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Home My WebLink AboutCOM 0633.001 2020-2022 }SY Os{�4' Mitchell D. Roth Deanna S. Sako Mayor :; • Director °" Steven A. Hunt Deputy Director County of Hawaii Finance Department 25 Aupuni Street,Suite 2103 • Hilo,Hawaii 96720 (808)961-8234 • Fax(808)961-8569 n February 17, 2022 r 0-"J --I al- Maile Medeiros David, Council Chair and - -< Members of the Hawaii County Council -"1�= Hawai`i County Council s 25 Aupuni Street Hilo, Hawaii 96720 Re: Nonprofit Grant Applications In compliance with Chapter 2, Article 25 of the Hawaii County Code, I am submitting the applications from eligible nonprofit organizations for your review and appropriation of funds for the FY 2022 - 23 nonprofit grant program. The applications are submitted as received through the electronic documents compiled by Council, which contained the extracted information from the online application submittals. Documents have been printed single-sided for easy scanning. There may be some applications with"blank"pages or other additional pages within them, which we left in-tact, so the page numbering is not changed. 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 Lisa Tada at 961-8489. Deanna S. Sako Director of Finance Enc. Applications for Nonprofit Grant Funds List of Nonprofit Grant Applicants Comm. No. Ref. To: {4 5 SSC- Ref. Date FEB 1 8 2022 Hawaii County is an Equal Opportunity Employer and Provider NONPROFIT GRANT APPLICANTS FOR FY2022-23 Sort order matches separation sheet numbers(hard copies). Note that the disqualified applicants sort order are AFTER qualified 2ealicant's. Numerical Sort Order Order , ORGANIZATION NAME PROGRAM NAME REQUESTED 51 3 After-School All-Stars Hawaii After-School Programs in Middle Schools 45,000.00 173 5 Aloha Club of Hilo Hale'Oluea Clubhouse 20,000.00 148 6 Aloha Ilio Rescue Aloha Ilio Rescue 40,000.00 73 9 ALS Ohana of Hawaii Excellence in ALS Care—Professional Care Management 20,000.00 83 10 ALS Ohana of Hawaii Excellence in ALS Care-Equipment Loan Program 10,000.00 9 11 American National Red Cross,The Disaster Preparedness&Response in Hawaii County 35,000.00 103 13 Arts&Sciences Center ASC Community Learning Program 40,000.00 122 14 Arts and Science Center Villages 10,000.00 21 15 Big Island Mediation,Inc. Community Mediation and Outreach 15,000.00 43 16 Big Island Mediation,Inc. Youth Conflict Resolution Education 10,000.00 Hawaii Ulu Cooperative:Youth Education to Increase Local Staple 105 17 Big Island Resource Conservation and Development Council Crop Production&Consumption 25,000.00 110 18 Big Island Resource Conservation and Development Council Mauna Kea Watershed Alliance 15,000.00 111 19 Big Island Resource Conservation and Development Council Nutrition Grown Farming Educational Prograrr15,000.00 Growing Edible Gardens Using Best Management and Sustainable 112 20 Big Island Resource Conservation and Development Council Practices 20,000.00 Big Island Invasive Species Committee Invasive Plant Eradication 113 21 Big Island Resource Conservation and Development Council Program 40,000.00 164 35 Boys&Girls Club of the Big Island Daily Meal Support for Income-Challenged Youth and Families 50,000.00 Daily Transport Services of Critical Needs Resources for Income- 171 36 Boys&Girls Club of the Big Island Challenged Youth,Kupuna,and Families 50,000.00 "Academic Tutoring and Homework Support for Income-Challenged 175 37 Boys&Girls Club of the Big Island Youth" 50,000.00 180 38 Boys&Girls Club of the Big Island "Public Safety Careers:Workforce Development Program" 50,000.00 184 39 Boys&Girls Club of the Big Island "Mentoring for At-Risk Youth on Hawaii Island" 50,000.00 "Healthy Lifestyles and Sports Programming for Income Challenged 187 40 Boys&Girls Club of the Big Island Youth" ___ 50,000.00 "Child Care and Youth Development Services for Hawaii Island 191 41 Boys&Girls Club of the Big Island Families" 50,000.00 "Building Income-Challenged Youth to Become Leaders on Hawaii 195 42 Boys&Girls Club of the Big Island Island" 50,000.00 "Social/Emotional Learning&Development for Hawaii Island Income 201 43 Boys&Girls Club of the Big Island Challenged __ 50,000.00 "Wellness and Mental Health for Income-Challenced Youth and 203 44 Boys&Girls Club of the Big Island Families"Mental Health 50,000.00 151 45 Brantley Center,Inc Job Skills Development Program 25,000.00 154 46 Bridge House,Inc. Clean&Sober Living Program 50,000.00 190 47 Bridge House,Inc. Vocational Skills Building Program 20,000.00 204 48 Bridge House,Inc. Care Coordination 5,000.00 22 49 Center for Getting Things Started Farm to Family 50,000.00 135 51 Child and Family Service Alternatives to Violence 50,000.00 142 52 Child and Family Service Domestic Abuse Shelters(DAS) 50,000.00 10 53 East Hawaii Cultural Council Young at Art 2023 10,000.00 17 54 East Hawaii Cultural Council Hawaiian Translation Project 5,000.00 47 55 East Hawaii Cultural Council EHCC Out of Doors 20,000.00 49 56 East Hawaii Cultural Council EHCC Lecture Series 5,000.00 120 57 Educational Services Hawaii Foundation dba EPIC Foundation Imi'Ike Learning Center at Hilo ____ 50,000.00 NONPROFIT GRANT APPLICANTS FOR FY2022-23 Sort order matches separation sheet numbers(hard copies). Note that the disqualified applicants sort order are AFTER qualified applicants. - 168 61 Five Mountains Hawaii On-Board Psychologist 50,000.00 50 64 Friends of the Children's Justice Center of East Hawaii Special Needs,Enhancement,Support,Education&Training 7,500.00 11 66 Friends of the Palace Theater Annual Musical 10,000.00 92 67 Friends of the Palace Theater Hawaiian Roots Festivals of Talent 15,000.00 97 68 Friends of the Palace Theater Youth Theater Program 10,000.00 90 69 Full Life Renaissance of Inclusion 15,000.00 78 71 Going Home Hawaii Reentry and Recovery Housing 50,000.00 81 72 Going Home Hawaii Hawaii Island Going Home Consortium(HIGHC) 40,000.00 64 73 Goodwill Industries of Hawaii Ola I Ka Hans Youth Program _ 30,000.00 Career Services–Employment Services for low-income and 65 74 Goodwill Industries of Hawaii reintegrating individuals 35,000.00 66 75 Goodwill Industries of Hawaii Ho'olana Educational and Arts Program _ 50,000.00 Hawai'i Diaper Bank(a fiscally sponsored prograrn of Hawai'i 156 85 Hawaii Children's Action Network Children's Action Network) — 30,000.00 20 93 HAWAII ISLAND ADULT CARE,INC. Hilo Adult Day Center 30,000.00 94 96 Hawaii Island Home for Recovery,Inc HIHR Permanent Supportive Housing Program 30,000.00 93 97 Hawaii Island Home for Recovery,Inc. HIHR Kitchen&Pantry Outreach Programs 20,000.00 96 98 Hawaii Island Home for Recovery,Inc. HIHR Transitional Shelter Program 30,000.00 16 100 Hawaii Rise Foundation Together We Can 50,000.00 86 101 Hawaii Society of Obstetricians and Gynecologists Hawaii County OB/GYN Resident Program 2022-2023 50,000.00 19 103 Heart Ranch Heart Ranch 25,000.00 95 104 Hilo Community Players 45th Annual Shakespeare in the Park Festival 10,000.00 123 105 Hilo Community Players Na Mea Hawai'i Theatre 7,500.00 129 106 Hilo Community Players Kid-Shakes! 5,000.00 139 107 Hilo Community Players Rising Stars 10,000.00 147 108 Hilo Community Players Disney in the Park 5,000.00 150 109 Hilo Community Players LBGTQIA+Outreach Through Theatre 5,000.00 157 110 Hilo Community Players Dinner With Divas 5,000.00 167 111 Hilo Community Players Annual Musical Theatre Program 15,000.00 196 114 Holualoa Foundation for Arts&Culture 50,000.00 166 115 Holualoa Village'Ohana Holualoa Coffee&Art Stroll 2,500.00 209 116 HOlualoa Village'Ohana HOlualoa Music&Light Festival 2,500.00 144 122 HOPE Services Hawaii,Inc. Sacred Heart Community for Kupuna 20,000.00 53 123 Hospice of Kona,Inc. Volunteer Services 2,500.00 68 124 Hospice of Kona,Inc. Nakamaru Hale,hospice residential care 20,000.00 80 125 Hospice of Kona,Inc. Maluihi Grief Center-Bereavement Services 15,000.00 118 126 Housing and Land Enterprise of Hawaii County,The Community Marketing and Development Outreaci 30,000.00 7 131 Hui Pono Holoholona Low Cost Spay/Neuter Clinics 25,000.00 91 132 Innovations Public Charter School Foundation Na Kalai Ola-Life Navigators-Wellness Prograr' 10,000.00 5 133 Island of Hawaii YMCA Family Visitation Center 50,000.00 NONPROFIT GRANT APPLICANTS FOR FY2022-23 Sort order matches separation sheet numbers(hard copies). Note that the disqualified applicants sort order are AFTER qualified applicants. 