 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Direct contributions $5,000 Foundation/trust grants $24,550 County of Hawaii nonprofit grant $10,000 TOTAL: $39,550 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 1) Research and apply for new and continuing grants from foundations, locally and nationally. To support peer mediation in n FY 2018-19,to date we have received $2,500 from the Friends of Hawaii Charities, Inc.and$5,000 from the Anderson-Beck Fund. We are also awaiting notification from the Atherton Family Foundation, Healy Foundation,and HEI Charitable Foundation. , 2)Approach private donors, both individuals and businesses,to support the program. For example,both KTA Super Stores and Big Island Candies(BIC)pledged 3 years of support for peer mediation from 2015 to 2017. We will attempt to replicate this long-term program sponsorship for the upcoming fiscal year(s). BIC shared that,"It's a great idea to start at a young age." And KTA shared,"We look forward to a most successful[peer mediation]program because we also believe that early intervention is the best means of prevention." 3)Explore new partnership opportunities on the local and state levels for program and fund development. These include working with School Principals,Complex Area Superintendents,and Department of Education to cost-share the program in each school,plus consider applying for a State Grant-in-Aid to support peer mediation in FY 2019-20 in conjunction with West Hawaii Mediation Center. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Approximately 175 students will be trained as peer mediators(direct)to serve approximately 1,200 students(indirect)from some of the most rural,disadvantaged areas of the state. Of these 3 schools,one has 79%and two have 100%enrolled in free or reduced lunch, indicating high levels of need. In the 2016-2017 school year,"Schools in the Kau-Keaau-Pahoa Complex Area reported more than half of all Class A and Class B[misconduct]offenses islandwide last year. The complex area contained just under one-fourth of the island's public school student population." (Hawaii Tribune-Herald,7/24/2017). 2)At each school, hold the following activities: a.School year-start program planning and coordination(1 hour over 1 session), b. Faculty/staff conflict resolution training and/or peer mediation introductory presentation(.5 hour to 2 hours over 1 session) during first semester, c.Student peer mediation trainings(4 hours over 3 sessions per class)during first semester and follow-up trainings(1.25 hours over 1 session per class)during second semester, and d.School year-end student recognition events(1 hour over 1 session)during second semester. 3)We will develop curriculum to expand peer mediation into middle schools(slated to pilot in Volcano)and create stand-alone conflict resolution workshops for kids to offer at libraries,schools,and other youth program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 _ - -_ _A AgencyName:_ Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) #of schools participating 3 #of youth trained as peer mediators 175 #of peer mediation trainings held 12 %of peer mediation sessions that result in successful resolution 75% %of youth trained who know how to help peers resolve conflicts at school year-end 80% %of students who have improved their communication and behavior as a result of training 95% %of faculty/staff who are satisfied with the program at school year-end 95% • Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $30,000 $31,550 $8,350 Professional Fees Operations $6,500 $6,700 $1,000 Supplies $900 $950 $500 Equipment Other: Mileage $325 $350 $150 Other: Other: Other: PLEASE NOTE: FY 18-19 figures are estimates Other: since we are only 7 months into the FY TOTAL $37,725 $39,550 $10,000 *If applicable l EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate ' as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Aaron Brown POSITION: Director & Assistant Treasurer, Ku'ikahi Board of Directors May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director n The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Aaron Brown is the Deputy County Clerk and,as such,interacts regularly with all Hawaii County Council Members. To avoid any conflicts or potential conflicts of interest,Mr.Brown will recuse himself from any and all decision-making regarding Ku'ikahi Mediation Center contracts and grants with the County of Hawaii. ❑ If no conflicts exist, check here. Sig,ature of Auth• !zed Person (specify title) _r— Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 _- --.--__A enc__Name: _Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Ku'ikahi Mediation Center Program Name: Youth Peer Mediation Program 11. Certification of Understanding (Page o Pa e i i f ) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 01/30/2019 Sign ure of Author' ed Person (see checklist, 2nd item) Date EX€__w+- rG- 4 n Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency_Name: Ku'ikahi Mediation Center Program Name:Youth Peer Mediation Program 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result 3 #of schools participating 175 #of youth trained as peer mediators #of peer mediation trainings held 12 75% %of peer mediation sessions that result in successful resolution 30% %of youth trained who know how to help peers resolve conflicts at school year-end 35 %of students who have improved their communication and behavior as a result of training 95 %of faculty/staff who are satisfied with the program at school year-end TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $8,350 Professional Fees Operations $1,000 Supplies $500 Equipment Other: Mileage $150 Other: Other: Other: PLEASE NOTE: FY 18-19 figures are estimates Other: since we are only 7 months into the FY TOTAL $10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Legal Aid Society of Hawaii Hawai'i Island Medical-Legal Partnership 119 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Legal Aid Society of Hawaii Program Name: Hawaii Island Medical-Legal Partnership Agency Director: M. Nalani Fujimori Kaina Phone No.: (808) 527 — 8014 Contact Person: Claudia Shockley Phone No.: (808 ) 329 — 3910 Mailing Address: Address: 924 Bethel Street Address: City,ST,Zip Honolulu, Hawai'i 96813 Facility Address: Address: 75-170 Hualalai Road Address: Suite B303A City,ST,Zip Kailua-Kona, Hawaii 96740 Email Address: Fax No.: (808 ) 334 — 9650 Accountant/CPA: Jim Gagne, Director of Finance Phone No.: (808 ) 527 — 8060 Firm (if applicable): Mailing Address: Address: 924 Bethel Street Address: City,ST,Zip Honolulu, Hawai'i 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna Hamakua ✓❑ North Kona ✓❑South Hilo ✓❑ North Kohala ✓❑South Kona ❑✓ North Hilo ✓❑South Kohala n Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Youth Victims of Crimes ❑ Culture and the arts Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ✓❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Legal Aid Society of Hawaii Program Name: Hawaii Island Medical-Legal Partnership 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $16,250 $10,000 *$14,975 2.Agency Mission Statement: Legal Aid Society of Hawai'i (LASH)'s mission is to address critical legal needs through high quality legal advocacy, outreach and education in the pursuit of fairness and justice. Legal Aid, a community-based, non-profit law firm, has empowered low-income and disadvantaged people throughout our state for nearly 65 years. It 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'i to urban Honolulu. Legal Aid has two offices on the island of Hawaii. Hilo's office was established in the 1950's and the Kona office opened its doors in 1979. Both offices are a vital part of the communities, providing free legal assistance to low-income individuals and families in the areas of consumer,family, public benefits, housing, and elder law cases. "please note: prior year funding listed above represents total funding for two Hawaii County grant programs;funding specifically for MLP was$5,675 for FY18-19 3. Program Description: g p With aid from the Hawaii County nonprofit grant program, and the State of Hawaii STOP grant, LASH has experienced some success over the first six months of fiscal 2019 in establishing a medical-legal partnership with the West Hawaii Community Health Center. (WHCHC)The two organizations have worked together to determine how best to combine efforts to achieve positive health outcomes by meeting the civil legal needs of low-income individuals and families in the County. LASH Staff Attorney Dan Mistak currently works in the WHCHC several days a week and is becoming part of the"check-up" process for WHCHC patients. In doing so,the two organizations have achieved at least two of the goals of the prior year's grant program--we have increased communication and collaboration between the two agencies in the service of Hawai'i County's low-income residents., and we have co-located a Staff Attorney at the WHCHC in order to provide wrap-around services. LASH requests$10,000 for the coming year in order to build on the success of the current program and begin to explore further potential partners on Hawaii Island with whom LASH could develop a medical-legal partnership. Goals for the coming year include: (1)conducting at least 6 training and outreach events to medical and mental health facility staff and patients; (2) continue to increase the number of referrals received through such coordinated efforts; (3)continue the on-site partnership with WHCHC and develop best practices for the establishment of future medical-legal partnerships, including best practices for on-site legal assistance;and, (4)initiate a medical-legal partnership with at least one other service provider in Hawai'i County. Support for and expansion of the existing program will increase service to County residents most in need. By using a coordinated approach to service, individuals and families will see health outcomes improved when civil legal needs(such as access to public benefits or housing)are met. 4. Total Budget& Position Count: Total Program.Budget: $152,152 Total Program Position Count: 2.75 Total Agency Budget: $6,450,500 Total Agency Position Count: 100 • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: \ Legal Aid Society of Hawaii Program Name: Hawaii Island Medical-Legal Partnership 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii Nonprofit Grant $10,000 STOP MLP Big Island DV Grant $117,434 State DHS Homeless Grant $7,150 VOCA(Victims of Crime) Grant $12,500 Hawai'i Island United Way $5,104 TOTAL: $152,152 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: There is a good deal of potential to increase support for this program, as it has achieved some success in the first year. LASH has already been awarded State STOP(OVW)funds to support this program in the coming fiscal year. LASH, along with several partner organizations, has applied for Federal HRSA funding to support coordinated medical-legal approaches to opiold abuse in Hawai'i county, and LASH plans to continue seeking such funding that not only expands the reach of existing medical-legal partnerships,'but also increases the number of such partnerships island wide, in order to address a variety of legal issues that impact health'-related outcomes.Additionally,the eventual goal of medical-legal partnerships is that they become self-sustaining through both contractual agreements and through expenses appropriately billed to Medicaid and other providers. 7. Program Objectives Using County Nonprofit Grant Program Funds: Should this request receive full funding, LASH will continue to provide outreach and community coordination,as well as intake, counsel and advice, brief services and/or full representation in 24 cases, either referred through or in cooperation with Hawaii Island healthcare providers. These services will continue to be provided free to individuals and families whose incomes fall below 200%of the federal poverty level. LASH is able to provide a wide variety of civil legal services, not all of which will be funded through this program.Alternative sources of funding will be used to provide service in cases in which specialized assistance is required (for example, elder law, assistance to crime victims, etc.). The current(2019)project was modeled after a successful LASH medical-legal partnership on Oahu, and the current project has met several significant project milestones. In the coming year(2020), LASH proposes to expand further by partnering with one other healthcare provider, and to make significant educational inroads into the various Hawaii Island communities in order to impact any health outcomes that are affected by civil legal issues. LASH has already been in discussion with several healthcare providers regarding the concomitant medical-legal problems frequently faced by victims of opioid abuse,and this particular area will continue to serve as one of the areas most likely to benefit from both medical and legal services. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Legal Aid Society of Hawaii Program Name: Hawaii Island Medical-Legal Partnership 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Education and Outreach Events Conducted with healthcare providers and patients 6 Assistance provided in income security and insurance issues 4 Assistance provided in housing-related matters 4 Assistance provided in matters of personal and family stability 6 Education and employment support 2 Addressing with legal status and vital document needs 2 Assisting culturally and linguistically isolated populations/individuals 2 Attach additional pages as necessary. • 9. TABLE II: • PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 2,837.50 100,788 8,303 Professional Fees 4,000 Operations Supplies 927 927 Equipment 2,870 Other: Mileage 2,973 570 Other: Cell phone service/telecommunications 3,588 200 Other: Airfare 2,797 Other: Lease/Rental of Space 1,000 Other: TOTAL 2,837.50 152,152 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Legal Aid Society of Hawaii Program Name: Hawaii Island Medical-Legal Partnership 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest'that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council n The Mayor ❑ The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: • n If no conflicts exist, check here. January 28, 2019 M.Nalani Fuji ori Ka' a,Exec tive D'• cto Signature of Authorizes Per.o I •ecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Legal Aid Society of Hawaii Program Name: Hawaii Island Medical-Legal Partnership 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template,provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Legal Aid Society of Hawaii Program Name: Hawaii Island Medical-Legal Partnership 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. - January 28, 2019 Signature of Authorized Pe '--- checklist, 2nd item) Date M. Nalani Fujimori Kaina,Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Legal Aid Society of Hawaii Program Name: Hawaii Island Medical-Legal Partnership 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Outreach,education,workshops and events 6 Keeping Children Safe and Secure 4 Promoting Safety,Security and Health 4 Preserving the Home 6 Maintaining Economic Security 2 Assisting culturally and linguistically isolated communities 2 Addressing legal status and identification needs 2 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 8,303 Professional Fees Operations' Supplies 927 Equipment Other: Mileage 570 Other: Cell phone service/telecommunications 200 Other: Airfare Other: Lease/Rental of Space Other: TOTAL 10,000 _ _ _ Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Legal Aid Society of Hawaii Providing Civil Legal Access to Rural Communities 120 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Legal Aid Society of Hawaii - Program Name: Providing Civil Legal Access to Rural Communities Agency Director: M. Nalani Fujimori Kaina Phone No.: ( 808 ) 527 — 8014 Contact Person: Claudia Shockley Phone No.: (808 ) 329 — 3910 Mailing Address: Address: 924 Bethel Street Address: City,ST,Zip Honolulu, Hawaii 96813 Facility Address: Address: 75-170 Hualalai Road Address: Suite B303A City,ST,Zip Kailua-Kona, Hawaii 96740 Email Address: Fax No.: (808 ) 334 — 9650 Accountant/CPA: Jim Gagne, Director of Finance Phone No.: (808 ) 527 — 8060 Firm (if applicable): Mailing Address: Address: 924 Bethel Street Address: City,ST,Zip Honolulu, Hawaii 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO • PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna n Hamakua n North Kona n South Hilo n North Kohala n South Kona • ❑✓ North Hilo ❑✓ South Kohala n Ka`0 Services or Activities To Be Provided: (One or more can be checked) n Educational concerns n Youth n Victims of Crimes n Culture and the arts ❑✓ Aged n Victims of Health or Social Crises n Needs of the poor ❑✓ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019 -2020 Page 1 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Legal Aid Society of Hawaii Program Name: Providing Civil Legal Access to Rural Communities 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 1647 FY 17-18 FY 18-19 $16,250 $10,000 *$14,975 2. Agency Mission Statement: Legal Aid Society of Hawai'i (LASH)'s mission is to address critical legal needs through high quality legal advocacy, outreach and education in the pursuit of fairness and justice. • LASH, a community-based, non-profit law firm, has empowered low-income and disadvantaged people throughout our state for nearly 65 years. It 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'i to urban Honolulu. LASH has two offices on the island of Hawaii. Hilo's office was established in the 1950's and the Kona office opened its doors in 1979. Both offices are a vital part of the communities, providing free legal assistance to low-income individuals and families in the areas of consumer,family, public benefits, housing, and elder law cases. *Note: $14,975 listed for FY18-19 is for two separate programs funded by Hawai'i County NP grant; funding for this particular program amounted to$9,300. 3. Program Description: LASH requests$25,000 under this grant program to serve the critical civil legal needs of low-income residents throughout Hawai'i County. Our continuing emphasis under this particular program is on serving the residents of the Ka'u and Kohala areas,farm workers, Native Hawaiians, linguistically isolated populations, and the homeless. Over the last year, LASH has been responsive to the needs of Hawai'i County residents experiencing hardship. LASH sought out funding from federal and foundation sources in order to meet the needs of those affected by volcanic activity,for example, and our paralegals and attorneys continue to assist in ongoing legal needs related to this.While none of the disaster aid was provided under this grant, the Hawaii County grant allowed LASH to continue general services during the aftermath of the disaster--continuing to provide outreach and education in the most rural parts of the county; continuing visit and serve clients in their own neighborhoods, rather than requiring them to find transportation to Hilo or Kona; continuing to assist with difficult processes such as powers of attorney, advanced healthcare directives, guardianships, adoptions, divorces, and custody matters. LASH has offered significant assistance with housing-related matters as well, along with bringing expertise to the county in order to address issues related to healthcare and public benefits. During the first half of the current fiscal year, LASH has primarily assisted rural Hawai'i County residents with matters related to wills and estates, custody/visitation, advanced directives, and income security. LASH requests a contribution for the coming fiscal year in the amount of$25,000 in order that we may continue to provide consistent staffing and high levels of direct service and outreach, as well as allowing us to cover significant on-island travel costs and modest meeting space fees when required. Most of the cases open in the current fiscal year remain open, as civil legal issues frequently take time to resolve. In one instance, a mother in Hawi is awaiting a child custody hearing, after having received extensive advice and assistance. In another instance, LASH staff assisted an Ocean View woman in working with her bank to prevent foreclosure and, thus, remain in her house. LASH is prepared to assist with a diversity of legal problems county-wide. 4. Total Budget & Position Count: Total Program Budget: $82,500 Total Program Position Count: 0.5 Total Agency Budget: $6,450,500 Total Agency Position Count: 100 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Legal Aid Society of Hawaii Program Name: Providing Civil Legal Access to Rural Communities 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii Nonprofit Grant $25,000 Federal Funding $12,500 Hawaii County Office on Aging (Title III) $23,000 State DHS Neighbor Island DV funding $22,000 TOTAL: 82,500 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: As a longstanding and effective nonprofit agency, LASH continually seeks funding aligned with its mission, priorities and programs. In general, LASH seeks funding from communities that will benefit from the specific proposed programmatic work, as well as diversified funding from state,federal and other resources whose funding priorities align with LASH programmatic priorities.As a statewide nonprofit, LASH will always seek funding to support provision of civil legal services to low-income residents of Hawaii County. 7. Program Objectives Using County Nonprofit Grant Program Funds: In FY19-20, LASH will continue to provide outreach and community coordination, intake, counsel and advice, brief services and/or full representation in 85 cases and will participate in eight outreach and education events, primarily in the most rural parts of the county.These services will, as always, be provided for free to low-income individuals and families whose incomes are less than 200%of the federal poverty level. Potential clients will also be screened for eligibility for assistance through other LASH funding sources which may be more specific in their requirements(age limits,victimization status, etc.). This County Nonprofit grant funding makes a significant difference in LASH's ability to effectively and efficiently serve the most vulnerable residents of Hawai'i County, and past funding has allowed us to make a significant difference in people's lives and in the overall health of the community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Legal Aid Society of Hawaii Program Name: Providing Civil Legal Access to Rural Communities 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? • PROGRAM PERFORMANCE MEASURES Applicant Projected Results • (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Supporting families 15 clients served • Keeping children safe and secure 15 clients served Promoting safety, security& health 30 clients served Preserving the home 10 clients served Maintaining economic security 10 clients served Assisting culturally and linguistically isolated communities 10 clients served Outreach, education,workshops &events 8 events Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $4,365 $67,700 $23,125 Professional Fees $1,200 Operations $7,000 Supplies $1,100 $550 Equipment $1,250 Other: Mileage $1,650 $750 Other: Telecommunications $2,600 $575 Other: (FY18-19 "actual" represents Hawaii County grant funding actual) Other: Other: TOTAL $4,365 $82,500 $25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Legal Aid Society of Hawaii Program Name: Providing Civil Legal Access to Rural Communities 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council ❑ Staff appointed by a member of the Council n The Mayor n The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: [� If no conflicts exist, check here. �.. January 28, 2019 M.Nalani Fujimori Kama,Execu fie Director Signature of Authorized Person (sp cify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Legal Aid Society of Hawaii Program Name: Providing Civil Legal Access to Rural Communities 11.. Certification of Understanding (Page 1 of 2) 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 —2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Legal Aid Society of Hawaii Program Name: Providing Civil Legal Access to Rural Communities 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. January 28, 2019 Signature of Authorized Persil csee ecklist, 2nd item) Date M. Nalani Fujimori Kaina, Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Legal Aid Society of Hawaii Program Name: Providing Civil Legal Access to Rural Communities 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 15 clients served Supporting families Keeping children safe and secure 15 clients served Promoting safety, security and health 30 clients served 10 clients served Preserving the home Maintaining economic security 10 clients served Assisting culturally and linguistically isolated communities 10 clients served Outreach, education,workshops and events 8 events TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $23,125 Professional Fees Operations Supplies $550 Equipment Other: Mileage $750 Other: Telecommunications $575 Other: (FY18-19 "actual" represents Hawaii County grant funding actual) Other: Other: TOTAL $25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Lokahi Treatment Centers, Inc. Adolescent Substance Abuse Treatment Programs 121 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adolescent Substance Abuse Treatment Programs Agency Director: Jamal F.Wasan, Ph.D. Phone No.: (808 ) 883 —0922 Contact Person: Corey Causey Phone No.: (808 ) 969 —9292 Mailing Address: Address: P.O.Box 383401 Address: City,ST,Zip Waikoloa,HI 96738 Facility Address: Address: (Corporate)68-1845 Waikoloa'Road,Ste.224 B Address: City,ST,Zip Waikoloa,HI 96738 Email Address: causey@ilhawaii.net Fax No.: (so )969 —7337 Accountant/CPA: Carbonaro CPA&Associates Phone No.: (so )930 —6850 Firm (if applicable): Carbonaro CPA&Associates Mailing Address: Address:P.O.Box 4372 Address: City,ST,Zip Hilo,HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $28,000 Geographical Areas To Be Served: (One or more can be checked) Puna 11 Hamakua ®North Kona South Hilo ® North Kohala Ij South Kona ® North Hilo ®South Kohala ® Ka u Services or Activities To Be Provided: (One or more can be checked):. Educational concerns ®Youth ®Victims of Crimes ❑Culture and the arts ❑Aged ®Victims of Health or Social Crises Needs of the poor Physical/Emotional Disabilities iz Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adolescent Substance Abuse Treatment Programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $14,875 $11,250 $9,953 2.Agency Mission Statement: To provide the highest quality mental health and substance abuse treatment services that are culturally appropriate to Big Island adults,adolescents and children. This mission is accomplished through the use of an integrated approach to treatment utilizing both cognitive-behavioral and existential psychotherapy.This allows the individual to formulate a reason for changing and create strategies to experience emotional,cognitive,and spiritual growth. Our guiding principles are as follows: *We believe in a holistic approach to restore harmony and unity to the individuals,families and communities that we serve. *We believe in the highest level of care,while respecting cultural values. *We believe in outreach and assessment of community needs;and advocacy for the provision of those needs. *We believe in strength-based and client centered treatment with linkages and referralsto other community-based resources for continued recovery. *We believe in a non-judgmental approach with compassion,respect and dignity for all. 3. Program Description: Lokahi Treatment Centers(LTC)Adolescent Substance Abuse Programs provide comprehensive treatment services for adolescents(aged 10-18)at all six(6)office locations throughout Hawaii Island.Treatment services are for individuals that complete a substance use assessment and through this detailed assessment are determined to be in need of treatment services that includes the provision of education to abstain from the use of substances,the development of relapse prevention skills and a treatment plan,individual counseling to address other problematic factors,and case management services. LTC's continuum of care(levels of care)includes:Intensive Outpatient,Outpatient,Continuing/After Care,and Prevention Programs. A majority of adolescent clients are referred for substance treatment services from Juvenile Probation or Teen Court. Recently, local schools have begun to also refer students who are in need of treatment.LTC's adolescent substance abuse treatment programs are integrated to include mental health services,to address co-occurring disorders that are impacting their recovery process. LTC's adolescent substance treatment program utilizes evidence-based methods and best practice standards that comply with the Commission on Accreditation of Rehabilitation Facilities(CARF)standards.Evidence-based curriculum's are consistently updated to include well-developed strategy models that are proven effective by behavioral health care treatment accreditation facilities throughout the nation.These curriculum's include the inclusion of family members and other supportive individuals; through these individuals,adolescents become well adjusted and develop the ability to create healthy long-term relationships that aide in relapse prevention,criminal thinking and behaviors,and a reduction in trauma-induced mental illness factors. 4.Total Budget&Position Count: Total Program Budget: $155,000 Total Program Position Count: 6 Total Agency Budget: $1,093,000 Total Agency Position Count: 21 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adolescent Substance Abuse Treatment Programs 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Managed Care(Third Party Insurance) $127,000 County of Hawaii, Nonprofit Grant Contract $28,000 TOTAL: $155,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We are in the process of scheduling meetings with managed care providers,i.e.,HMSA, UHA,etc.to develop incentive programs for Lokahi Treatment Centers to provide enhanced out-patient treatment services targeting opioid use and suicide prevention for our youth. LTC would also include the consequences of drug use in teenage pregnancies. Opioid use during pregnancy can result in a drug withdrawal syndrome in newborns called neonatal abstinence syndrome,or neonatal opioid withdrawal syndrome(NAS/NOWS),which cases costly hospital stays. An analysis by the National Institute of Drug Abuse (NIDA)showed that an estimated 32,000 babies were born with this syndrome in the United States in 2014,which was more than a 5-fold increase since 2004. NIDA concluded that every 15 minutes,a baby is born suffering from opioid withdrawal.A January 2019 report from NIDA stated that every day,more than 130 people in the United States die after overdosing on opioids. The misuse of and addiction to opioids,including prescription pain relievers,heroin,and synthetic opioids such as fentanyl,is a serious public health crisis here in Hawaii County that affects our social and economic welfare. It has devastating consequences. In the past several months,we have seen a dramatic increase of clients,including adolescents who have used or still using opioids. This grant will help us to maintain the increasing number of participants,while we negotiate payment rates and incentive programs with managed-care providers, We will also continue to recruit volunteers for fundraising activities. LTC is committed to meet the multiple needs of the population we serve. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide immediate access to treatment services to any adolescent that is assessed and diagnosed with any substance use disorder.Treatment services will also include linkages to mental health treatment services(integrated)and other behavioral treatment that may be deemed necessary in order for long-term recovery and to maintain sobriety. 2. Provide enhanced out-patient treatment services targeting opioid use and suicide prevention for adolescents. 3. Increase the availability of outpatient treatment services to adolescents in need of treatment services.Partner with community service providers to develop accessible locations within existing locations;will aide in the ease of access to treatment. 4. Increase LTC's participation in community events that are targeted for adolescents(outreach and engagement).This will include strengthening partnerships with community service providers and school officials(Dept.of Education;principals, school-based counselors,teachers). 5. Increase the availability and ease of access to out-patient treatment services in Ka'u. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adolescent Substance Abuse Treatment Programs 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Increase#of adolescents who remain in treatment for full course of recommended services Increase by 25% Provide suicide prevention workshops through community&professional partnerships 4 workshops/Events Increase the number of adolescent social supports during treatment&at time of discharge Increase by 25% Increase#of surveys to evaluate performance measures based on patient experience Increase by 25% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual*to Total Budget Grant Req Salary and Wages $100,000 $28,000 Professional Fees $25,000 Operations $20,000 Supplies $8,000 Equipment $2,000 Other: Other: Other: Other_ Other: TOTAL $155,500 $28,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adolescent Substance Abuse Treatment Programs 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Donna Guerpo POSITION: Human Resources Officer May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ® Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director n The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: A strict Conflict of Interest Policy upheld by the organization to avoid any/all potential conflicts of interest that may occur. n If no conflicts exist, check here. lIF° January 29, 2019 Sig ture of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adolescent Substance Abuse Treatment Programs 11.Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. 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 receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are i:. complete and accurate prior to submittal. I (we) understand that all documents requiring a current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report,using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adolescent Substance Abuse Treatment Programs 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 ofthe year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. January 29, 2019 Signature of Authorized Person (see checklist, 2nd item) Date co Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adolescent Substance Abuse Treatment Programs 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increase#of adolescents who remain in treatment for full course of recommended services Increase by 25% Provide suicide prevention workshops through community&professional partnerships 4wcrksnops/Events Increase the number of adolescent social supports during treatment&at time of discharge Increase by 25% Increase#of surveys to evaluate performance measures based on patient experience Increase by 25% s TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $28,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $28,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Lokahi Treatment Centers, Inc. Adultt Substance Abuse Treatment Programs 122 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adult Substance Abuse Treatment Programs Agency Director: Jamal F.Wasan, Ph.D. Phone No.: (sos )883 —0922 Contact Person: Corey Causey Phone No.: (808 ) 969 —9292 Mailing Address: Address: P.O.Box 383401 Address: City,ST,Zip Waikoloa, HI 96738 Facility Address: Address: (Corporate)68-1845 Waikoloa Road,Ste.224 B Address: City,ST,Zip Waikoloa.HI 96738 Email Address: causey@ilhawaii.net Fax No.: (aos )969 —7337 Accountant/CPA: Carbonaro CPA&Associates Phone No.: (808 )930 —6850 Firm (if applicable): Carbonaro CPA&Associates Mailing Address: Address:P.O.Box 4372 Address: City,ST,Zip Hilo,HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000 Geographical Areas To Be Served: (One or more can be checked) Puna Hamakua ® North Kona ▪South Hilo ®North Kohala South Kona ® North Hilo ®South Kohala ® Ka`u Services or Activities To Be Provided: (One or more can be checked) Educational concerns ❑Youth ®Victims of Crimes ❑Culture and the arts Aged IZ Victims of Health or Social Crises ®Needs of the poor I1 Physical/Emotional Disabilities ®Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adult Substance Abuse Treatment Programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $13,750 $13,000 $11,453 2.Agency Mission Statement: To provide the highest quality mental health and substance abuse treatment services that are culturally appropriate to Big Island adults,adolescents and children. This mission is accomplished through the use of an integrated approach to treatment utilizing both cognitive-behavioral and existential psychotherapy.This allows the individual to formulate a reason for changing and create strategies to experience emotional,cognitive,and spiritual growth. Our guiding principles are as follows: *We believe in a holistic approach to restore harmony and unity to the individuals,families and communities that we serve. *We believe in the highest level of care,while respecting cultural values. *We believe in outreach and assessment of community needs;and advocacy for the provision of those needs. *We believe in strength-based and client centered treatment with linkages and referralsto other community-based resources for continued recovery. *We believe in a non-judgmental approach with compassion,respect and dignity for all. 3. Program Description: Lokahi Treatment Centers(LTC)Substance Abuse Programs provide comprehensive treatment services for adults at all six(6) of our office locations throughout Hawai'i Island.Treatment services are for individuals that complete a substance use assessment and through this detailed assessment are determined to be in need of treatment services that includes the provision of education to abstain from the use of substances,the development of relapse prevention skills and a treatment plan,individual counseling to address other problematic factors,and case management services.LTC's continuum of care(levels of care) includes:Intensive Outpatient,Low-Intensity Outpatient,Outpatient,Continuing/After Care,and Prevention Programs. Substance abuse has a significant impact on the entire community and creates various difficulties for individuals themselves, family members,children,employers,etc.More so,the safety of our community is impacted when substance abuse is involved; typically a rise in crimes associated with substance use begin to occur more frequently as a result of continuous use without proper treatment interventions.This creates a substantial burden and strain on the criminal justice system,service providers,and emergency medical services.As our jails and prisons become overpopulated due to the incarceration rates of drug offenses,the cost to the public is increasingly overwhelming.LTC has developed programs utilizing evidence-based methods and best practice standards that comply with the Commission on Accreditation of Rehabilitation Facilities(CARF)standards.CARF evaluates rehab facilities'abilities to meet very strict standards that factor into higher success rates for patients.LTC remains committed to providing substance treatment services that integrate mental health treatment to ensure that all clients receive the proper healthcare services to enable clients to reach long-term sobriety. 4.Total Budget&Position Count: Total Program Budget: $1,060,000 Total Program Position Count: 13 Total Agency Budget: $1,093,000 Total Agency Position Count: 21 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adult Substance Abuse Treatment Programs 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate State of Hawaii,Third Circuit Court-Big Island Drug Court $25,000 State of Hawaii, Dept. of Human Services-Substance Abuse Assessment and Monitoring $25,000 Hawai'i Paroling Authority $30,000 County of Hawai'i, Nonprofit Grant Award 40,000 Managed-Care (Third Party Insurance) $805,500 TOTAL: $925,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We are in the process of scheduling meetings with managed care providers,i.e.,HMSA, UHA,etc.to develop incentive programs for Lokahi Treatment Centers to provide enhanced out-patient treatment services targeting opioid use,specifically for and not limited to pregnant women. Opioid use during pregnancy can result in a drug withdrawal syndrome in newborns called neonatal abstinence syndrome,or neonatal opioid withdrawal syndrome(NAS/NOWS),which cases costly hospital stays. An analysis by the National Institute of Drug Abuse(NIDA)showed that an estimated 32,000 babies were born with this syndrome in the United States in 2014,which was more than a 5-fold increase since 2004. NIDA concluded that every 15 minutes,a baby is born suffering from opioid withdrawal.A January 2019 report from NIDA stated that every day,more than 130 people in the United States die after overdosing on opioids. The misuse of and addiction to opioids,including prescription pain relievers, heroin,and synthetic opioids such as fentanyl,is a serious public health crisis here in Hawaii County that affects our social and economic welfare. It has devastating consequences. In the past several months,we have seen a dramatic increase of clients who are addicted to opioids. This grant will help us to maintain the increasing number of participants,while we negotiate payment rates and incentive programs with managed-care providers, We will also continue to recruit volunteers for fundraising activities. LTC is committed to meet the multiple needs of the population we serve. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1.Enhance out-patient treatment plan for opioid use and addiction,which includes a combination of medication management and counseling services. 