41 134 Island of Hawaii YMCA New Horizons Youth Program 15,000.00 15 140 Kamuela Philharmonic Orchestra Society Community Concerts __ 10,000.00 104 141 Kamuela Philharmonic Orchestra Society Elementary Music Education Program 5,000.00 25 142 Keaukaha One Youth Development RISE 21st Century After School Program 50,000.00 29 143 Keaukaha One Youth Development Paahana Vaa(formerly known as Youth Paddling Program) 30,000.00 lomakualani Voyaging Canoe(formerly known as Hckualakai 35 144 Keaukaha One Youth Development Restoration Project) 50,000.00 37 145 Keaukaha One Youth Development Hoola Hou-Hawaiian Warriorship Program 20,000.00 39 146 Keaukaha One Youth Development VEX 10 Robotics Program 15,000.00 55 147 Keaukaha One Youth Development Na Anela Kai(formerly known as Junior Lifeguarcing Program) 25,000.00 58 148 Keaukaha One Youth Development Temple Children Collaboration Project 25,000.00 60 149 Keaukaha One Youth Development Hui Kui Hao-Welder's Hui 50,000.00 8 150 Kohala Animal Relocation and Education Service(KARES) Veterinary Care and Spay/Neuter for Hawaii Island Family Pets 30,000.00 59 155 Ku'ikahi Mediation Center Community Mediation&Facilitation Services 15,000.00 145 156 Ku'ikahi Mediation Center Conflict Prevention&Resolution Education 15,000.00 71 158 La'i'opua 2020 Ho'okahua--La'i'opua 2020/Palamanui Culinary P-oject 20,000.00 134 159 Laupahoehoe Train Museum Honeybee Education Program Professional Deveopment 10,000.00 141 160 Laupahoehoe Train Museum Aina-based Education for Youth and Community_ 15,000.00, 133 161 Legal Aid Society of Hawaii Civil Legal Services for Rural Residents 10,000.00 140 162 Legal Aid Society of Hawaii Medical-Legal Partnership 7,500.00 4 163 Little Big Tots Foundation Ike Loa Program 10,000.00 44 164 Lokahi Treatment Centers Health&Fitness Program 15,000.00 45 165 Lokahi Treatment Centers Domestic Violence Intervention Treatment Programs 30,000.00 46 166 Lokahi Treatment Centers Anger Management Treatment Programs _ 30,000.00 63 167 Lokahi Treatment Centers Adult Substance Abuse and Mental Health Treatment Programs 50,000.00 Adolescent Substance Abuse and Mental Health Treatment 79 168 Lokahi Treatment Centers Programs 35,000.00 128 170 MALA'AI The Hawaii Island School Garden Network 25,000.00 138 171 MALA'AI (The Culinary Garden of Waimea Middle School 25,000.00 98 172 Malama 0 Puna Food Security Program 25,000.00 130 173 Malama 0 Puna Hawaii Tracker(HT) 45,000.00 124 176 Mental Health Kokua Residential Rehabilitation 15,000.00 125 177 Mental Health Kokua Case Management 15,000.00 13 179 Neighborhood Place of Puna FRC-Family Strengthening Program 15,000.00 70 180 North Kohala Community Resource Center North Kohala Reunion 7,500.00 194 181 North Kohala Community Resource Center North Kohala Golf Park 5,000.00 202 182 North Kohala Communtiy Resource Center Ho'ola Honey Bee Relocation 7,500.00 179 184 Orchidland Neighbors Multi-Purpose Community Complex 50,000.00 18 186 PETFIX Spay and Neuter Spay and Neuter Clinics 20,000.00 126 187 Pohaha I Ka Lani Kahuli 50,000.00 NONPROFIT GRANT APPLICANTS FOR FY2022-23 Sort order matches separation sheet numbers(hard copies). Note that the disqualified applicants sort order are AFTER qualified applicants. 69 188 Project Vision Hawaii HiEHiE Homeless Outreach 45,000.00 143 189 Puna Canoe Club Keiki Wa'a Camp 50,000.00 Salvation Army,a California corporation:DBA;The Salvation 82 191 Army-Family Intervention Services,The Independent Living Skills Program—East Hawaii 10,000.00 Salvation Army,a California corporation:DBA;The Salvation 84 192 Army-Family Intervention Services,The _Project TLP Hilo 10,000.00 Salvation Army,a California corporation:DBA;The Salvation 85 193 Army-Family Intervention Services,The Puna Prevention and Outreach Programs 20,000.00 101 196 Society for Kona's Education&Art Art Camps for Children and Teens 5,000.00 116 197 Society for Kona's Education&Art South Kona Events&Workshops 5,000.00 100 198 Special Olympics Hawaii Special Olympics West Hawaii-General Fund 15,000.00 108 199 Special Olympics Hawaii Special Olympics East Hawaii 20,000.00 172 201 The Children's Law Project of Hawaii Victim Options for Child Empowerment and Safety 15,000.00 178 202 The Children's Law Project of Hawaii Project Permanence:Guardianships and Adoptio-is for At-Risk Kids 10,000.00 The Salvation Army,a California corporation;DBA The Salvation 77 205 Army-Family Intervention Services Cultural Based Program 10,000.00 181 206 West Hawaii Community Health Center Inc. Outreach to Vulnerable Populations Program 45,000.00 40 207 YWCA Hawaii Island YWCA Developmental Presch000l 25,000.00 42 208 YWCA of Hawaii Island Sex Assault Nurse Examiner Program(SANE) 30,000.00 61 209 YWCA of Hawaii Island Sexual Assault Support Services(SASS) 30,000.00 Total 3,305,000.00 RI�, ' ° �� - �.:� I .mow x - '#1 A A; f#4,401 '! i/ 7 ; "° a °.a ;.. .d Y .r>, .,i k.,,.�✓ P „ ,,, y , a . ag„, .. 159 1 '0 Maku'u Ke Kahua Community Center Papa Ku'i'Ai 20,000.00 163 2 '0 Maku'u Ke Kahua Community Center Mala Ho'oulu'Ike 50,000.00 1 76 4 Alexander&Duke De Rego Foundation Water Safety&Ocean Awareness 35,000.00 102 7 Aloha Independent Living Hawaii Independent Living Program 10,000.00 208 8 Aloha Kuamo'o'Aina Kuamo'o Virtual Learning Space 50,000.00 186 12 Arc of Hilo Arc of Hilo Disability Employment-Landscape Services 35,000.00 2 22 Big Island Substance Abuse Council Community Outreach and Training 10,000.00 23 23 Big Island Substance Abuse Council East Hawaii Substance Abuse Treatment 50,000.00 24 24 Big Island Substance Abuse Council Hawaii Island Health&Wellness Multi-Disciplinary Treatment 20,000.00 26 25 Big Island Substance Abuse Council HIHWC Specialized Group,Couples and Individual Therapy 50,000.00 27 26 Big Island Substance Abuse Council Hawaii Island Health and Wellness Provider Trairing 50,000.00 28 27 Big Island Substance Abuse Council Intensive Case Management Services _ 50,000.00 30 28 Big Island Substance Abuse Council Ola Kino Health and Fitness Program 30,000.00 31 29 Big Island Substance Abuse Council Po'okela Vocational Training Program 35,000.00 32 30 Big Island Substance Abuse Council Therapeutic Living and Clean and Sober Housing 50,000.00 33 31 Big Island Substance Abuse Council West Hawaii Dual Diagnosis Treatment 50,000.00 34 32 Big Island Substance Abuse Council Youth Services Program 15,000.00 67 33 Big Island Substance Abuse Council Rural Wellness and Recovery For Kohala 117 34 Boy Scouts of America Hawaii Island Scouting Program-Scoutreach 50,000.00 NONPROFIT GRANT APPLICANTS FOR FY2022-23 Sort order matches separation sheet numbers(hard copies). Note that the disqualified applicants sort order are AFTER qualified applicants. 3 50 Changemakers Community Economic Development Corporation Eve-conomics Women's Financial Empowerment 20,000.00 127 58 Equality HI Equality Hi Waiwai Connections 30,000.00 56 59 Family Support Services of West Hawaii Fatherhood Initiative 20,000.00 57 60 Family Support Services of West Hawaii Healthy Keiki 20,000.00 12 62 Food Basket Inc.,The Emergency Food Distribution Program 52 63 Friends For Fitness Friends For Fitness 50,000.00 54 65 Friends of the Future Neighborhood Place of Kona Mobile Family Outreach 30,000.00 182 70 Girl Scouts of Hawaii Girl Scout Leadership Experience-Hawaii Island 30,000.00 114 76 Grassroots Community Development Group Media Literacy 5,000.00 119 77 Grassroots Community Development Group La'au'Ohana Ekolu 5,000.00 152 78 Grassroots Community Development Group Hands 7,500.00 38 79 Habitat for Humanity Hawaii Island,Inc. ,Through Shelter,We Empower 50,000.00 74 80 Hamakua Harvest,INC Grow Your Agribusiness Course Series 7,500.00 75 81 Hamakua Harvest,INC Mahi Noeau-The Demonstration Orchard at Harrakua Harvest 40,000.00 109 82 Hamakua Youth Foundation,Inc HYC Garden 10,000.00 107 83 Hamakua Youth Foundation,Inc. HYC Keiki 40,000.00 14 84 Hana Laulima Lahui 0 Ka'u Kahea Mai Ka Aina Academy 25,000.00 170 86 Hawaii County Economic Opportunity Council PRODUCE 4 TUTU 30,000.00 177 ' 87 Hawaii County Economic Opportunity Council Transportation Program 50,000.00 207 88 Hawaii County Economic Opportunity Council Personal Safety and Care Items for Kupuna _ 25,000.00 176 89 Hawaii Environmental Restoration Keau'ohana Native Rainforest Restoration 30,000.00 174 90 Hawaii Institute for Pacific Agriculture Farmer Training and Workforce Development 30,000.00 193 91 Hawaii Institute for Pacific Agriculture Kupuna Care Box;Building Capacity for KFH 30,000.00 161 92 Hawaii Institute of Pacific Agriculture Kupuna Care Box;Capacity Building for KFH 30,000.00 Hawaii Island HIV AIDS Foundation dba Kumukahi Health+ 200 94 Wetness STI Testing Education and Treatment --_ 50,000.00 Hawaii Island HIV/AIDS Foundation dba Kumukahi Health+ 169 95 Wellness Community Food Pantry Program 25,000.00 6 99 Hawaii Keiki Museum HKM Phase 2-Exhibit Expansion 50,000.00 206 102 Hawaiian Sanctuary 501(c)3 Plant Aloha _ 50,000.00 Waiwai Ho'opa'a:Equitable Access to Housing,Food Security,and 132 112 Ho'oulu Lahui Recreation for Families in Puna 35,000.00 158 113 Ho'ola Veteran Services HF2C:Resiliency Project 25,000.00 89 117 Homeless Task Force Fab Rehab Program 30,000.00 115 118 Homeless Task Force Return to Work Program 35,000.00 149 119 Homeless Task Force Safe Haven Option:Housing 35,000.00 199 120 Homeless Task Force A Vision For You Program 45,000.00 62 121 Homeless Task Force dba 808 Homeless Task Force Family Reunification Proram __ 40,000.00 146 127 Hui Ho'oleimaluo Puakahinano Student Program 50,000.00 153 128 Hui Ho'oleimaluo Malama __ 50,000.00 197 129 Hui Ho'oleimaluo Waiuli Fest 50,000.00 NONPROFIT GRANT APPLICANTS FOR FY2022-23 Sort order matches separation sheet numbers(hard copies). Note that the disqualified applicants sort order are AFTER qualified applicants. 106 130 Hui Ho'oleimaluo Puakahinano Student Program 50,000.00 88 135 Japanese Cultural Center of Kona Consultant Fees related to Purchase of Land 50,000.00 121 136 Kahilu Theatre Foundation 2022-2023 Kahilu Performing Arts,Education,and Exhibits Season 50,000.00 155 137 KALAMAPII PLAY SCHOOL Kalamapi'i PLAY School 50,000.00 188 138 Kama'aina Hale Apartments Kama'aina Hale Community Garden 30,000.00 198 139 Kama'aina Hale Apartments KHA Community Outreach Program 35,000.00 162 151 Kona Association for Retarted Citizens DBA/The Arc of Kona Health and Wellness for All Abilities 15,000.00 136 152 Kona Dance and Performing Arts,Inc. Youth After School and Weekend Program 25,000.00 131 153 Kona Task Force on Feeding the Hungry Meet and Eat 10,000.00 165 154 Kona Vocational and Life Education Center Kona Vocational and Life Education Center 20,000.00 72 157 Kupu Hawaii Youth Conservation Corps(HYCC)Summer Program 50,000.00 MAGICAL CREATURES OF HAMAKUA-ANIMAL RESCUE AND 1 169 SANCTUARY Outreach&Education 25,000.00 183 174 Malamalama Waldorf School,Inc. Hawaiian Arts and Culture 10,000.00 192 175 Malamalama Waldorf School,Inc. Learning Garden 5,000.00 189 178 Multiplier Nest for Families 40,000.00 87 183 Nostalgia Music Consortium,Inc. Nostalgia Jazz Lab 50,000.00 48 185 Pacific Tsunami Museum Workplace Tsunami Resilience Program 20,000.00 205 190 Re-use Hawaii Hawaii Island Waste Reduction Program 35,000.00 99 194 Services for Seniors Inc. Services for Seniors 30,000.00 185 195 SHAG Foundation Agricultural Development 7,500.00 36 200 Teach For America Teach For America Hawaii—Hawai'i Island Initia,ives 40,000.00 The Daniel R.Sayre Memorial Foundation HFD Water Safety 160 203 The Daniel R.Sayre Memorial Foundation,Inc. Program 50,000.00 Ulu La'au Invasive and Non-Native Tree Removal,Pruning and 137 204 The Outdoor Circle Chipping 40,000.00 Total 2,582,500.00 After-School All-Stars Hawaii After-School Programs in Middle Schools 3 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:After-School All-Stars Hawaii Contact Person: Paula Fitzell, President and CEO Contact Email: pfitzell@asashawaii.org Contact Phone: 808-734-1314 Program Information Program Name:After-School Programs in Middle Schools g g Program Years in Operation: 10 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Hilo, Kea'au, Pahoa Program Target Audience:School Age (6-11),Adolescence (12-17) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor,Youth Amount Applying For: $45000 After-School All-Stars Hawaii-After-School Programs in Middle Schools I Page 1 Program Details • Organization Mission:After-School All-Stars Hawaii (ASAS Hawaii) provides comprehensive out of school programs that keep children safe and help them achieve in school and in life. Founded in 2009,ASAS Hawaii partners with Title I schools, eight on Oahu and three on Hawaii Island, serving an average 2,071 students annually over the last five years prior to Covid-19.This is the only free after-school program operating on middle/intermediate campuses for three hours a day,five days a week. Program Overview:ASAS Hawaii programs operate at partner school sites,with a full-time staff member located at each school.This enables program staff members to get to know students and parents, while working closely with school faculty and administration. Our partner schools on Hawaii Island are Waiakea Intermediate, Keaau Middle,and Pahoa Intermediate. For the current school year,there are 847 participants and an average 369 students attending every day. (Programs take place on school campus for three hours per day,five days a week during the school year. Each day, students receive tutoring and do homework and then take part in sports and enrichment activities. Students are also introduced to high school transition, service learning, career exploration and sports-based youth development initiatives. With three daily after-school hours and summer programs, ASAS Hawaii provides more than 600 extended learning hours per year at each of its programs. Program Objectives & Performances Resources Needed:The resources needed to carry out this program are organizational skills,staffing expertise and knowledge, and partnerships with schools and the greater community. Staffing includes Site Coordinators,working directly with students,teachers and administrators every day. Site coordinators have one or more years' experience working in a leadership or supervisory capacity in an after-school or community youth setting. Program Leaders teach classes, run activities, assist with homework, chaperone field trips and collaborate with partner instructors. Each program operates on school campus,with schools providing in-kind office space, classroom space, outdoor areas, and cafeteria space for activities. ASAS Hawaii collaborates with community partners, including HIDOE, University of Hawaii, Hawaii Special Olympics, Police Athletics League, and 100 other agencies and organizations.We work with public and private funders to ensure long-term sustainability of these programs. Major Activities to be Completed:The major activity is to provide learning and leadership opportunities through out-of-school programs for 900 students at Keaau, Pahoa and Waiakea.After-school programs operate for three hours every day, following the regular school calendar. Summer programs operate for four hours daily over four weeks during June and/or July 2023. Every day after school, students access a dedicated academic hour,STEM classes, cultural and enrichment activities, sports and field trips, and support for their social and emotional development. We supplement classroom instruction with cultural activities such as Native Hawaiian games,field trips, After-School All-Stars Hawaii-After-School Programs in Middle Schools' Page 2 Hawaiian language, hula, and lei making. Students learn and practice Hawaiian values such as lokahi, kuleana, and haahaa. We encourage parent and family engagement with quarterly events to showcase student achievements. In 2020-21,401 Hawaii County parents (duplicated) engaged with their students' learning by attending a virtual quarterly event. Outputs to be Completed:The following outputs will be completed: 1) 900 Hawaii County students participate in ASAS Hawaii programs during the school year. 2)450 parents and family members will attend quarterly events,virtually or in-person. 3) Each school site will provide English/Language Arts and STEM classes/ 4)There will be two Sports Showdown events, bringing students together in friendly competition. 5) Students will participate in quarterly service learning projects for a total of 12 projects. Measurable Outcomes:ASAS Hawaii will provide learning and leadership opportunities through after- school programs in three Hawaii County schools.The following outcomes will be achieved in the upcoming school year: 1) Students will increase leadership skills through service-learning projects. 2) Students will improve academically through daily homework help and academic classes. 3) Students will gain confidence and teamwork skills through sports and fitness activities. 4) Parents and family members will increase engagement by attending quarterly events. Attachments Program Budget(Income & Expenses) Certificate of Understanding Conflict Disclosure After-School All-Stars Hawaii-After-School Programs in Middle Schools I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:After-School All-Stars Hawaii Program Name:After-School in Middle Schools CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 45,000 0 45,000 Applicant organizational budget: 0 0 Individual contributions 15,000 15,000 15,000 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets 3,612,702 0 3,612,702 Other funding sources(list below): Grant Revenue 1,962,505 1,496,651 1,962,505 Private Foundation Grants 315,000 292,500 315,000 Fundraising Income 100,000 138,719 138,719 Corporate Contributions 15,000 706 706 Total Cash Income 2,407,505 1,943,576 2,476,930 IN-KIND CONTRIBUTION Anticipated Committed Total School Facilities for Programs 345,000 345,000 345,000 Total In-Kind Contributions 345,000 345,000 345,000 TOTAL PROGRAM INCOME 2,752,505 2,288,576 2,821,930 Appendix D--Budget Sheets (Page 2 of 2) ;Project Budget Form: Expenses County of Hawaii o Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:After-School All-Stars Hawaii Program Name:After-School for Middle Schools Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 30,000 583,079 0 613,079 Professional Fees 0 14,600 0 14,600 Operations 2,037 2,037 0 4,074 Supplies 15,000 13,320 0 28,320 Equipment 0 0 0 0 Staff Training 6,601 6,601 Field Trip Fees and Materials 10,000 10,000 Transportation 54,400 54,400 School Facilities for Programs 345,000 345,000 SUBTOTAL 45,000 682,000 345,000 1,072,000 TOTAL PROGRAM BUDGET 45,000 682,000 345,000 1,072,000 =fr ^^` ^ 'l�� '?�� County �^ �� l ]� Grant Application FY ��-�� Agency Name: After-School All-Stars Hawaii Program Name: After-School for ddl MEDDECIIMEMIZIWISMNINOWNIIIENCIMO Certification of Understanding (Page lof 2) I (we) have read and understood all of the eliibility requirementsgrant conditions;award procedures; and records, reportingandfisoa| accountabi|ityrequirennentsaonnandatedinArtkz|e25, Sections2- 135-2-l42.1, HawmilCountyCode, ne|atYng 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 forwhich dused. � funds 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 Hawaili, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Expressand 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 Hawari, 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 Hmxma;^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, usinq the temp/ate provided, will impact the evaluation of your program's or agency's future funding requests. of ':' FY '� �� County ^^�,,=" ^ Nonprofit Grant Application '�^v�.^�-.