2. Develop the electronic capacity to gather opioid in-house data to manage the effectiveness of out-patient treatment,and safety; 3.Develop partnerships with organizations,including health care facilities and services,that will help to expand the access and availability of supportive services for out-patient treatment participants so they can pursue healthy,productive,and satisfying goals while gaining the benefits of abstinence and accountability. This becomes a part of the participants'extended treatment plan; 4.Upgrade and/or customize electronic patient-centered case-management software to enable tracking changes on out-patient treatment over time,allowing evaluation of population-level interventions and identification of emerging needs;and 5. Increase the availability and ease of access to out-patient treatment services in Ka'u. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adult Substance Abuse Treatment Programs 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Increase#of participants who remain in treatment for full course of recommended services Increase by 25% Increase after care consultations to reduce recidivism rates Increase by 25%(Determined on case by case) Increase professional development opportunities 4 workshops/staff/year Increase the number of social supports at time of discharge-compared to admission At least 50%of participants Utilization of enhanced web-based data-patient centered case management systems Enhanced Electronic data and tracking system Increase#of surveys to evaluate performance measures based on patient experience Increase by 25% specific to opioid addiction treatment Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wag-s $700,000 $40,000 Professional Fees $30,000 Operations $260,000 Supplies $40,000 Equipment $30,000 Other: Other: Other: Other: Other: TOTAL 1,060,000 $40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adult Substance Abuse Treatment Programs W. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Donna Guerpo POSITION: Human Resources Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ® Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: A strict Conflict of Interest Policy upheld by the organization to avoid any/all potential conflicts of interest that may occur. n If no conflicts exist, check here. D January 29, 2019 Sig ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adult Substance Abuse Treatment Programs 11.Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property,or records pertinent to the grant,contract, or program for which funds were used. 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 receiving our County NonprofitGrantsubmittal,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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report,using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adult Substance Abuse Treatment Programs 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30thshallresult in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I(we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report.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. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. • - • _ January 29, 2019 Signature of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Adult Substance Abuse Treatment Programs 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increase by 25% Increase#of participants who remain in treatment for full course of recommended services by Increase after care consultations to reduce recidivism rates Increase on case by case)case)Determined Increase professional development opportunities 4 workshops/staff/year Increase the number of social supports at time of discharge-compared to admission At least 50%of participants Enhanced Electronic data and Utilization of enhanced web-based data-patient centered case management systems racking system ncrease by 25% Increase#of surveys to evaluate performance measures based on patient experience specific to opioid addiction treatment TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $40,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Lokahi Treatment Centers, Inc. Anger Management Treatment Programs 123 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Anger Management Treatment Programs Agency-Director: Jamal F.Wasan, Ph.D. Phone No.: (808 )883 —0922 Contact Person: Corey Causey Phone No.: (808 ) 969 —9292 Mailing Address: Address: P.O.Box 383401 Address: City,ST,Zip Waikoloa, HI 96738 Facility Address: Address: (Corporate)68-1845 Waikoloa Road,Ste.224 B Address: City,ST,Zip Waikoloa,HI 96738 Email-Address: causey@ilhawaii.net Fax No.: (808 )969 —7337 Accountant/CPA: Carbonaro CPA&Associates Phone No.: (808 )930 —6850 Firm (if applicable): Carbonaro CPA&Associates Mailing Address: Address:P.O.Box 4372 Address: City,ST,Zip Hilo,HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) Puna m Hamakua ® North Kona South Hilo ® North Kohala ®South Kona 121 North Hilo Ic6 South Uhala Ka'u Services or Activities To Be Provided: (One or more can be checked) ILI Educational concerns VI Youth Victims of Crimes 0 Culture and the arts 13,6 Aged ®Victims of Health or Social Crises Needs of the poor Physical/Emotional Disabilities 1211 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Anger Management Treatment Programs 1:Prior Year Award of County Nonprofit.Grant-Program Funds: FY 16-17 FY 17-18 FY 18-19 $9,250 $0 $9,953 2.Agency Mission Statement: To provide the highest quality mental health and substance abuse treatment services that are culturally appropriate to Big Island adults,adolescents and children. This mission is accomplished through the use of an integrated approach to treatment utilizing both cognitive-behavioral and existential psychotherapy.This allows the individual to formulate a reason for changing and create strategies to experience emotional,cognitive,and spiritual growth. Our guiding principles are as follows: *We believe in a holistic approach to restore harmony and unity to-the individuals,families and communities that we serve. *We believe in the highest level of care,while respecting cultural values. *We believe in outreach and assessment of community needs;and advocacy for the provision of those needs. *We believe in strength-based and client centered treatment with linkages and referralsto other community-based resources for continued recovery. *We believe in a non-judgmental approach with compassion,respect and dignity for all. 3. Program Description: Lokahi Treatment Centers Anger Management Program has one primary goal: To help a person decrease the heightened emotional and physiological stressors associated with anger and learn how to control reactions and respond in a socially appropriate manner. To reach this goal,clients learn skills and abilities in the following areas: 1. Identifying and expressing feelings appropriately a. Client takes real and practice"Time-Outs"on a weekly basis. b. Client completes anger journal on a weekly basis. c. Client demonstrates ability to identify physical and behavioral signs of anger. d. Client demonstrates ability to identify and communicate other fellings. 2. Conflict and stress management skills a. Client demonstrates ability to manage emotional stress effectively. b. Client has been free of aggressive behaviors and domestic violence. c. Client can reduce emotional stress through positive self-talk. d. Client is able to teach peers behavioral skills and educational concepts. 3. Recognizing signs and indicators of anger management a. Client is able to recognize minimization,denial,and blaming in self and others. b. Client acknowledges complete responsibility for his/her anger. 4.Total Budget&Position Count: Total Program Budget: $75,000 Total Program Position Count: 6 Total Agency Budget: $1,093,000 Total Agency Position Count: 21 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Anger Management Treatment Programs 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Managed Care(Third Party Insurance) $40,000 County of Hawaii, Nonprofit Grant Contract $20,000 Self- Pay $15,000 TOTAL: $75,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We are in the process of scheduling meetings with managed care providers,i.e.,HMSA,UHA,etc.to develop incentive programs and/or negotiate new rates for Lokahi Treatment Centers to continue to provide Anger Management Treatment services for adults,teens and children. Managed Care reimbursements have not increased and we are seeing our clients struggle to make their co-payments for treatment because of the high cost of living increases here in Hawaii. Some court-ordered individuals without insurance are also struggling to make payments. This grant will help us to maintain the increasing number of participants who need to attend anger management classes, while we negotiate payment rates and incentive programs with managed-care providers. We will also continue to recruit volunteers for fundraising activities. LTC is committed to meet the multiple needs of the population we serve. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1.Upgrade Therascribe software to include tools for treatment planning interventions that are specifically focused on the needs of the individual;to include pre and post-test measures. 2. Develop curriculum for adolescents that will help them implement calming strategies as part of a new way to manage confrontations with peers,as evidenced by eliminating physical aggression at school. 3. LTC will provide outreach at community events as well as coordinate and facilitate in-services at community partner agencies in order to share treatment service information. 4.Increase the availability and ease of access to Anger Management Intervention Treatment Services in Ka'u. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Anger Management Treatment Programs 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Increase#of adolescents enrolled into anger management treatment Increase by 25%- adolescents/year Increase#of social supports during treatment&at the time of discharge Increase by 25% Increase#of participants who remain in treatment for full course of recommended services Increase by 25% Staff training/workshops on anger management 4 workshops/web-based training Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $50,000 $20,000 Professional Fees $5,000 • Operations $10,000 Supplies $5,000 Equipment $5,000 Other: Other: Other: Other: Other: TOTAL $75,000 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Anger Management Treatment Programs 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Donna Guerpo POSITION: Human Resources Officer May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): • Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director n The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: A strict.Conflict of Interest.Policy upheld by the organizationtoavoid any/allpotential conflicts of interest thatmay occur. n If no conflicts exist, check here. January 29, 2019 Sign ture of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Anger Management Treatment Programs ii. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report,using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Anger Management Treatment Programs 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. s January 29, 2019 Sig a ure of Authorized Person (see checklist, 2nd item) Date CEO Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Anger Management Treatment Programs 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increase by 25%- Increase#of adolescents enrolled into anger management treatment adolescents/year Increase#of social supports during treatment&at the time of discharge Increase by 25% Increase#of participants who remain in treatment for full course of recommended services Increase by 25% 4 workshops/web-based Staff training/workshops on anger management training s TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $20,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Lokahi Treatment Centers, Inc. Domestic Violence Intervention Treatment Programs 124 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Domestic Violence Intervention Treatment Programs Agency Director: Jamal F.Wasan, Ph.D. Phone No.: (808 )883 —0922 Contact Person: Corey Causey Phone No.: (808 ) 969 —,9292 Mailing Address: Address: P.O.Box 383401 Address: City,ST,Zip Waikoloa, HI 96738 Facility Address: Address: (Corporate)68-1845 Waikoloa Road,Ste.224 B Address: City,ST,Zip Waikoloa,HI 96738 Email Address: causey@ilhawaii.net Fax No.: (808 )969 —7337 Accountant/CPA: Carbonaro CPA&Associates Phone No.: (808 )930 —6850 Firm (if applicable): Carbonaro CPA&Associates Mailing Address: Address:P.O.Box 4372 Address: City,ST,Zip Hilo,HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $28,000 Geographical Areas To Be Served: (One or more can be checked) ®Puna Hamakua ® North Kona ▪South Hilo VI North Kohala ®South Kona ® North Hilo ®South Kohala ® Ka'u Services or Activities To Be Provided: (One or more can be checked) Educational concerns ®Youth IZIVictims of Crimes Culture and the arts ®Aged 123 Victims of Health or Social Crises 21 Needs of the poor Physical/Emotional Disabilities 171 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County. of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Domestic Violence Intervention Treatment Programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $9,250 $10,000 $10,954.75 2.Agency Mission Statement: To provide the highest quality mental health and substance abuse treatment services that are culturally appropriate to Big Island adults,adolescents and children. This mission is accomplished through the use of an integrated approach to treatment utilizing both cognitive-behavioral and existential psychotherapy.This allows the individual to formulate a reason for changing and create strategies to experience emotional,cognitive,and spiritual growth. Our guiding principles are as follows: *We believe in a holistic approach to restore harmony and unity to the individuals,families and communities that we serve. *We believe in the highest level of care,while respecting cultural values. *We believe in outreach and assessment of community needs;and advocacy for the provision of those needs. *We believe in strength-based and client centered treatment with linkages and referralsto other community-based resources for continued recovery. *We believe in a non judgmental approach with compassion,respect and dignity for all. 3. Program Description: Lokahi Treament Centers(LTC) Domestic Violence Intervention(DVI)programs focuses on evidence-based,cognitive behavioral DVI services for adjudicated adult offenders,to include linkages with additional supportive services that may be provided by other community providers.The DVI program is available to adults at all six(6)office facilities operated by LTC throughout Hawaii Island.In the last fiscal year,there has been a consistent increase in the amount of adult offenders who are referred to seek domestic violence treatment services;which prompted LTC to expand access to services to all locations. The DVI program services provide offenders with the knowledge and skills necessary to prevent further battering,including cognitive-behavioral skills training to strengthen their ability to make different behavioral choices and accept responsibility (accountability)for their unacceptable actions.LTC's overall program objective is to build thorough case plans focused on criminogenic needs and dynamic risk factors aimed at reducing recidivism so that all clients are able to successfully complete the program and go on to lead healthier lives free from re-offending. Domestic violence is one of the most serious social problems nationally and in Hawaii,not only for the immediate victim,but also for children. 4.Total Budget&Position Count: Total Program Budget: $148,000 Total Program Position Count: 6 Total Agency Budget: $1,093,000 Total Agency Position Count: 21 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Domestic Violence Intervention Treatment Programs 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Managed Care(Third Party Insurance) $100,000 County of Hawaii, Nonprofit Grant Contract $28,000 Adult Probation Services-State of Hawaii $20,000 TOTAL: $148,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We are in the process of scheduling meetings with managed care providers,i.e.,HMSA,UHA,etc.to develop incentive programs and/or negotiate new rates for Lokahi Treatment Centers to continue to provide Domestic Violence Intervention treatment. Manage Care reimbursements have not increased and we are seeing our clients struggle to make their co-payments for treatment because of the high cost of living here in Hawai'i. Costs keep rising and income rates cannot keep up with it. This grant will help us to maintain the increasing number of participants,while we negotiate payment rates and incentive programs with managed-care providers, We will also continue to recruit volunteers for fundraising activities. LTC is committed to meet the multiple needs of the population we serve. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1.Provide immediate access to all individuals who are assessed and diagnosed as needing domestic violence intervention treatment services. 2.Increase the availability of domestic violence intervention treatment services to individuals that need treatment. 3.Identify and strengthen the availability of community linkages that support continuity of treatment.This will lead an increase of social support networks that will enable individuals receiving treatment services to achieve long-term healthy behaviors,thus decreasing recidivism and increasing public safety. 4.Increase the availability and ease of access to Domestic Violence Intervention Treatment Services in Ka'u. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Domestic Violence Intervention Treatment Programs 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (Le.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Increase treatment service units Increase by 25%=200 units/year Increase after care consultations to reduce recidivism rates Increase by 25% Increase#of participants who remain in treatment for full course of recommended services Increase by 25% Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $100,000 $28,000 Professional Fees $10,000 Operations $20,000 Supplies $10,000 Equipment $8,000 Other: Other: Other: Other: Other: TOTAL $148,000 $28,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Domestic Violence Intervention Treatment Programs W. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. NAME: Donna Guerpo POSITION: Human Resources Officer May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ▪ Member or members of the Council ❑ Staff appointed by a member of the Council O The Mayor ❑ The Managing Director n The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: A strict Conflict of Interest Policy upheld by the organization to avoid any/all potential conflicts of interest that may occur. n If no conflicts exist, check here. • r January 29, 2019 Sig'ture of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Domestic Violence Intervention Treatment Programs 11.Certification of Understanding (Page 1 of 2) 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—2442.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov,complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report,using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Domestic Violence Intervention Treatment Programs 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we)understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. January 29, 2019 Signature of Authorized Person (see checklist, 2nd item) Date C5.o Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Lokahi Treatment Centers, Inc. Program Name: Domestic Violence Intervention Treatment Programs 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Increase by 25%=200 Increase treatment service units units/year Increase after care consultations to reduce recidivism rates Increase by 25% Increase#of participants who remain in treatment for full course of recommended services Increase by 25% s TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $28,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $28,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Mental Health Kokua Residental Rehabilitation Services 125 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services Agency Director: Greg Payton Phone No.: (808) 737 - 2523 Contact Person: Julie Agno Phone No.: (808) 769 - 5725 Mailing Address: Address: Mental Health Kokua Address: 1221 Kapiolani Blvd.,Ste 345 City,ST,Zip Honolulu, HI 96814 Facility Address: Address: Mental Health Kokua Address: 208 Wainaku Avenue City,ST,Zip Hilo, HI 96720 Email Address: gpayton@mhkhawaii.org,jagno@mhkhawaii.org Fax No.: (808 ) 734 - 1208 Accountant/CPA: Summer B. Uwono,CPA Phone No.: (808 ) 737 - 2523 Firm (if applicable): N/A Mailing Address: Address: Mental Health Kokua Address: 1221 Kapiolani Blvd.,Ste 345 City,ST,Zip Honolulu, HI 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ✓❑ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ✓❑South Kohala ❑✓ Kali Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ✓❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 Countyof Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $5,875 $6,750 $6,675 2.Agency Mission Statement: The Mission of Mental Health Kokua(MHK)is to assist people with mental health and related challenges to achieve optimum recovery and functioning in the community. MHK provides housing,case management,and outpatient services on behalf of Hawaii citizens,and those with major mental illness and co-occurring conditions,since 1973. 3. Program Description: Our Residential Rehabilitation Services program provides community based housing to adults recovering from severe mental illness.The goal is to enable the consumer to move on to more independent living.Staff provide daily living skills training while facilitating educational,social,and recreational activities as well as linkage to community resources and assistance in finding long-term community placement. 4.Total Budget& Position Count: Total Program Budget: 1,745,000 Total Program Position Count: 36 Total Agency Budget: 12,312,945 Total Agency Position Count: 276 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii 10,000 State of Hawaii—DOH 1,433,611 United Way 15,000 Program Service Fees 175,000 Private Insurance—Case Mgmt 550,000 TOTAL: 2,183,611 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Ongoing,agency wide efforts are being made and will continue to be made to pursue additional grant funding from trusts and foundations such as the Harry and Jeanette Weinberg Foundation,G.N.Wilcox,the BOH Charitable Foundation and the Visitor Industry Charity Walk. In addition,fund raising events are held to support our program and the population we serve. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1)Provide residential services to 140 unduplicated consumers.2)Limit psychiatric hospitalization to less than 3%.3)At least 95%of consumers served are satisfied with services received.4)Improvement in daily living skill scores upon discharge.5) Discharge to more independent housing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of unduplicated consumers served 140 %consumers requiring psych hospitalization Less than 3% % discharged to more independent living 75% %of consumers satisfied with services 95% Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 1,668,554 1,718,611 Professional Fees 55,000 60,000 335 002 350 000 Operations Supplies 45,000 55,000 Equipment 10,000 Other: Other: Other: Other: Other: TOTAL 2,103,556 2,183,611 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. 1/17/2019 Signature of Authorized P rson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai`i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grantparticipation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1/17/2019 - Signature of Authorized Person (see checklist, 2nd item) Date Chief Executive Officer Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of unduplicated consumers served 140 %consumers requiring psych hospitalization Less than 3% % discharged to more independent living 75% %of consumers satisfied with services 95i TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees Operations Supplies Equipment 10,000 Other: Other: Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Na Kalai Wa`a Hoea Moku 126 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Agency Director: Keomailani Case Phone No.: ($oa) 665 — 959i) Contact Person: Keomailani Case Phone No.: (g) 997 - 8709 Mailing Address: Address: 65-1206 Mamalahoa Hwy.Ste 1-101 Address: City,ST,Zip Kamuela,Hi 96743 Facility Address: Address: 65-1206 Mamalahoa Hwy Address: City,ST,Zip Kamuela,Hi 96743 Email Address: wdkeomailanic@gmail.com Fax No.: ( qs) $87 — 1ret4 Accountant/CPA: Ron Dolan CPA and Associates Phone No.: (sob) 935 — 5433 Firm (if applicable): Ron Dolan CPA and Associates Mailing Address: Address: 16 Railroad Ave#A Address: City,ST,Zip Hilo, Hi 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) El Puna Q✓ Hamakua 0 North Kona 11 South Hilo Q✓ North Kohala ❑✓ South Kona [�North Hilo Q South Kohala ❑Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓0 Educational concerns El Youth ❑Victims of Crimes Culture and the arts [J Aged 0 Victims of Health or Social Crises ❑Needs of the poor 0 Physical/Emotional Disabilities []Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Na Kalai wa'a Program Name: Hoea Moku 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 $36,500 $23,164 2.Agency Mission Statement: The mission of Na Kalai Waa(NKW)is to protect,perpetuate and honor the indigenous Hawaiian traditions and practices of wa'a(canoe)culture through the Makali'i voyaging canoe programs,for the past,present,and future generations. Na Kalai Wa'a(NKW),is a 501(c)3 non-profit organization,established in 1995 and dedicated to the continued practice of Hawaiian sailing canoe traditions. Mauloa,a single hulled coastal canoe was the first wa'a built in 1993 through traditional methods and with traditional materials. In 1995, Makalr i,a 54 foot double hulled voyaging canoe was completed,launched and sailed to Tahiti on its maiden voyage. These wa'a provide vessesl for educational and cultural experiences in Hawaii Island communities,firmly instilling a sense of kuleana to each other and to our Earth.Built upon this foundation,Na Kalai Wa'a continues to provide activities and programs designed to support community involvement while maintaining the seaworthy integrity of Makali i, Mauloa and the vessels in the Na Kalai Wa'a family. 3. Program Description: Before the introduction of modern tools and materials,building a canoe in Hawaii was a process that required an in-depth knowledge of environmental resources,of cultural values,and of protocols,customs,and rituals. Therefore canoe building was one of the most prestigious occupations during ancient times because it required an immense amount of knowledge and dedication to complete the canoe. It was said that if you possessed a canoe,but did not have the knowledge to build one,then. you simply have a finite resource that could one day be gone. Having the knowledge of canoe building tells you which plants to use,which methods to employ,which tools to use at each stage of building,and also what to listen for in order to find the right tree for your wa'a. In the early 1990's a number of Hawaiian men asked for just this knowledge,as they desired to build a canoe and to learn this valuable skill in order to be called kalai wa'a(canoe builders)and to ultimately share their gained knowledge with future generations. It was through the guidance and teachings of Master Navigator Mau Piailug that these men experienced every step of the process and built the 5-man coastal canoe Mauloa,using only traditional tools and traditional methods. In looking for the tree that would be used to build the canoe Mauloa,these men realized that the forest area was in a poor state and they became very concerned with the state of our island environment. This was their ultimate reality then and continues to be a focus of concern for Na Kalai Wa'a today. At Hoea Moku,therefore,we focus on the cultivation of canoe gardens,gardens that sustain some of the canoe plants that support our wa'a traditions today. These are the la'au wa'a,they are plants that were important in the building of Mauloa back in 1993 and continue to be important to the continued practice of canoe building. Most especially they are the plants used for cordage,like olona,a nearly extinct endemic plant that is know for its strength and endurance and niu(coconut fiber),used to make sennit rope for lashing and rigging the canoe. 'Ulu is another of the plants grown at Hoea and used for caulking and a sealant on the canoe. The kukui groves at Hoea will be used for making the dye for the canoe. 4.Total Budget&Position Count: Total Program Budget: '119,694 Total Program Position Count: 1 Total Agency Budget: 933,054 Total Agency Position Count: 15 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Na Kalai Wa`a Program Name: Hoea Moku 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate NKW Sanaral Rind RR 747 In-kinri (Pwn MactAr Navinatnrl 15 nnn ANA- Hanauna Ola Project(Current Federal Grant( 2.750 ANA-Mauloa Project(oendina 2019 Grant application) 21.500 TOTAL: 75,997 Attach additional pages,if needed, 6. Explain what plans your agency or program has to increase revenues to support this program: Na Kalai Wa'a program fees are accessed for school visits that have a budget for school excursions. Fees are based on the length and number of Hoea Moku activities offered. As the canoe gardens continue to flourish,it is the intent of Na Kalai Wa'a to sell products that can be made from the plants on the property. Bundles of lauhala for weaving,kukui nuts for products such as inamona(a relish used in many Hawaiian dishes), and kukui nut oil can also be produced and sold. In the future Na Kalai Wa'a wuld like to hold learning workshops where thoes who have mastered the practices described in this grant proposal can teach others these traditional skills. We would be able to charge a nominal fee for the workshops,which is another way to bring in revenue for this program 7. Program Objectives Using County Nonprofit Grant Program Funds: The goal of the Hoea Moku Canoe garden program is to provide opportunities for our Hawaii Island communities to learn and perpetuate the traditional practices that support canoe traditions through the following objectives: a.engage participants in the process of uluna lauhala(utilizing the hala groves at Hoea Moku)in order to produce a hala sail for the traditional canoe Mauloa b.engage participants in the process of pilina kaula(utilizing the olona and niu plants grown at Hoea Moku)in order to produce cordage for the traditional canoe Mauloa c.engage participants in the process of kalai wa`a(utilizing the'ulu and kukui plants grown at Hoea Moku)in order to produce caulking and dye for the traditional canoe Mauloa EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 1 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Na Kalai Wa`a Program Name: Hoea Moku 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific) Students that will oarticipaote in activities that support.the Hoea canoe gardens 150 Cordage workshops that utilize cordage plants from Hoea Moku Canoe gardens 5 Lauhala weavina workshops that utilize hala plants from Hoea Moku Canoe gardens 5 School visits conducted at Hoea Moku to teach the importance of caring for canoe resourcE 8 Community participants trained canoe building,cordage making,and hala weaving ao Olona(endangeredendemic cordage plant)plants propogated 30 Olona(endangered endemic cordage plant)harvested and processed to produce cordage 50 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 48,280 50,360 17,680 Professional Fees 7,654 8,134 4,067 Operations 12,000 12,000 0 Suppliec w_. 14,186 20,000 10,500 4,500 2,500 2,500 Equipment Other: Rpstnratinn Wnrk(Mai.ilo4) 0 12,000 3,000 Other: Utilities (Water) 1,161 2,200 2,200 Other: Stinends for Cultural nractitinners /teachers 3,000 12,000 3,750 Other: Other: TOTAL 90,781 119,694 43,697 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): O Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid,in fact or appearance,any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. l' ,014/tt4,;()&4AA' Clew__ Executive Director January 30, 2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Na.Kalai Wa'a Program Name: Hoea Moku 11.Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative, or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the reauirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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 timed complete,an accurate year-end report, usina the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I(we)understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. ttn/ January 30, 2019 Signature of Authorized Person(see checklist,2nd item) Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Students that will participate i activities that sunnort the Hoea canoe aardens 150 Cordaae workshops that utilize cordaae plants from the Hoea Moku canoe aardens Lauhala weaving workshoops that utilize the hala plants from the Hoea Moku canoe garde! 5 School visits at Hoea Moku that teach the importance of caring for canoe resources 8 Community participants trained in canoe building,cordage making,and hala weaving 4° Olona(endangered endemic cordaae plant)plants or000aated 3° Olona(endangered endemic cordage plant)harvested and processed to produce cordage 50 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 17,680 Professional Fees 4,067 Operations 0 Supplies 10,500 Equipment 2,500 Other: Restoration Work (Mcw loa ) 3,000 Other: Utilities(Water) 2,200 Other: Stipends for Cultural practitioners/teachers 3,750 Other: Other: TOTAL 43,697 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 County of Hawaii Nonprofit Grant Application FY 2019-20 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku #3 Program Description (continued from page 2) The direction for Hoea Moku is to focus on the restoration of our very first canoe Mauloa using the resources that continue to be cultivated in the canoe gardens there and by doing so,to support a cohort of 10 trainees each who will participate in the training of kalai wa'a (canoe building), ulana lauhala (lauhala weaving),and pilina kaula(cordage making),with a total number of 30 trainees. Hoea Moku will also provide activities for schools that visit the property in order to learn about the specific plants that are used on the canoe. This is also an opportunity to teach students about resource management and malama`aina (caring for the land). Hoea Moku Canoe gardens are the perfect model of responsibly caring for the land and in doing so providing learning opportunities that directly support the continuation of our important canoe traditions. Neighborhood Place of Puna Family Strengthening, Support, and Outreach Program 127 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening, Support, and Outreach Program Agency Director: Paul Normann Phone No.: (808) 965 — 5550 Contact Person: Paul Normann Phone No.: (808) 965 — 5550 Mailing Address: Address: 16-105 Opukahaia St. Address: City,ST,Zip Keaau, HI 96749 Facility Address: Address: 16-105 Opukahaia St. Address: City,ST,Zip Keaau, HI 96749 Email Address: paul@neighborhoodplace.org Fax No.: (808 ) 965 — 5109 Accountant/CPA: Doug Vincent. Phone No.: (808) 930 — 6850 Firm (if applicable): Carbonaro CPAs&Management Group Mailing Address: Address:.136 Kinoole St. Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening, Support, and Outreach Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $25,500 $21,750 $16,425 2. Agency Mission Statement: The goal of Neighborhood Place of Puna is to prevent child abuse and neglect by ensuring that families have access to the resources and skills they need to raise safe and healthy children. NPP's Mission:"Empowering families and communities in Puna by building strong foundations through healthy relationships that value each person's uniqueness. E malama pono kakou." 3. Program Description: Child abuse and neglect can have lifelong impacts on the health,well-being, and success of children. Hawaii County has the highest rates, per capita,of child abuse and neglect in the State.The majority of incidents of child-maltreatment occur in Puna and South Hilo. Neighborhood Place of Puna serves families in Puna and South Hilo.We are one of the very few child abuse and neglect prevention programs that provides voluntary and free,on-going,weekly, in-home,supportive case management,and family strengthening services within the context of a developmentally appropriate parenting curriculum. Neighborhood Place of Puna is the only program that provides these services to families with older minor children(youths)in addition to families with children five years of age or younger. Home visiting programs like our Family Strengthening,Outreach,and Support program,which provides ongoing in-home services,are some of the most effective at preventing child abuse and neglect. Using an evidence based model,our program focuses on teach developmentally appropriate parenting and ensuring that the Protective Factors in the home. Research continues to show that when present in the home,the Protective Factors reduce the risk for child maltreatment and promotes the healthy development and well-being of children. 4. Total Budget& Position Count: Total Program Budget: 275,800.00 Total Program Position Count: 4 Total Agency Budget: 310,000.00 Total Agency Position Count: 4.5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 1 . Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening, Support, and Outreach Program 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Blueprint for Change(State DHS funding) 153,000.00 Hawaii Children's Trust Fund 50,000.00 Private Foundation Grants 30,000.00 County of Hawaii 25,000.00 Donations 17,800.00 TOTAL: 275,800.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Neighborhood Place of Puna is a successful child abuse and neglect prevention program serving a community that lacks many resources, has a high level poverty,and some of the highest rates of child abuse and neglect, per capita, in the state. Based on ALICE data for Hawaii County,we know that families on our Island--especially singled parent families--experience extremely high rates of poverty,even when they are employed. Neighborhood Place of Puna aggressively seeks diverse funding to support this program. Unfortunately, intensive,ongoing, in-home, prevention programs,while vital in the prevention of child abuse and neglect,are some of the hardest programs to sustain financially. Over half of our budget for this program comes from government sources.The remaining funding for the program comes from foundations, HIUW, and donors. Each year our program helps between•50 and 70 families who are at risks for child maltreatment. If our program prevents just one incident of child abuse and neglect a year,it practically pays for itself by keeping one family out of the child welfare system and preventing the traumatic and lifelong negative impacts that occur when a child is abused and/or neglected. 7. Program Objectives Using County Nonprofit Grant Program Funds: The primary objective of the Family Strengthening,Support,and Outreach program is to prevent child abuse and neglect in Puna and South Hilo through providing ongoing weekly in-home, prevention and family strengthening services to families with underage children who have some risk for child maltreatment. We determine risk for child abuse and neglect through a variety of assessment tools.Some of these assessments are surveys which are administered in a pre and post format to help measure the effectiveness of program elements in reducing the risk for child maltreatment. Our program addresses and seeks to minimize identified risks,while helping families develop their strengths.Our primary focus is on supporting families in creating a safe and nurturing home environment through developmentally appropriate parenting. However,we also help parents and families address concrete needs such as housing stabilization,accessing healthcare, connecting to essential resources,and ensuring that children,when age appropriate, are attending school. The long-term objective is to reduce the incidents of child abuse and neglect in the County. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 • County of Hawai`i Nonprofit Grant.Application FY2019-20 Agency Name: Neighborhood Place of Puna, Program Name: Family Strengthening, Support, and Outreach Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (Le.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Ongoing, intensive, in-home visits and case-mangagment 50 families Family Safety Assessment and development of Service Plan to address risks 50 families Families will successfully complete service plan 80%of families • Exit assessment surveys will show improvement(reduction of risk for child abuse) , 85%of families Families will remain free of child abuse and Neglect while in the program 85%of families Families will be free of child abuse and Neglect 6 months from completion of service plan 85%of families Attach additional pages as necessary.• • 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary andUVages 214,960.00 215,000.00 25,000.00 Professional Fees 10,250.00 15,800.00 Operations 44,074.00 35,000.00 Supplies 11,000.00 10,000.00 Equipment Other: Other: Other: Other: • Other: TOTAL 280,284.00 275,800.00 25,000.00 *If applicable • • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening, Support, and Outreach Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Paul Normann POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council n The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist,check here. ENgli I lady r q1/4 Signatu of Authorized = •- I y title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening, Support, and Outreach Program 11. Certification of Understanding.(Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening; Support, and Outreach Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. Signat re of Authorized Person (see checklist, 2nd item} Date CO 6 or- Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION " FY 2019-2020 Page 7 of 8 County of Hawai`.i Nonprofit Grant Application FY2019-20 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening, Support, and Outreach Program 12. COUNCIL AWARD.WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 50 families 50 families 80%of families 85%of families 85%of families 85%of families TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 25,000.00 Professional Fees Operations Supplies Equipment Other: • Other: Other: Other: Other: TOTAL 25,000.00 Additional Council directives regarding award: • EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 North Kohala Community Resource Center Ho'ola Honey Bee Relocation 128 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: North Kohala Community Resource Center Program Name: Ho`ola Honey Bee Relocation Agency Director: Christine Richardson Phone No.: (808) 889 — 5523 Contact Person: Leslie Nugent Phone No.: (808) 889 — 5527 Mailing Address: Address: PO Box 519 Address: City,ST,Zip Hawi, HI 96719 Facility Address: Address: 55-3393 Akoni Pule Hwy Address: City,ST,Zip Hawi, HI 96719 Email Address: info@northkohala.org Fax No.: (808 ) 889 — 5527 Accountant/CPA: Alida Adamek Phone No.: (808) 889 — 5523 Firm (if applicable): Mailing Address: Address: PO Box 519 Address: City,ST,Zip Hawi, HI 96719 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $8,700 • Geographical Areas To Be Served: (One or more can be checked) ❑ Puna Hamakua V North Kona ❑South Hilo V North Kohala ❑South Kona V North Hilo VI South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities V Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: North Kohala Community Resource Center Program Name: Ho`ola Honey Bee Relocation 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $7600 2.Agency Mission Statement: - North Kohala Community Resource Center(NKCRC), is a 15-year-old, 501(c)3 non-profit serving the district of North Kohala, on the northern tip of the Big Island. Our mission is to increase the number of successful community improvement projects that benefit the people of North Kohala.We do this by providing education, a.fiscal umbrella, and bridges to funding, along with coaching and support for a wide range of community efforts. Currently we sponsor 85 projects that include youth,sports,senior, arts, education, equine,cultural,agricultural and land preservation programs. NKCRC has been the fiscal sponsor for Ho'ola Honey Bee Relocation since 2016. The Ho'ola Honey Bee Relocation project was organized in 2016 with a mission to save honey bees and support Hawai'i's • natural environment and agricultural community. Run by a knowledgeable duo with years of beekeeping and carpentry experience,the project aims to decrease the number of honey bee colonies killed each year by improper pesticide use and ensure safe and healthy conditions for all. Ho'ola Honey Bee Relocation offers live bee removal and relocation services, preventing millions of honey bees from illegal extermination yearly in unwanted places such as homes,schools, and public areas. The project also encourages responsible pollinator protection practices in the greater community through educational and outreach programs. Honey bees are vital to a local,sustainable food system as key pollinators of our food resources. In fact, Hawai'i's bee • pollinated produce is valued at$212 million dollars statewide annually. However, honey bees are threatened by pests, • diseases, and..pesticides causing considerable colony loss in the past decade in Hawaii(source: Hawaii Apiary Program). 3. Program Description: Ho'ola Honey Bee Relocation program provides free and prompt swarm catching services in the North and South Kohala districts,as well as live structural removal and relocation services throughout the Northern half of Hawaii Island at sliding scale fees based on need for established colonies that have never been sprayed or poisoned. In the last two years,the Ho'ola Honey Bee Relocation project received an average of 70 bee removal inquiries per year from across the island, including referrals from the Hawaii Department of Agriculture's Apiary Program, pest control companies, and State of Hawai'i Vector Control. Since the program began,73 colonies have been successfully rescued from extermination on Hawaii Island,with 60%of those removals performed voluntarily at no cost or reduced price with sliding scale fees based on need. Depending on variables, each structural bee removal costs an average of$800 and includes materials, fuel, and 20 plus hours of labor in addition to bi-monthly monitoring of hives with some colonies taking up to a year or longer to reach a healthy • state. Since pest control companies are not licensed to treat honey bees, many property owners who cannot afford the full cost of a live removal attempt extermination with generic pesticide spray. Not only is off label pesticide use illegal, it has significant and detrimental effects on human health as well as hive health. Often times,spraying poison does not kill the entire bee colony, lead ing to more defensive bees,dangerous situations, and a more expensive and difficult removal. Poisoned colonies are also more susceptible to pests and diseases which can easily spread to other hives in the area, affecting not only Hawai'i's honey bee population as a whole, but the livelihood of beekeepers,farmers, and local businesses on the island. The second focus of the program is an education and outreach campaign to raise awareness and ensure the future health of our bees in Hawai'i. Honey bee pests and diseases can be managed by responsible beekeeping methods, however harmful pesticides and human ignorance continue to be a major threat to pollinators.With the use of a live observation hive at in-school nroeon+o+innc nnrl rnmm,Inib,even+c I-In'nlo knokoanerc ehnro+1-in rn inial rnlo+ho+hnnov Ianna f,dfill in a,,r envirnnmen+ a 4.Total Budget& Position Count: Total Program Budget: $39730 Total Program Position Count: 1 FT/1 PT Total Agency Budget: $210,050 Total Agency Position Count: 1 FT/2 PT EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: North Kohala Community Resource Center Program Name: Ho'ola Honey Bee Relocation 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Sliding scale fees based on need for live structural bee removals (average$600 per removal/® 15030 Fundraising ($400/month) 4800 Grants 19000 Cash and in-kind donations 900 TOTAL: 39730 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The project aims to increase revenues through fundraising with monthly sales of honey harvested from rescued hives at the Waimea Mid Week farmers market. Fundraising efforts will also increase publicity and support of the project within the community and beyond Hawai'i with the hopes of attracting new donors gifting monetary support as well as in kind donations. The project will also be reaching out for monetary support from other foundations, local Hawai'i companies and corporations with interests in Hawai'i agriculture and protecting our pollinators.We will continue to work with County, State, and Federal organizations and other high end corporations by providing bee removal services and hope to expand our contacts within these systems and grow our credibility with these larger companies that have the capacity to pay total costs for live bee removals. • • 7. Program Objectives Using County Nonprofit Grant Program Funds: County funds will be used by the Ho'ola Honey Bee Relocation project to meet the following objectives: 1)Successfully complete 24 live honey bee removals including relocations of swarms and established colonies.These services will be provided to community members at reduced price with sliding scale fees based on reasonable financial need. 2)Conduct 6 in school/community presentations, reaching a total of 250 K-12 students. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: North Kohala Community Resource Center Program Name: Ho`ola Honey Bee Relocation 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of hives successfully relocated 24 hives successfully relocated Number of in school presentations 6 in-school presentations Number of K-12 students reached 250 students served Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req • Salary and Wages Labor 24000 19800 4800 Professional Fees Fiscal sponsorshipfee,8%ofgrantsanddonations 652 1535 696 Operations Website fees,fuel,utilities,insurance 9972 9610 3204 Supplies Apiary,tools,office supplies,protective equipment 3043 4410 0 Equipment waxmelter,storage 2000 1375 0 Other: Machine work for apiary prep 1000 3000 0 Other: Other: Other: Other: TOTAL 40667 39730 8700 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: North Kohala Community Resource Center Program Name: Ho`ola Honey Bee Relocation 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Christine Richardson POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. (- 24-- I Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: North Kohala Community Resource Center Program Name: Ho`ola Honey Bee Relocation ii. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: North Kohala Community Resource Center Program Name: Ho`ola Honey Bee Relocation ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from • future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. • I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. • Signature of Authorized Person (see checklist, 2nd item) Date `6D--2 • Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: North Kohala Community Resource Center Program Name: Ho`Ola Honey Bee Relocation 12. COUNCIL AWARD WORKSHEET • TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 24 hives successfully relocate d 6 in-school presentations 250 students served TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 4800 Professional Fees 696 Operations 3204 Supplies 0 Equipment 0 Other: Machine work for apiary prep 0 Other: Other: Other: Other: TOTAL 8700 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 North Kohala Community Resource Center Kohala Radio 129 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: North Kohala Community Resource Center Program Name: Kohala Radio Agency Director: Christine Richardson Phone No.: (808) 889 — 5523 Contact Person: Leslie Nugent Phone No.: (808) 889 — 5523 Mailing Address: Address: P.O.Box 519 Address: City,ST,Zip Hawi, HI 96719 Facility Address: Address: P.O. Box 519 Address: City,ST,Zip Hawi, HI 96719 Email Address: leslie@northkohala.org Fax No.: (808.) 889 — 5527 Accountant/CPA: Alida adamek Phone No.: (808 ) 889 — 5523 Firm (if applicable): Mailing Address: Address: P.O.Box 519 Address: City,ST,Zip Hawi, HI 96719 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $9,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑✓ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ✓❑Youth ❑Victims of Crimes ❑✓ Culture and the arts ✓❑Aged ❑✓ Victims of Health or Social Crises - ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: North Kohala Community Resource Center Program Name: Kohala Radio 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $5,750 2.Agency Mission Statement: The North Kohala Community Resource Center(NKCRC)is a seventeen year old non-profit based in North Kohala.Their mission is to increase the number of successful community improvement projects in North Kohala. NKCRC has successfully provided fiscal sponsorship,education and training for over 180 community improvement projects since they began in 2002. They serve as the fiscal sponsor for Kohala Radio.The mission of Kohala Radio is to operate a financially sustainable, low power,non-commercial FM radio station serving the North Kohala community.The Radio's fundamental purpose is to build community through an emphasis on inclusiveness and broad participation while providing programming with a local focus. 3. Program Description: Kohala Radio, KNKR LP 96.1 FM, is an all volunteer community radio station exclusively serving the North Kohala community of 6,500 residents since July 3,2015.Our 35 volunteers represent a broad spectrum of our diverse community and we broadcast in both English,on occasion Philippine,and Pidgin.We have a full 7 am to 10 pm schedule Sunday through Saturday.We also have partnerships with the public schools in the community and provide an excellent platform for interns and students of all ages.Over 200 students have worked in our station and recorded public service announcements and other messages. In March of 2018 two high school seniors became the first certified Operators who were on the air two hours a week for four months after a concentrated five month training program.Also in 2018 we revised our Training Program to allow for more on-line study and a faster completion time which is much appreciated by our trainees. Our telephone random survey of a cross section of 346 residents in late 2016 showed that 72%listen to radio,and of that audience,75%listen to KNKR.This equates to a listening audience of 3,510 residents.We are confident that this audience has grown over the last several years.We provide local news and, most importantly,emergency broadcasting in collaboration with the State and County Departments of Civil Defense. In the last three years we have broadcast over 700 Emergency Alerts to our community.We operate with a Core Group of eight of our volunteers,four women and four men,who meet regularly to make decisions as needed. We are a Hawaii Domestic Nonprofit and a sponsored project of the North Kohala Community Resource Center.Although we are all volunteers who are not paid,our ongoing annual expense to stay on the air has averaged approximately$44,000 a year. In 2018 we managed to reduce these costs so that our current budget for fiscal year 2019-2020 is$40,379. 4.Total Budget& Position Count: Total Program Budget: $40,379 Total Program Position Count: 0 Total Agency Budget: 210,050 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: North Kohala Community Resource Center Program Name: Kohala Radio 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Donations $20,000 Operating Grants $11,000 Underwriting $6,000 TOTAL: $37,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In addition to our request of the County for funds in this application,we expect continued support from our local donors and additional donors as our broadcast hours and listener base increase.We are also requesting support from the State of Hawaii through our Senator who helped with major funding in 2017.We are looking fora volunteer who can ramp up our Underwriting during this fiscal year by talking with West Hawaii businesses with an aim to significantly increase the$6,000 we achieved in 2018, 7. Program Objectives Using County Nonprofit Grant Program Funds: Key objectives in 2019-2020: 1. Using our new Volunteer Training Program,continue to increase the attractiveness of our on air shows to gain listener support 2.Continue to increase the number of volunteer broadcasters 3.Continue to increase the number of student interns trained at the station who will attract additional student listeners . 4. Increase our underwriting subscriptions 5.Gain major financial support from the State of Hawaii in 2019 6. Perhaps most importantly,with the El Nino weather predicted in 2019,we expect more hurricanes with higher winds than we have seen in the past, probably more impact on the Kohala coast than we have ever seen, and increased shore line erosion,all of which means that Kohala Radio must be prepared to stay on the air throughout the hurricane season and during any high wind conditions to keep our audience fully informed.We practice simulated storm conditions and with our back up broadcast antenna we are able to be on the air within five minutes of losing our primary antenna due to high winds. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: North Kohala Community Resource Center Program Name: Kohala Radio 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Certify 8 volunteers to help teach our new training program to at least 10 new graduates 12 volunteers certified as Chief Opeators Train and certify at least 12 new volunteers this year Add 12 new volunteers Certify at least two high school students in broadcasting and podcasting Certify 4 student interns in Broadcasting Increase underwriting subscriptions Raise$10,000 in underwriting Staying on the air during any high wind/high surf hurricane conditions Zero on air downtime during all hurricanes • Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 0 0 Professional Fees $1,830 $2,100 Operations $5,655 $6,195 • Supplies $0 $100 Equipment $1,332 $1,500 Other: Station Rent $25,634 $22,034 $5,000 Other: Utilities $2,853 $2,900 $1,500 Other: Internet $2,625 $2,500 $1,500 Other: Telephone $2,923 $2,000 $1,000 Other: National Federation of Community Broadcasters annual dues $1,050 $1050 TOTAL $43,902 $40,379 $9,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: North Kohala Community Resource Center Program Name: Kohala Radio 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the Council n The Mayor n The Managing Director The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: North Kohala Community Resource Center Program Name: Kohala Radio 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: North Kohala Community Resource Center Program Name: Kohala Radio 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an • additional insured prior to receiving any payment(s). - I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. • By signing below, you are acknowledging that you have read and understood these requirements. 4. • ie . • Signature of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: North Kohala Community Resource Center • Program Name: Kohala Radio 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result 12 volunteers certified as Chief Opeators Add 12 new volunteers Certify 4 student interns in Bros Raise$10,000 in underwriting Zero on air downtime during all hurricanes TABLE II: • FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award • Salary and Wages Professional Fees Operations Supplies Equipment Other: Station Rent $5,000 Other: Utilities $1,500 Other: Internet $1,500 Other: Telephone $1,000 Other: National Federation of Community Broadcasters annual dues TOTAL $9,000 Additional Council directives regarding award: • EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 10 Ka`u Kakou Family Fun Fest 130 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Family Fun Fest Agency Director: Wayne Kawachi Phone No.: (808) 937 — 4773 Contact Person: Nadine Ebert Phone No.: (808) 938 — 5124 Mailing Address: Address: P.O.Box 365 Address: City,ST,Zip Pahala, HI 96777 Facility Address: Address: Aspen Center Address: Ninole Loop Road City,ST,Zip Pahala, HI 96777 Email Address: okaukakou.org@gmail.com Fax No.: (808 ) 928 — 8961 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $7,000 Geographical Areas To Be Served: (One or more can be checked) ❑Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala 0 Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑Culture and the arts 0 Aged ❑Victims of Health or Social Crises [' Needs of the poor ❑ Physical/Emotional Disabilities ❑Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Family Fun Fest 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $3,000 $4,500 . $6,000 2.Agency Mission Statement: '0 Ka'u Kakou was organized exclusively for charitable,educational,cultural and economic support of the people of Ka'u. Operative income and assets are acquired entirely by donations,grants and fund raisers. '0 Ka'u Kakou is a 100 per cent volunteer run community service organization that responds to a wide variety of needs often partnering with other community groups to achieve its goals. The mission statement reads: To support and promote a healthy community through education, cultural and economic development opportunities that improve the quality of like in rural Ka'u. 3. Program Description: This is a annual family oriented event held in conjunction with the'0 Ka'u sponsored Independence Day parade in Na'alehu. We provide fun and healthy activities for all ages. These activities include inflatable water slides,train and rock wall for the keiki. Then they are treated to hot dogs,water melon and shave ice for lunch. For the kupuna,we have bingo where everyone goes home with a prize. They also are treated to lunch. 4.Total Budget& Position Count: Total Program Budget: $8,000 Total Program Position Count: 0 Total Agency Budget: 95,000 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Family Fun Fest 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County Grant $7,000 Donations $1,000 TOTAL: $8,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Any help we get from the County helps us not only with this project,but it also helps give more to the community projects that are not covered by grant money. We are always seeking monetary and in-kind donations. We have also scheduled fund raising projects such as selling hot dogs and shave ice at Punalu'u Black Sand Beach and other locations around Ka'u. 7. Program Objectives Using County Nonprofit Grant Program Funds: This is a program to provide a fun day for keiki,their families and the kupuna of Ka'u. While celebrating our nation's birthday with a parade,we bring families together to have a fun day in the park. Additionally,the Ka'u kupuna always look forward to playing bingo,winning household products and having lunch. This project meets our mission statement of supporting and promoting a healthy community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Family Fun Fest 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Served 600 hot dogs 650 hot dogs Served 600 shave ice 650 shave ice 81 bingo participants 95 bingo participants 62 volunteers 65 volunteers 600 volunteer hours 600 volunteer hours 39 parade units 45 units 110 adult lunches 120 adult lunches Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies $2,582 $2,600 $2,000 Equipment Other: Security $137 $150 Other: Advertising $780 $850 $800 Other: Food $1,607 $1,700 $1,700 Other: Prizes $1,256 $2,700 $2,500 Other: TOTAL $6,362 $8,000 $7,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Family Fun Fest so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ • The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist,check here. 4t1410.71 , 0119 1QO8 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Family Fun Fest 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express,and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Family Fun Fest 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 46/J441‘ 61 /9-9 /xi7 Signature of Authorized Person (see checklist,2nd item) Date .26,e/LeAt Title/Position of uthorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Family Fun Fest 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 650 hot dogs 650 shave ice 95 bingo participants 65 volunteers 600 volunteer hours 45 units 120 adult lunches TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees Operations Supplies $2,000 Equipment Other: Security Other: Advertising $800 Other: Food $1,700 Other: Prizes $2,500 Other: TOTAL $7,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 '0 Ka'u Kakou Ka'u Coffee Trail Run 131 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Coffee Trail Run Agency Director: Wayne Kawachi Phone No.: (808) 937 — 4773 Contact Person: Nadine Ebert Phone No.: (808) 938 — 5125 Mailing Address: Address: P.O Box 365 Address: City,ST,Zip Pahala, HI 96777 • Facility Address: Address: Aspen Center Address: Ninole Loop Rd. City,ST,Zip Pahala,HI 96777 Email Address: okaukakou.org@gmail.com Fax No.: (808 ) 928 — 8971 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE.DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $9,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna - ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑Culture and the arts ❑✓ Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Coffee Trail Run 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $3,730 $4,750 $6,000 2.Agency Mission Statement: '0 Ka'u Kakow was organized exclusively for charitable,educational,cultural and economical support of the people of Ka'u. Operating income and assets are acquired entirely by donations,grants and fun raisers. Ka'u Kakou is a 100 per cent volunteer run community service organization that responds to a wide variety of needs often partnering with other community groups to achieve its goals. The mission statement reads: To support and promote a healthy community through educational,cultural and economic development opportunities that improve the quality of like in rural Ka'u. 3. Program Description: This event is a scenic trail run consisting of a 5K, 10K,and 1/2 marathon. It is an international event,drawing runners from all over the United States as well as Europe and Asia. The event is held on the slopes of Mauna Loa at the Ka'u Coffee Mill,thus promoting Ka'u as an international vacation destination as well as promoting the Ka'u coffee industry. Additionally,the event provides a day of outdoor physical activity for the whole family by encouraging family registration. 4.Total Budget& Position Count: Total Program Budget: $10,000 Total Program Position Count: 0 Total Agency Budget: $95,000 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Coffee Trail Run 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County Grant $9,000 Donations $1,000 TOTAL: $10,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continue to seek donations and while the community supports the efforts of'0 Ka'u Kakou,we have used non-specific donations for those programs we are not asking the County's help to maintain. We continue to look for new venues for fund raising and community donations to become self-sustaining. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our objective is to promote a healthy lifestyle through physical fitness by providing and opportunity for family participation. We also use this project to promote Ka'u coffee and to promote Ka'u as a vacation destination. Through this program we are fulfilling our mission of improving the quality of life in Ka'u. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Coffee Trail Run 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 2018 we had 237 registered runners 350 registered runners 2018 we had 119 volunteers 130 volunteers 2018 food for 237 runners and 119 volunteers Food for 350 people Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages Professional Fees $205 $1,200 $1,200 Operations $378 $400 $400 Supplies $6,376 $6,400 $6,200 Equipment Other: Food $1,735 $1,800 $1,000 Other: Advertising $150 $200 $200 Other: Other: Other: TOTAL $8,844 $10,000 $9,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 it - County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Coffee Trail Run 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer, director, or administrator of your organization may have with they County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. '44' ♦, 61/29 //of? Signa re of Authorized Person (specify ftle) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Coffee Trail Run 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative, or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Coffee Trail Run 11. Certification of Understanding (Page 2 of 2) • If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction,materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 4/JedWil. Mt/WI or/aQ/2o/9 Signature of Authorized Person (see checklist, 2nd item) Date Title/Position of A orized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Coffee Trail Run 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 350 registered runners 130 volunteers Food for 350 people TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees $1,200 Operations $400 Supplies $6,200 Equipment Other: Food $1,000 Other: Advertising $200 Other: Other: Other: TOTAL $9,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 '0 Ka`U Kakou Ka'u Sanitation Program 132 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: 'O Ka'u Kakou Program Name: Ka'u Sanitation Program Agency Director: Wayne Kawachi Phone No.: (808) 937 — 4773 Contact.Person: Nadine Ebert Phone No.: (808) 938 — 5124 Mailing Address: Address: P.O Box 365 Address: City,ST,Zip Pahala, HI 96777 Facility Address: Address:. Aspen Center Address: Ninole Loop Road City,ST,Zip Pahala,HI 96777 Email Address: okaukakou.org@hawaii.rr.com Fax No.: (808 ) 928 — 8961 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $4,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala D South Kona ❑ North Hilo 0 South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns D Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 1 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Sanitation Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $5,5000 $8,000 $9,300 2.Agency Mission Statement: '0 Ka'u Kakou was organized exclusively for charitable,cultural,and economical support of the people of Ka'u. Operating income and assets are acquired entirely by donations,grants and fund raisers. '0 Ka'u kakou is 100 per cent volunteer run community service organization that responds to a wide variety of needs,often partnering with other community groups to achieve its goals. The mission statement reads: To support and promote a healthy community through educational cultural and economic development opportunities that improve the quality of life in rural Ka'u. 3. Program Description: '0 Ka'u Kakou has provided and maintained 2 portable toilets at South Point fishing and visitor area and 2 portable toilets at the boat ramp at the Punalu'u Black Sand Beach. DHHL will be taking over the South Point area but we will continue to provide these sanitation units at Punalu'u Black Sand Beach. Providing these portable toilets at the boat ramp area helps keep this area clean and allows people to enjoy the beauty we are so proud of in Ka'u. It is part of our mission statement to promote a healthy community. 4.Total Budget& Position Count: Total Program Budget: $4,000 Total Program Position Count: 0 Total Agency Budget: $95,000 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Sanitation Pro ram 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County grant $4,000 TOTAL: $4,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Since DHHL will be taking over the more expensive half of our costs we will only be asking for$4,000 this year. While we feel this is one of our more important programs,we find that it is hard to get additional outside support for this less glamorous project. 7. Program Objectives Using County Nonprofit Grant Program Funds: These funds will help'0 Ka'u Kakou continue this program of providing portable toilets at Punalu'u Black Sand Beach. While we have not done a study on the number of visitors and fishermen at this site the popularity of the portable toilets is measurable. They are serviced once a week. This weekly schedule was determined based on the need to empty the toilets. We know of no plans for anyone to install restrooms facilitiesat this site. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Sanitation Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific) 2 portable toilets at Punalu'u boat ramp with weekly service 2 portable toilets Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations $9,295 $4,000 $4,000 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $9,295 $4,000 $4,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Sanitation Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the Council n The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist,check here. ebsei / 9/,2w/7 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Sanitation Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express,and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Sanitation Program ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 44„.. e_ ®i/gq/ 0/7 Signature of Authorized Person (see checklist, 2nd item) Date Title/Position o uthorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Sanitation Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 2 portable toilets TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees Operations $4,000 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $4,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 . Page 8 of 8 '0 Ka`u Kakou Ka`u Veterans' Day Celebration 133 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Veterans' Day Celebration Agency Director: Wayne Kawachi. Phone No.: (808) 937 — 4773 Contact Person: Nadine Ebert Phone No.: (808) 938 — 5124 Mailing Address: Address: P.O.Box 365 Address: City,ST,Zip Pahala, HI 96777 Facility Address: Address: Aspen Center Address: Ninole Loop Rd. City,ST,Zip Pahala, HI 96777 Email Address: okaukakou.org@gmail.com Fax No.: (808 ) 928 — 8961 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $3,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua .❑ North Kona ❑South Hilo ❑North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑✓ Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Veterans' Day Celebration 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 N/A N/A N/A 2.Agency Mission Statement: '0 Ka'u Kakou was organized exclusively for charitable,educational,cultural and economic support of the people of Ka'u. Operating income and assets are acquired entirely by donations,grants and fund raisers. 'O Ka'u Kakou is a 100 per cent volunteer run community service organization that responds to a wide variety of needs often partnering with other groups to achieve its goals. The mission statement reads: To support and promote a healthy community through educational cultural and economic development opportunities that improve the quality of life in rural Ka'u. 3. Program Description: While there are other Veterans'Day celebrations scattered around the island,there is nothing in Ka'u. We want to let our Veterans know we appreciate their service to country. This is to be a day of music in Na'alehu park,a few speeches and a nice meal for all. 4.Total Budget&Position Count: Total Program Budget: $4,000 Total Program Position Count: 0 Total Agency Budget: $95,000 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Veterans' Day Celebration 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source - Estimate County grant $3,000 Donations $1,000 TOTAL: $4,000 Attach additional pages,if needed. 6. Explain what plans your agency or,program has to increase revenues to support this program: We are always looking for new sources for donatioons and fortunate to have business who support us. However this is a new event for us. 7. Program Objectives Using County,Nonprofit Grant Program Funds: We hope to bring people together for a day of fun and food,but to also honor the Veterans of Ka'u. We also hope to build on a sense of community that builds pride in Ka'u EXHIBIT A NONPROFIT GRANT APPLICATION ' FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Veterans' Day Celebration 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Attendence for our 1st celebration was 350 400 Served 400 lunches 450 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages Professional Fees $1,000 $500 Operations Supplies $377 $450 $450 Equipment Other: Food $1,042 $2,000 $1,500 Other: Advertising $520 $550 $550 Other: Other: Other: TOTAL $1,939 $4,000 $3000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Veterans' Day Celebration io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. t / V-,1 / o q Signature of Authorized Person (specify title) / Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Veterans' Day Celebration 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express,and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Veterans' Day Celebration ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. .i7,nw.hhi', 4 6`,,,,S oi 1,1_30/1 f)icy Signature of Authorized Person (see checklist, 2nd item) Date 40.p Title/Position of AVorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Ka'u Veterans' Day Celebration 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 400 450 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees $500 Operations Supplies $450 Equipment Other: Food $1,500 Other: Advertising $550 Other: Other: Other: TOTAL $3000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 '0 Ka`u Kakou Punalu'u Annual Fishing Tournament 134 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament Agency Director: Wayne Kawachi Phone No.: (808) 937 — 4773 Contact Person: Nadine Ebert Phone No.: (808) 938 — 5124 Mailing Address: Address: P.O Box 365 Address: City,ST,Zip Pahala, HI 96777 Facility Address: Address: Aspen Center Address: Ninole Loop Road City,ST,Zip Pahala,HI 96777 Email Address: okaukakou.org@gmail.com Fax No.: (808 ) 928 — 8961 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $7,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala Ka`u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ['Youth ❑Victims of Crimes ✓❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 1748 FY 18-19 $2,125 $4,125 $5,500 2. Agency Mission Statement: '0 Ka'u Kakou was organized for charitable,educational,cultural and economic support of the people of Ka'u. Operating income and assets are acquired entirely by donations,grants and fund raisers. '0 Ka'u Kakou is a 100 per cent volunteer run community service organization that responds to a wide variety of needs often partnering with other groups to achieve its goals. The mission statement reads: To support and promote a healthy community through educational,cultural and economic development opportunities that improve the quality of life in rural Ka'u. 3. Program Description: This is a catch and release fishing tournament for keiki ages 1 to 14 years of age. Each child receives a prize and then special prizes are given for the biggest catch,most fish caught,etc. Poles,bait,lunch,shave ice and entertainment is provided free to everyone. We invite all family members of the registered participants to enjoy the lunch and shave ice with their keiki. 4.Total Budget&Position Count: Total Program Budget: $9,000 Total Program Position Count: 0 Total Agency Budget: $95,000 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County Grant $7,000 Donations $2,000 TOTAL: $9,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We are always looking for new sources for donations and are fortunate to have businesses and individuals who support this event on an annual basis. However,many non-specific donations go to our many other projects such as scholarships,senior projects,caring for cemeteries,helping the schools with donations for students to travel for various events,etc. 7. Program Objectives Using County Nonprofit Grant Program Funds: This event is to promote a healthy love for the art of shoreline fishing by providing an opportunity for family participation in a supervised fishing tournament. Each child up to the age of 14 must be accompanied by a parent or guardian in order to participate in the tournament. This event is one of'0 Ka'u Kakou's major family oriented projects. This event provides a way of meeting our mission statement of promoting a healthy community through education and family fun. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Kau Kakou Program Name: Punalu'u Annual Fishing Tournament 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 2018 376 fishermen, 455 pre-registered 500 pre-registered 2018 over 800 lunches, 900 lunches 2018 100 breakfasts for volunteers 150 breakfasts 2018 132 volunteers 150 volunteers 2018 1150 volunteer hours 1200 hours Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies Equipment $888.00 $1,000 $500 Other: Food $2055.00 $2,500 $2,000 Other: Prizes $4870.00 $5,500 $4,500. Other: Other: Other: TOTAL $7,813 $9,000 $7,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: anyfamilial relationship,with anyof the Mayhave a conflict or potential conflict of interest, including following(check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council ❑ The Mayor n The Managing Director IT The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in genera!to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. eickd , 14291.9 19' Signature of Authorized Person (specify titleDate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express,and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 64-a /to.9 / Signature of Authorized Person (see checklist, 2nd item) Date J.,2412-e-ta7 Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: '0 Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 500 pre-registered 900 lunches 150 breakfasts 150 volunteers 1200 hours TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees Operations Supplies Equipment $500 Other: Food $2,000 Other: Prizes $4,500. Other: Other: Other: TOTAL $7,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Pacific Tsunami Museum Tsunami Sites: Signage (Phase 2) 135 County of fIawai`i Nonprofit Grant Application FY2019-20 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Sites: Signage (Phase 2) Agency Director: Marlene Murray Phone No.: (808 ) 935 — 0926 Contact Person: Marlene Murray Phone No.: (808 ) 935 — 0926 Mailing Address: Address: P.O. Box 806 Address: City,ST,Zip Hilo, HI 96721 Facility Address: Address: 130 Kamehameha Avenue Address: City,ST,Zip Hilo, HI 96720 Email Address: director@tsunami.org Fax No.: ( ) — Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City,ST,Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $22,037 Geographical Areas To Be Served: (One or more can be checked) n Puna ❑✓ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑ South Kona ❑✓ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns n Youth ❑Victims of Crimes n Culture and the arts ❑Aged ❑Victims of Health or Social Crises n Needs of the poor ❑ Physical/Emotional Disabilities Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 Countyof Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Sites: Signage (Phase 2) 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 4875 4125 7125 2. Agency Mission Statement: We believe that through education and awareness, no one should ever again die due to a tsunami. 3. Program Description: In the second year of this project,the Pacific Tsunami Museum will continue to create signage for sites impacted by tsunamis along East Hawaii,which will be organized as both driving and walking tours. The driving tour will include at least(8)locations, including Laupahoehoe Point,Alae,Wailuku River, Pacific Tsunami Museum, Bayfront Lighthouse, Bayfront across Bishop Street,Wailoa Center/Shinamachi Memorial and Keaukaha. The walking tour will include at least(5)locations, including Wailoa River, Suisan, Coconut Island (Moku Ola), Reed's Bay, Waiakea Kai Clock. The signage will contain information on the historical site, including photographs and eye witness statements or quotes and how the area was impacted by tsunami. For cost cutting and eco-friendly reasons,we will not be printing guidebooks, as stated in our previous proposal. Instead we will print only a brief one pager,which will include site maps. Detailed information that would have been included in an extensive guidebook will now be accessed through a QR reader which will be linked to pages on the museum website. 