�'� Agency Name: PName: - Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawan, 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-Rrant-formst on or about May30 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, 2023 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 24 2022 Signature of Authorized Person Date Paula Fitzell, President and CEO Title/Position of Authorized Person County -f--a. ~^`~ Nonprofit Grant = FY 2022-23 Agency Name: After-School All-Stars Hawaii Program Name: After-School for Middle Schools 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 HavvaiI 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 nfwhether oconflict exists. NAME: POSITION: May have a conflict or potential conflict of interestincluding any familial relationship,with any of the following (check all that apply): [-I Member or members of the Council [i] Staff appointed by a member of the Council U| 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 existcheck here. January �� 2022 -~ ^:SignatureofAuthsriaed Person (specify title) Date Paula Fitzell, President and CEO,ASAS Hawaii Aloha Club of Hilo Hale 'Oluea Clubhouse 5 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:Aloha Club of Hilo Contact Person: Renee Bertolette Contact Email:thealohaclubofhilo@gmail.com Contact Phone: 8088545761 Program Information Program Name: Hale 'Oluea Clubhouse Program Years in Operation: 31 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Honoka'a, Kalapana, Kapoho, Kea'au, Kurtistown, Laupahoehoe, Leilani Estates, Mountain View, Nanawale Estates, Ninole, Ocean View, 'O'okala, Orchidlands Estates, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa`ikou, Pepe'ekeo, Pohoiki, Volcano, Wainaku Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Needs of the poor,Aged, Physical/Emotional Disabilities,Victims of Health or Social Crises Amount Applying For: $20000 Aloha Club of Hilo-Hale'Oluea Clubhouse I Page 1 Program Details Organization Mission: Hale 'Oluea Clubhouse's mission is to offer comprehensive psychosocial rehabilitation services to adults with serious and persistent mental illness (SPMI)to help them enhance their abilities needed for successful reintegration into the community and to improve quality of life.The Clubhouse provides a supportive and nurturing environment that enhances self-motivation, respect for self and others, and a desire to work.The Aloha Club of Hilo is the non-profit entity for Hale Oluea Clubhouse. Program Overview: Hale 'Oluea Clubhouse is a virtual and on-site psychosocial rehabilitation program for adults with (SPMI), such as schizophrenia, bi-polar disorder and major depression.The Clubhouse is affiliated with Clubhouse International (https://clubhouse-intl.org/) who's mission is "Ending social and economic isolation for people with mental illness by growing the number and quality of Clubhouse rehabilitation programs worldwide." The Clubhouse supports members' challenges with housing,food insecurity, mental health symptoms/crisis,while providing linkages to case managers/psychiatrists and therapists. We offer opportunities for employment, education, on-line and in person Clubhouse training/conferences, consensus decision-making, social events, advocacy outreach, public speaking and civic involvement to educate and raise community awareness about SPMI, non-profit board , participation and fundraising, wellness activities, financial planning/budgeting and social security/benefits counseling. Program Objectives & Performances Resources Needed:We request funds for training fees ($15,000) and technology($5,000)totaling $20,000. This would assist us in obtaining and maintaining Clubhouse International Accreditation.The State of Hawaii and Clubhouse International require that we acquire and maintain our accreditation status. Also, it has been documented through research that accredited Clubhouses are more successful in all areas of operations.A condition of this accreditation, and a standard of Clubhouse International, is that we send staff and members to GENERAL and specialized Clubhouse International training for important education,guidance and support in following the Clubhouse Model . Currently only 3 staff (out of 9) and only 3 members out of a membership base of 86 have been trained in required GENERAL Clubhouse training.Additionally,our director has not received required Clubhouse Director Training.As training is now offered virtually we also need more computers for the members to use for training. Major Activities to be Completed: Major Activities planned are: 1)Sending 2 staff and 2 members to Clubhouse International Training. 2.) Purchasing computers and training members and staff on computer operations to get most out of training. 3.)Staff and members will create an action plan at the training session. 4.)Staff and members will bring back the action plan and work within Clubhouse to put it into practice. 5.)Applying for 3 year accreditation. 6.) Reporting to Clubhouse community and community at large (Board members, donors, stake holders) about our progress. 7.) Increasing outreaches via fundraisers and presentations to advocate and educate community at large about the needs of individuals with SPMI and how we can address them. Aloha Club of Hilo-Hale'Oluea Clubhouse' Page 2 Outputs to be Completed:The following outputs to be completed are: 1.)Two staff and two members will attend Clubhouse International Training. 2.) Five computers will be purchased. 3.) One action plan will be created.4.)A 3-year accreditation will be awarded. 5.) One special newsletter will be published and sent out to all constituents, funders, donors, employers and board members to keep the public abreast of progress. 6.) Five community fundraising events and six community Zoom outreach presentations will be conducted. 8.) Current membership base of 86 will receive Clubhouse International training-informed services and membership will increase by 10%. 9.) 10% increase in active member's and staff's understanding of the Clubhouse Action Plan. Measurable Outcomes:The measurable outcomes to the public and our program are that Hale 'Oluea Clubhouse will: 1.) Satisfy requirements of State of Hawaii and Clubhouse International by obtaining accreditation. 2.) Maintain accreditation, ensuring that the Clubhouse meets the state's standards for public money being spent wisely to provide quality Mental Health programming for those in the community with SPMI. 3.) Be more successful evidenced by a 10% increase in active member's and staff's understanding of the Clubhouse Action Plan.4.) Network with community at large and create ripple effects by reporting to board members and other key stake holders and donors via newsletter. 5.) Be more successful evidenced by a 10% increase in attendance. 6.) Increase access to technology and training by 500%for members by purchasing 5 additional computers for training. 7.) Staff and members Increase outreach to the general community through fundraisers and virtual or in-person educational presentations by 20%. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Aloha Club of Hilo-Hale'Oluea Clubhouses Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)—Fiscal Year 2022-2023 Organization Name: Aloha Club of Hilo Program Name: Hale 'Oluea Clubhouse CASH Anticipated Committed Total County Nonprofit Grant-in-Aid(Waiwai Grant) $20,000 $20,000 Applicant organizational budget: Individual contributions $5,000 0 $5,000 Membership fees 0 0 0 Earned income (Food Sales,Thrift Store) $3,000 0 $3,000 Current cash assets $7,000 0 $7,000 Other funding sources (list below): - Atherton Grant $25,000 0 $25,000 - Fundraising $2,000 0 $2,000 - State of Hawaii 0 $758,592 $758,592 Total Cash Income $62,000 $758,592 $820,592 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME $62,000 $758,592 $820,592 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)—Fiscal Year 2022-2023 Organization Name: Aloha Club of Hilo Program Name: Hale 'Oluea Clubhouse Nonprofit Expense Description (Waiwai) Other Cash In-Kind TOTAL Source Contribution Grant Salary Wages 0 $564,864 0 $564,864 Professional Fees 0 $4,000 0 $4,000 Operations 0 $6,000 0 $6,000 Supplies 0 $6,000 0 $6,000 Equipment $6,000 0 0 $6,000 Training and Travel Expenses $14,000 0 0 $14,000 Cost of Food Sales 0 $8,000 0 $8,000 Member Cell Phone Program 0 $8,000 0 $8,000 Maintenance and Repair 0 $10,000 0 $10,000 Operating Costs 0 $193,728 0 $193,728 SUBTOTAL $20,000 $800,592 0 $820,592 TOTAL PROGRAM BUDGET $20,000 $800,592 0 $820,592 P County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: AVAla Cu c5C Program Name: 1,;,q‘e IcALieq c= e. Certification of Understanding (Page 3.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 Hawal'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,arid 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 fa?fact the evaluation aour .roe ram's or airenc 's uture undin. re.uests, County of Hawai`i -Nonprofit Grant Application FY 2022-23 Agency Name: Alt4-16t Program Name: v.Ake..‘ntttsc, ckwcAlOtA .., Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawan, I(we)understand that a current Certificate of liability ($1,000,000 general liability,$50,000 each occurrence)must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s), (we)understand that failure to submit the final report within 60 days of June 3O shall result in loss of all grant funds received during the grant period(must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written re.ort is submitted to and accepted by,the council. (we)understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www hawaiicounty.govpn-nonorofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs.Any funds unused by June 30,2023 must be returned to the County of Hawaii with the final report.Failure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital improvements(Cast of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. 1—Signature - Signature of Authorized Person Date 71-- Title/Position of Authorized Person fa111 A1raacd)uos c p �•41ny;cs a.lrtieu2is *wail s}paya "-slatiwo3 Qu it � a :lsaiaiul jo S$pq UO) ,..t,,, ° ,._.• _: "F-„,,°.,, U;e Ol soinseau,1 uule2ll1 (le pue Aue Rjtaads asealci 1 r+ r, -.Dam;p a 4trt 04 itlutalt,/050.1404,1 lasUno) �, uatle�OdJo)a41 ri apavo et AI a 41 0 ..,,.cetA4 44i El < adde jge1 L , 3tgtuat„,t ,<3 guaayq (Aidde 1e41 lie Aaag)) uarl ia$ ,: f'dlusuojle60i,t let a€el Aue 2topni0ut lsaxUlud 1,0 3arl})a,03 lef1UL3lOd spa 0tgta +a e aA.etg Aexv, alealldnp area `palltut0, x Jo)to 0g aU0 slat Uu)(Jul; M0laq pals((0S041"quo"l,temeH ICY ti ;-,, p sing l£'y `3a10aJ p'laac 30 c ui w paecaq Aue l l isaialw 1°SPil 3 9ellu to ab sla1l}ucaAue as ; s p ase ,o { 38flSODDSIO .1311JNO3 NO1IVZINV 23O tit 3 o ,'tOvr Z-ZZ }Z ; a t t r�� Ei r 1UiU Itjo duo\ t,!€ ,wr t jo ) County of I la\vat*i Nonprofit (irant Application FY 2022-23 Agency Name: Atox,a. cx C 4k‘o Program Name: vIA.te, 'C‘ucte.1 uce ORGANIZATION CONFLiCT DISCLOSURE FORM Please disclose an a conflicts or notitcz. conflicts of interest that any board member,officer,director, or administrati„ organization.may have with the County of Haw: Only those listed below be filsform Per Person with a conflict is neede:: 'lets ex;st,one form for cts exis-r option checked rteecis to be satainitted. Pleas duplicate i,ectic ti„, i,,C9xpre„tornIS Muir be si toed re*oftitess pityhether o conflict exists. NAM(, VeNs60.'s)..sci: POSITION, Afx(Nbey- ct.t 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 1,-71 Staff appointed by a member of the Council ✓ The Mayor • The Managing Director Et The Director of Finance n The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel conflict of interest is gefd as osabsiancgg prababonty that art n token by on gia..--wdooi w S iesuir Inlei7sunable direct benefits accruing to the:individual as apposed to benefits oorturngiin pen so to on 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, tjeti Ken" e - 4 I-Ca-t3 agnate of Authoitied Person(specify hilt i Date a ,J Mr V° 3 r, m6: c`' C2 ' sa a T! ?_ 4 ,1 o "sQ *" _,Ca _a"ft rs Q ,e c3z rotn to a E ro fi 3 f- £`.. i '�. = r _ _t;aelc f`1 aisY " irx ». n.,..;.' a S i„ rcx 0 v a Ci. E,' o o -. /1,, f'' o ''''' - J 0 —3 yrt z to 71 I., rt r5 a �;�.> ? :,..,�/ ��t�:` :,,. .'�', ,',.... County ofIlay\al`i \ofalprolit (irant Application FY 202?-23 Agency Name: A'O Gv.. ee E4,1\o Program Name: r CAuecx C;taO cOU. rr ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflict,or potential conflicts of interest tls.:at any ter and member,officer,director, or administrator of your organization may have with the County of kfawai'i,Oniy those fisted below rued 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 r>ubmitted. Please duplicate as needed to fully disclose. Ai disclosure forms mustbe sac ed reocrrdfess whether tr con het exists NAME": '''a.edt cOv't ‘1-0-1 POSITION: \I'<Ui. rf.eStc,et"t - 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 O Staff appointed by a member of the Council • The Mayor • The Managing Director E] The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Cont at Interest is defined as:a substoratiatprobability that(Knorr token by on ind:vaduot w tt result in meosurubie direct benefits accruing to the individual os opposed to henef is accruing in genera'to on Industry. Please specify any and all mitigation measures to avoid,in fact or appearance,any conflicts or potential conflicts of interest: rn$ � if no conflicts exist,check here. .—1 gueers,llet,' lr 'nature of Authorized Person •.ecify title! bate County of llawal‘t Nonprofit Grant Application F Y 70,?-?3 Agency Name: 9tov,a cam a 41to Program Name: ,,lc t i C °Lt-g 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 rlawa.`s 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 ddsciosure forms must be signed,regardless of whether a conflict exists. NAME. %4o r i mr,ne POSiTiON, c.�,lr 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 O Staff appointed by a member of the Council El The Mayor tj The Managing Director • The Director of Finance El The Corporation Counsel,the Assistant Corporation Counsels or a Deputy Corporation Counsel Conflict of interest is defined as:rt'substantial birobabar<t y that octan tc aer by or,individual witt result in rne4tsutabliP dfr t t'nef€t5 0-Ce'a'rnR to frit','a'indual et'nedoyed rc5 rient''f its aca:d-a=1Q 1n Qt",,eqatlri or industry Please specify any and all mitigation measures to avoid,in fact or appearance,any conflicts or poterstrat conflicts of interest. f„, ,,iattf'dki”stai•uttiss„ Iljrni if no conflict',exist,:check sec Signature Atittacs ted rir,on ,,>: Counts' ?t` I la,A ai`i Nonprofit (it-ant Application FY 2022-23 J\ . nnf_v 4lotia Cts „ ° fir to Program Name: i4=z1k.. 'Uiut x C.f� tous< ORGANIZATION CONFLICT DISCLOSURE FORM officor,etrector, s below n for .i Staff appointed by a rnerrtber of 4•.-- [ The Mayor Ej 7"he h'ianaing D rector The Director of F trance j The Corporation Cora' t91re t CC,'; .+ Counsel confti t Of interest Y defined.5=a Slit,sreavrid p Q rrti, or or.fico taAe tte cna or�F tdBTP to iff tosotC eaf 3'•- benefits vert itng to the sntfi xiuot rrs cott§ed to benefits otttite`rsro tr# metol Kb en peb{,tustry,. Please specify any and all mitigation measures to avoid,in fact or appearance,any confifcts or p t.ential conflicts of interest- If no conflicts exist,check here. ,, - tet; ' r Lt)41fa� Sigrnaturr fAuthorizediPerson(sfrecif titles sate County of 1-lawai`i Nt)nprofit Grant Application FY 2022-23 Agency Name: Program Name: 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 Hawan,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. Ail disclosure forms trust he signed,regardless of whether o conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check an that apply): 11 Member or members of the Council U Staff appointed by a member of the Council CI The Mayor [2] The Managing Director 0 The Director of Finance 0 The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Coiperaflor Counsel Conflict of Interest gs oefoleo as stibitontnri prdbabfhty(dor ,OatOn taken by do ma,wriudi$4,0 tesuir medsorcatue direct oenr frt,0(Cnitn9 to(he Jrld(vhdcwt crs oppe(ed to benrit occn,.,o/o in genera/to oo,ndostry 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:%,,f;.,,,,„„„•;',,ay"' I , z t Signature of Authorized Person(speofy title) Date Uountv of I lawai‘i Nonprofit Cirant ,Application FY 2022-23 Agency Name: AIL)hc.C.,ILtip of Hat" Program Nmi at olueot Ctubhowa..., ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts " mensher,officer,director, or administrator of your organization may have sx le County cr s Only those tsted below need to be disclosed,One form per person with a poflict is need, tonflicts exist,one form for the organization,with the"No conflicts exist"opt on checked need:, tubrnitted, Please duplicate As needed to fully disclose, Ali disc tostire_forms must be sfaned,reqarii; ,pf whether a conflict exists, NAMt Mer0,, Pale. POSCT,ON: kic)4/..r-cA Pres ioTerli- May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that apoly)- fl ftilernber or members of the Council 0 Staff appointed by a member of the Council 0 The Mayor 0 The Managing Director fl The Director of finance LJ The Corporation Counsel,the Assistant Corporanon Coon I,or a Deputy Corporation Counsel conflict of Interest is defined as a s.ubstantia pic)bobaity that actron rokbn by on individual will rest-40 iii meciurobie direct benefits accruing to the individual as opposed to benefits issuing in genera/to as,hidustry. Please specify any and all mitigation measures to avoid,in fact or appearance,any conflicts or potential conflicts of interest: . , . „ . „ . *Ir If no conflicts exist,check here, Pc Signature of Authorized Person(spec/qv title) Date Aloha Ili® Rescue Aloha Ilio Rescue 6 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:Aloha Ilio Rescue Contact Person:Asta Miklius Contact Email: nalehua.asta@gmail.com Contact Phone: 808-937-5734 Program Information Program Name:Aloha Ilio Rescue Program Years in Operation: 8 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Eden Roc, Fern Acres, Fern Forest, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Kalapana, Kapoho, Kea'au, Kurtistown, Leilani Estates, Mountain View, Na'alehu, Nanawale Estates, Orchidlands Estates, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki,Volcano, Wainaku, While we are based in and focus on East Hawai'i,we assist dogs and people from the entire island Program Target Audience:School Age (6-11),Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment Amount Applying For: $40000 Aloha Ilio Rescue-Aloha Ilio Rescue' Page 1 Program Details Organization Mission:Aloha 'Tlio Rescue (AIR) was founded in 2014 to minimize the overpopulation of dogs on the Island of Hawai'i and to effect change in the mindset of our community about animal welfare and responsible pet ownership through education. AIR quickly became a trusted and valued resource. Funded largely by community support,the rescue has grown from spaying/neutering and rehoming less than 200 dogs/year to more than 600 dogs in 2021. Program Overview: We are seeking funds to spay and neuter the stray, abandoned