4.Total Budget& Position Count: Total Program Budget: 44,162 Total Program Position Count: 2 Total Agency Budget: 279,300 Total Agency Position Count: 4 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Sites: Signage (Phase 2) 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate We currently do no have funding to support this program FY19-20. 0 TOTAL: 0 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Since admissions, membership dues and donations only cover our year to year expenses,we continue to pursue grants and other fundraising opportunities. We anticipate that this project will continue to gain traction,with members of the community, (organizations and businesses) supporting it through sponsorship,as well as donations of materials and labor. 7. Program Objectives Using County Nonprofit Grant Program Funds: The threat of tsunamis is an ever-present reality to all who live in the Hawaiian Islands.Scientists and experts agree that it is not a matter of if, but when the next one will strike.The Pacific Tsunami Museum's mission is to save lives through education and awareness. Almost three generations have passed without ever having experienced a major tsunami.This can create complacency and have potentially deadly consequences if warnings are not heeded by residents and visitors. The informative signs will serve to provide important historical information as well as emphasize the need for increased awareness of this dangerous hazard which has caused major destruction in Hawaii, and present it in an interesting and impactful manner.The real goal is to prevent future tragedy,the next time a tsunami strikes our shores. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Sites: Signage (Phase 2) 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Create signs for tsunami sites 11 signs Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 782 1400 1400 Professional Fees 712 2204 2204 Operations Supplies 2100 4800 4800 Equipment Other: Graphic Artist 1000 1500 1500 Other: Fabrication and Installation 2531 11100 11100 Other: QR Code Development 1033 1033 Other: Other: TOTAL 7,125 22,037 22,037 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Sites: Signage (Phase 2) 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest thatrany board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council n Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. 'E.Kee-GA:fiv - 1 /30/19 Signature of Authorize erson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Sites: Signage (Phase 2) 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 , Agency Name: Pacific Tsunami Museum Program Name: Tsunami Sites: Signage (Phase 2) 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1 /30/1 9 Signature of Authorized Person (see checklist, 2nd item) Date Ve ✓"�C��O� Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Sites: Signage (Phase 2) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 11 signs TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 1400 Professional Fees 2204 Operations Supplies 4800 Equipment Other: Graphic Artist 1500 Other: Fabrication and Installation 11100 Other: QR Code Development 1033 Other: Other: TOTAL 22,037 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Paddling for Hope Breast Cancer Education and Survivor Support 136 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Paddling For Hope Program Name: Breast Cancer Education and Survivor Support Agency Director: Derek Park Phone No.: (808) 896 — 5747 Contact Person: Derek Park Phone No.: (808) 896 — 5747 Mailing Address: Address: Paddling for Hope Address: P.O. Box 6111 City,ST,Zip Kamuela, Hawaii 96743 Facility Address: Address: Address: City,ST,Zip Email Address: paddlingforhope@gmail.com Fax No.: ( ) — Accountant/CPA: Derek Park Phone No.: (808 ) 896 _ 5747 Firm (if applicable): n/a Mailing Address: Address: Paddling for Hope Address: P.O. Box 6111 City,ST,Zip Kamuela, Hawaii 96743 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $13,000.00 Geographical Areas To Be Served: (One or more can be checked) Q Puna Hamakua Q North Kona Q South Hilo n North Kohala Q South Kona [' North Hilo ['South Kohala n Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑Victims of Crimes g Culture and the arts ❑Aged ❑Victims of Health or Social Crises n Needs of the poor ❑ Physical/Emotional Disabilities ▪ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Paddling For Hope Program Name: Breast Cancer Education and Survivor Support 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 n/a n/a n/a 2. Agency Mission Statement: Paddling for Hope's mission is to promote breast cancer early detection and education for the Big Island of Hawaii. 3. Program Description: The Breast Cancer Education and Survivor Support Program tackles the difficulties of breast cancer by promoting preventative measures, as well as providing support and relief to breast cancer patients and survivors. We work directly with community health care providers to do two things:decrease the rate of breast cancer occurrence on Hawaii Island through education and self-examination kits, and provide support to cancer survivors through the shared experience of outrigger canoe paddling and sailing. We select and partner with various cancer centers/health care providers to supply funding solely for breast cancer prevention through education in conjunction with breast self-examination kits. Last year we partnered with Hui Malama Ola Na `Oiwi and the Kona Community Hospital Cancer Treatment Center. Paddling for Hope also works with these partners to do public educational outreach at cancer support events and community wellness events. During these events we offer wa'a (canoe) excursions as an opportunity for cancer patients and survivors to connect with one another and their natural environment, making the wa'a a vessel for healing and a source of solidarity through shared experiences. 4.Total Budget & Position Count: Total Program Budget: 10,000 Total Program Position Count: 1 Total Agency Budget: 6,000 Total Agency Position Count: 2 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of FIawai`i Nonprofit Grant Application FY2019-20 Agency Name: Paddling For Hope Program Name: Breast Cancer Education and Survivor Support 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Donations 5,000.00 Merchandise Sales 2,000.00 Honor Names Sales and Donations 4,000.00 TOTAL: 11,000.00 Attach additional pages, if needed. Lxpancnlg 0 puonclengageme n$andcnlar'keting Campaigns o os radcllling t Hope$sto viisolllt�sparamount to as hleving our fiscal goals of increased donations, private sponsorships, and sales of honor names.An increase in marketing specifically includes capturing quality photos/video,doubling our amount of promotional flyers and geographic location of flyers, promoting online calls-to-action using mixed media content on social media, and developing/maintaining a website capable of accepting donations. Part of our marketing campaign will highlight the canoe excursions we offer while working with our partners at community wellness events.The more we can take patients, survivors, and the general public out to experience the joy of the canoe,the more our mission can be shared and supported. In expanding our public visibility we expect our revenue to increase by at least 40%in the next two years. We are doubling our health care partners and community wellness events in the next two years, and are working on partnerships with Hilo Medical Center, Kona Hospice, and North Hawaii Community Hospital. We are currently on track to more than double our sales in honor names this year, and reach our goal of selling$4,000 worth in honor names.These names honoring individuals afflicted by cancer are displayed on Paddling for Hope's one-man canoe, and raced inter-island at two world-class championship paddling events.This novel fundraising approach attracts sponsorships and donations merely through word of mouth. Its low overhead leaves exponential room for financial growth, as we intend to add more sponsored paddlers to our program once our honor names surpass 500. Our five year plan is to create our own community wellness paddling event as an annual fundraiser. Our marketing campaign will use media to capitalize on the honor names' popularity, as well as showcase our provision of canoe rides. Increased revenue will support our program's breast cancer education, self-examination kits, and canoe rides at community wellness events. 7. Program Objectives Using County Nonprofit Grant Program Funds: -Increase program funds for Paddling for Hope by boosting public visibility through visual marketing.This includes building and maintaining a website by the end of the fiscal year, and providing content for flyers and social media. -Use professionals to acquire quality media content we can use for our marketing campaign. -Increase our capacity to take cancer patients,volunteers, and others at community wellness events in the wa'a by purchasing a double-hull canoe that can fit three times the amount of people we can currently take.The purchase of the double-hull will be the last large equipment expense. -Double our partner agencies and grow event participation to spread breast cancer education. -Advertise our honor names in more geographic locations to raise another$1,500 worth in breast self-examination kits. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Paddling For Hope g Y Program Name: Breast Cancer Education and Survivor Support 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Professional documentation of events 4 Number of marketing methods used 6 Number of canoe rides given during an event 6-8 depending on conditions Number of community wellness events attended 4 Amount of money donated to partners for breast cancer education and self-exam kits 1,500 Complete Paddling for Hope website by the end of the fiscal year 1 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages Professional Fees 3,000 Operations 3.50 100 Supplies 199.57 200 2,707.97 2,000 10,000 Equipment Other: travel 3,515.18 3,500 Other: Racing dues 200 200 Other: Other: Other: TOTAL 6,626.22 6,000 13,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency PaddlingFor Hope g Y Name: P Program Name: Breast Cancer Education and Survivor Support 10a ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance n .The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. t . 3 ► - 2otet Signature ut orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Paddling For Hope Program Name: Breast Cancer Education and Survivor Support ii. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Paddling For Hope Program Name: Breast Cancer Education and Survivor Support 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is noprovision for further notification to submit the final report. Information p and instructions are available at htip://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of thisapplication, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 3l - 2.0lY Signature of Authorized Person (see checklist, 2nd item) Date kecwi4ve— Dtrec.4-o�' Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Paddling For Hope Program Name: Breast Cancer Education and Survivor Support 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Professional documentation of events a Number of marketing methods used 6 Number of canoe rides given during an event 6-8 depending on conditions a i\htfr}e)r OC CosUllWlur\i+ i ell\e,S5 etRA-I-3 Amount of money donated to Oartners for breast cancer education and self-exam kits 1,500 1 Complete Paddling for Hope website by the end of the fiscal year TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees 3,000 Operations Supplies Equipment 10,000 Other: travel Other: Racing dues Other: Other: Other: TOTAL 13,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Project Vision Hawaii Better Vision for Keiki - Hawai`i Island 137 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: Better Vision for Keiki - Hawaii Island Agency Director: Elizabeth "Annie" Valentin, Executive Director Phone No.: (808) 282 - 2265 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: P.O. Box 23212 Address: City,ST,Zip Honolulu, HI 96823 Facility Address: Address: 1110 Nuuanu Avenue Address: City,ST,Zip Honolulu, HI 96817 Email Address: annie@projectvisionhawaii.org Fax No.: (808 ) 591 - 9909 Accountant/CPA: Greg Wong Phone No.: (808 ) 222 - 4848 Firm (if applicable): Hawaii Care Services Mailing Address: Address: 1288 Ala Moana Blvd. Suite 201 Address: City,ST,Zip Honolulu, HI 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ❑✓ Youth ['Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019 -2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: Better Vision for Keiki - Hawaii Island 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $7,625 $8,875 $5,925 2. Agency Mission Statement: Project Vision Hawai'i is a locally grown nonprofit with a mission to work in partnership with the people of Hawaii to increase access to healthcare. Our success in serving vulnerable populations comes largely because of two unique strategies: (1)we bring services to access-challenged communities via mobile screening units;and(2)services are always 100%free of charge to participants. Project Vision provides the only mobile health screening units in Hawaii targeting communities with access to care issues such as lack of insurance,geographic challenges,cultural barriers and limited or no income. In 2018, Project Vision accomplished the following: D Vision-screened 18,889 keiki in 83 public schools,which was a 95% increase over 2017 ❑ Provided vision and health screenings to 2,139 adults and 3,679 keiki at 89 events ❑Worked to reduce preventable falls by screening 1,423 seniors on six islands ❑ Provided 1,349 hot showers through mobile hygiene for people experiencing homelessness 3. Program Description: Project Vision proposes to increase access to vision healthcare for children in partnership with public schools on Hawaii Island. Children will benefit from improved vision, reduced risk of undetected eye problems,and improved academic performance. Our project partner is Vision to Learn,which has provided children with more than 550,000 screenings, 140,000 eye exams, and 115,000 pairs of glasses, nationwide.Vision to Learn serves children in low-income communities in more than 220 cities from Honolulu to Baltimore, becoming the largest school-based program of its kind in the nation. Project Vision partners with Hawaii Department of Education (HIDOE), schools, Hawai'i Keiki Nurses, local Lions Clubs, and Vision to Learn to conduct school-wide screenings, provide comprehensive exams, manage parent/guardian consent forms, coordinate schedules on each island, and manage project data.The organization performs vision screenings using the Plusoptix mobile vision screener.This technology enables one student to be screened in less than three minutes and accurately assesses visual acuity and depth perception. As a result of the school-wide vision screenings, students receive comprehensive eye exams and free eyeglasses as needed. Vision to Learn visits each school in a mobile clinic staffed with a trained optometrist and optician. If a student needs glasses, the optician helps him or her choose a frame from a wide selection at the clinic. Free eyeglasses are delivered and fitted at school about one month after the exams.Vision to Learn provides replacement glasses and returns to each school site every other year to provide continuity of care.The cost for exams and glasses as needed is$100 per student to Vision to Learn. 4. Total Budget & Position Count: Total Program Budget: $142,750 Total Program Position Count: 4 Total Agency Budget: $1,402,180 Total Agency Position Count: 16 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: Better Vision for Keiki - Hawaii Island 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Atherton Family Foundation -statewide grant/25%allocated to HI County 6,250 First Hawaiian Bank Foundation -statewide grant/25%allocated to HI County 6,250 Hawaii State Grant-In-Aid-pending statewide grant/18% allocated to HI County 90,000 TOTAL: 102,500 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Project Vision continually pursues funding to support our work of ensuring health equity and better quality of life for all.We strive for a diverse revenue plan with various types and sources of income.The 2019 operating budget includes corporate and foundation contributions(50%), pubic grants(36%), a special event(11%), and earned income for services(2%). Project Vision also generates earned income through contracts such as one with the Department of Human Services to promote its Supplemental Nutrition Assistance Program (SNAP).Contracts such as this provide reliable income and closely align with our mission.We are developing a social venture to rent out mobile hygiene facilities for weddings and events,which will enable ongoing revenue to support our homelessness outreach, HiEHiE Hospitality Project. One strategy Project Vision uses to address the funding challenge is to convene stakeholders and"hui up"funders in order to support greater impact.We have used this strategy to scale up Better Vision for Keiki, bringing funders together and building a group that takes ownership of our proposed solution.This hui is working toward multi-year commitments with public-private buy-in and will continue to pursue dedicated public funding for vision screenings in public schools. Also supporting Better Vision for Keiki,we are pursuing reimbursements by Medicaid/Med-Quest and Children's Health Insurance Program(CHIP).Vision to Learn has led similar efforts in several states in the U.S. 7. Program Objectives Using County Nonprofit Grant Program Funds: Better Vision for Keiki will pursue the following objectives in FY2020-Hawaii Island Objective 1: Project Vision will conduct at least 5,000 vision screenings of students in public school to identify children who require eye exams. Objective 2: A projected 750 children will be referred to Vision to Learn for eye exams. Objective 3: Vision to Learn will provide 600 eye exams and glasses as needed to children. Project Vision and our partner,Vision to Learn,have the experience, relationships and resources to respond to these community • needs.Our program model involves physically driving mobile health RVs to low-income schools, bringing trained technicians, physicians and resources to underserved communities.Working with innovative technology and impactful partners,we are able to screen large numbers of children at a low cost. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: Better Vision for Keiki - Hawaii Island 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of vision screenings provided to public school children on Hawaii Island 5,000 Number of children referred to Vision to Learn for eye exams 750 Number of eye exams delivered with glasses as needed 600 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $0 72,750 13,000 Professional Fees Operations 3,500 1,500 Supplies 7,750 2,500 Equipment Other: Inter-Island Travel 500 Other: Vision to Learn -80 exams X$100 60,000 8,000 Other: Other: Other: TOTAL N/A $144,500 $25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: Better Vision for Keiki - Hawaii Island 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council Staff appointed by a member of the Council n The Mayor n The Managing Director Ti The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no inflicts exist, check here. .I fi?Ai(ci Signat re .' Auth• ized Persons ( pecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: Better Vision for Keiki - Hawaii Island 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: Better Vision for Keiki - Hawaii Island 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. Signatures uthorized Person (see checklist, 2nd item) Date Elizabeth "Annie" Valentin, Executive Director Title/Position of Authorized Person • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: Better Vision for Keiki - Hawaii Island 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Number of vision screenings provided to public school children on Hawaii Island 5,000 Number of children referred to Vision to Learn for eye exams 750 Number of eye exams delivered with glasses as needed soo TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 13,000 Professional Fees Operations 1,500 Supplies 2,500 Equipment Other: Inter-Island Travel Other: Vision to Learn -80 exams X$100 8,000 Other: Other: Other: TOTAL $25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Project Vision Hawaii HiEHiE Hospitality Project 138 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: HiEHiE Hospitality Project Agency Director: Elizabeth "Annie"Valentin, Executive Director Phone No.: (808) 282 - 2265 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: P.O. Box 23212 Address: City,ST,Zip Honolulu, HI 96823 Facility Address: Address: 1110 Nuuanu Avenue Address: City,ST,Zip Honolulu, HI 96817 Email Address: annie@projectvisionhawaii.org Fax No.: (808 ) 591 - 9909 Accountant/CPA: Greg Wong Phone No.: (808) 222 - 4848 Firm (if applicable): Hawaii Care Services Mailing Address: Address: 1288 Ala Moana Blvd. Suite 201 Address: City,ST,Zip Honolulu, HI 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $50,000 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna ✓❑ Hamakua ❑✓ North Kona ✓❑South Hilo ✓❑ North Kohala ❑✓ South Kona ✓❑ North Hilo 2 South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) [' Educational concerns ✓❑Youth ['Victims of Crimes ❑ Culture and the arts ✓❑Aged ❑Victims of Health or Social Crises O Needs of the poor ✓❑ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: HiEHiE Hospitality Project 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $7,625 $8,875 $5,925 2. Agency Mission Statement: Project Vision Hawai'i is a locally grown nonprofit with a mission to work in partnership with the people of Hawai'i to increase access to healthcare. Our success in serving vulnerable populations comes largely because of two unique strategies: (1)we bring services to access-challenged communities via mobile screening units; and(2)services are always 100%free of charge to participants. Project Vision provides the only mobile health screening units in Hawaii targeting communities with access to care issues such as lack of insurance,geographic challenges,cultural barriers and limited or no income. In 2018, Project Vision accomplished the following: 0 El Vision-screened 18,889 keiki in 83 public schools,which was a 95%increase over 2017 ❑ Provided vision and health screenings to 2,139 adults and 3,679 keiki at 89 events ❑Worked to reduce preventable falls by screening 1,423 seniors on six islands ❑ Provided 1,349 hot showers through mobile hygiene for people experiencing homelessness 3. Program Description: The HiEHiE Hospitality Project uses mobile hygiene trailers to bring hot showers and resources to people experiencing homelessness on Hawaii Island. HiEHiE meets the basic need for hygiene,which has positive implications for health, well-being,and disease prevention. In addition to the tangible benefit of hot showers, participants gain access to resources and information provided by HiEHiE and its partners.At each location, HiEHiE trailers becomes a gathering place, connecting people with services in collaboration with public agencies, community organizations, and local churches. Participants gain access to:onsite vision and health screenings, referrals, and basic necessities such as dental care supplies, hair care products and hygiene products.The HiEHiE trailers have three compartments,each with a private shower, sink and toilet;a utility room; and outdoor awnings to allow for a small gathering area.They are ADA accessible and are powered with solar panels. Through HiEHiE, Project Vision has cultivated a culture of"radical hospitality."This means we provide an unexpected level of care-clean facilities, hot water,toiletries and clean clothes-for children and adults experiencing homelessness. It means we take time to build relationships with shower users and treat them with utmost respect.This opens doors for conversations about the barriers to housing,toward the goal of helping people discover a path forward. We also collect and manage data regarding the usage,demographics, locations and general feedback,which informs the public discussion on addressing homelessness.We work with the network of public and private agencies focused on homelessness to improve data management, including HI State Point in Time Count, UH Center on Family Homeless Utilization and HMIS. 4.Total Budget& Position Count: Total Program Budget: $237,273 Total Program Position Count: 4 Total Agency Budget: $1,402,180 Total Agency Position Count: 16 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: HiEHiE Hospitality Project 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Zilber Family Foundation-20% allocated to HI County FY20 15,000 Anonymous Donor-20%allocated to HI County FY20 40,000 Hawaii State Grant-In-Aid-25%allocated to HI County FY20 25,000 Hawaii State Grant-In-Aid-capital grant for mobile hygiene trailer for HI County 70,000 TOTAL: 150,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Project Vision continually pursues funding to support our work of ensuring health equity and better quality of life for all.We strive for a diverse revenue plan with various types and sources of income.The 2019 operating budget includes corporate and foundation contributions(51%), individual contributions(2%), public grants(43%),and earned income for services(4%). Recognizing that public grants are not necessarily reliable and repeatable,we are seeking to increase individual contributions. We launched a special event, "The Eye Ball,"to broaden our base of support and introduce the giving community to our services • and mission. The organization also pursues earned income opportunities.We have the capacity to provide screening and preventative services for a fraction of the cost that would be incurred by private and government agencies.We are pursuing relationships and developing fee-for-service income in areas that provide public health benefits. For example,we secured a contract with the Department of Human Services to promote its Supplemental Nutrition Assistance Program(SNAP). Contracts such as this provide reliable income and closely align with our mission.Also toward the goal of sustainable income, PVH is pursing legacy gifts with guidance from Hawaii Community Foundation and expanding solicitation of individual donations. Overall, Project Vision raised more than$900,000 last year through various revenue streams. 7. Program Objectives Using County Nonprofit Grant Program Funds: Homelessness is a complex issue with no single,definite solution. Our local community has put forth different approaches to reducing the number of people experiencing homelessness and to improve conditions for this population.There is no quick-fix; however,we believe in the power of people coming together with great ideas that make a difference. The program will be considered successful if we achieve the following objectives on Hawaii Island in FY20: -Provide 1,500 showers to people experiencing homelessness. -Host 50 HiEHiE pop-up care village events on Hawaii Island. -Engage 30 partners in HiEHiE project. -Develop three intervention strategies to increase access to resources and reduce barriers to housing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: HiEHiE Hospitality Project 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of showers provided 1,500 Number of pop-up care village events on Hawaii Island 50 Number of partners engaged 30 Number of intervention strategies developed in year one 3 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $0 $142,063 $30,000 Professional Fees Operations $23,760 $4,900 Supplies $12,600 $3,500 Equipment $12,350 $2,600 Other: Portable Information Technology $12,500 $4,000 Other: Water and Dumping Charges $16,500 $2,500 Other: Miscellaneous $17,500 $2,500 Other: Other: TOTAL N/A $237,273 $50,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: HiEHiE Hospitality Project 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council n Staff appointed by a member of the Council The Mayor n The Managing Director The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no flicts e•ist, check here. ‘ 12Aiki Signature o Auth•rize. Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: HiEHiE Hospitality Project 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: HiEHiE Hospitality Project ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Lir I IMI (1 Signature o Authorized Person (see checklist, 2nd item) Date Elizabeth "Annie" Valentin, Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: HiEHiE Hospitality Project 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of showers provided 1500 Number of pop-up care village events on Hawaii Island 50 Number of partners engaged 30 Number of intervention strategies developed in year one 3 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $30,000 Professional Fees Operations $4,900 Supplies $3,500 Equipment $2,600 Other: Portable Information Technology $4,000 Other: Water and Dumping Charges $2,500 Other: Miscellaneous $2,500 Other: Other: TOTAL $50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Project Vision Flawai`i WE...A Hui for Health - Hawai'i Island 139 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: WE...A Hui for Health - Hawaii Island Agency Director: Elizabeth"Annie"Valentin, Executive Director Phone No.: (808) 282 - 2265 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: P.O. Box 23212 Address: City,ST,Zip Honolulu, HI 96823 Facility Address: Address: 1110 Nuuanu Avenue Address: City,ST,Zip Honolulu, HI 96817 Email Address: annie@projectvisionhawaii.org Fax No.: (808 ) 591 - 9909 Accountant/CPA: Greg Wong Phone No.: (808) 222 - 4848 Firm (if applicable): Hawaii Care Services Mailing Address: Address: 1288 Ala Moana Blvd. Suite 201 Address: City,ST,Zip Honolulu, HI 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna ✓❑ Hamakua ✓❑ North Kona ✓❑South Hilo North Kohala ✓❑South Kona ✓❑ North Hilo ✓❑South Kohala ✓❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ✓❑Youth ❑Victims of Crimes [' Culture and the arts ✓❑Aged ❑Victims of Health or Social Crises ✓❑ Needs of the poor ✓❑ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: WE...A Hui for Health - Hawaii Island 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $7,625 $8,875 $5,925 2.Agency Mission Statement: Project Vision Hawaii is a locally grown nonprofit with a mission to work in partnership with the people of Hawaii to increase access to healthcare.Our success in serving vulnerable populations comes largely because of two unique strategies: (1)we bring services to access-challenged communities via mobile screening units; and(2)services are always 100%free of charge to participants. Project Vision provides the only mobile health screening units in Hawai'i targeting communities with access to care issues such as lack of insurance,geographic challenges,cultural barriers and limited or no income. In 2018, Project Vision accomplished the following: ❑Vision-screened 18,889 keiki in 83 public schools,which was a 95%increase over 2017 ❑ Provided vision and health screenings to 2,139 adults and 3,679 keiki at 89 events ❑Worked to reduce preventable falls by screening 1,423 seniors on six islands ❑ Provided 1,349 hot showers through mobile hygiene for people experiencing homelessness 3. Program Description: Project Vision proposes to bring health and human services to the most vulnerable populations on Hawaii Island via mobile health vehicle.Through WE..A Hui for Health,we are partnering with agencies to bring vision screenings,diabetes screenings, blood pressure tests, and other healthcare services to people in need.This is needed because,despite the advanced scientific and medical technologies available,too many disadvantaged people lack access to fundamental, basic healthcare. Thus, preventable and treatable diseases disproportionately affect low-income, rural and poor populations.As long as these inequities exist,there is a need for community outreach dedicated to increasing access to healthcare. Vision problems also contribute to difficulties for homeless people and elderly adults.Again,the formidable challenge is access to preventative, regular healthcare. For example,while blindness from diabetes is largely preventable with annual evaluation and treatment,the Hawaii Diabetes Report estimates that there are up to 29,000 cases of blindness from diabetes each year in Hawai'i.Through free, local, accessible vision and retinal screenings, Project Vision is able to help people identify and treat medical problems, including diabetes, glaucoma and macular degeneration. For elderly individuals, poor vision is one of four issues that contribute to falls,which can have a devastating effect on their health and way of life. Falls are the leading cause of both fatal and nonfatal injuries for people over the age of 65. Falls can result in hip fractures, broken bones, and head injuries. Even falls without a major injury can cause an older adult to become fearful or depressed, making it difficult for them to stay active,according to the National Council on Aging. 4.Total Budget& Position Count: Total Program Budget: $77,425 Total Program Position Count: 3 Total Agency Budget: $1,402,180 Total Agency Position Count: 16 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: WE...A Hui for Health - Hawaii Island 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Not applicable. $0 TOTAL: $0 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Project Vision continually pursues funding to support our work of ensuring health equity and better quality of life for all.We strive for a diverse revenue plan with various types and sources of income.The 2019 operating budget includes corporate and foundation contributions(50%), pubic grants(36%),a special event(11%), and earned income for services(2%). Project Vision also generates earned income through contracts such as one with the Department of Human Services to promote its Supplemental Nutrition Assistance Program (SNAP). Contracts such as this provide reliable income and closely align with our mission.We are developing a social venture to rent out mobile hygiene facilities for weddings and events,which will enable ongoing revenue to support our homelessness outreach, HiEHiE Hospitality Project. One strategy Project Vision uses to address the funding challenge is to convene stakeholders and"hui up"funders in order to support greater impact.We have used this strategy to scale up Better Vision for Keiki, bringing funders together and building a group that takes ownership of our proposed solution.This hui is working toward multi-year commitments with public-private buy-in and will continue to pursue dedicated public funding for vision screenings in public schools. Also supporting Better Vision for Keiki,we are pursuing reimbursements by Medicaid/Med-Quest and Children's Health Insurance Program(CHIP).Vision to Learn has led similar efforts in several states in the U.S. 7. Program Objectives Using County Nonprofit Grant Program Funds: Project Vision seeks$25,000 to support WE..A Hui for Health-Hawaii Island, an outreach initiative to bring vision services, health screenings, and human services resources to communities in need. The measurable outcomes are: 1. Project Vision will provide or partner on 30 Community Care events. 2. 1,000 adults will access vision and health screenings. 3. 450 seniors will access vision and health screenings. This program targets three distinct populations: 1)low-income adults;2)low-income seniors; and 3)people experiencing homelessness, including adults,seniors and children.We will serve individuals and families who lack health insurance or are under-insured;those living in remote areas, in shelters, or who are unsheltered; and seniors who desire to maintain sufficient health so they can"age in place,"and stay in their home as long as possible. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: WE...A Hui for Health - Hawaii Island 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results pP (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Number of of community care events on Hawaii Island 30 Number of adults provided vision and health screenings 1,000 Number of seniors provided vision and health screenings 450 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $0 51,000 16,375 Professional Fees Operations 7,000 2,000 Supplies 7,100 2,600 Equipment 3,000 900 Other: Medications and Vitamins 2,825 1,025 Other: Cleaning Fees and Laundry 2,000 600 Other: Miscellaneous 4,500 1,500 Other: Other: TOTAL N/A 77,425 25,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: WE...A Hui for Health - Hawaii Island io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflic exist, eck here. ► �1h1 Signature of Au oriz-d Perso (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 - Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: WE...A Hui for Health - Hawaii Island 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: WE...A Hui for Health - Hawaii Island 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-non profit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returnedto the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. L r I A lv Signature of A tho zed Person (see checklist, 2nd item) Date Elizabeth "Annie" Valentin, Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Project Vision Hawaii Program Name: WE...A Hui for Health - Hawaii Island 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Number of of community care events on Hawaii Island so Number of adults provided vision and health screenings 1,000 Number of seniors provided vision and health screenings 450 TABLE II: FY 19-20 Grant Council . PROGRAM EXPENDITURES Request Award Salary and Wages 16,375 Professional Fees Operations 2,000 Supplies 2,600 Equipment 900 Other: Medications and Vitamins 1,025 Other: Cleaning Fees and Laundry 600 Other: Miscellaneous 1,500 Other: Other: TOTAL 25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Rainbow Friends Animal Sanctuary Community and Pet Spay/Neuter Program 140 County of FIawai`i Nonprofit Grant Application FY2019-20 Agency Name: Rainbow Friends Animal Sanctuary Program Name: Community and Pet S•ay/Neuter Program Agency Director: Machteld Krijgsman Phone No.: (so8) 982 — 5110 Contact Person: Kathy Buono Phone No.: (808) 260 — 0317 Mailing Address: Address: P.O.Box 1259 Address: City,ST,Zip Kurtistown,HI 96760 Facility Address: Address: 17-382 13 Mile Road Address: City,ST,Zip Kurtistown,HI 96760 Email Address: kathy@rainbowlriends.org Fax No.: ( ) — Accountant/CPA: Sau-Yin Yeung (990) Scott Leabman(P&L) p Phone No.: (808) 935 — 5433 Firm (if applicable): Ron Dolan,CPA&Assoc. Harbor Asset Planning Mailing Address: Address: 16A Railroad Ave. P.O.Box 78 Address: City,ST,Zip Hilo,HI 96720 Belmont,MA 02478 Phone:(617)826-3004 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $32,775 Geographical Areas To Be Served: (One or more can be checked) ✓❑Puna ❑Hamakua ❑North Kona ✓❑South Hilo ❑North Kohala ❑South Kona ❑North Hilo 0 South Kohala ❑Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ❑Victims of Health or Social Crises ®Needs of the poor ❑Physical/Emotional Disabilities ✓❑Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Rainbow Friends Animal Sanctuary Program Name: Community and Pet Spay/Neuter Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0.00 $0.00 $5,550.00 2.Agency Mission Statement: People Helping Animals-Animals Helping People To assist Hawaii County residents in alleviating the animal abandonment and overpopulation issues facing our island,as well as promoting the social,emotional and health benefits of animal companionship. Rainbow Friends Animal Sanctuary is dedicated to the well-being of both Hawaii Island's residents and the unwanted,abandoned,abused or otherwise neglected cat and dog companion animals and feral cats.Its services include educating the public on responsible pet ownership,spay/neuter clinics, rescuing,fostering,provision of food,medical care and safe sheltering of these animals until they can be permanently placed into caring and responsible homes or allow them to live out their lives at the Sanctuary or foster locations or return them to their companions. 3. Program Description: Cat and dog overpopulation still remains a significant and heartbreaking problem as evidenced by intake of strays and owner surrenders at the Kea'au branch of the Hawaii Island Humane Society(HIHS)(average of 581/month)and the number of calls to Rainbow Friends from residents.—500 calls/month are received of which—30%are requests to take in dogs or cats. Rainbow Friends will conduct one cat clinic(sterilizing—70 cats)and one dog clinic(sterilizing—35 dogs)per month. Professional fees include all supplies needed for the surgeries,e.g.anesthesia,sterile surgical instruments,gloves,gauze,etc. Supplies include wellness items such as flea treatment and dewormer.Salaries and Wages include one vet tech per clinic at $150/day.Vet techs are in short supply so offering payment will attract the skills we need.Our clinics are always full with a waiting list.We also conduct mini-clinics of—10-12 animals several times a month to accommodate those who have an immediate need.We have been successful helping to curtail the overpopulation of pets through education and provision of free spay/neuter services.Our efforts have been well-received by grateful residents but the work is not yet done.The target population for the free clinics is the Puna district. Puna pet owners have limited financial resources for even the most basic health care for their pets,let alone spay/neuter.They also want to help community(feral)cats live better lives.The natural disasters of this past year have contributed to the need for those low-income residents who have lost all to the lava or flooding. Experienced Rainbow Friends'volunteers work tirelessly with the vet team to run efficient,free clinics.We feel it is imperative to continue this life-saving work. Rainbow Friends also educates the public on the need to reduce the population of stray or abandoned animals through the spaying and neutering of their companion animals,promotes responsible companionship with animals by educating the public on the need to have their pets wear identification,instructs as to the proper care of pets and provides resources for pet care. 4.Total Budget&Position Count: Total Program Budget: $84,900.00 Total Program Position Count: 9 Total Agency Budget: $392,736.72 Total Agency Position Count: 40 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Rainbow Friends Animal Sanctuary Program Name: Community and Pet Spay/Neuter Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Petco Foundation(TBD) $5,000.00 Petsmart Charities(TBD) (CY2020) $37,125.00 Hawaii Community Foundation (TBD) $5,000.00 Private Donations(TBD) $5,000.00 TOTAL: $52,125.