and owner- surrendered dogs that come into our care. Many of the dogs that we spay/neuter and rehome are brought directly to us, but some are transferred from Hawai'i County Animal Control, as part of our partnership with them to alleviate the overwhelming burden on their limited facilities in East Hawai'i. We would also use program funds to spay and neuter pets of our East Hawai'i's homeless population and pets of low-income families or individuals that request our assistance. Program Objectives & Performances Resources Needed:The resource that we need help with is funding for clinic fees for spaying and neutering surgeries. In 2021, we spent almost$35,000 for spay/neuter surgeries and, given the ever- increasing number of dogs we serve, we expect these expenditures to be in excess of$40,000 this year. We have access to low cost services at the Good Karma Spay and Neuter Clinic in Hilo, allowing us to stretch program funds. We currently have the staffing, kennel space and fostering network to support the spaying/neutering and pre/post-operative care of the dogs. We also have a van for transporting the dogs to and from the clinic, driving to homeless encampments to offer assistance and to remote areas to pick up dogs in need. We have a database system to track our intakes and their medical procedures. We also have a robust social media base to spread the word about availability of spay/neuter services and about our fundraising events to support the operational costs associated with the program. Major Activities to be Completed:Aloha 'Tlio Rescue (AIR) will intake stray, abandoned and owner- surrendered dogs and puppies, as well as those transferred to us from County Animal Control, housing them and caring for them at AIR's facility in Paradise Park and with fosters. All unaltered animals will be spayed or neutered and rehomed. AIR will proactively reach out to the homeless in our community to offer spay/neuter services, including transport and post-operative care.We will also fund spay and neuter surgeries for pets of families and individuals that need financial assistance. AIR will continue our fundraising campaigns and donor outreach programs to fund the operation of this program. AIR will track the spay and neuter surgeries with our database software. Aloha Ilio Rescue-Aloha Ilio Rescue' Page 2 Outputs to be Completed:We will be able to spay or neuter at least 550 dogs with the funding that we are requesting. Measurable Outcomes:The ultimate outcome of the program will be mitigation of dog overpopulation on the Island of Hawai'i. The program will be especially impactful in the East Hawai'i communities of the Puna and South Hilo districts, where many families struggle to make ends meet and can easily become overwhelmed by the cost of caring for pets, such as spay and neuter surgery expenses.This often results in abandonment of both the animal and the puppies that result from not spaying/neutering.AIR has built a reputation within the community as place that provides either medical care, such as spaying/neutering, or, if they must surrender the animal, a safe place for these families to bring their pets,where they can be assured that the dog will be well cared for, spayed or neutered, and rehomed in a timely and thoughtful manner with people that want a dog as part of their family and can better provide for them. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Aloha Ilio Rescue-Aloha Ilio Rescue I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Aloha Ilio Rescue Program Name: Aloha Ilio Rescue Spay and Neuter Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 40,000 40,000 Applicant organizational budget: Individual contributions 10,000 0 10,000 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets 0 0 0 Other funding sources (list below): HCF-East HI 4,467 4,467 4,467 HCF-West HI 4,284 4,284 4,284 Total Cash Income 17,648 17,648 17,648 IN-KIND CONTRIBUTION Anticipated Committed Total 1,000 1,000 1,000 Total In-Kind Contributions 1,000 1,000 1,000 TOTAL PROGRAM INCOME 50,000 18,648 50,000 Appendix D--Budget Sheets (Page 2 of 2) `Project Budget Form: Expenses `County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Aloha Ilio Rescue Program Name: Aloha Ilio Rescue Spay and Neuter Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 4,460 4,460 0 7,920 Professional Fees 0 0 0 0 Operations 2,037 10,000 0 10,000 Supplies 2,400 2,400 0 4,800 Equipment 0 0 0 0 Clinic fees for spay/neuter surgeries 40,000 40,000 SUBTOTAL 8,897 8,897 - 0 16,794 TOTAL PROGRAM BUDGET 40,000 10,000 0 50,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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. County of Hawai`i Nonprofit Grant Application. FY 2022-23 Agency Name: Program Name: Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawari, 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 Hawail 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:41yovvv.haw:al v EQyjfp 1-15,/ 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, 2023 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 Auth, ized Person Date A/V/hi/04 Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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 conflict or potential conflict of interest, including any familial relationship,with any of the following(check ail that apply): Member or members of the Council fl Staff appointed by a member of the Council The Mayor El The Managing Director El The Director of Finance El 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 alt mitigation measures to avoid,in fact or appearance, any conflicts or potential conflicts of interest: Fr If no conflicts exist, check here. .ad Aitor140y, (President) 0214,2t9V-0 Signature of Auth/zed Person (specify title) Date ALS Ohana of Hawaii Excellence in ALS Care—Professional Care Management 9 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information • Organization Name:ALS Ohana of Hawaii Contact Person: Natalie Fonda, President and Treasurer Contact Email: nataliefonda@hotmail.com; ALSOhanaHawaii@gmail.com Contact Phone: 808-258-9388 Program Information Program Name: Excellence in ALS Care—Professional Care Management Program Years in Operation: 8 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, `Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O`okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, 'Umikoa,Volcano,Waikoloa Village,Waimea, Wainaku, Wai`ohinu,Weloka,All, as needed Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment, Youth,Aged, Physical/Emotional Disabilities,Victims of Health or Social Crises Amount Applying For:$20000 ALS Ohana of Hawaii-Excellence in ALS Care—Professional Care Management I Page 1 Program Details Organization Mission:ALS Ohana of Hawaii (ALSOH)was founded in 2013 to enhance the quality of life for Hawaii's ALS ohana by providing compassionate, practical support. ALS, a fatal neurodegenerative disease, robs a person of the ability to speak, move,swallow and breathe. People of all ages and backgrounds are affected; costs for medical and home care and equipment can exceed $200,000/year. ALSOH partners with mission-aligned program providers including the Golden West Chapter(GWC) of The ALS Association. Program Overview:ALSOH seeks funds to support a vital service for County of Hawaii residents, professional care management for people living with ALS. A dedicated ALS Care Manager(CM) will connect individuals and families to essential information, community resources and events, educational opportunities, other people with ALS and their families, and coordinate access to and training for durable medical equipment and technology(power wheelchairs, communication devices, etc.) necessary to make living with ALS easier as the disease progresses.The CM collaborates with multidisciplinary clinical teams to provide specialized, expert care related to neurology, pulmonology, speech, physical and occupational therapy, nutrition; all of these disciplines are essential to the proactive treatment of ALS.The CM serves as an advocate, available via both telehealth platforms and in person visits when safe,to ensure that clients have access to a model of care proven to help people live longer and better with ALS. Program Objectives & Performances Resources Needed: Funding is needed to offset salary expenses for professional care management and support for those diagnosed with ALS in the County of Hawaii. Until there are effective treatments and cures for ALS,the most effective way to help people live longer and better with ALS is to ensure that they have access to robust, comprehensive,expert multidisciplinary care, offered at no charge.The GWC's CM, a highly valued resource for those affected by ALS in the County of Hawaii, is dedicated to creating access to the model of care and equipment that helps people live longer and better while also providing opportunities for community connection and participation in ALS research and ALS awareness campaigns. Other resources needed include expenses covered by the GWC for basic infrastructure to support the CM's activities such as technology, supplies and materials, supervision, direct assistance grants, travel, program publicity and more. Major Activities to be Completed:The major activities to be completed include: • CM client consultations with people with ALS and their families in routine and emergency situations; • CM participation in multidisciplinary clinic