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: - Rainbow Friends Animal Sanctuary has submitted a proposal to the state requesting funding for a Director of Development. This Director's key duties would include raising the needed funds for operations,capital improvements and an endowment to sustain our mission in perpetuity from local community outreach and solicitation of donors nationwide. - The Sanctuary is a member of the National Association of Nonprofit Organizations&Executives.As a member,access to the National Development Institute's fundraising platform has assisted us in building a system that will allow us to create campaigns that will attract donors. - Rainbow Friends utilizes social media to fundraise and holds fundraising events throughout the year. - PetSmart Charities have supported us in the past and are currently supporting Rainbow Friends with a$37,125 grant for spay/neuter for CY2019.The funding will support five months of free spay/neuter clinics(632 dogs and cats),starting February 2019 and ending June 2019.This is the only confirmed funding Rainbow Friends currently has for spay/neuter.Another request will be submitted for CY2020 later this year,which would apply to the second half of the county FY. - A grant proposal was submitted to the Petco Foundation in September 2018 requesting$51,000 for spay/neuter(200 owned dogs,300 owned cats,500 feral cats).We are awaiting the decision of the Foundation but history has shown we usually receive only a portion of the request.Last year we received$5,000.00. - Applications for funding will be submitted to other grant possibilities yet to be identified. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objective of this program is to assist economicallydisenfranchised Hawaii Island residents with the spay and neuter needs of P 9 PY their companion and community animals.These residents care deeply for these animals and depend on them for emotional support.Residents are heartbroken when they see community(feral)cat colonies growing and when they don't have the means to prevent their own pets from reproducing.Many residents who contact us have contacted HIHS but their clinics are full and all the coupon vouchers are given out the first few days of the month.Additional spay/neuter services are needed. By holding one cat and one dog spay neuter clinic per month,along with several mini-clinics per month,we can and have made an impact.But, we can do more with more funding. PetSmart Charities funding of$37,125 for CY2019 will fund our clinics through June 2019. The requested$32,775.00 from the county,in addition to the possible funding from the revenue sources cited above,will fund FY2019-2020.During the 12-month county FY,approximately 39 dogs and 86 cats will be spayed and neutered each month for free for a total of 1,500 animals.The ultimate objective is to decrease the number of dogs and cats born,which in turn,will decrease the number of animals entering HIHS resulting in a decrease of shelter deaths at the Humane Society that will lead to a no-kill environment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Rainbow Friends Animal Sanctuary Program Name: Community and Pet Spay/Neuter Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) One cat spay/neuter clinic per month sterilizing 70 cats ;840 cats sterilized One dog spay/neuter clinic per month sterilizing 35 dogs 420 dogs sterilized Two mini clinics per month sterilizing 4 dogs and 16 cats 240 dogs and cats sterilized Residents served per month(many bring more than one cat)35-86 420-1030 residents Residents served per month(many bring more than one dog)15-39 180-468 residents 80 Volunteer hours/month cat clinics 960 volunteer hours 80 Volunteer hours/month dog clinics 960 volunteer hours Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $0.0 $3,600.00 $3,600.00 Professional FPPS $62,336.23 $66,300.00 $22,275.00 Operations $250.00 $0.00 $0.00 Supplies $10,737.75 $15,000.00 $6,900.00 Equipment Other: Other: Other: Other: Other. TOTAL $73,323.98 $84,900.00 $32,775.00 *If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Rainbow Friends Animal Sanctuary Program Name: Community and Pet Spay/Neuter Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer,director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. c-A2C(A7)1 ,/0 . 6/11d(Al49 joi Signature o uthorized Person (specify title) ate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 ISI County of FIawai`i Nonprofit Grant Application FY2019-20 Agency Name: Rainbow Friends Animal Sanctuary Program Name: Community and Pet Spay/Neuter Program 11.Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code,relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Rainbow Friends Animal Sanctuary Program Name: Community and Pet Spay/Neuter Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I(we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.govffn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report.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. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. cea4 . is.u,e)yit-- //3//(2?0/ Signature of Au rized Person (see checklist, 2nd item) Date i V / / / , Title/Position of Authorized Person EXHIBITA NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Rainbow Friends Animal Sanctuary Program Name: Community and Pet Spay/Neuter Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result One cat spay/neuter clinic per month sterilizing 70 cats 840 cats sterilized One dog spay/neuter clinic per month sterilizing 35 dogs 420 dogs sterilized Two mini clinics per month sterilizing 4 dogs and 16 cats 240 dogs and cats sterilized Residents served per month(many bring more than one cat)35-86 420-1030 residents Residents served per month(many bring more than one dog)15-39 180-468 residents 80 Volunteer hours/month cat clinics 960 volunteer hours 80 Volunteer hours/month dog clinics 96ovolunteer hours TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $3,600.00 Professional Fees $22,275.00 Operations $0.00 Supplies $6,900.00 Equipment Other: Other: Other: Other: Other: TOTAL $32,775.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Salvation Army - Family Intervention Services, The Cultural Program 141 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army - Family Intervention Services Program Name: Cultural Program Agency Director: Roxanne E. Costa, Executive Director Phone No.: (808) 959 — 5855 Contact Person: Same as Above Phone No.: ( ) — Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1786 Kino'ole Street Address: City,ST,Zip Hilo, HI 96720 Email Address: roxanne.e.costa@usw.salvationarmy.org Fax No.: (sos ) 959 — 2301 Accountant/CPA: Cary Ebesugawa Phone No.: (808 ) 959 — 5855 Firm (if applicable): Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army - Family Intervention Services Program Name: Cultural Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 N/A N/A N/A 2. Agency Mission Statement: "To provide youth with the skills for a healthy life, and instill purpose, hope, and vision to youth and their families." This is the philosophy that guides us in the implementation of services. It is our belief that in order to succeed, youth must feel a sense of belonging to their community,their culture,their peers, and within their families. 3. Program Description: The Salvation Army-Family Intervention Services(TSA-FIS)Cultural-Based Program provides a safe and nurturing environment along with access to opportunities, experiences, and services to support cultural identity positive youth development and prevention of risky behaviors. We utilize a prevention approach to address risk factors and increase protective factors. Program services are offered to youth ages 10-21 in East Hawaii. The main goals of this program are:to encourage each participant to develop their own sense of cultural identity, increase their knowledge and skills, and be able to then utilize those skills to help others in their community. Program services include the implementation of our Ahupua'a"From the Mountain to the Sea"curriculum that promotes fundamental life skills through the combination of concepts and skills that have been derived from many different resources. It is also a blending of western and native ideas that teach individuals how to navigate the modern world with the same core values that were held by our ancestors. Program activities build upon the the Ahupua'a curriculum which include skill building opportunities such as basic water safety, First Aid and CPR, environmental conservation, native plant identification, hiking, canoe paddling and education on the fundamentals of safety and preparedness. In addition,youth take part in community service learning projects and other activities that increase community connectedness and family strengthening. 4. Total Budget& Position Count: Total Program Budget: 70,000 Total Program Position Count: 6 Total Agency Budget: 4,000,000 Total Agency Position Count: 65 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army - Family Intervention Services Program Name: Cultural Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Department of Human Services-Office of Youth Services 60,000 County of Hawaii 10,000 TOTAL: 70,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services continuously explores funding avenues in the private, State and Federal sectors to continue and enhance program services. We annually seek grants and partnerships to build our program services and to address the increase of services requested in our communities. In line with our mission and the work that we do,we do rely heavily on funding at all levels of government. 7. Program Objectives Using County Nonprofit Grant Program Funds: Of the 50 youth targeted for participation in the Cultural-Based Program in East Hawaii, 80%will demonstrate an increase in competencies through the Ahupua'a Curriculum. Of the 50 youth,70%will participate in activities that promote cultural awareness and identity, community service learning projects and social skill building opportunities. Of the 50 youth and their families, 50%will participate in family activities that promote family strengthening and connection to community resources and services. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army - Family Intervention Services Program Name: Cultural Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) • Completion of the Ahupua'a Curriculum Program 40 Culutral Awareness/Service Learning/Social Skill Building Activities 35 Family Engagement Activities 25 • Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 42,201 Professional Fees 8,140 1,000 Operations 8,499 Supplies 5,760 4,800 Equipment Other: Program Activites 5,400 4,200 Other: Other: Other: Other: TOTAL 70,000 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of awai` Nonprofit Grant Application FY2019.20 Agency Name: The Salvation Army Family Intervention Services Program Name: Cultural Program so; ORGANIZATION CONFLICTDISCLOSURE Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as neededto fully disclose. Alldisclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ . The Mayor O The Managing Director Cj The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability,that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to on industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflictsof interest: J❑ . If no conflicts exist,check here. p, , - Divisional Secretary for Business "Z-2—• Sign. Z - Sign. of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army Family Intervention Services Program Name: Cultural Program is. Certification of Understanding (Page 1 of 2) 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—2-142.1,Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I(we)agree to allow the County(the Legislative Auditor, the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility, equipment,property,or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express,and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov,complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractualyear for which the grant was awarded,The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusingon specific, measurable outcomes),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,using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army Family Intervention Services Program Name: Cultural Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i,I(we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided,to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit thefinal report within 60 days of June 30th shall result in loss of all grant funds receivedduring the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and. accepted by,the council. I(we)understand there is no provision for further notification to submit the final report. Information and instructions are available at htp://www.hawaiicounty.gov/fn-nonprofit=grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019.must be returned to the County of.Hawaii .with the final report.Failure to return these funds in a timely manner.will impact the evaluation of your agency's future funding request and may result in actionstaken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials, insurance or securities)on private properties unless otherwise authorized by.law. By signing below,you are acknowledging that you have read and understood these requirements.. Sign., ire of Authorized Person(see checklist,2nd item) Date ac1'✓J ,C,Cfz ati -firc55)Yl t ( ) 7 LZ;S Title/Position of Authorized Person EXHIBIT'A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army - Family Intervention Services Program Name: Cultural Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Completion of the Ahupua'a Curriculum 40 Culutral Awareness/Service Learning/Social Skill Building Activities 35 Family Engagement Activities 25 • TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees 1,000 Operations Supplies 4,800 Equipment Other: Program Activites 4,200 Other: Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Salvation Army - Family Intervention Services, The Hawaiian Cultural Program 142 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army-Family Intervention Services Program Name: Hawaiian Cultural Program Agency Director: Roxanne Costa Phone No.: (808) 959 - 5855 Contact Person: Annette Honda Phone No.: (808) 323 - 8081 Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: 82-6130 Mamalahoa Hwy. Building 3 Address: City,ST,Zip Captain Cook, Hawaii 96704 Email Address: annette.honda@usw.salvationarmy.org Fax No.: (808 ) 323 - 8084 Accountant/CPA: Cary Ebesugawa Phone No.: (808 ) 959 - 5855 Firm (if applicable): Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ❑South Hilo ❑✓ North Kohala ❑✓ South Kona ❑ North Hilo ['South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) [' Educational concerns ❑✓ Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army-Family Intervention Services Program Name: Hawaiian Cultural Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 NA NA 5,050 2. Agency Mission Statement: The Salvation Army's Mission Statement: "To preach the gospel of Jesus Christ and to meet human needs in His name without discrimination." The Salvation Army-Family Intervention Services Mission Statement: "TO PROVIDE YOUTH WITH SKILLS FOR A HEALTHY LIFE AND TO INSTILL PURPOSE, HOPE AND VISION TO YOUTH AND THEIR FAMILIES"is our mission statement and represents the philosophy we strive towards. It is our belief that in order to succeed,youth need to have a sense of belonging with their community,their culture,with their peers and most importantly with family. When this is achieved, opportunities come forth, involvement of the community become prevalent and both the youth and family experience growth. 3. Program Description: The Hawaiian Cultural program is designed to assist all youth participating in our"The Salvation Army-Family Intervention Services"(TSA-FIS)programs. We propose to provide our participants a cultural program perpetuating their culture and host culture encompassing sustainability for our generation and future generations. The program will seek to teach our youth and their families cultural practices and approaches in the hope that they will become stronger and be connected to their communities. We will focus on the concepts of ALOHA and integrate these ideas into daily living. The following traits of character that express the charm,warmth and sincerity of Hawai'i's people,the working philosophy of Native Hawaiians and was presented as a gift to the people of Hawai'i are the following: "Akahi,"meaning kindness,to express with tenderness; "Lokahi,"meaning unity,to be expressed with harmony; "Oluolu,"meaning agreeable,to be expressed with pleasantness; "Haahaa,"meaning humility,to be expressed with modesty; "Ahonui,"meaning patience,to be expressed with perseverance. We have incorporated the"Spirit of Aloha"guiding themes provided by the Native Hawaiian Education Council(NHEC). These guiding themes include: 1. 'Ike Pilina(Value of Relationship) 5. 'Ike Ho'oko(Value of Applied Achievement 2. 'Ike Mauli Lahui(Value of Cultural Identity) 6. 'Ike Piko'u(Value of Personal Identity 3. 'Ike Kuana'Ike(Value of Cultural Perspective) 7. 'Ike Honua(Value of Place 4. 'Ike Na'auao(Value of Intellect) We will provide the Cultural Curriculum in 9 sessions each quarter. 4. Total Budget& Position Count: Total Program Budget: 70,000 Total Program Position Count: 6 Total Agency Budget: 4,000,000 Total Agency Position Count: 65 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army-Family Intervention Services Program Name: Hawaiian Cultural Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii 10,000 Department of Human Services-Office of Youth Services 60,000 TOTAL: 70,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services constantly explores new funding avenues in the private, State and Federal sectors to support and enhance program services. We annually seek grants and/or partnerships to build program services. In harmony with our mission statement and the services we provide,we still rely heavily on funding at all levels of government including the County of Hawai'i. 7. Program Objectives Using County Nonprofit Grant Program Funds: Out of the 50 youth, ages 10-21 participating in our program,37 will successfully complete the Hawaiian Cultural Program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army-Family Intervention Services Program Name: Hawaiian Cultural Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Provide Intake and Assessment Services 50 Particpation in at least 5 sessions 37 Participation in activities provided 37 Participation in Kihe Making 37 Participation in Ho'ike 37 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 18,651 41,352 Professional Fees 2,911 8,140 1,000 Operations 2,577 8,508 Supplies 742 6,000 4,800 Equipment Other: Program Activities 1,023 6,000 4,200 Other: Other: Other: Other: TOTAL 25,904 70,000 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 810SaSed O Oz-6IOz NOu.vIndddiNVJ)J.IUOtIdNON VIrelHX3 ales' (allll Ajpads)laved pazpoglnv JO leugIS t,I ` I .. sszutsn2.d CJ ,J.1Y:T, 1 ..C'tq lit i_ lop .. .. .. •a.lay)jaayp'IS!X SP11Juo3 OU�! :Isaiah)!jo slDllduo3 le lualod.lo SlnIuo3 Age'a3ueJeadde Jo 13e u! ' lone o�sainseaw uoi eSl lw a ue Aue pads asea 3 p .l 3 i0 p � id . . Aosn ul uo a� oiaua6 ur&gamy s1!aua oa asoddo soon ►,qua .)o;6ulni��o sar aua. p t � g t? 1 P Pl g .� R pa.itp atgomsaaw ut tfnsar ttlM 1Qnptnrput UV/to ua4o1 uo 20;u n rt7rtrgagaad lopuolsgns o:se pau jap sm isa.saiul#o pluuao lesunop uolleJodroD Alndao e JO'lasunop uolleJodJoa luelsissv ayl'lasunoj uoile.iodio ayeE a3ueu j Jo aolaaaltiayl0 aolaaila Sul2euein ayl : [� JoAelAJ.ay. . 0 1p3unop ayl Jo Jaquaw e Aq palulodde DEIS nzunoa siagg.laUJ Jo Jaw-gain :(Aldde legl iie 3ay3)BulmoIod aqua Age yllnl'diysuollelas leiiluael hue SulpnpuI 'lsa.ialu!jo ionjuo leilualod.Jo lali.uoa e aney Rely N0WSOd :31AWN 's4sixa..7gjuoa o Jawatirvi Jo ssaepJobad 'paubrs aq jsnui swioj aansopslp tfv 'asopslp Allnj al papaau se aleoudnp aseaid •palliuigns aq pl spaau papaya uotldo„ls!xa s13!uuo3 o j,,ayl yalrw'uollezlue Ja aye JQJ UJJ®J auo 'lsrxa spq uo3 ou jl •papaau s!13!guo3 e ylIM uosJad iad LuJoJ euo•pasopslp:aq of paau nno apals!!aso 1/quo l !arms o Aluno a 3 yl!nn aAeg AEU!uollezluegio JnoA o JoleilsIultu a Jo `JOPailp'aaDIJJO'iagwaw pieoq Aim leyl lsaJalu!Jo s131lJuo3 lellualod`JO slalIJuo3Aue asopslpaseaid tat ,. WeJ6oad ueHeme :aulep ure.12O.1d seoIAJG9 uo!jue e.l11 AHWEd-ALLIJV U0119AIeS 9L JADuaSy .attxte uo11. oij lutio igoiduomi pmE jo /ClutioD County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army-Family Intervention Services Program Name; Hawaiian Cultural Program 11.Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating.to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility,equipment, property,orrecords pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express,and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov,complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT iiRANTAPPLICATION FY 2019-2020 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY201.9-20 Agency Name: The Salvation Army-Family Intervention Services Program Name: Hawaiian Cultural Program is.Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i,I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence)must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s): I(we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future rant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I(we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that anyfunds awarded will be restricted for the purposes stated in the application,except for a maximumtenpercent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with thefinal report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. _I.rff Signa";,re of Authorized Person(see checklist,2nd item) Date. i )51C- Uctv5 Title/Position of Authorized Person EXHIBIT A . NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army-Family Intervention Services Program Name: Hawaiian Cultural Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Participation in Intake and Assessment Services 50 Participation in at least 5 sessions 37 Participation in Activities provided 37 Participation in Kihe Making 37 Participation in Ho'ike 37 • TABLE II: PROGRAM EXPENDITURES FY 19-20 Grant Council Request Award Salary and Wages Professional Fees 1,000 Operations Supplies 4,800 Equipment Other: Program Activities 4,200 Other: Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Salvation Army - Family Intervention Services, The Independent Living Skills Program 143 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army-Family Intervention Services Program Name: Independent Living Skills Program • Agency Director: Roxanne Costa Phone No.: (808) 959 — 5855 Contact Person: Annette Honda Phone No.: (808) 323 — 8081 Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: Kona Civic Center Bldg. 3 • Address: 82-6130 Mamalahoa Hwy. • City,ST,Zip Captain Cook, Hawaii 96704 Email Address: annette.honda@usw.salvationarmy.org Fax No.: (808 ) 323 — 8081 Accountant/CPA: Cary Ebesugawa Phone No.: (808 ) 959 — 5855 Firm (if applicable): Mailing Address: Address: Address: P.O. Box 5085 City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ❑South Hilo ❑✓ North Kohala ❑✓ South Kona ❑ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army-Family Intervention Services Program Name: Independent Living Skills Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 16,250 9,250 5,175 2.Agency Mission Statement: The Salvation Army's Mission Statement: "To preach the gospel of Jesus Christ and to meet human needs in His name without discrimination." The Salvation Army-Family Intervention Services Mission Statement: "TO PROVIDE YOUTH WITH SKILLS FOR A HEALTHY LIFE AND TO INSTILL PURPOSE, HOPE AND VISION TO YOUTH AND THEIR FAMILIES"is our mission statement and represents the philosophy we strive towards. It is our belief that in order to succeed,youth need to have a sense of belonging with their community,their culture,with their peers and most importantly with family. When this is achieved, opportunities come forth, involvement of the community become prevalent and both the youth and family experience growth. 3. Program Description: The Independent Living Skills program is designed to help foster youth, emancipated youth and voluntary extended foster care young adults ages 12-26 to prepare for and manage the transition to productive self-sufficiency in adulthood with a essential base of independent living skills. The Goals 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 and 3)provide linkages and resources to services in the community including: housing, health care/insurance, career opportunities and other vital needs. According to the 2017 Child Welfare League of America, Hawaii's Children 2017, 1360 children lived apart from their families in an out of home setting in 2015. A growing body of research suggests that youth who exit the foster care system without stable relationships and supports to help them navigate during this development transition are at risk of a number of poor outcomes across several domains including: lacking a high school diploma or GED;economic hardship; greater risk of physical and mental health issues; and higher risks of unplanned pregnancy and involvement in the criminal justice system. (Hawaii Kid's Count, Fall 2012) Our Independent Living Skills program is in line with national and local strategies to help diminish the challenges faced by transitioning aged out foster youth. The proposed budget here in supports our operational cost for this program. For foster youth over the age of 18 and attending college,the program provides supportive services each month with the distribution of higher education vouchers,financial aid assistance, career planning and academic counseling. 4. Total Budget& Position Count: Total Program Budget: 101,038 Total Program Position Count: 7 Total Agency Budget: 4,000,000 Total Agency Position Count: 65 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army-Family Intervention Services Program Name: Independent Living Skills Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii 10,000 Department of Human Services 91,038 TOTAL: 101,038 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services constantly explores new funding avenues in the private, State and Federal sectors to support and enhance program services. We annually seek grants and/or partnerships to build program services. In harmony with our mission statement and the services we provide,we still rely heavily on funding at all levels of government including the County of Hawaii. 7. Program Objectives Using County Nonprofit Grant Program Funds: Of the 30 foster youth, ages 12-26 participating in this program,75%with successfully complete and benefit from their Independent Living Skills program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army-Family Intervention Services Program Name: Independent Living Skills Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results • (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Completion of Independent Living Skills Intake and Assessment 30 Participation in Independent Living Skills Activities 20 Participation in Higher Education Services 15 Participation in Voluntary Extended Care Services 10 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req - Salary and Wages _ 25,726 _65,305 _ _ Professional Fees 4,015 11,183 1,240 Operations 5,524 17,707 5,160 Supplies 846 3,243 2,400 Equipment Other: Program Activities 1,804 3,600 1,200 Other: Other: Other: Other: TOTAL 37,915 101,038 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County ofHawaii'i Nonprofit Grant Application. 19-20 Agency Name: The Salvation Army-Family Intervention Services - Program Name: independent Living Skills Program is ORGANIZATION COrkilFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hewer].Only those listed below need to be disclosed.One form per person with a,conflict is needed: If no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted.. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists, NAME:. POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council. ❑ The Mayor O The Managing Director O T he Director of Finance ❑ The Corporation Counsel,the.Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid,in fact or appearance,any conflicts or potential conflicts of interest: ® If no conflicts exist,check here. Efiffi i,�' Divisional Secreta for Business Ti--- Sig rare of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 I County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army-Family Intervention Services Program Name: Independent Living Skills Program 11. Certification of Understanding (Page 1 of 2) 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- 135-2-142.1,Hawai'i County Code,relating to Appropriation of Funds to Nonprofit Organizations: I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility,equipment,property,or records pertinent to the grant,contract,or . program for which funds were used. I (we)hereby certify that information supplied herein, including all supporting documents,is correct and that l(we) have the authority and ability to fully administer the program(s)pursuant to law. I (we) understand that informationsupplied 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 receiving 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 requiringa current 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 enroll with Hawai'i Compliance Express,and be compliant prior to receiving payment(s). To register,go to.http://vendors.ehawaii.gov,complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 g 40 L aged OZOZ•6T0Z AJ NOILVDllddV 1NVH911UO2ldNON V 118IHX3 uosaad paz!aoyiny;o uo!i!sod/ali!1 SPV 1 Sal 71)14,1 S c(wai!puZ'islpp p eas).uosaad pazpoypnyjo u2!g /PR jr.� I •sluawaJ!nbal asap pooisaapun pue peal anal noA iegi SuPpalmouae aie noA'►v►o!aq.Su!uS!s Ag 'MEI Aq pazpoyine as!wuaq o ssalun sapiadoad aieitpd uo(sa! Jnaas Jo aaueansu!'sie aa;eui'uo!ian4isuo3 Jo;soO)s;uawanoadwi lei!de3 ao}spun;apinoad;ouuea spaennd •spun'asayi.1anooaa of uaioi suo!P0 u!;tnsa r Aow oun;sanbar burpunf aininf s,Aauabo.rnoAJo uoaonlona,ayp.iaodwr wm Jauuout ARLIN o u!spun!asatp urnia r o;aanwol leu!i ayi 1.11!m !,!emeH 3o diuno0 a43 of pauaniai aq isnw 6T0Z 'OE:aunt Aq pasnun spun; Auy •siso3 peayaano pue an!ieais!u!wpe Jo;(%oI)ivaaaad uai wnw!xew e ao;idaaxa'uo!iep!Idde ayi u! paieis sasodand ayi Ali paiopisaa aq!pm papieme spun;Aue ieyi a8pa!moulae noA:'uonea!ldde s!yi 3o iced sy -anp s!iaoda i !eu!;ayi aeaA ayi jo 0E Ae!m inoge ao uo/swJoJ-iueJS-ado.iduou-u3/noB•AiunoD!!emewmmm//:duy ie aigel!ene a.+e suo!ipnaisu! pue uo!lewao;ui •podaa leug ayi ilwgns of uopeDgpou iayian;ao;uols!noad ou sr alayi puelsaapun(ann)i •!!aunoa ayi'Aq paidaaae pue'o3 pawwgns,st .iodaa uallpann a Il;un ao aea auo;o wnw!u!uw e ao;uo!;edp!iaed;ueJS aurin} woe;uo!snpxa pue(Aiunop of papun;aa aq;snw)po!aad;uead ayi Supnp panlaaaa spunk iuea2 ile;o ssoi u!iinsa.+ !legs y,0s aunt jo sAep 09 u!yf!nn iaodaa leu!;alp i!wgns of aanl!ej ieyi pueisaapun (am) i •(s)ivawAed Aue Sul/gape.' ao!ad paansu! leuowppe ue s!!,!emeH 3o A4unoj ayi legs saiea!pu!Applidxa pue Allen!jpads tonim'ivawiaeda0 a3ueuid !,!emey;o Aiuno0 ayi of papinod aq isnw (aauaiJnaao yaea 000'os$'Ai!!!ge!! league 000'0001$) Ai!ime!-I;oa2e3!;liaa0 iva.un3 a puelsaapun (am) i'L emey;o Aiuno)ayi woad iuea;i e papaeme ji (z 40 Z aged) 2uipuelsiapun uoi3epgt.paD it Wwa60id WAS 5uinii luapuedapui :auzeN W11 Oad sa3uues uoguatualu) AI!uaed-Auaay uogenies eq1 :atueN 1C3ua2v OZ-61 OZAd uoi uollddV lutio lgoiduoN mumBH Jo iclunoj County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army-Family Intervention Services Program Name: Independent Living Skills Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result • Completion of Independent Living Skills Intake and Assessment so Participation in Independent Living Sills Activities 20 Participation in Higher Education Services 15 Participation in Voluntary Extended Care Services 10 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees 1,240 Operations 5,160 Supplies 2,400 Equipment Other: Program Activities 1,200 Other: Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Salvation Army - Family Intervention Services, The Kea'au Prevention and Outreach Programs 144 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army - Family Intervention Services Program Name: Keaau Prevention and Outreach Programs Agency Director: Roxanne E. Costa, Executive Director Phone No.: (808) 959 - 5855 Contact Person: Same as Above Phone No.: ( ) — Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1786 Kino'ole Street • Address: City,ST,Zip Hilo, HI 96720 Email Address: roxanne.e.costa@usw.salvationarmy.org Fax No.: (808 ) 959 - 2301 Accountant/CPA: Cary Ebesugawa Phone No.: (808 ) 959 - 5855 Firm (if applicable): Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona ❑South Hilo [' North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities [' Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army - Family Intervention Services Program Name: Keaau Prevention and Outreach Programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 13,125 10,125 4,800 2. Agency Mission Statement: "To provide youth with the skills for a healthy life, and instill purpose, hope, and vision to youth and their families." This is the philosophy that guides us in the implementation of services. It is our belief that in order to succeed,youth must feel a sense of belonging to their community,their culture,their peers, and within their families. 3. Program Description: The Salvation Army-Family Intervention Services(TSA-FIS)Keaau Prevention and Outreach Programming provides a safe and nurturing environment along with access to opportunities, experiences, and services to support positive youth development, and prevention of substance use, and other risky behaviors. Services are offered to youth ages 10-21 and their families residing in the Keaau communities. We utilize a prevention approach to decrease the use and abuse of alcohol,tobacco and other illicit drugs, involvement in gangs and violence, delinquent behaviors,early sexual behaviors,family conflict,and to improve academic performance and truancy. Program services and activities include the implementation of evidence-based curriculum sessions that promote fundamental life skills; community service learning projects to increase community connectedness;family engagement opportunities to support family strengthening; and cultural-based activities to honor all cultural identities and ensure cultural competency. 4. Total Budget& Position Count: Total Program Budget: 110,000 Total Program Position Count: 8 Total Agency Budget: 4,000,000 Total Agency Position Count: 65 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army - Family Intervention Services Program Name: Keaau Prevention and Outreach Programs 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii 10,000 Department of Health-Substance Abuse Prevention 100,000 TOTAL: 110,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services continuously explores funding avenues in the private, State and Federal sectors to continue and enhance program services. We annually seek grants and partnerships to build our program services and to address the increase of services requested in our communities. In line with our mission and the work that we do,we do rely heavily on funding at all levels of government. 7. Program Objectives Using County Nonprofit Grant Program Funds: Of the 60 youth targeted for participation in the Prevention and Outreach Programs in Keaau (upper Puna), 80%will demonstrate an increase in competencies through the Botvin Life Skills Training Curriculum. Of the 60 youth, 70%will engage in Positive Alternative Activities including cultural awareness, community service learning projects, and youth leadership and peer mentoring opportunities. Of the 60 youth and their families, 50%will participate in family activities that promote family strengthening and connection to community resources and services. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army - Family Intervention Services Program Name: Keaau Prevention and Outreach Programs 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Completion of the Botvin LifeSkills Training Curriculum 48 Positive Alternative Activities 42 Family Engagement Activities 30 Follow-up and Monitoring Services 60 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 36,820 63,861 Professional Fees 5,483 12,260 1,300 Operations 4,147 19,839 4,440 Supplies 1,887 6,240 2,460 Equipment Other: Program Activities 2,509 7,800 1,800 Other: Other: Other: Other: TOTAL I 50,846 110,000 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of : a at`i Nonprofit Grant Application FY2019-20' Agency Name: The Salvation Army Family Intervention Services Program NameKeatau Prevention and Outreach Programs 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any boardmember,officer,director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose: Al!disclosure forms must be signed, regardless of whether a conflict exists. NAIv E POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that apply).: ❑ Member or members of the Council ❑ Staff appointed by a member of the Council Li The Mayor ❑ The Managing Director El The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel., Conflict of Interest is defined as:o substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid,-in fact or appearance,any conflicts or potential conflicts of interest: If no conflicts exist,check here. '44j r�,/ iIvisional Secretary for Business Siirf _' 'ure of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County-of Hawai`i Nonprofit Grant Application FY2019 2Q Agency Name: The Salvation Army Family Intervention Services Program Name: Kea'au Prevention and Outreach Programs 11.Certification of Understanding(Page 1 of 2) 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- 135-2-142.1,Hawaii County Code,relating to Appropriation of Funds to Nonprofit Organizations.' I (we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full, free,and unrestricted access and authority • to examine and inspect any facility,equipment,property,or records pertinent to the grant,contract,or program for which funds were used. 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 bemade public according to Chapter92F, Hawaii Revised Statutes. I (we)understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibility to ensure that all documents are completeand accurate prior to.submittal. I (we) understand'.that all documents requiring a current signature must be the.ORIGINAL,SIGNED. document.Unsigned documents will be disqualified. Faxed or copied documents will not be accepted. as original documents. If awardeda grant from the County of Hawaii,I(we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express,and be compliant prior to receiving. payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process,. . and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply withthe reauirement to submit a year-end report to the County Council within 60 days after June 30of the contractual year. for which the grant was awarded.The report,using the template provided;shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific,.• measurable outcomes),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. using the template provided, will Impact the evaluation of your program's or agency's future funding requests: EXHIBITA. NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army Family Intervention Services Program Name: Kea'au.Prevention and Outreach Programs 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County '�of Hawaii, I(we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence)must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured rior to p receiving any payment(s). I(we)understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report.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: Awards cannot provide funds for Capital Improvements(Cast of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law: By signing below,you are acknowledging that you have read and understood these requirements. r AV _ � `r G/;;2i/ici t Signature of Authorized.Person(see checklist, 2nd item) Date 1 (dl S)an ccre_-.1-341Cv(Fics.)Il't-65S Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army - Family Intervention Services Program Name: Keaau Prevention and Outreach Programs 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Completion of the Botvin LifeSkills Training Curriculum 48 Positive Alternative Activities 42 Family Engagement Activities 30 Follow-up and Monitoring Services 60 • • TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees 1,300 Operations 4,440 Supplies 2,460 Equipment Other: Program Activities 1,800 Other: Other: Other: Other: TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Salvation Army - Family Intervention Services, The Pahoa Prevention and Outreach Programs 145 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army - Family Intervention Services Program Name: Pahoa Prevention and Outreach Programs Agency Director: Roxanne E. Costa, Executive Director Phone No.: (808) 959 - 5855 Contact Person: Same as Above Phone No.: ( ) — Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1786 Kino'ole Street Address: City,ST,Zip Hilo, HI 96720 Email Address: roxanne.e.costa@usw.salvationarmy.org Fax No.: (808 ) 959 - 2301 Accountant/CPA: Cary Ebesugawa Phone No.: (808 ) 959 - 5855 Firm (if applicable): Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION-CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) [' Puna ❑ Hamekua ❑ North Kona ❑South Hilo ❑ North Kohala ❑South Kona ❑ North Hilo ❑South Kohala ❑ Ka'O Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ['Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ['Victims of Health or Social Crises ❑ Needs of the poor [' Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army - Family Intervention Services Program Name: Pahoa Prevention and Outreach Programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 13,250 7,625 4,800 2. Agency Mission Statement: "To provide youth with the skills for a healthy life, and instill purpose, hope, and vision to youth and their families." This is the philosophy that guides us in the implementation of services. It is our belief that in order to succeed, youth must feel a sense of belonging to their community, their culture,their peers, and within their families. 