visits as a member of the clinic team to ensure coordination of treatment plans; • Support group facilitation; and ALS Ohana of Hawaii Excellence in ALS Care Professional Care Managements Page 2 • . Partnering with other ALS organizations to promote quality care and programs that benefit the County of Hawaii's ALS community. Client consultations are highly variable, as is the disease progression for each person diagnosed with ALS and the capacity for each client to act upon information provided. CMs will provide focused assistance to ensure that each individual has access to information about local resources and equipment.They will help individuals understand and navigate insurance benefits, home modifications, hiring professional caregivers, and more. New clients may require more assistance.The CM's activities adjust to meet the needs of every client. Outputs to be Completed: During the grant period,the following outputs will be completed: • 8 clients will have access to CM services • More than 80 client engagements Most people diagnosed with ALS, along with their loved ones, are not familiar with what to expect from an ALS diagnosis.They are in shock and have a steep learning curve once they learn about the disease trajectory. Everyone in the household is affected by the diagnosis and have different coping strategies and roles to play in supporting the loved one living with ALS.The CM's involvement is designed to help the person diagnosed with ALS maintain health, safety, quality of life, agency and dignity, while supporting the entire ohana. Measurable Outcomes:The outcomes to the public and program participants include: • Maximizing access to care support, expert multidisciplinary medical care and community resources to help people live longer and better with ALS • Increasing health, wellness, safety and quality of life for those diagnosed with ALS and their loved ones • Reducing financial burden on those diagnosed with ALS and their loved ones • Expanding opportunities for community involvement, engagement and awareness • Reaching people living with ALS in the earliest stages of the disease • Generating ALS awareness and support for the ALS community Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure ALS Ohana of Hawaii-Excellence in ALS Care—Professional Care Management I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative: Professional Care Management CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $20,000 $20,000 Applicant organizational budget: 0 0 Individual contributions TBD 0 0 Membership fees N/A 0 0 Earned income N/A 0 0 Current cash assets N/A 0 0 Other funding sources (list below): N/A HCF-East HI 4,467 4,467 4,467 HCF-West HI 4,284 4,284 4,284 Total Cash Income $20,000 N/A $20,000 IN-KIND CONTRIBUTION Anticipated Committed Total 1,000 1,000 1,000 Total In-Kind Contributions 1,000 1,000 1,000 TOTAL PROGRAM INCOME $20,000 N/A $20,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:ALS Ohana of Hawaii 'Program Name: Excellence in ALS Care Initiative: Professional Care Management Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $20,000 4,460 0 $20,000 Professional Fees 0 0 0 0 Operations 2,037 2,037 0 4,074 Supplies 2,400 2,400 0 4,800 Equipment 0 0 0 0 SUBTOTAL $20,000 N/A N/A $20,000 TOTAL PROGRAM BUDGET $20,000 N/A N/A $20,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative—Professional Care Management 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.Rov, 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. • County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative--Professional Care Management 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-form 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, 2023 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 /ariaoa-?s Signature of Authorized Person Date President and Treasurer Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative—Professional Care Management 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 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 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: II If no conflicts exist, check here. c)--5s I a-a a-b-- Signature of Authorized Person (specify title) Date ALS Ohana of Hawaii Excellence in ALS Care - Equipment Loan Program 10 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:ALS Ohana of Hawaii Contact Person: Natalie Fonda, President and Treasurer Contact Email:ALSOhanaHawaii@gmail.com; nataliefonda@hotmail.com; nataliejones@alsohana.org Contact Phone: 808-258-9388 Program Information Program Name: Excellence in ALS Care- Equipment Loan Program Program Years in Operation: 8 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach:All, as needed Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment,Youth,Aged, Physical/Emotional Disabilities,Victims of Health or Social Crises Amount Applying For: $10000 ALS Ohana of Hawaii-Excellence in ALS Care-Equipment Loan Program I Page 1 Program Details Organization Mission: ALS Ohana of Hawaii (ALSOH) was founded in 2013 to enhance the quality of life for Hawaii's ALS ohana by providing compassionate, practical support. ALS, a fatal neurodegenerative disease, robs a person of the ability to speak, move, swallow and breathe. People of all ages and backgrounds are affected; costs for medical and home care and equipment can exceed $200,000/year. ALSOH partners with mission-aligned program providers including the Golden West Chapter(GWC) of The ALS Association. Program Overview:ALSOH seeks funds to support a crucial resource for County of Hawaii residents, an ALS Equipment Loan Program (ELP). Most people diagnosed with ALS require durable medical equipment (power wheelchairs, shower chairs, ramps, etc.) and adaptive communication technology (speech generating devices, adaptive switches, etc.) to live safely and sustain quality of life as the disease progresses and individuals lose the ability to move, speak, swallow and breathe. Most people in the County are also unable to easily identify and secure some of the critically needed items including power wheel chairs, speech generating devices, respiratory equipment, batteries and generators, etc. ALSOH partners with the Golden West Chapter of The ALS Association (GWC) to provide essential equipment to every person living with ALS in the County as equipment is needed. GWC staff are uniquely positioned to assess and provide equipment loans safely and quickly. Program Objectives & Performances Resources Needed:The following resources are needed: an ELP coordinator-a trusted specialist in the community, equipment purchases, expenses related to shipping, storage, repairs, and supplies, ELP coordinator travel expenses, and technology costs to ensure equipment usability. With a smaller population and remote location, the County of Hawaii's ALS ohana has limited access to the specialists and specialty equipment necessary to adapt to the devastating disease progression that leads to total paralysis.The ALS ELP ensures that the ALS community has access to the highly valued, high demand adaptive equipment as well as lesser known niche devices that offers solutions to the physical challenges when muscle function deteriorates and affects mobility, speech and respiration. In many instances,these equipment solutions are life altering (eye gaze and speech generating devices) and life sustaining (respiratory equipment and generators for those who rely on electricity to maintain breathing functions). Major Activities to be Completed:The major activities to be completed include: • GWC staff consultations with clients and clinicians including equipment assessments, device customization, equipment trials and training sessions • Coordination of ordering, tracking, delivering and picking up equipment • Inventorying, cleaning, repairing equipment ALS is a highly variable disease -each client has a unique disease presentation in terms of how the body is first affected and how fast the disease will progress and, in some cases, cognitive abilities will be compromised too. Each client also has a unique physique and personality profile; each household has a ALS Ohana of Hawaii-Excellence in ALS Care-Equipment Loan Program I Page 2 unique family dynamic and support system, and each home has a unique configuration-all of these must be factored into every equipment decision. GWC staff are trained to determine and secure the best equipment solutions that account for these variables and support the person with ALS and loved ones in getting the most benefit from the loaned equipment. Outputs to be Completed: During the grant period,the following outputs will be completed: 10 client consultations for adaptive equipment solutions 10 equipment loans 10 equipment training sessions Most people diagnosed with ALS, along with their loved ones, are not familiar with the equipment interventions designed to help those dealing with progressive paralysis. The ELP is designed to help educate clients and solve issues quickly.These interventions are essential to helping people live longer and better with ALS;they serve to improve independence, agency and dignity for the person with ALS and reduce stress for all clients including loved ones in the household. Measurable Outcomes:With access to an ALS equipment loan program for a wide variety of needed low-and high-tech devices, a wide range of program outcomes, including many benefits to the public and program participants, are