3. Program Description: The Salvation Army-Family Intervention Services(TSA-FIS)Pahoa Prevention and Outreach Programming provides a safe and nurturing environment along with access to opportunities, experiences, and services to support positive youth development, and prevention of substance use, and other risky behaviors. Services are offered to youth ages 10-21 and their families residing in the Pahoa communities. We utilize a prevention approach to decrease the use and abuse of alcohol,tobacco and other illicit drugs, involvement in gangs and violence, delinquent behaviors, early sexual behaviors, family conflict, and to improve academic performance and truancy. Program services and activities include the implementation of evidence-based curriculum sessions that promote fundamental life skills; community service learning projects to increase community connectedness;family engagement opportunities to support family strengthening; and cultural-based activities to honor all cultural identities and ensure cultural competency. 4. Total Budget& Position Count: Total Program Budget: 110,000 Total Program Position Count: 8 Total Agency Budget: 4,000,000 Total Agency Position Count: 65 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army - Family Intervention Services Program Name: Pahoa Prevention and Outreach Programs 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii 10,000 Department of Health -Substance Abuse Prevention 100,000 TOTAL: 110,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army-Family Intervention Services continuously explores funding avenues in the private, State and Federal sectors to continue and enhance program services. We annually seek grants and partnerships to build our program services and to address the increase of services requested in our communities. In line with our mission and the work that we do,we do rely heavily on funding at all levels of government. • 7. Program Objectives Using County Nonprofit Grant Program Funds: Of the 60 youth targeted for participation in the Prevention and Outreach Programs in Pahoa, 80%will demonstrate an increase in competencies through the Botvin Life Skills Training Curriculum. Of the 60 youth, 70%will engage in Positive Alternative Activities including cultural awareness, community service learning projects, and youth leadership and peer mentoring opportunities. Of the 60 youth and their families, 50%will participate in family activities that promote family strengthening and connection to community resources and services. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army - Family Intervention Services Program Name: Pahoa Prevention and Outreach Programs 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Completion of the Botvin LifeSkills Training Curriculum 48 Positive Alternative Activities 42 Family Engagement Activities 30 Follow-up and Monitoring Services 60 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 36,820 63,861 Professional Fees 5,483 12,260 1,300 Operations 4,147 19,839 4,440 Supplies 1,887 6,240 2,460 Equipment Other: Program Activities 3,122 7,800 1,800 Other: Other: Other: Other: TOTAL 51,459 110,000 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County ofHawaii Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army Family Intervention Services Program Name: Pahoa Prevention and Outreach Programs io: ORGANIZATION CONFLICT Please disclose any conflicts or potential conflicts of interest that any board member,officer,,director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed:One form per person with a conflict is needed: If no conflicts exist,one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please,duplicate as needed to fullydisclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that apply); O Member or members of the Council ❑ Staff appointed by a member of the.Council ❑ The Mayor O The Managing Director • The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruingto the individual as opposed to benefits accruingin general to an fi i�A .f ' industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ® If no conflicts exist,check here. , �'.�_- Divisional Secretary for Business es t7 Sign- re of Authorized Person(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020. Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2.019-20 Agency Name: The Salvation Army Family Intervention Services Program Name: Pahoa Prevention and Outreach Programs 1. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code,relating to Appropriation of Funds to Nonprofit Organizations. I(we)agree to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expendingjoversight agency)full,free, and unrestricted access and authority to examine and inspect any facility,equipment,property,or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express,and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov,complete the easy step-by-step process,. and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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 atimely,complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 , County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: The Salvation.Army. Family Intervention Services Program.Name: pahoa Prevention and Outreach Programs ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii,I(we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence)must be providedto the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insuredrior to receivingany p payment(s).. I (we) understand that failure to submit the final report within 60 days of June30th shall result in loss of all grant funds received duringthe grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I(we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging.that you have read and understood these requirements. I 2v G° tea/ Signat /ofAuthorizéd Person (see checklist,2nd item) Date , (G' i15'WV( C7.G ri✓"Tpt Or--13a$l C5S Title/Position of.Authorized Person EXHIBITA NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army - Family Intervention Services Program Name: Pahoa Prevention and Outreach Programs 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Completion of the Botvin LifeSkills Training Curriculum 48 Positive Alternative Activities 42 Family Engagement Activities 30 Follow-up and Monitoring Services 60 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees 1,300 Operations 4,440 Supplies 2,460 Equipment Other: Program Activities 1,800 Other: Other: Other: Other: • TOTAL 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Salvation Army - Family Intervention Services, The Project TLP Hilo 146 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo Agency Director: Roxanne Costa Phone No.: (808) 959 — 5855 Contact Person: Same as Above Phone No.: ( ) — Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1786 Kino'ole St. Address: City,ST,Zip Hilo, HI 96720 Email Address: roxanne.e.costa@usw.salvationarmy.org Fax No.: (808 ) 959 — 2301 Accountant/CPA: Cary Ebesugawa Phone No.: (808 ) 959 — 5855 Firm (if applicable): Mailing Address: Address: P.O. Box 5085 Address: City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑South Kona ❑✓ North Hilo ❑South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $0 $8250 $7300 2. Agency Mission Statement: "To provide youth with skills for a healthy life, and instill purpose, hope, and vision to youth and their families." This is the philosophy that guides us in the implementation of services. It is our belief that in order to succeed,youth must feel a sense of belonging to their community,their culture,their peers, and within their families." 3. Program Description: Research has shown that vulnerable young adults, youth transitioning from foster care, and those that are living in an unstable situations, comprise of one of the most fast growing groups of homeless individuals. The Salvation Army Family Intervention Services is determined to help these young adults to overcome these various barriers. We aim to stabilize, house, educate, and empower these young adults to overcome these barriers and become self-sufficient. With the support and collaboration of our local programs, agencies, realtors, rental agents, and private landlords,we will be able to help them get a fresh start in their lives. Project TLP will be the responsible agent for these young adults by subsidizing the rental-fee for those who are eligible for a six month period. Based on extenuating circumstances, rental periods may be extended as needed.With our support they will learn simple strategies such as: balancing a check book,writing a resume, finding employment,time management, signing a rental agreement and setting and keeping realistic goals for themselves to help with their transition to independence. Should issues arise participants will be referred to the appropriate resources/services and given opportunities to address issues and concerns as needed. Project TLP's main objective is to help these young adults achieve their short and long-term goals for sustainable housing. 4. Total Budget& Position Count: Total Program Budget: 85,000 Total Program Position Count: 6 Total Agency Budget: 4,000,000 Total Agency Position Count: 65 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii 10,000 Victoria and Bradley Geist Foundation 75,000 Private Donor 50,000 TOTAL: 135,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army Family Intervention Services continuously explores funding avenues in the private, State, and Federal sectors to continue and enhance program services. We annually seek grants and/or partnerships to build program services. In line with our mission and the work that we do,we do rely heavily on funding at all levels of government. We have also been fortunate enough to enter into a partnership late in 2018 with a private donor who has been very interested in our program and helping the young people we are committed to serving. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Be able to connect our Young Adults with the proper resources and services that they may need 2) Provide links to resources in the areas of Continuing Education and/or Employment 3)Provide our Young Adults with employment attire, food, hygiene products, and possibly a starter kit(ie. kitchen ware,towels, blankets,etc.)as needed 4)To promote awareness in the housing community of the struggles that former foster youth must go through in obtaining appropriate housing. 5) Establish collaborative relationships with realty companies and private landlords in the community to provide appropriate housing for participants. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Completion of Financial Literacy Curriculum 4 participants Participation in Weekly Individual Meetings with Case Worker 4 participants Participate in Follow Up and Monitoring 4 participants Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 9,457 24,150 Professional Fees 457 8,500 1,000 Operations 1,726 10,680 2,230 Supplies 962 5,670 1,970 Equipment Other: Program Activities 18,336 86,000 4,800 Other: Actual Expenditures through 12/31/18* Other: Other: Other: • TOTAL 30,938 135,000 10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 Countyof - awai`i Nonprofit Grant Application F 2 19-20 Agency Kerne: The Salvation Army.Family intervention Services Program Name: Project TLP Hilo ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed.One form per person with a conflict is needed. If no conflicts.exist,one form for the organization,with the"No conflictsexist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that apply): O Member or members of the Council ❑ Staff appointed by a member of the Council O The Mayor ❑ The Managing Director El . The Director of Finance a The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest:is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid,in fact or appearance, any conflictsor potential conflicts of interest: ❑ If no conflicts exist, check here. 4 fir-I /II� Divisional Secretary for Business t I . Sign of Aut orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION • P12019.2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 11. Certification of Understanding (Page1 of 2) 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- 135-2-142.1,Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I(we)agree to allow the County(the Legislative Auditor, the Department of Finance,designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility,equipment, property,or records pertinent to the grant,contract,or program for which funds were used. (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 receiving 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 current 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 enroll with Hawai'i Compliance Express,and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov,complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 ofthe contractual year for which the grant was awarded.The report,using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a completeaccounting 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,using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application. FY2019-20 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii,I (we)understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we)understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submittedto,and accepted by,the council. I(we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except fora maximum ten percent(10%)for administrativeand overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report.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. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. dal /1/ rfr Signa ure of Authorized Person (see checklist, 2nd item) Date Vl5'JOY'01 ceer'ettr cow`.mssll'\eSs Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: The Salvation Army Family Intervention Services Program Name: Project TLP Hilo 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Completion of Financial Literacy Curriculum a participants Participation in Weekly Individual Meetings with Case Worker 4participants Participate in Follow Up and Monitoring 4 participants • TABLE II: FY 19-20 Grant Council _ PROGRAM EXPENDITURES - Request Award Salary and Wages Professional Fees 1,000 Operations 2,230 Supplies 1,970 Equipment Other: Program Activities 4,800 Other: Actual Expenditures through 12/31/18* Other: Other: Other: TOTAL I 10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 - Page 8 of 8 Society for Kona's Education & Art (SKEA) Art Camps for Children &Teens 147 O 1 c /4.3/4- County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: Art Camps for Children and Teens Agency Director: Susan B. Rice Phone No.: (808) 328 — 9392 Contact Person: Susan B: Rice Phone No.: (808) 896 — 5858 Mailing Address: Address: PO Box 256 Address: City,ST,Zip Honaunau,Hawaii 96726 Facility Address: Address: 84-5191 Mamalahoa Highway Address: City,ST,Zip Honaunau,Hawaii 96726 Email Address: susanrice@hawaii.rr.com Fax No.: (808 ) 328 — 9392 Accountant/CPA: Eric Curtis Phone No.:: (808) 322 — 0055 Firm (if applicable): Tax Partners Mailing Address: Address: PO Box 230 Address: City,ST,Zip Kealakekua, Hawaii 96750 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $ 14 3 000 . Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua [' North Kona ❑South Hilo [' North Kohala Q South Kona ❑North Hilo ❑South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns ✓❑-Youth ❑Victims of Crimes 0 Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities `❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Pagel of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: Art Camps for Children and Teens 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $3,750 $2,750 $4,925 ;itt9 frO i AI of aqe, <heeg ciety for Kona's Education&Art (SKEA)serves the people of Hawaii Island by providing a arts and educational opportunities through programs, projects,and events that contribute to a vibrant community. Vision:Enhancing lives through creativity and knowledge. The Society for Kona's Education&Art(SKEA)is a 501©3 community organization in South Kona,founded in 1981 by a group of young families who wished to provide education in the arts for their own&others'children.SKEA owns a.75 acre KS/BE lease in Honaunau which includes two historic buildings that provide space for the office,pottery studio,&2 large rooms for classes,art camps,workshops,and community events.We now provides education in the arts to over 1,500 students each year,as well as classes&workshops for adults at our site. An active Board of Directors meets monthly&volunteer their time&expertise on a regular basis.The part- time staff(executive director,administrative assistant, Art of Learning director&Art Camp director)have years of experience in their position with SKEA,&have contacts with many artists in the community who are experienced teachers in their medium. 3. Program Description: SKEA offers day camps in the visual and performing arts during the fall,spring,and summer school breaks.Magic Camp will be a 5-day(15 hrs.)program focused on the techniques and performance of magic,for ages 8 through 18,an underserved group in our rural community.We have found that scheduling the camp in the summer,during th last week of June,has yielded the best attendance. Taught by professional magicians,the students will perform at the end of camp for the communty some of the things that they I earned: Legerdemain-the skillful use of one's hands when perfomring tricks Prestidigitation-a show of skill or deceitful cleverness Prognostication-to foreshadow,portend Stagecraft-the art of performance,holding and keeping the attention of the audience Magic tricks-specific tricks using cards, ropes,scarves,boxes,hats,etc. The secret of making and using special magic props. Fall,Spring&Summer Art Camps(one week in October 2020,one week in March 2020,and 2 weeks in June,2020)provide a fun learning experience in the arts for children ages 6-11. Local teaching artists offer a activities such as painting&drawing,collage&mixed media projects,pottery,music,dance, theatre arts,&yard games.high school students are hired and trained to act as teaching assistants;the on- site supervisor is a DOE teacher;teaching artists are experienced as well.The quality of the instruction is high and the students are able to produce an excellent body of work that is on display at the end-of-camp performance. 4.Total Budget& Position Count: Total Program Budget: $44,000 Total Program Position Count: 12 part time Total Agency Budget: $ 108,500 Total Agency Position Count: 15 part time EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Program Name: 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Hawaii State Foundation on Culture and the Arts $3,000 Hawaii Community Foundation FLEX grant 1,000 Kona Brewers Festival 3,000 Rotary Club of Kona Mauna 1,000 tuition fees and scholarship donations 10,000 Hawaii Hotel Association Charity Walk 1,000 TOTAL: $19,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: During the 2017-18 fiscal year,the State Foundation on Culture and the Arts cut back on funding, which continued during the 2018-19 FY, and this seems to be a trend.Also,the FLEX grant has become highly competitive,so we cannot count on being awarded it every year. We will c ontinue to write proposals for support for the Art Camp program, although it must be noted that this is a long- standing program and many funders only wish to help establish new programs. The tuition for the camps is very reasonable, but it is still a hardship for many families in our community. We therefore are Commi tted to keeping the tuition at the current rate.We solicit scholarship donations so that we are able to offer generous discounts.A dditionally, our organization does a lot of fundraising each year to support our programs, and we will continue to do so. 7. Program Objectives Using County Nonprofit Grant Program Funds: Program Objectives: • Expose children ages 5-18 to the various artistic mediums-magic,visual arts, pottery, performance and drama, music-and to working artists and their methods and materials. • Improve the students artistic and performance skills and knowledge, stimulate creative thinking and communication, and create positive self-esteem and poise through mastery and performance. • Provide meaningful work experience for teens in our community, giving our young people the opportunity to learn responsibility, cooperation, organization, as well as providing specific job skills and monetary compensation. • Provide an opportunity for adolescent students in the Magic Camp to take part in a professional magic show,the annual Magic Spectacular at the Aloha Theatre. • Increase the avaialblty of culturally enriching activities for children and yung people in our community. • Provide a safe venue for fun, healthy, and educational activity during the school breaks. • Provide opportunities for artists in our community to share their skills. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Society for Kona's Education &Art (SKEA) Program Name: Art Camps for Children and Teens 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) see attached see attached Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees $13,500 $13,500 $6,000 Operations 5,000 5,000 $2,000 2,000 3,000 $1,500 Supplies Equipment 0 0 0 Marketing 2,000 2,500 1,500 Other: Registrations, administration 2,000 2,000 500 Other: teen counselors (ages 16-19) 6,000 7,000 3,000 Other: Other: hospitality 100 150 0 Other: all numbers in 1st column are budget projections for current FY yeas TOTAL $30,600 $33,150 $14,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 Society for Kona's Education&Art Art Camps for Children and Teens Program Performance Measures: Attendance Records:We can accommodate up to 28 (maybe 30) children in the camp.We expect to enroll 25-30 each week of art camp (based on prior enrollments.) The Magic Camp can accommodate up to 22 students, and we expect to fill the camp,based on our prior enrollments. Written evaluations by parents and teaching artists:we distribute a one-page evaluation that we ask all parents to fill out.We make an effort to get them back and we usually receive about 15- 20 each camp.Teaching artists are required to fill it out. Written evaluation report by the Program Director- describes the activities participation, and observations on the children's level of engagement,their behaviors, etc. and the specifics of what they learned. Narrates the positives and negatives of the camp,what could be done differently, etc. Direct observation by Board and Staff- several Board members act as teaching artists,and there is usually extra staff on the premises during camps. Level of creative output by students-projects completed-the students level of engagement and focus, and whether they complete their projects .For the Magic Camp, the students level of interest and engagement can be measured by how well the learn their tricks and whether they practice at home. Photographs-we will document the activities with photos. County of Hawai`i Nonprofit Grant Application FY2019-20 de Agency Name: c GQ -bY� ,f S � �l�- 1 2 �rf Program Name: .f pc -Poi. C h 024A I cji 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council D Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director n The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here.. ' 1'6'.1/14n / 64;(--/.52-- dOen i --S. 1 V-..0 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: SkEA-- Program Name: , }—( naps 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: 5 Program Name: ,-v--c- erj -@/yl es 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, specifically which s ecificall and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. go 4 Signature of Authorized Person (see checklist, 2nd item) Date X 0-0J Title/Position of Authorized Person. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: OC.1 YOYlot✓S 1ZCvl 6r-1- CS 4) ' I Program Name: ` p S ,/ L Iry 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Society for Kona's Education & Art (SKEA) South Kona Workshops and Events 148 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Society for Kona's Education &Art (SKEA) Program Name: South Kona Workshops and Events Agency Director: Susan B. Rice Phone No.: (808) 328 — 9392 Contact Person: Susan B. Rice Phone No.: (808) 896 _ 5858 Mailing Address: Address: PO Box 256 Address: City,ST,Zip Honaunau,Hawaii 96726 Facility Address: Address: 84-5191 Mamalahoa Highway Address: City,ST,Zip Honaunau,Hawaii 96726 Email Address: -hri/C-E.@ MJOW .V i/, e_04" Fax No.:%D (V )3 2' — q-39 Accountant/CPA: Eric Curtis Phone No.: (808) 322 _ 0055 Firm (if applicable): Tax Partners Mailing Address: Address: PO Box 230 Address: City,ST,Zip Kealakekua, Hawaii 96750 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: A, 7 Ciro Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ❑South Hilo ❑ North Kohala ❑✓ South Kona ❑North Hilo ❑South Kohala- ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns Youth ❑Victims of Crimes ❑✓ Culture and the arts ❑Aged 9 Victims of Health or Social Crises ❑ Needs of the poor 9 Physical/Emotional Disabilities 9 Public Health and Welfare of the People and the Environment • EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Society for Kona's Education &Art (SKEA) Program Name: South Kona Workshops and Events 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $2,250 $1,875 $4,250 2.Agency Mission Statement: With a focus on South Kona,the Society for Kona's Education&Art (SKEA)servers the people of Hawaii Island by providing a rtsand educational opportunitie through programs,projects;.and events that contribute to a vibrant community. Vision:Enhancing lives through creativity and knowledge. The Society for Kona's Education&Art(SKEA)is a 501©3 community organization in South Kona,founded in 1981 by a group of young families who wished to provide education in the arts for their own&others'children.SKEA owns a.75 acre KS/ BE lease in Honaunau which includes two historic buildings that provide space for the office,pottery studio,&2 large rooms for classes,art camps,workshops,and community events.We now provides education in the arts to over 1,500 students each yea r,as well as classes&workshops for adults at our site. An active Board of Directors meets monthly&volunteer their time&expertise on a regular basis.The part- time staff(executive director,administrative assistant,and two program directors)have years of experience in their position with SKEA,&have contacts with many artists and performers in the community. • 3. Program Description: see attached • 4.Total Budget&Position Count: Total Program Budget: $11,550 Total Program Position Count: 12 part-time Total Agency Budget: $10$,500 Total Agency Position Count: 15 part-time EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 PROGRAM DESCRIPTION: South Kona Workshops&Events 2019-2020 Through funding from the State Foundation on Culture and the Arts,and the County of Hawai'i (2016-17 FY), SKEA has offered a series of'Growing, Living, Creating'workshops.The response has been overwhelmingly positive, every workshop has been well attended (several to capacity,up to 30 people), and the community is asking for more. Participants have been mostly seniors (50+),but also some younger adults and children and adolescents, accompanied by a parent or grandparent.The workshop fees are VERY reasonable,and we feel this is a crucial element of success in this rural community. People are able to leave 3 hours later with a beautiful,handmade item, or new knowledge of a subject or art medium that is of interest. We propose to offer the most popular workshops again,and offer some new ones: Botanical Drawing and Painting- October, 2019 Gourd Design- October 2019 Mushroom Cultivation- November 2019 Wreathmaking- December 2019 Coconut baskets-January 2020 Handmade Books March 2020 Edible Landscaping- May 2020 Lei Making- May, 2020 Oil Painting- March, 2020 Hawaiian Quilting- March, 2020 Gyotaku- February 2020 4P0Photography-April2020—WeAry - A-ug 202-D We hire taleifted.praction rs in each field who also have good teaching skills.Marketing each workshop will be done through our newsletter,posters,press releases to newspapers and radio, email marketing, social media, and some paid advertising. SKEA offers the community several free or very low-cost events throughout the year,that are attended by residents and also visitors. Music on the Lawn- September, 2019; Local musicians will play a variety of songs in different genres, with the last hour being kanikapila. $7 donation requested. Annual Membership Meeting-January, 2020 An afternoon of live local music,pupus,and a showing of local art. The SKEA Board is introduced and we update guests on SKEA's programs at a short meeting. A kanikapila ends the afternoon. Free and open to the public. Quilt Show- February,2020-local artists display their quilts in a variety of styles. South Kona Studio Tour- in association with the South Kona Artists Cooperative, SKEA will host 3 or 4 South Kona artists at our site.February, 2019 Mauka Talent Show April, 2020. A family entertainment variety show of local performers of all ages, preschool to seniors.$7 donation. Artists,performers,and musicians donate their time for these events,and volunteers help with the activities on the day of the event. Marketing expenses include paid advertising,posters,flyers, roadside signs,web calendars, email marketing, etc. Outcomes: 1.we expect that a total of 2,000+residents and visitors will attend the workshops and events. 2.Residents and visitors from around the island will visit South Kona and enjoy its scenic beauty, restaurants, and other cultural sites. 3. Local artists will be supported and recognized.4.The SKEA organization will make new friends and supporters in the community and connect with old ones. County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Society for Kona's Education &Art (SKEA) Program Name: South Kona Workshops and Events 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate State Foundation on Culture and the Arts $1,000 tuition and fees $3,000 SKEA fundraising $1,000 County of Hawaii $7,000 TOTAL: $12,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We will continue to work with community volunteers and other groups and organization(e.g.the South Kona Artists Cooperativ e,the Aloha Quilters)in bringing high quality workshops and events to South Kona. We may also write proposals to local foundations that are interested in,the arts(e.g.Atherton Foundation,Cooke Foundation,both of which have partially funded programs for us in the p ast.)The SKEA Board and other volunteers will continue with fundraising activities to help pay for site expenses and other progr am expenses.We will maintain our connections with artists and performers in our community;many of them offer their services free of charge. • 7. Program Objectives Using County Nonprofit Grant Program Funds: Workshop objectives: *to give the opportunity for creative expression to people in our community,especially seniors. "to encourage the use of natural materials in making beautiful things. "to provide new knowledge in areas of agriculture and art. "to engage in social interaction. *to educate participants in the names of plants,the history of their use,and the techniques of how to use them. *to educate particpants on environmental stewardship and responsibilities(e.g.the ban of transport of ohia in light of the rapid ohia virus that is affecting our forests). Event objectives: "to create and implement a comprehensive marketing plan for each event. "to showcase local art,artists,and performers and develop the community of South Kona as a destination for cultural events. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Society for Kona's Education &Art (SKEA) g Y Program Name: South Kona Workshops and Events 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) attendance records-workshops 130 attendees attendance records-events 1,300 #of workshops held 12 it of events held 5 surveys from attendees 50 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 Pt 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $500 Professional Fees $3,500 4, 250 1,50p 500 750 500 Operations 1,500 2,000 750 Supplies Equipment 500 500 500 Other Marketing events and workshops 2,000 3,000 2,500 workshops-registration &coordination 500 750 500. Other: Other: events coordination and site set-up in-kind in-kind 0 Other: hospitality 250 250 250 Other: all numbers in 1st column are budget projections for current year TOTAL $8,750 11,500 $7,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops and Events 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor • ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in genera!to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. 0711/lir\/6 CtUri, , 2S 19 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops and Events 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free,and unrestricted access and authority to examine and inspect any facility,equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual ear for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops and Events 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. q5W2TA-A--- i - , 22' c2019 Signature of Authorized Person (see checklist, 2nd item) Date • i(kM/A-1/Nre utzckz, - Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Society for Kona's Education & Art (SKEA) Program Name: South Kona Workshops and Events 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Special Olympics Hawai'i Special Olympics Hawai'i -East Hawaii 149 County of Hawaii Nonprofit Grant Application FY201.9-20 Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii - East Hawaii Agency Director: Nancy Bottello Phone No.: (808 ) 695 - 3522 Contact Person: JaNeal Stevens Phone No.: (360) 490 - 2610 . Mailing Address: Address: PO Box 7265 • Address: City,ST,Zip Hilo, HI 96720 Facility Address: Address: NONE Address: City,ST,Zip Email Address: EastHawaiiAD@sohawaii.org Fax No.: ( ) — Accountant/CPA: Akamine, Oyadomari&Kosaki Phone No.: (808 ) 941 - 0500 Firm (if applicable): Akamine, Oyadomari& Kosaki Mailing Address: Address: 1440 Kapiolani Street #900 Address: City,ST,Zip Honolulu, HI 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $22,000 Geographical Areas To Be Served: (One or more can be checked) • n Puna Q✓ Hamakua n North Kona n South Hilo n North Kohala I ' South Kona Q✓ North Hilo n South Kohala I✓l Ka'u Services or Activities To Be Provided: (One or more can be checked) • n Educational concerns n Youth n Victims of Crimes n Culture and the arts n Aged n Victims of Health'or Social Crises 111 Needs of the poor Q✓ Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019 - 2020 Page 1 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Special Olympics \-1auoai, Program Name: Special Olympics - East Hawaii 1. Prior Year-Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 $21,375 $16,080 2. 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 children and adults with 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. 3. Program Description: see attached • • • 4. Total Budget& Position Count: Total Program Budget: $158,100 Total Program Position Count: 1 Total Agency Budget: $2,361,521 Total Agency Position Count: 12FT 7PT EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 • County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: Special Olympics 1-NaiYa Program Name: Special Olympics - East Hawaii 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii $22,000 Fundraisers $76,200 Charity Walk $2200 SOHI Airfare fund $3200 Individual donations $9500 Businesses $5000 Hilton Sponsoship $40,000 TOTAL: $158,100 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: see Attached • 7. Program Objectives Using County Nonprofit Grant Program Funds: see Attached EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Special Olympics i-kau_ Program Name: Special Olympics - East Hawaii 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served, workshops or events held,volunteer hours,etc.Describe,be specific.) Number of athletes served 250 Number of unified partners served 200 Number of volunteers from the community helping our program 700 Number of family members served 150 Number of coach staff 30 Number of delegations within our area program 9 Number of area and state competitions attended 9 Attach additional pages as necessary. 9. TABLE II: • PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $15,000 $15,000 Professional Fees $4000 $4350 Operations $9000 $9000 $2500 Supplies $6250 $4500 Equipment $5500 $5000 Other: Airfare for Athletes competing at State level $84606 $80,500 $12,500 • Other: Coaches clinic in Oahu $2,100 $2000 $2000 Other: Area competitions $7,450 $7950 $5000 Other: Fundraising $38,810 $23,500 Other: Volunteer Management $4000 $2000 TOTAL $176,716 $158,100 $22,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Special Olymics 1*3a< < -_Program Name: EastHawaii= 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer,,director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council I The Mayor The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. - to— CE-0 i/,y Signature Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page S of 8 I , County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii - East Hawaii 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Special Olymics 1- at %.i Program Name: East Hawaii ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-farms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. . By signing below, you are acknowledging that you have read and understood these requirements. (64))4 ///4-./// , Signature of Authorized Person (see checklist, 2nd item) Date - ? /C1.)6c :( Cfo Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Special Olympics I-duica-L Program Name: Special Olympics -. East Hawaii L 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 250 200 700 150 30 9 9 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees Operations $2500- . Supplies Equipment ' Other: Airfare for Athletes competing at State level $12,500 Other: Coaches clinic in Oahu $2000 Other: Area competitions $5000 Other: Fundraising Other: Volunteer Management TOTAL $22,000 Additional Council directives regarding award: i EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Agency Name: Special Olympics Program Name: East Hawaii Special Olympics #3.Program Description Special Olympics Hawaii—East Hawaii Area program is open to everyone with intellectual disabilities in Hawaii, regardless of the extent of their disability. People who are isolated from life experiences by a disability have little chance for the developmental growth and acquisitions of important skills that they will need to gain employment, maintainrelationships,and function within the community. Special Olympics believes 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. We currently serve almost 250 youth and adult athletes across the East side of the Island,who are supported by over 200 Unified Partners with the help of over 700 volunteers. All costs, including airfare for our athletes and coaches, are covered by Special Olympics East Hawaii.There is never a fee to any athlete or their family to participate in our program.The geographical area that makes up East Hawaii is North Kohala,Waimea, Honokaa, Hilo, Pahoa and Kea'au all the way to Kau, which constitutes the largest reach on the island. The East Hawaii program is proud to say that we are the only neighboring island that offers the Young Athlete Program for keiki age 2.5—5 years old, providing curriculum as well as a playday for 4 elementary schools. We also offer the only school program on Big Island, collaborating with Hilo High,Waiakea High and Pahoa High school, in addition we have partnered with After School All Stars and provide an inclusionary sports program for Kea'au Intermediate and Pahoa Intermediate schools. #6. We currently raise through our fundraising efforts over$70,000 of our budget expenses. In addition for the first time ever,the East Hawaii Area Director worked with the Hilton Waikoloa and secured a $40,000 sponsorship. This donation will fully pay for the airfare for the entire Area to participate in the Holiday Classic which is the state winter competition in Oahu. Due to this donation the athletes from East Hawaii can participate in two State games,which they haven't been able to in years prior due to the expense of airfare. We continue to raise more money each year through our collaboration with the Hawaii Police Department. Our Cop_on Top fundraiser raised$20,000 last year and we anticipate raising just as much this year. #7. 1)To provide quality sports training&Olympic type competitions in our area program to 250 athletes and 200 unified partners by June 2020. 2)To provide sports specific coaches training or recertification's for 10 coaches in various Olympic type sports & various ability levels so that they may provide appropriate training to the athletes within their delegations by June 2020. 3) Engage at least 1 new school into our Unified Champion Schools program. 4) Provide a Young Athletes Playday for 100 children in East Hawaii Special Olympics Hawai'i - West Hawai'i General Fund 150 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: SPECIAL OLYMPICS HAWAII - WEST HAWAII Program Name: GENERAL FUND Agency Director: NANCY BOTTELO Phone No.: (808) 531 — 1888 Contact Person: DENISE LINDSEY Phone No.: (808) 345 — 0433 Mailing Address: Address: SPECIAL OLYMPICS WEST HAWAII Address: P.O.BOX 390358 City,ST,Zip KEAUHOU-KONA,HI. 96739 Facility Address: SPECIAL OLYMPICS HAWAII c ty Address: Address: 1833 KALAKAUA AVE.,SUITE 500 City,ST,Zip HONOLULU,HAWAII 96815 Email Address: denise@bigislandtv.com Fax No.: ( ) — Accountant/CPA: AKAMINE,OYADOMARI&KOSAKI Phone No.: (808) 941 — 0500 Firm (if applicable): AKAMINE,OYADOMARI&KOSAKI,CPA'S INC. • Mailing Address: Address: 1440 KAPIOLANI BLVD., Address: SUITE#900 City,ST,Zip HONOLULU,HAWAII 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ❑South Hilo Q North Kohala ❑✓ South Kona ❑ North Hilo ❑✓ South Kohala ❑ KaTI Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ✓❑Youth ❑Victims of Crimes ❑Culture and the arts ✓❑Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: SPECIAL OLYMPICS HAWAII - WEST HAWAII Program Name: GENERAL FUND 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0.00 20,125.00 11,375.00 2.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 children and adults with 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. 3. Program Description: Training and competition opportunities are available for every athlete,regardless of gender,age or ability. No matter what their ability level may be,athletes can benefit from Special Olympics.Special Olympics West Hawaii offers training and competition in 9 sports,including 3 Statewide competitions.Athletes receive training conducted by over 50 certified coaches. Special Olympics Hawaii offers Unified Sports®events in Track&Field,Softball,Soccer,Bocce,and Bowling. Unified@ events allow athletes with intellectual disabilities to train&compete together with persons without intellectual disabilities,called Special Partners. 4.Total Budget&Position Count: Total Program Budget: 92,100 Total Program Position Count: 3 PT Total Agency Budget: 2,363,916.00 Total Agency Position Count: 12 FT/6 P/T EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: SPECIAL OLYMPICS HAWAII - WEST HAWAII Program Name: GENERAL FUND 5. Program Funding Sources(identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate County of Hawaii-General Fund Grant 20000.00 Kona Brewers Fest Grant 1500.00 Young Brothers Grant 1000.00 Walmart Foundation Grant 2500.00 Visitor Industry Charity Walk Grant 4000.00 Individual Contributions 1600.00 Service Club Donations 300.00 TOTAL: 30900.00 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Special Olympics West Hawaii continues to fundraiser on a monthly basis. From small fundraisers to big ones we must be diligent on bringing in income to sustain our program. Big Island Candies is new for us,and we encourage our Special Olympics Athletes to be active in selling these candies. Also,our KTA Steakfry is another way our Athletes get involved with our fundraising by selling tickets. 7. Program Objectives Using County Nonprofit Grant Program Funds: Travel costs again are our biggest foe. Special Olympics West Hawaii will use a good portion to support our Athletes on travel to the State Special Olympics Games on Oahu. Another big expenditure is our Regional Area Games,Special Olympics West Hawaii hosts over 250 participants at our Regional Softball competition and our Law Enforcement Torch Run,so some of the funds will be used for those events. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 Special Olympics Hawaii -West Hawaii GENERAL FUND FY 2019-2020 SPECIAL EVENTS/FUNDRAISERS KTA Steak Fry $1,700.00 Hilton Christmas crafts fair $ 6,100.00 ZUMBAThon $ 1,500.00 Golf Tournament $ 6,500.00 Cross Fit $ 1,500.00 Roller Dereby Fundraiser $ 350.00 Kona Marathon $ 600.00 Paniolo Police Plunge &Torch Run $ 2,000.00 Lavaman Aide Station (2 events) $ 750.00 Underpants Fundraiser $ 3,000.00 ,Cop on top $30,000.00 Torch Run shirt sales $3,500.00 Big Island Candies $1,600.00 Roberts Hawaii Bus Pull $ 2,100.00 Sub Total $61,200.00 Sub Total from Page#3 $ 30,900.00 TOTAL PROGRAM FUNDING $92,100.00 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: SPECIAL OLYMPICS HAWAII - WEST HAWAII Program Name: GENERAL FUND 8.TABLE I: • What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 25 Athletes to travel to Oahu for State Summer Games May 24-25,2019 5425.00 25 Athletes to travel to Oahu for Fall Games August 3-4,2019 5425.00 25 Athletes to travel to Oahu for Winter Games November 16-17,2019 5425.00 Regional Softball Tournament&Law Enforcement Torch Run Awards and Meals 4/20/19 1000.00 Regional Soccer&Bocce Tournament Awards and Meals 6/29/19 1000.00 Regional Bowling Tournament Awards and Meals 10/06/19 1000.00 Purchase of Law Enforcement Torch Run T-shirts 725.00 Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 14303.00 15700.00 15700.00 Professional Fees 0.00 0.00 0.00 Operations 63883.00 46725.00 46725.00 Supplies 8350.00 5787.00 5787.00 Equipment 4000.00 3887.00 3887.00 Other: Lunches,Awards for Softball and Soccer Tournaments 1564.00 0.00 Other: Awards and Meals for 3 Regional Area Games+LETR T-Shirts 3725.00 3725.00 Other: 25 Athletes to State Summer Games in May 5425.00 5425.00 Other: 25 Athletes to Fall State Games in June 5425.00 5425.00 Other: 25 Athletes to Winter State Games in November 5425.00 5425.00 TOTAL 92,100 92,099 92099.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Program Name: 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist; check here. )66A--6 cE0 ` / lel/ ? Signature •f Auth• zed Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: SPECIAL OLYMPICS HAWAII - WEST HAWAII Program Name: GENERAL FUND 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we)agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility,equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report,using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Program Name: 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawalicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawaii with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. )1,7. /(30_#,to /02A0/.2 Signature of Authorized Person (see checklist, 2nd item) Date n/avic �3oTfeLo �l1Qs;de i / C( y � Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: SPECIAL OLYMPICS HAWAII - WEST HAWAII Program Name: GENERAL FUND 12. COUNCIL AWARD WORKSHEET TABLE I:. PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 25 Athletes to travel to Oahu for State Summer Games May 24-25,2019 5425.00 25 Athletes to travel to Oahu for Fall Games August 3-4,2019 5425.00 25 Athletes to travel to Oahu for Winter Games November 16-17,2019 5425.00 Regional Softball Tournament&Law Enforcement Torch Run Awards and Meals 4/20/19 1000.00 Regional Soccer&Bocce Tournament Awards and Meals 6/29/19 1000.00 Regional Bowling Tournament Awards and Meals 10/06/19 1000.00 Purchase of Law Enforcement Torch Run T-shirts 725.00 TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 15700.00 Professional Fees 0.00 Operations: 46725.00 Supplies 5787.00 Equipment 3887.00 Other: Lunches,Awards for Softball and Soccer Tournaments 0.00 Other: Awards and Meals for 3 Regional Area Games+LETR T-Shirts 3725.00 Other: 25 Athletes to State Summer Games in May 5425.00 Other: 25 Athletes to Fall State Games in June 5425.00 Other: 25 Athletes to Winter State Games in November 5425.00 TOTAL 92099.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 1 Teach For America Flawai°i Ho'imi Pono Initiative (Teacher Recruitment) 151 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Ho'imi Pono Initiative (Teacher Recruitment) Agency Director: Jill Baldemor Phone No.: (808) 521 — 1371 Contact Person: Jazzmin Cabanilla Phone No.: (808) 854 — 7279 Mailing Address: Address: 500 Ala Moana Blvd 3-400 Address: City,ST,Zip Honolulu, Hawaii 96813 Facility Address: Address: 75-5706 Kuakini Hwy.Suite 102 Address: City,ST,Zip Kailua-Kona,Hawaii 96720 Email Address: jill.baldemor@teachforamerica.org Fax No.: ( ) — Accountant/CPA: GrantThronton Phone No.: (212) 599 — 0100 Firm (if applicable): Mailing Address: Address: 666 Third Avenue 13th Floor Address: City,ST,Zip New York,NY 10017-4011 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua n North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑./ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns . ❑✓ Youth n Victims of Crimes n Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawaii Program Name: Ho'imi Pono Initiative (Teacher Recruitment) 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 5,500.00 4,550.00 2. Agency Mission Statement: Teach for America's mission is to find,develop and mobilize promising future leaders to grow and strengthen the movement for educational equity and excellence. In Hawai'i,we are especially looking to find individuals who are deeply committed to our community,including but not limited to kama'aina,kanaka maoli(Native Hawaiians),and Hawaii public school graduates. We seek to find individuals who embody our regional values of kuleana,'ohana and aloha and who are driven by a social justice orientation to creating a more fair and just community for all of our keiki. We seek to develop innovative learners and leaders who work in partnership with students,families and communities to empower students to achieve academically,grow personally and activate their own leadership. We cultivate humble leaders who make life-long commitments to address educational inequity through classroom teaching,school and district leadership,public policy making,and other wide ranging roles and fields that collectively contribute to a robust ecosystem of opportunities for all keiki. 3. Program Description: Ho'imi Pono focuses on: (1)Early Engagement Initiatives;and(2)Finding local and diverse leaders to teach on Hawaii Island. Early Engagement Initiatives include:programs,workshops, learning opportunities,and partnerships that focus on inspiring high school and college students to be leaders in their communities. Through community and school partnerships we are able to:(1) provide and/or connect students to opportunities that explore education and teaching as viable college and career options and (2)connect students to leadership development opportunities in their communities and with local partners. Finding Local and Diverse Leaders to Teach on Hawaii Island: we will continue to prioritize kama'aina and Native Hawaiian recruitment,with an increased emphasis on recruiting former students who were taught by TFA Hawai'i teachers in the schools and communities where we work. As employment opportunities expand and the cost of living steadily increases it will become increasingly difficult to keep up with the demand for teachers and educational leaders,this reality has led Teach For America Hawai'i to re-design it's recruitment efforts to: (1)intentionally focus on sourcing within Hawai'i;(2)identifying applicants with roots to Hawai'i during the application process;and(3)remaining inclusive by considering outstanding candidates who are passionate to learn more about our island home and genuinely want to teach on Hawai'i Island. 4.Total Budget& Position Count: Total Program Budget: $237,892 Total Program Position Count: Portion of 1 role Total Agency Budget: $3,757,242 Total Agency Position Count: 19 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Ho'imi Pono Initiative (Teacher Recruitment) 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Americorps $4,541 Nanea Foundation $16,666 JB McIntosh $8,333 Zierk Family Foundation $8,333 Roberts Foundation $66,666 TOTAL: $104,539 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Plans to increase revenues to support this program are provided below: (1) Continue to steward positive relationships with existing donors. (2) Continue to work with diverse community organizations to cultivate new relationships with potential supporters. (3) Identify and establish healthy partnerships with philanthropists and/or philanthropy organizations who have connections to Hawai'i and Hawai'i Island. (4) Design and secure multi-year commitments from new and/or existing donors. (5) Continue to designate on island staff to execute development work on Hawai'i Island. Sustainability of our organization and the support of the community is not only important but necessary in order for us to continue our work on Hawai'i Island. Thus we remain committed to working with the community to gain consistent, positive on island support of our organization and programs. 7. Program Objectives Using County Nonprofit Grant Program Funds: Program Objectives: To support Ho'imi Pono team leads with the listed outcomes. (1) Deepen partnerships with Hawaii Island staff and alumni to co-create an approach to early and local recruitment that is grounded in the unique needs of Hawaii Island's variety of communities and integrates the community relationships,expertise, and resources that already exist. (2) Design and execute recruitment events(formal and social)focused on UH Hilo. (3) Design and execute early engagement initiatives with partner schools,TFA teachers/alumni and community organizations. (4) Explore our partnership with the Honoka'a Kealakehe Kohala Konawaena complex area(grow your own initiative and Hokupa'a Program). EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Ho'imi Pono Initiative (Teacher Recruitment) 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) At least ten(10)new teachers placed to work in schools on Hawai'i Island. At least ten(10)new teachers. Engage with 50 underclassmen and 50 high school students through different At least fifty(50)underclassmen and fifty(50) opportunities,engagements and experiences. high school students participate in TFA Hawaii opportunities,engagements and/or experiences. At least 25%of our total incoming corps will identify as kama'aina and/or Native Hawaiian. At least 25%of our total incoming corps will identify as kama'aina and/or Native Hawaiian. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wags $31,783 10,000 Professional Fees Operations $1,167 Supplies Equipment Other: National Recruitment&Admissions Costs $200,000 Other: National Shared Services Costs $4,942 Other: Other: Other: TOTAL $237,892 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Ho'imi Pono Initiative (Teacher Recruitment) 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Jill Baldemor POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor ❑ The Managing Director • The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. etti, Executive Director 1 .25.2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawaii. Program Name: Ho'imi Pono Initiative (Teacher Recruitment) 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Ho'imi Pono Initiative (Teacher Recruitment) 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 1 .25.2019 Signature of Authorized Person (see checklist, 2nd item) Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Ho'imi Pono Initiative (Teacher Recruitment) 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result At least ten(10)new teachers. At least fifty(50) underclassmen and fifty(50) high school students participate opportunities,engagements and/or experiences. At least 25%of our total incoming corps will identify as kama'fina and/or Native Hawaiian. TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 10,000 Professional Fees Operations • Supplies Equipment Other: National Recruitment&Admissions Costs Other: National Shared Services Costs Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 • Teach For America Hawai'i Ho'opulapula Program (1st and 2nd Year Teacher Program 152 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Ho'opulapula Program (1st and 2nd Year Teacher Program) Agency Director: Jill Baldemor Phone No.: (808) 521 — 1371 Contact Person: Jazzmin Cabanilla Phone No.: (808) 854 — 7279 Mailing Address: Address: 500 Ala Moana Blvd Suite 3-400 Address: City,ST,Zip Honolulu, Hawai'i 96813 Facility Address: Address: 75-5706 Kuakini Hwy.Suite 102 Address: City,ST,Zip Kailua-Kona,Hawaii 96720 Email Address: jill.baldemor@teachforamerica.org Fax No.: ( ) — Accountant/CPA: Grant Thronton Phone No.: (212) 599 — 0100 Firm (if applicable): Mailing Address: Address: 666 Third Avenue 13th Floor Address: City,ST,Zip New York,NY 10017-4011 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua n North Kona n South Hilo ❑✓ North Kohala ❑✓ South Kona n North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑./ Youth ❑Victims of Crimes ❑ Culture and the arts ❑ Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Ho'opulapula Program (1st and 2nd Year Teacher Program) 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 5,500.00 7,175.00 2.Agency Mission Statement: Teach for America's mission is to find,develop and mobilize promising future leaders to grow and strengthen the movement for educational equity and excellence. In Hawai'i,we are especially looking to find individuals who are deeply committed to our community,including but not limited to kama'aina,kanaka maoli (Native Hawaiians),and Hawaii public school graduates. We seek to find individuals who embody our regional values of kuleana,'ohana and aloha and who are driven by a social justice orientation to creating a more fair and just community for all of our keiki. We seek to develop innovative learners and leaders who work in partnership with students,families and communities to empower students to achieve academically,grow personally and activate their own leadership. We cultivate humble leaders who make life-long commitments to address educational inequity through classroom teaching,school and district leadership,public policy making,and other wide ranging roles and fields that collectively contribute to a robust ecosystem of opportunities for all keiki. 3. Program Description: The Ho'opulapula program is the Hawai'i Island branch of our nationally accredited Alternate Route to Certification program. The program focuses on cultivating and supporting our corps members(1st and 2nd year teachers)in their development as teacher leaders on Hawaii Island. We know that the keiki of Hawai'i deserve the very best and we continue to develop a vision based teacher development program that contributes positively to the growth of life long classroom teacher leaders and education advocates for our island. Over the last few years we have designed a living,thoughtful program that attempts to meet the unique needs of our students, Programming; and our participants. This year the program will continue to include; (1) Pre Service Training and g rammin g, and(2)On-Going Support,Development and Culturally Responsive Programming. Pre-Service Training and Programming: (1)On-boarding pre/post experiences and support; (2)Teacher Development Summer Institute;and (3)Orientation in Hawai'i. On-Going Support, Development and Culturally Responsive Programming: (1)1 on 1 Coaching(diverse and differentiated coaching will occur throughout the year);and(2)PLC's(on-going professional development via content based learning communities and professional development days(TFAmily Days). 4.Total Budget& Position Count: Total Program Budget: $682,207 Total Program Position Count: 4 Total Agency Budget: $3,757,242 Total Agency Position Count: 19 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Ho'opulapula Program (1st and 2nd Year Teacher Program) 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Americorps $4,541 Nanea Foundation $16,666 JB McIntosh $8,333 Zierk Family Foundation $8,333 Roberts Foundation $66,666 TOTAL: $104,539 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Plans to increase revenues to support this program are provided below: (1) Continue to steward positive relationships with existing donors. (2) Continue to work with diverse community organizations to cultivate new relationships with potential supporters. (3) Identify and establish healthy partnerships with philanthropists and/or philanthropy organizations who have connections to Hawai'i and Hawai'i Island. (4) Design and secure multi-year commitments from new and/or existing donors. (5) Continue to designate on island staff to execute development work on Hawai'i Island. The support of the community is vital for us to be able to continue our work on Hawaii Island and so we remain committed to working with the community to gain consistent,positive on island support of our organization and programs. 7. Program Objectives Using County Nonprofit Grant Program Funds: Program Objectives: To support Ho'opulapula team leads with the listed objectives. (1) Design and Implement a Hawai'i Island Orientation for 1st year teachers. (2) Provide teachers with on-going teacher support and culturally responsive programming specifically: (1)1 on 1 coaching (diverse and differentiated coaching will occur throughout the year);and(2)PLC's(professional development via content based learning communities and professional development days). (3) Design a Hawai'i based Institute that will allow new teachers to do all of their Pre-Service Training and Programming in Hawai'i. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Ho'opulapula Program (1st and 2nd Year Teacher Program) 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 90%of 1st year teachers will attend the Hawai'i Island Orientation. 90%of 1st year teachers will participate. 90%of 1st and 2nd year teachers will participate in professional development days. 90%of 1st and 2nd year teachers will attend. 90%of 1st and 2nd year teachers will receive 1 on 1 coaching support and attend PLCs. 90%of participants will receive 1 on 1 coaching and participate in PLCs. Draft proposal of Hawaii based Summer Institute completed. Draft proposal of Hawai'i Summer Institute completed. Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $335,275 $10,000 Professional Fees Operations $118,818 Supplies Equipment Other: National Institute Costs $160,000 Other: National Shared Services Costs $68,114 Other: Other: Other: TOTAL $682,207 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Ho'opulapula Program (1st and 2nd Year Teacher Program) 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Jill Baldemor POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. c ;t - —T Executive Director 1 .25.2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Ho'opulapula Program (1st and 2nd Year Teacher Program) 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Ho'opulapula Program (1st and 2nd Year Teacher Program) 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. ---- 1 .25.2019 Signature of Authorized Person (see checklist, 2nd item) Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Ho'opulapula Program (1st and 2nd Year Teacher Program) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 90%of 1st year teachers will participate. 90%of 1st and 2nd year teachers will attend. 90%of participants will receive coaching and participate in PLCs. Draft proposal of Hawaii Summer Institute completed. TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $10,000 Professional Fees Operations Supplies Equipment Other: National Institute Costs Other: National Shared Services Costs Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Teach For America Hawaii Pathways Program 153 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Pathways Program Agency Director: Jill Baldemor Phone No.: (808) 521 — 1371 Contact Person: Jazzmin Cabanilla Phone No.: (808) 854 — 7279 Mailing Address: Address: 500 Ala Moana Blvd Suite 3-400 Address: City,ST,Zip Honolulu, Hawai'i 96813 Facility Address: Address: 75-5706 Kuakini Hwy. Suite 102 Address: City,ST,Zip Kailua-Kona, Hawaii 96720 Email Address: jill.baldemor@teachforamerica.org Fax No.: ( ) — Accountant/CPA: Grant Thronton Phone No.: (212 ) 599 — 0100 Firm (if applicable): Mailing Address: Address: 666 Third Avenue 13th Floor Address: City,ST,Zip New York,NY 10017-4011 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) n Puna n Hamakua n North Kona n South Hilo n North Kohala n South Kona n North Hilo n South Kohala n Ka`u Services or Activities To Be Provided: (One or more can be checked) n Educational concerns n Youth n Victims of Crimes n Culture and the arts n Aged n Victims of Health or Social Crises [' Needs of the poor n Physical/Emotional Disabilities n Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Pathways Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 5,500 0 4,300 2. Agency Mission Statement: Teach for America's mission is to find,develop and mobilize promising future leaders to grow and strengthen the movement for educational equity and excellence. In Hawai'i,we are especially looking to find individuals who are deeply committed to our community,including but not limited to kama'aina, kanaka maoli(Native Hawaiians),and Hawai'i public school graduates. We seek to find individuals who embody our regional values of kuleana,'ohana and aloha and who are driven by a social justice orientation to creating a more fair and just community for all of our keiki. We seek to develop innovative learners and educational leaders who work in partnership with students,families and communities to empower students to achieve academically,grow personally and activate their own leadership. We cultivate humble leaders who make life-long commitments to address educational inequity through classroom teaching,school and district leadership,public policy making,and other wide ranging roles and fields that collectively contribute to a robust ecosystem of opportunities for all keiki. 3. Program Description: The Pathways Program focuses on developing leaders both in and out of the classroom. Program leads support 2nd year teachers and alumni participants by: (1)Providing 2nd year teachers and alumni opportunities to co-design their own leadership development opportunities; (2)Supporting 2nd year teachers and alumni in building leadership skills to prepare for leadership roles in their classrooms,within the Department of Education and/or in other sectors;and(3)Assisting participants in connecting to and building meaningful relationships with community partners and organizations. Since it's inception the Pathways program has evolved and continues to be shaped by our closest partners including but not limited to;alumni,students,school administrators and partners,and community stakeholders/organizations. It is through these important partnerships that we are able to design thoughtful programming for all of our participants. This year we will continue to support the leadership development of 2nd year teachers and alumni in the following areas: (1) Schools and Systems Leadership(SSL)-teachers and alumni in this pathway receive direct support and guidance in learning and preparing for roles in school and systems leadership;(2) Values, Diversity and Culture(VDC)-participants are provided access to resources including one on one coaching,stand alone sessions and professional learning communities that raise awareness and encourage advocacy around systems of inequity and it's impact on students and schools in low-income communities;and(3) School and Community Solutions(SCS)-teacher leaders and alumni work closely with students,families and communities to create new opportunities and contribute to positive school impact. 4.Total Budget& Position Count: Total Program Budget: $121,720 Total Program Position Count: Portion of 2 roles Total Agency Budget: $3,757,242 Total Agency Position Count: 19 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Pathways Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Americorps $4,541 Nanea Foundation $16,666 JB McIntosh $8,333 Zierk Family Foundation $8,333 Roberts Foundation $66,666 TOTAL: $104,539 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Plans to increase revenues to support this program are provided below. (1) Continue to steward positive relationships with existing donors. (2) Continue to work with diverse community organizations to cultivate new relationships with potential supporters. (3) Identify and establish healthy partnerships with philanthropists and/or philanthropy organizations who have connections to Hawai'i and Hawai'i Island. (4) Design and secure multi-year commitments from new and/or existing donors. (5) Continue to designate on island staff to execute development work on Hawai'i Island. The support of the community is vital for us to be able to continue our work on Hawai'i Island and so we remain committed to working with the community to gain consistent,positive on island support of our organization and programs. 7. Program Objectives Using County Nonprofit Grant Program Funds: Program Objectives: To support Pathways team leads with the listed outcomes. (1) Provide all participants access to leadership development opportunities that strengthen their skill sets via Pathways ro rammin P .9 9 (2) Provide support to all participants in the form of one on one coaching,professional learning communities and focused stand alone sessions. (3) Support participants who express interest in learning more about and applying for the Hawai'i Certification Institute for School Leaders program. (4) Support teachers and alumni with engaging in, building partnerships and developing healthy relationships with other entities within Hawai'i's educational landscape. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Pathways Program 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) At least(15)2nd year teachers and alumni participate in Pathways programming and At least(15)2nd year teacher/alumni receive direct support via 1 on 1 coaching, PLCs and stand alone sessions. participants. At least(2)Hawai'i Island alumni identified and receiving support to apply for the Hawai'i At least(2)alumni receive HICISL support. Certification Institute for School Leaders program. At least(2)community engagement opportunities with community partners. At least(2)community engagement opportunities with community partners. Attach additional pages as necessary. 9. TABLE II: FY 18-19 FY 19-20 FY 19-20 PROGRAM EXPENDITURES Actual* Total Budget Grant Req Salary and Wages $96,510 $10,000 Professional Fees Operations $9,333 Supplies Equipment Other: National Shared Services Costs $15,877 Other: Other: Other: Other: TOTAL $121,720 $10,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Pathways Program 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Jill Baldemor POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n Member or members of the Council n Staff appointed by a member of the Council n The Mayor n The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measuresto avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. L6 - Executive Director 1 .25.2019 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Pathways Program 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Pathways Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. restricted for the purposes As part of this application, you acknowledge that any funds awarded will be s p p stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. • 1 .25.2019 Signature of Authorized Person (see checklist, 2nd item) Date Executive Director Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Teach For America Hawai'i Program Name: Pathways Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result At least(15)2nd year teacher/alumni participants. At least(2)alumni receive HILI At least(2)community engagement opportunities with community partners. TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages $10,000 Professional Fees Operations Supplies Equipment, Other: National Shared Services Costs Other: Other: Other: Other: TOTAL $10,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Three Ring Ranch Interns, Externs, Afterschool Mentors 154 County of Hawai`i Nonprofit Grant Application, FY2019-20 Agency Name: Three Ring Ranch Program Name: Interns, Externs & Afterschool Mentors Agency Director: Ann Goody Phone No.: (808 ) 331 — 8778 Contact Person: Ann Goody Phone No.: (808 ) 331 — 8778 Mailing Address: Address: 75-809 Keaolani Address: • City,ST,Zip kailua Kona Facility Address: Address: 75-809 Keaolani Dr Address: City,ST,Zip Kailua Kona Email Address: animals@threeringranch.org Fax No.: (866 ) 365 — 5097 Accountant/CPA: Monica Phone No.: (808 ) 329 — 9220 Firm (if applicable): Aloha Business Services Mailing Address: Address:74-5596 Pawai PI Address: City,ST,Zip Kailua Kona HI 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $10,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala n South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ❑Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Three Ring Ranch Program Name: Interns, Externs & Afterschool Mentors 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 6500 7250 6550 2. Agency Mission Statement: 3RR Mission Statement Our mission is to positively impact the environment while educating Hawaii ' s children about their place in the natural world. We assist in the development of an environmentally responsible generation of youth while caring for exotic animal residents. Vision Statement As Hawaii ' s only accredited animal sanctuary we do not buy sell or breed animals.We educate the public through a variety of programs while teaching about the fragile ecosystem we impact on a daily basis giving visitors a rare chance to see the animals up close and improving the lives of the animals in our care. In compliance to the policies and guidelines of regulatory and our accreditation bodies.We will always assist in actions that result in the improvement of animal lives here in Hawaii and across the globe. 3. Program Description: This is a repeat request for four of our very successful educational programs. 1. Internships, residential x 2 sessions of 4-6 weeks.Total of 6 pre-vet and second year vet student interns in the summer. Pre-vet students are paired with vet students to allow the pre-vets a chance to learn from the advanced partner.The program includes surgical clinics for feral cats,clinics for farm animals, hands on training and surgical work at HIHS, Hands on clinical and routine care at 3RR in addition to outings within the community that offer additional opportunities for learning experiences. The highest preference is to accept students from the BI,following this to students from Hawaii as well as those with family ties to the BI and HI. Screening applicants now and one BI and one Oahu applicant pending. 2. Externships, residential x 2 for 4th or 5th year vet students.These residential programs last 3-4 weeks depending on the universities requirements.Very hands on clinical rotations with all of the components of the Internships but much more advances as the students are in their final year of school.Additional emphasis on rural animal care,farm animal care and providing care to creatures whose owners do not have the same resources as more affluent communities. Highest preference is to accept students from the BI,following this to students from Hawaii as well as those with family ties to the BI&HI. 3. High school residential program. One session during school break to allow up to three local students the chance to explore the animal care field. Some wish to enter animal care as vets,farmers, ranchers or move into roles within their family livestock operation.This is open to BI and HI students. Mainland students accepted only if space and no local student as applied. 4.Afterschool Mentors,4 hour sessions offered 2 x weekly including during school breaks.All children are age 11 and up and come from public, private, charter and home schools.All BI students. 3RR 2019 budget below is very lean. 0 paid staff,est 6 volunteer staff for all four programs,40 volunteer staff total. 3RR 2019 budget below is very lean.0 paid staff, est 6 volunteer staff for all four programs,40 volunteer staff total. 4. Total Budget& Position Count: Total Program Budget: 23200 Total Program Position Count: 6 Total Agency Budget: 115325 Total Agency Position Count: 40 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 5 age 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Three Ring Ranch Program Name: Interns, Externs & Afterschool Mentors 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Tillyaeva Family (confirmed), Jill & Dick Davis (confirmed), other private donors 3,000 Ironman Foundation (pending, will know in Oct) 1,000 Hawaii County non-profit grant 10000 3RR Curator in Kind 2000 3RR cash from International volunteer funds 2000 3RR cash general fund- 1200 Ludwick Family Foundation (pending, will know in Sept) 4,000 TOTAL: 23,200 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This may well be the last year we ask for assistance for our educational programs.Through social media, tour visitors, community education we are getting closer and closer each year to making the three types of educational programs all being sustainable. It will require us to continue to reach out to our supporters and continue to excite them with the results we are getting through these programs.We have slashed costs and formed alliances with other programs to offer our students the most varied hands on experiences possible in their time with us.Surgical clinics, HIHS clinic and tech days(we provide free help for HIHS)farm animal hands on days of care, assisting other feral cat groups to name a few. By being creative with our international volunteer program we can get help to run our educational programs without costing 3RR as much as in the past. Our agency budget far 2019 is far higher than in prior years due to some major capitol repairs required (roof, driveway, aviary replacement, NHP habitat work,taller fencing.All so that we can continue our work and keep the animals we rescue safe. But as always we are allocating funds for education out of our annual income.And we are allocating Curator&Keeper time to see that these programs continue without competition of tours on those days we are working with students. Due to the increased budget required to complete vital projects we can not afford the educational programs for all students and sessions in 2019 without help. 7. Program Objectives Using County Nonprofit Grant Program Funds: For each of our 4 programs our goals are as follows: 1. Internships, residential x 2 sessions of 4-6 weeks.Total of 6 pre-vet and second year vet student interns in the summer. 2. Externships, residential x 2 for 4th or 5th year vet students. Programs last 3-4 weeks depending on the universities requirements. 3. High school residential program, up to 3 students per session held in the school break(winter or summer). 4.Afterschool Mentors,4 hour sessions offered 2 x weekly including during school breaks and on make up group days when students are out of school.These days are open to all students prior or current.We will decrease to one session a week during the residential internships, externships and high school programs to allow those programs our full attention.The session about to start is made up of six Hilo students who are carpooling over to our side to participate for the next 12 weeks. Our goal is to encourage students from all parts of the island to attend incorporating creative solutions to the distance required to travel. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Three Ring Ranch Program Name: Interns, Externs & Afterschool Mentors 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) 1. Internships-6-8 students in 2 sessions-mix of vet and pre-vet All pre vets get accepted to vet school 2. Externships 2 fourth year vet students in final year of school Graduate and come to HI for work/relief work 3. High school residential 3-5 students during school break graduate and go on to college/university 4.Afterschool Mentors 3-6 per session,year round plus open days All graduate HS,90%attend college/univ Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 0 0 0 Professional Fees 400 400 200 Operations 4500 2500 1500 Supplies 300 300 Equipment 1500 0 0 Other: food, utilities, car, insurance 15500 10000 7000 Other: surgery clinics 3000 1000 1000 Other: loss of tour income 12800 9000 0 Other: Other: TOTAL 35800 23200 10000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 52;6/— Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Three Ring Ranch Program Name: Interns, Externs & Afterschool Mentors 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Ann Goody POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. • /ffd //20VZO/9 Signature of Aut fed Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Three Ring Ranch Program Name: Interns, Externs & Afterschool Mentors 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor,the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawaii Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020j` /� Page 6 of 8 i V �/ County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Three Ring Ranch Program Name: Interns, Externs & Afterschool Mentors ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. C ;i4" l/ ZZ 'W/7 Signature of Authorized Person (see checklist, 2nd item) Date Z/e(,i,ii7e—/.31/24(--7/01 Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Three Ring Ranch Program Name: Interns, Externs & Afterschool Mentors 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result All pre vets get accepted to vet school Graduate and come to HI for work/relief work graduate and go on to college/u All graduate HS,90%attend college/univ TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 0 Professional Fees 200 Operations 1500 Supplies 300 Equipment 0 Other: food, utilities, car, insurance 7000 Other: surgery clinics W00 Other: loss of tour income 0 Other: Other: TOTAL 10000 Additional Council directives regarding award: g � EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 Volunteer Legal Services Hawaii Hawaii County Pop-Up Legal Clinics 155 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics Agency Director: Angela Kuo Min Phone No.: (808) 528 - 7050 Contact Person: Angela Kuo Min Phone No.: (808) 522 - 0684 Mailing Address: Address: 545 Queen Street Address: Suite 100 City,ST,Zip Honolulu,Hawaii 96813 Facility Address: Address: 545 Queen Street Address: Suite 100 City,ST,Zip Honolulu,Hawaii 96813 Email Address: angela@vlsh.org Fax No.: (808) 524 - 2147 Accountant/CPA: Joseph Evans/Michelle Gray Phone No.: (808) 763 - 8723 Firm (if applicable): Mailing Address: Address: 545 Queen Street Address: Suite 100 City,ST,Zip Honolulu,Hawaii 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna Hamakua ✓❑ North Kona ❑✓ South Hilo ✓❑North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑Youth ❑Victims of Crimes ❑Culture and the arts ❑Aged ['Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 7500 9250 6425 2. Agency Mission Statement: Volunteer Legal Services Hawaii's("Volunteer Legal")mission is to mobilize the legal community to address the unmet legal needs of the indigent and disenfranchised members of our community. For 37 years,Volunteer Legal continues to be a community based organization with a goal of serving the needs of our community in a responsive and meaningful way. Volunteer Legal provides legal assistance to over two thousand Hawaii residents each year. Over 60%of those serviced by Volunteer Legal have incomes at or below 125%of the federal poverty guideline for Hawaii.This equates to just slightly over $36,000 gross annual income for a family of four.Volunteer Legal also provides services to those whose incomes are just above the income cut off for traditional legal aid services(up to the 250%federal poverty line), but do not make enough money to be able to afford a full market rate attorney. In 2018,Volunteer Legal conducted over two thousand intakes and provided qualified individuals legal services ranging from legal advice and counsel, limited scope assistance,and referrals to volunteer attorneys for pro bono direct representation. Approximately,11%of those serviced in 2018 were residents of Hawaii County. While VLSH's office is located in Oahu,VLSH provides legal services"virtually"via phone calls, live"Pop-Up"clinics, and via online at Hawaii Online Pro Bono(HOP)portal to neighbor islands including residents of Hawaii County. However,there is no denying that having that face-to-face contact is much more effective and preferred by our clients.As such,Volunteer Legal is proposing 8 Pop-Up Legal Clinics for Hawaii County residents for the next year throughout Hawaii County to allow for the individualized and in-person contact with volunteer attorneys. 3. Program Description: Funding will support a series of 8 Pop-Up Legal Advice Clinics in Hawaii County that will provide low-and-moderate income residents to the opportunity to meet with volunteer attorneys on an individual and in person basis for legal advice and limited legal assistance.The Pop-Up Legal Clinic model is based on Volunteer Legal's Neighborhood Legal Clinic model in which pre-screened individuals are matched with volunteer attorneys for counseling. Participants undergo an intake process which includes the collection of information regarding household income,and legal issue.Additionally, Intake staff collect pertinent facts and documents regarding the specific legal issue to relay to the volunteer attorney with whom the participant is matched with.This in-depth screening process enables volunteers to focus on providing actual legal advice at the clinics and guidance for next steps. Volunteer attorneys are recruited by Volunteer Legal and experienced in the following civil legal areas:family law(adoption, guardianship,divorce,child custody,visitation and support); estate planning; probate and trusts; Chapter 7 bankruptcy and consumer debt collections; private residential tenant issues;and VA benefits. Volunteer Legal staff will be on-site at each event to oversee logistics and follow-up services for participants in need of further assistance. The Pop-Up Legal Clinics will take place in rural districts with high poverty legals. In 2018,Volunteer Legal held Pop Up Clinics in Kona and Hilo. Volunteer Legal will work with local service providers and agencies to identify accessible locations and community appropriate venues. In addition,Volunteer Legal will engage in public awareness efforts to ensure that the community receives timely notice of each Clinic. Participant surveys will be collected at each Clinic for purposes of quality assurance and project effectiveness. 4.Total Budget & Position Count: Total Program Budget: 35,000 Total Program Position Count: 1 Total Agency Budget: 661,000 Total Agency Position Count: 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 5. Program Funding Sources(identify alt sources of funding applied to this program): FY19-20 Revenue Source Estimate The Hawaii State Judiciary-Purchase of Service Contract 20,000 TOTAL: 20,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Volunteer Legal has secured funds from the Hawaii State Judiciary-Purchase of Service Contract to support civil legal assistance for the homeless population in Hawaii County for Calendar Year 2019. Should state funding fall short for the proposed Pop-Up Clinics,Volunteer Legal will seek additional funding from other sources,including the Hawaii Justice Foundation,to support services to low and moderate income persons in Hawaii County for Calendar Year 2019. 7. Program Objectives Using County Nonprofit Grant Program Funds: By the end of the grant period,Volunteer Legal will have completed 8 Pop-Up Legal Advice Clinics in Hawaii County,serving at least 100 individuals in total. Of the 100 served at the Clinics,an estimated 40 will be provided additional legal assistance by way of limited scope services(i.e.drafting letters to creditors or landlords,completion of court forms,drafting a will,power of attorney,and/or health care directive),and referrals to volunteer attorney for direct services(negotiating with opposing party, attending court hearings,and full representation). The Pop-Up Legal Clinics will be held in rural districts with high poverty rates. Volunteer Legal plans to hold"Pop-Ups"around the island rotating different cities each time to reach the most residents possible. The proposed Pop-Up Legal Clinics will enhance current services offered to Hawaii County Residents through Volunteer Legal's core services and the Hawaii Online Pro bono(HOP)legal advice portal. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) At least 100 individuals will be provided legal advice at the 8 Pop-Up Clinics 100 Clinic Participants Of the estimated 100 clinic participants,40 will be provided further assistance 40 Additional Services Beyond Clinic Services 8 Pop-Up Legal Clinics will be presented in Hawaii County without fee to the public 8 Total Pop-Up Legal Clinics Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 8150 Professional Fees 0 Operations 500 Supplies 2,000 Equipment 1,500 Other: Airfare, Mileage&Parking 1,000 Other: Venue Rental Fees 1,000 Other: General Liability and Professional Liability Insurance 100 Other: Event refreshments for Volunteers and Participants 500 Other: Volunteer Appreciation 250 TOTAL 15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 I�_ County of Flawai`i Nonprofit Grant Application FY2019-20 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer,director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the Council n The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: n If no conflicts exist, check here. 11 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics is. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor,the Department of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility,equipment, property, or records pertinent to the grant,contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (see checklist, 2nd item) Date wxe h. TJ?i e o+-�r— Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 r x County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Pop-Up Legal Clinics 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 100 Clinic Participants 40 Additional Services Beyond Clinic Services 8 Total Pop-Up Legal Clinics TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages 8150 Professional Fees 0 Operations 500 Supplies 2,000 Equipment 1,500 Other: Airfare, Mileage&Parking 1,000 Other: Venue Rental Fees 1,000 Other: General Liability and Professional Liability Insurance 100 Other: Event refreshments for Volunteers and Participants 500 Other: Volunteer Appreciation 250 TOTAL 15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 West Hawaii Community Health Center, Inc. Adult Dental Program for Under-Served 157 r � County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: West Hawaii Community Health Center Inc. (WHCHC) Program Name: Adult Dental Program for Under-Served Agency Director: Richard Taaffe Phone No.: (808) 326 — 3878 Contact Person: Natasha Ala Phone No.: (808) 355 — 5673 Mailing Address: Address: 75-5751 Kuakini Hwy.,Ste 203 Address: City,ST,Zip Kailua Kona, HI 96740 Facility Address: Address: 75-5751 Kuakini Hwy.,Ste 203 Address: City,ST,Zip Kailua Kona, HI 96740 Email Address: nala@westhawaiichc.org Fax No.: (808 ) 328 — 0804 Accountant/CPA: Daine Pautz, CFO Phone No.: (808 ) 326 — 3883 Firm (if applicable): Mailing Address: Address: 75-5751 Kuakini Hwy.,Ste 203 Address: City,ST,Zip Kailua Kona, HI 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna n Hamakua n North Kona n South Hilo n North Kohala n South Kona ❑ North Hilo ✓❑South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns n Youth n Victims of Crimes n Culture and the arts n Aged ❑Victims of Health or Social Crises ❑✓ Needs of the poor n Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: West Hawaii Community Health Center Inc. (WHCHC) Program Name: Adult Dental Program for Under-Served 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 $21,250 $22,675 2.Agency Mission Statement: The mission of West Hawaii Community Health Center(WHCHC)is to make quality, comprehensive,and integrated health services accessible to all regardless of their ability to pay.These services will be culturally sensitive and will promote community well-being through the practice of'malama pono'. WHCHC was established as a non-profit 501 (c)3 entity in November 2003. In January 2005 WHCHC first opened it's doors to serve the public and one year later,in 2006,WHCHC received its Federally Qualified Health Center(FQHC)status, paving the way for a cost-effective approach to delivering health care to the under-served and uninsured in our community. Since 2006,WHCHC has improved the health of the people living on Hawaii Island by making primary health care services accessible to people of all ages,cultures, and income levels.We have achieved this by offering comprehensive medical,dental, and behavioral health services as well as enabling services. Over the years our enabling services have expanded to include: eligibility and enrollment support for the uninsured, under-insured,and low income people; referral services to specialists; assistance with prescription medications; language interpretation and translation services; care coordination for patients with chronic illnesses;and health education and community outreach programs. 3. Program Description: Oral health is critical to general health and well-being as the mouth is the gateway to the rest of the body, providing clues about overall health. It is sometimes the first place where signs and symptoms of other diseases such as diabetes are noticed. Causes of poor oral health are complex and access to dental care for adults is crucial for overall health and well-being. However,adults in West Hawaii are less likely to see a dentist then adults on average for the state.35.6%of West Hawaii Adults have had no dental care compared to the state rate of 29%. Moreover,the rate of oral health emergency room visits in West Hawaii is 58.9 per 100,000,significantly greater than the rate of 16.8 per 100,000 statewide.(State of Hawaii Primary Care Needs Assessment Data Book,2016) WHCHC provides care to the most under-served people in our community who have the most complicated health needs. Individuals with a range of chronic conditions are more susceptible to oral disease. Oral disease can also exacerbate chronic disease symptoms.With support from this Hawaii County Nonprofit grant,WHCHC will provide comprehensive adult dental prevention and phase 1 treatment services,to the most high risk and under-served populations including the elderly,those living in poverty,those who are homeless,and at-risk pregnant women. In 2018 WHCHC provided dental care to 838 adults.435 of these dental patients lived at 100%of the federal poverty level and qualified for only paying a minimal payment on the sliding fee discount program to receive treatment. Money from this grant award will go to support service and treatment to adults living at 100%of the federal poverty level. 4. Total Budget& Position Count: Total Program Budget: $235,890 Total Program Position Count: 6 Total Agency Budget: $19,966,162 Total Agency Position Count: 170 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: West Hawaii Community Health Center Inc. (WHCHC) Program Name: Adult Dental Program for Under-Served 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Adult Dental Billable Revenue $235,890 Hawaii County Nonprofit Grant $20,000 TOTAL: $255,890 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Providing oral health treatments for low income and vulnerable populations is an important pubic allocation of resources because preventative dental care reduces the escalation of other chronic health conditions.Addressing these issues in a timely manner helps patients avoid seeking costly health care services in the hospital emergency rooms where frequently the public is left to absorb these unpaid services. WHCHC dental eligibility specialists will work with patients to assist them in enrolling in a commercial dental plan,and will also help them sign up for receiving care based on our sliding fee payment plan. People who live 100%below the federal poverty level (depending on income level and family size)qualify for significantly reduced rates for oral health treatment at WHCHC. In some instances people may qualify for treatment at no cost and only have to pay the minimal sliding fee charge of$75 for a visit. Funds from this grant will go to help WHCHC cover cost incurred for providing treatment to people who qualify for the sliding fee payment system and who will not be paying for the cost of their care. 7. Program Objectives Using County Nonprofit Grant Program Funds: By providing comprehensive adult dental services to the most disadvantaged and under-served adults WHCHC will help reduce tooth loss in adults, and reduce the risks of patients receiving other periodontal diseases including oral cancer and gum disease. By improving oral health outcomes for the most disadvantaged adults in our community we will: 1. Reduce costs associated with emergency department visits for preventable oral health problems. 2. Improve pregnancy outcomes for low-income women. 3. Improve self-esteem,employability,decrease absenteeism, and improve mental health of target population. 4. Improve chronic health condition for target population. 5. Improve access to dental services for adults. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: West Hawaii Community Health Center Inc. (WHCHC) Program Name: Adult Dental Program for Under-Served 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) WHCHC will provide 1,500 adult dental visits Improve oral health in low income adults WHCHC will increase payment for treatment Program sustainability WHCHC will reduce ER visits for preventable dental care Lower health care cost Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $235,890 $20,000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $235,890 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director n The Director of Finance n The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: IX If no conflicts exist, check here. 2())7 Signature of Authorized P-rson ( pecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: West Hawaii Community Health Center Inc. (WHCHC) Program Name: Adult Dental Program for Under-Served 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free,and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Pers n (see checklist, 2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: West Hawaii Community Health Center Inc. (WHCHC) Program Name: Adult Dental Program for Under-Served 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 West Hawaii Community Health Center, Inc. WHCHC Community Outreach to Vulnerable Populations 158 County of Hawaii Nonprofit Grant Application FY2019-20 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations Agency Director: Richard Taaffe Phone No.: (808) 326 — 3878 Contact Person: Natasha Ala Phone No.: (808) 355 — 5673 Mailing Address: Address: 75-5751 Kuakini Hwy.,Ste 203 Address: City,ST,Zip Kailua Kona, HI 96740 Facility Address: Address: 75-5751 Kuakini Hwy.,Ste 203 Address: City,ST,Zip Kailua Kona, HI 96740 Email Address: nala@westhawaiichc.org Fax No.: (808 ) 327 — 1939 Accountant/CPA: Diane Pautz, CFO Phone No.: (808 ) 326 — 3883 Firm (if applicable): Mailing Address: Address: 75-5751 Kuakini Hwy.,Ste 203 Address: City,ST,Zip Kailua Kona, HI 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ['South Hilo [' North Kohala ❑✓ South Kona ❑ North Hilo ✓0 South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ✓❑ Physical/Emotional Disabilities [' Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 0 $21,250 $22,675 2.Agency Mission Statement: The mission of West Hawaii Community Health Center is to make quality,comprehensive,and integrated health services accessible to all regardless of their ability to pay.These services will be culturally sensitive and will promote community well-being through the practice of'malama pono'. WHCHC was established as a non-profit 501 (c)3 entity in November 2003. In January 2005 WHCHC first opened it's doors to serve the public and one year later, in 2006,WHCHC received its Federally Qualified Health Center(FQHC)status, paving the way for a cost-effective approach to delivering health care to the under-served and uninsured in our community. Since 2006,WHCHC has improved the health of the people living on Hawaii Island by making primary health care services accessible to people of all ages, cultures,and income levels.We have achieved this by offering comprehensive medical,dental, and behavioral health services as well as enabling services. Over the years our enabling services have expanded to include: eligibility and enrollment support for the uninsured, under-insured,and low income people; referral services to specialists; assistance with prescription medications; language interpretation and translation services;care coordination for patients with chronic illnesses;and Health Education and Community Outreach Programs. 3. Program Description: The Health Education and Community Outreach Program supports under-served and vulnerable populations such as the Marshallese,the Micronesians, Native Hawaiians,the Spanish speaking community,and disadvantaged youth groups by connecting these populations with resources and opportunities that will result in strengthening their community ties and promote community wellness in the spirit of malama pono. By addressing upstream issues and working to improve social determinants facing the most under-served populations in West Hawaii,WHCHC improves community well-being and decrease health disparities among low income and minority populations. The Health Education and Outreach Program provides the following services to the community: 1.WHCHC staff members participate regularly at community health fairs and events to promote and inform the public about personal health and disease prevention. Educational materials are provided in English, as well as other languages including: Spanish, Marshallese,and Ilocano/Tagalog. In addition,WHCHC has a multi-lingual staff fluent in English, Spanish and Marshallese. 2.WHCHC staff provide health education and training classes at public housing facilities,senior day care centers, homeless shelters,at public schools,churches, night clubs, in the coffee fields,and many other community gathering locations. 3.WHCHC staff collaborates with community leaders from the Marshallese community, Micronesian community,the Spanish speaking community,the farm working community,the LGBT community,and many others to develop trusted relationships and work to become partner in supporting and promoting the health and well-being of each community. 4.Total Budget& Position Count: Total Program Budget: $0 Total Program Position Count: 6 Total Agency Budget: $19,966,162 Total Agency Position Count: 170 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of fIawai`i Nonprofit Grant Application FY2019-20 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Currently WHCHC is seeking funding support through grants to help cover program cost for the Health Education and Community Outreach Program Hawaii County Nonprofit Grant $20,000 TOTAL: $20,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: WHCHC will continue to develop diverse sources of revenue to fund and support the Health Education and Outreach Program. Currently the services provided through this program are not billable services and thus WCHCH must rely on private foundations,government support,and donor contributions to fund these valuable public services. 7. Program Objectives Using County Nonprofit Grant Program Funds: County funds will be used for the printing and purchase of health educational materials(in multiple languages)to be distributed at health fairs and health education training classes.The West Hawaii Community Health Center service area extends from Kawaihae to Ocean View,an area of roughly 80 miles-funds will be used to pay for staff to travel to locations through out this vast service area where health education opportunities are limited. Funds well also be used to purchase medical supplies to be used for health screenings at public health fairs and other community events.Through the support of Hawaii County,the WHCHC Health Education and Outreach Program will reduce the social determinants that contribute to the disparities facing many of the under-served populations,thereby creating more productive and rewarding lives of our minority and youth populations in West Hawaii.Studies suggest that health does not occur in a vacuum. Instead, health status is embedded in larger living and working conditions.There is strong,suggestive evidence that viewing an individual as more than just a system of organs,and taking into account the social context in the delivery of healthcare services can have an important impact on improving health.There is growing evidence that the social determinants that negatively impact these under-served populations are costly to society in multiple ways.Through this generous County Nonprofit grant,WHCHC will support under-served populations in West Hawaii by helping them become proactive in promoting their own health and wellbeing and connecting vulnerable populations with primary health care services(medical,dental,and behavioral health),thus reducing costly ER visits and specialized treatments. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations B.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) WHCHC Outreach staff will attend 15 Health Fairs per year 2,500+people will be reached WHCHC Outreach staff will provide health education training to community groups 250+people will receive specialized training WHCHC Outreach staff will partner with orgaznations on public health issues Strengthen public health network for patinets Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages Professional Fees Operations Supplies $10,000 Equipment $5,000 Other: mileage reimbursment $5,000 Other: Other: Other: Other: TOTAL $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations so. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. Lioi I -eZcir- 2616/ Signature of Authorized Person (s cify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), 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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities) on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. 7-77/ I- 2.7 • 2,00 Signature of Authorized Pers n (see checklist, 2nd item) Date V Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of flawai`i Nonprofit Grant Application FY2019-20 Agency Name: West Hawaii Community Health Center Inc. Program Name: WHCHC Community Outreach to Vulnerable Populations 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 2,500+people will be reached 250+people will receive specialized training Strengthen public health netw TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES Request Award Salary and Wages Professional Fees Operations Supplies Equipment Other: mileage reimbursment Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 YWCA of Hawaii Island Sexual Assault Support Services 159 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services Agency Director: Kathleen McGilvray Phone No.: (808) 935 — 7141 Contact Person: Lorraine Davis Phone No.: (808) 854 — 5856 Mailing Address: Address: YWCA of Hawaii Island Address: 1382 Kilauea Avenue City,ST,Zip Hilo, HI 96720 Facility Address: Address: 1382 Kilauea Avenue, Hilo HI 96720 Address: 75-5706 Hanama Place, Suite 202, Kailua-Kona, HI 96740 City,ST,Zip Email Address: Idavis@ywcahawaiiisland.org Fax No.: (808 ) 961 — 9140 Accountant/CPA: Phone No.: (808) 935 — 5404 Firm (if applicable): Taketa, Iwata, Hara and Associates, LLC Mailing Address: Address: 101 Aupuni Street Address: Suite 139 City,ST,Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua 0 North Kona ['South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka`u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ✓❑Youth ❑✓ Victims of Crimes ❑Culture and the arts ❑Aged ['Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services • 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $20,000 $17,500 16,091 2.Agency Mission Statement: 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(YWCA),first organized in Hilo in 1919, has offered valuable programs and activities for the benefit of women, children, and their families. the YWCA was established as a 501(c)(3)non-profit organization in 1965,and has been a partner agency of the Hawaii Island United Way(HIUW)since 1979. It belongs to a national organization consisting of 300 YWCA Associations across the United States with 2.6 million members. Employing over 50 full-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 through the island of Hawai'i. Current programs in place include: Healthy Families Hawaii, a child abuse and neglect prevention program;Teen Court,a diversion program for first time,teen offenders; Developmental Preschool, a NAEYC accredited preschool serving 2-5 year olds;Sexual Assault Support Services,the only program operating a 24/7 rape crisis line and providing therapy to victims of sexual violence and their families island-wide; Sex Assault Nurse Examiners Program,a program to provide specially trained nurses to provide medical assessments and sex assault forensic examinations to victims of crime. 3. Program Description: SASS provides services for the healing of sexual violence. Sexual violence is a crime that crosses the boundaries of age, race, religion and gender. Sexual violence is pervasive on our island. From 7/1 -12/31/2018,the SASS program opened 184 new sexual assault cases. Last year,we opened 177 cases in the first 6 months of the year. We expect to open 370 cases by June 30. Of the cases opened,80%of the victims were female;57.7%were under the age of 17 and 93%of the victims knew their attacker. The cases that we opened constitute 30-40%of the total number of victims of sexual violence. Sexual violence is an underreported crime. The program has a 3-pronged victim-centered approach. The SASS program staffs a 24/7 crisis line to victims who call in for emotional support and information. It also serves as the conduit for professional and partner agencies to start care coordination for victims who disclose and are requesting services. We provide face to face services to victims who would like to police report,get a TRO,go through a forensic interview at the Children's Justice Center and/or a medical forensic examination with a nurse examiner. After initial contact with the victim,there is outreach by staff to check in and see how the program might support them. The SASS program also supplies therapeutic services to victims and their families. All of our services are at no cost to the victim and/or their family.The program also provides prevention education and awareness activities to schools, community events and groups who ask for information. In anticipation of increased need for services,we are asking for increased funds to maintain the same level of direct services and prevention education as last year. 4.Total Budget& Position Count: Total Program Budget: 539,057 Total Program Position Count: 15 Total Agency Budget: 2,542,521 Total Agency Position Count: 52 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Sex Abuse Treatment Center 413,967 Office of the Prosecuting Attorney,VOCA funds 95,000 Walk a Mile fundraising and donations 10,000 County of Hawaii Non Profit Ask 30,000 TOTAL: 548,967 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This program has a variety of funding streams because sexual violence is something that few want to talk about. Because our client load has steadily increased,this agency is taking the following steps to keep the SASS program funded: -- Direct fundraising. In the past seven years,the YWCA has sponsored"Walk a Mile"and"Y-Walk"where the program was recipient of all the funds raised. The Board of Director's is planning this event for Hilo to be held in October 2019. -- Continuous grant writing to foundations,granting agencies, and response to request for proposal that would support the efforts in alignment with the program services. -- Working within the program to increase the infrastructure to provide more services to the under-served populations like trafficking victims,the LGBTQI community, isolated communities on the island,elderly and limited English speaking population. As the program is developed to provide services,additional grant monies through the State of Hawaii and Federal Office of Victims will be applied for through their RFP process. -- Partnering with the community for support either in-kind or monetary help to support the program. -- Collaborate with community programs to enhance support, provide referrals and not duplicate services. -- Third party billing with licensed therapists. -- As a last resort,we have considered but have avoided, requesting payments for services from victims. 7. Program Objectives Using County Nonprofit Grant Program Funds: The SASS program is requesting funds to assist in maintaining direct services to our victims through staffing a 24/7 crisis hot line that covers the entire island,staffing to support face to face crisis intervention and stabilization activities,face to face emotional and advocacy support with forensic interviews and medical examinations and outreach to victims who have asked for additional services. The program also wants to provide prevention educational activities in our schools as well at provide community awareness through outreach and community events. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) The crisis line will be manned 24/7 for the entire island 365 days. There will be 2 people on call 24/7 Services will be offered at no cost to the victim and their family No services will be dropped or reduced Advocates will be available for Face to Face(F2F)services 140 victims will be provided F2F services Attach additional pages as necessary. 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages 369,914 395,000 20,000 Professional Fees 73,796 80,000 7,273 Operations 68,115 73,000 2,727 Supplies 1,815 2,500 0 Equipment 14,000 0 0 Other: Staff training 1,435 2,000 0 Other: Mileage 9,982 12,000 0 Other: Other: Other: TOTAL 539,057 564,500 30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: YWCA of Hawaii Island Staff and Board of Directors POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ri Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director n The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid; in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. CEO / 01-3/l9 Signature of Aut orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below, you are acknowledging that you have read and understood these requirements. Signat re of Authorized Person (see checklist, 2nd item) Date Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result There will be 2 people on call 24n No services will be dropped or reduced 140 victims will be provided F21 TABLE II: PROGRAM EXPENDITURES FY 19-20 Grant Council Request Award Salary and Wages 20,000 Professional Fees 7,273 Operations 2,727 Supplies 0 Equipment 0 Other: Staff training 0 Other: Mileage 0 Other: Other: Other: TOTAL 30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8 YWCA of Hawaii Island YWCA Developmental Preschool 160 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: YWCA Hawaii Island Program Name: YWCA Developmental Preschool Agency Director: Kathleen McGilvary Phone No.: (808) 938 - 2720 Contact Person: Michelle Flemming Phone No.: (808) 930 - 5767 Mailing Address: Address: YWCA Hawaii Island Address: 1382 Kilauea Avenue City,ST,Zip Hilo, Hawaii 96720 Facility Address: Address: YWCA Developmental Preschool Address: 145 Ululani Street City,ST,Zip Hilo, Hawaii 96720 Email Address: mflemming@ywcahawaiiisland.org Fax No.: (808 ) 935 - 5150 Accountant/CPA: Phone No.: (808 ) 935 - 5404 Firm (if applicable): Taketa, Iwata, Hara&Associates Mailing Address: Address: Hilo Lagoon Center Association Address: 101 Aupuni Street#139 City,ST,Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua [' North Kona ['South Hilo ❑ North Kohala ❑South Kona ❑✓ North Hilo ❑South Kohala ❑ Ka`u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑Victims of Crimes ❑ Culture and the arts ❑Aged ['Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities [' Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 1 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: YWCA Hawaii Island Program Name: YWCA Developmental Preschool 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 16-17 FY 17-18 FY 18-19 $ 0 $ 13,750 $ 10,468 2. Agency Mission Statement: YWCA Hawaii Island is dedicated to eliminating racism, empowering women and promoting peace,justice,freedom and dignity for all. In 1919,visionary Hilo women responded to the need for safe housing for young women, founding the YWCA Hawaii Island as part of a national and world-wide women's movement. Over the years,the needs of women and their families have shaped the programs and services provided by the YWCA.Today,we remain advocates for women and children, ready as ever to respond to the needs and desires of women to make their place in the world. In keeping with our mission statement,the preschool empowers women through providing a healthy,safe, learning environment in which to place their child when they are in school to better their family's future or so they can be gainfully employed without having to worry about their child. The preschool also works toward eliminating racism, and promoting peace,justice,freedom and dignity for all through our curriculum which provides for character and values education as well as teaching tolerance and cooperation through mentoring, modeling and being a caregiver(Lickona, 1992). Reference: Lickona,T. (1992). Educating for Character: How Our Schools Can Teach Respect and Responsibility. New York. Bantam Book 3. 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 Serves(DHS)and we are accredited through the National Association for the Education of Young Children(NAEYC). YWCA Developmental Preschool is unique because we expose children to the academic world in a nurturing,safe and secure environment that is catered to each individual child. We are able to accomplish this through the curriculum we use which is Teaching Strategies Creative Curriculum. In our classrooms,the children get a balance of a structured learning environment as well as time to learn through their own self-initiated discovery. Our indoor and outdoor school environment offer opportunities for children to make choices that will enhance their naturally emerging skills. Our belief is that children don't need to be forced to learn,they want to learn, and they will. "The demand for early childhood care and education programs continues to increase not only in response to the growing demand for out-of-home child care but also in recognition of the critical importance of educational experiences during the early years. Several decades of research clearly demonstrate that high-quality,developmentally appropriate early childhood programs produce short-and long-term positive effects on children's cognitive and social development." (http://www.naeyc.org/ policy/excellence). The YWCA is requesting assistance for providing the following to our keiki: short term tuition assistance for struggling parents as a stop gap measure while they seek other tuition subsidies;food program assistance to continue providing 2 meals and a snack daily at no additional cost to the parents and culturally specific and specialty teachers to encourage learning and growth in new areas, such as music, language and arts. 4.Total Budget& Position Count: Total Program Budget: $ 780,986 Total Program Position Count: 14 Total Agency Budget: $ 2,542,521 Total Agency Position Count: 52 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 2 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: YWCA Hawaii Island Program Name: YWCA Developmental Preschool g P 5. Program Funding Sources (identify all sources of funding applied to this program): FY19-20 Revenue Source Estimate Hawaii Island United Way $ 12,000 Castle low-income tuition assistance $ 20,000 Castle Expansion Grant $ 5,000 Program Fees $ 656,000 Weinberg low-income tuition assistance $ 14,000 USDA $ 60,000 Annual Fundraiser $5,000 TOTAL: $ 772,000 Attach additional pages,if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The program has,and will continue to, hold an annual fundraiser to help support the program needs. This past November,with the help of staff and families,the preschool raised$4,500.00. The program has also planned to increase tuition as expenses,for example, minimum wage and cost for goods and supplies,increases. The program and agency actively seeks additional funding for equipment and participation in enrichment activities. Our Program and Agency are actively seeking funding steams that benefit our program and families we serve,such as funding for tuition assistance for families with more than one child enrolled, families in transition, low-income high-risk families, program enhancements,and specialty teachers that will educate our children with culture and art. 7. Program Objectives Using County Nonprofit Grant Program Funds: The YWCA Developmental Preschool works with the whole child,stimulating their love of learning in a developmentally appropriate way, in a safe, nurturing environment that provides good nutrition,structure and excitement about learning. Children who are hungry are not able to concentrate,and pay attention in class. Prior to the food program children sometimes had home lunch of 3 musubis or lunchables for the day, no vegetables or fresh milk. Feeding our keiki a nutritious breakfast, lunch and snack ensures that everyone is ready to learn,and their nutritional needs are met.We use this money to support it because 66%of our families are low income and cannot afford the additional cost.We are asking for 5%of our total food budget of$75,526. Many of our families experience temporary job loss, relocation,family separation and housing uncertainty.When this happens and there is not enough money,families often pull their children out of preschool. Keeping children in school,their routine, helps insulate them from the chaos that their families are going through.Short-term Tuition Assistance for families helps children who are the hardest to serve and most in need stay in school.We use this funding when all other funding has been exhausted,so it is especially crucial. We are requesting$5,000,and expect to help 13 or more children stay in school. Specialty teachers help us to create a foundation of excitement and interest in learning,when it means the most, in their formative years. We know our keiki are excited about classes like Olelo' Hawaii, Ukulele,Art&German Specialty classes because our families tell us they can't stop talking about it at home too. We're requesting$3,636 to provide approximately 7 hours of instruction per classroom, per month and introduce keiki to a variety of specialty classes. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 3 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: YWCA Hawaii Island Program Name: YWCA Developmental Preschool 8.TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.:Number of clients served,workshops or events held,volunteer hours,etc.Describe,be specific.) Parents in need will be provided tuition assistance Up to 13 families will receive assistance All children will be provided with a USDA approved breakfast, lunch and snacks 100%of the children will receive meals Provide 100 hours of support in art, music, cooking and dance 100 hours of face to face instruction will occur Attach additional .as necessary. pages Y 9.TABLE II: PROGRAM EXPENDITURES FY 18-19 FY 19-20 FY 19-20 Actual* Total Budget Grant Req Salary and Wages $ 488,774 $ 503,437 Professional Fees $ 151,137 $ 167,100 Operations $ 97,775 $ 100,708 $ 1,364 Supplies $ 14,960 $ 15,409 Equipment Other: Breakfast Lunch and Afternoon Snack $ 73,326 $ 75,526 $ 5,000 Other: Art, Music, Dance and Cooking classes $ 3,636 $ 3,636 Other: Short Term Tuition Assistance $ 5,000 $ 5,000 Other: Other: TOTAL $ 15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 4 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: YWCA Hawaii Island Program Name: YWCA Developmental Preschool 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization,with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): n M- ember or members of the Council ❑ Staff appointed by a member of the Council n The Mayor n The Managing Director n T- he Director of Finance ri T- he Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. t�sr Gto itzghf Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: YWCA Hawaii Island Program Name: YWCA Developmental Preschool 11. Certification of Understanding (Page 1 of 2) 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—2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency)full,free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 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 receiving 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 current 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 enroll with Hawai'i Compliance Express, and be compliant prior to receiving payment(s). To register,go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. 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 contractual year for which the grant was awarded.The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes),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, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 6 of 8 County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: YWCA Hawaii Island Program Name: YWCA Developmental Preschool 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%)for administrative and overhead costs. Any funds unused by June 30, 2019 must be returned to the County of Hawai'i with the final report. 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. Awards cannot provide funds for Capital Improvements (Cost of Construction, materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. • / S37/9 Signature of Authorized Person (see checklist, 2nd item) Date ao Title/Position of Authorized Person EXHIBIT A NONPROFIT GRANT APPLICATION FY 2019-2020 Page 7 of 8 • County of Hawai`i Nonprofit Grant Application FY2019-20 Agency Name: YWCA Hawaii Island Program Name: YWCA Developmental Preschool 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Up to 13 families will receive assistance 100%of the children will receive meals 100 hours of face to face instru • TABLE II: FY 19-20 Grant Council PROGRAM EXPENDITURES • Request Award Salary and Wages Professional Fees Operations $ 1,364 Supplies Equipment Other: Breakfast Lunch and Afternoon Snack $ 5,000 Other: Art, Music, Dance and Cooking classes $ 3,636 Other: Short Term Tuition Assistance $ 5,000 Other: Other: TOTAL $ 15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2019-2020 Page 8 of 8