anticipated. The use of adaptive and assistive technologies ensures greater inclusion and interaction for a very vulnerable population, people living with ALS and their loved ones. Those outcomes fall into the following categories: • Increased health, wellness, safety and quality of life for those diagnosed with ALS and their loved ones • Reduced financial burden on those diagnosed with ALS and their loved ones • Expanded opportunities for community involvement and engagement • Enhanced ability to serve as an ALS ambassador for others requiring support and representation Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure ALS Ohana of Hawaii-Excellence in ALS Care-Equipment Loan Program I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative: Equipment Loan Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $10,000 $10,000 Applicant organizational budget: 0 0 Individual contributions TBD 0 0 Membership fees N/A 0 0 Earned income N/A 0 0 Current cash assets N/A 0 0 Other funding sources (list below): N/A HCF-East HI 4,467 4,467 4,467 HCF-West HI 4,284 4,284 4,284 Total Cash Income $10,000 N/A $10,000 IN-KIND CONTRIBUTION Anticipated Committed Total 1,000 1,000 1,000 Total In-Kind Contributions 1,000 1,000 1,000 TOTAL PROGRAM INCOME $10,000 N/A $10,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative: Equipment Loan Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $2,500 4,460 0 $2,500 Professional Fees 0 0 0 0 Operations $1,500 2,037 0 $1,500 Supplies 2,400 2,400 0 4,800 Equipment $6,000 0 0 $6,000 SUBTOTAL $10,000 N/A N/A $10,000 TOTAL PROGRAM BUDGET $10,000 N/A N/A $10,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative—Equipment Loan Program 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. (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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: ALS Ohana of Hawaii g Y Program Name: Excellence in ALS Care Initiative— Equipment Loan Program 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,-rant-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, 2023 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 Date President and Treasurer Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: ALS Ohana of Hawaii Program Name: Excellence in ALS Care Initiative—Equipment Loan Program 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 El 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. 'Iarc-/a-oa Zr-- Signature of Authorized Person (specify title) Date American National Red Cross, The Disaster Preparedness & Response in Hawaii County 11 Countyof Flawai`i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:The American National Red Cross Contact Person: Minette Lew-McCabe Contact Email: minette.lew@redcross.org Contact Phone: 808-348-8593 Program Information Program Name: Disaster Preparedness & Response in Hawaii County Program Years in Operation: 105 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo`o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli`i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, 'Umikoa,Volcano, WaikOloa Village, Waimea, Wainaku,Wai'ohinu,Weloka Program Target Audience: Infancy (0-3), Play Age (3-5), School Age (6-11), Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment Amount Applying For: $35000 The American National Red Cross- Disaster Preparedness& Response in Hawaii County' Page 1 Program Details Organization Mission:The mission of the American 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. We are mandated by the U.S. Congress to provide disaster relief assistance. In 2015,the Red Cross signed an agreement with FEMA that renewed the Red Cross role as the co-lead for provision of mass care. The American Red Cross of Hawaii was founded in 1917 and has assisted in every major disaster in the islands' history. Program Overview:The Disaster Preparedness & Response program provides a safety net for vulnerable populations. During Disaster Response,volunteer caseworkers are on the scene within two hours of any disaster to meet the immediate emergency needs of victims,to provide emotional support to help them cope with loss, and to refer them to other community partners to further assist individual needs for recovery.They may also conduct damage assessment in neighborhoods, serve as shelter managers, and conduct crisis counseling. Volunteers also assist with community disaster education outreach,through which individuals receive lifesaving disaster preparedness information,thus increasing community resiliency, mitigating damage caused by disasters, and decreasing the number of fire-related injuries and deaths.To respond to changing health conditions,we developed the capacity to transition between complete virtual service delivery and a hybrid model combining virtual and limited in-person presence. Program Objectives & Performances Resources Needed:The main resource the Hawaii Red Cross needs is funding for salaries. Our primary input is staff which recruits, trains, and manages Disaster Volunteers who perform 90%of work we do. Our community partnerships also play a large role in providing support in terms of labor and resources. Major Activities to be Completed: Recruiting and training disaster volunteers-Voluntary service is the heart of our organization.Therefore,volunteers need to be recruited and trained, scheduled for on-call duty, and deployed at a moment's notice when there is a disaster.To ensure quality and consistency of service,volunteers require supervision and coordination. Responding to disasters-Volunteer caseworkers are on the scene within two hours of any disaster to meet the immediate emergency needs of victims,to provide emotional support to help them cope with loss, and to refer them to other community partners to further assist individual needs for recovery. Providing preparedness presentations to the community-Volunteers assist with community disaster education outreach,through which individuals receive lifesaving disaster preparedness information, thus increasing community resiliency, mitigating damage caused by disasters, and decreasing the number of fire-related injuries and deaths. Outputs to be Completed: 80 Volunteers maintained* 12 Disaster Responses The American National Red Cross- Disaster Preparedness& Response in Hawaii County I Page 2 24 Individuals assisted after a disaster 350 Individuals outreached with Preparedness Presentations *Note:The Red Cross is currently subject to the Federal Contractor Vaccine Mandate and has required all of our staff and in-person volunteers to be fully vaccinated by February 15, 2022. All Hawaii Red Cross employees are vaccinated.As of mid-January, more than 40%of our volunteers have submitted proof of vaccination.Those who do not submit their vaccination status by the deadline will be contacted by the department and will be offered a virtual position.Volunteers who are not interested in a virtual position or cannot find a virtual volunteer position that is a good fit will be inactivated. We anticipate the size of our available workforce may be significantly impacted. Measurable Outcomes:Short Term Outcomes-Volunteers are trained in Red Cross disaster skills. Immediate needs of disaster victims are satisfactorily met. Knowledge is gained by community members in how to prepare for and survive the most common disasters. Medium Term Outcomes-Adequate numbers of volunteers are maintained. Longer term needs of disaster victims are satisfactorily met. Lives are saved, especially from home fires. Reduced property damage from disasters. Increased community connection. Long Term Outcomes—Volunteer numbers are increased. Decrease cost of disaster recovery, especially in requiring out-of-state assistance. Decrease in poverty caused by major disasters. Community resiliency—the ability to recover quickly after major disasters. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure The American National Red Cross-Disaster Preparedness& Response in Hawaii County I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:The American National Red Cross Program Name:Disaster Preparedness & Response in Hawaii County CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 35,000 35,000 Applicant organizational budget: 0 0 Individual contributions 168,760 0 168,760 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets 0 0 0 Other funding sources (list below): West Hawaii Fund of the HCF 2,916 1,250 4,166 Hawaii Island United Way 25,000 4,284 25,000 Subsidy by American Red Cross to meet deficit 450,554 450,554 Total Cash Income 231,676 451,804 683,480 IN-KIND CONTRIBUTION Anticipated Committed Total 1,000 1,000 1,000 Total In-Kind Contributions 1,000 1,000 1,000 TOTAL PROGRAM INCOME 231,676 451,804 683,480 Appendix D--Budget Sheets (Page 2 of 2) ;Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)- Fiscal Year 2022-2023 !Organization Name:The American National Red Cross Program Name:Disaster Preparedness & Response in Hawaii County Nonprofit Other Cash in-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 35,000 416,741 0 451,741 Professional Fees 0 38,516 0 38,516 Operations 2,037 2,037 0 4,074 Supplies 2,400 5,566 0 5,566 Equipment 0 5,575 0 5,575 Disaster Relief(Financial Assistance) 84,252 84,252 Travel 12,796 12,796 Printing & Promotionals 3,730 3,730 Buildings &Occupancy 21,419 21,419 Contractual Services 32,590 32,590 Depreciation 27,295 27,295 SUBTOTAL 35,000 648,480 0 683,480 TOTAL PROGRAM BUDGET 35,000 648,480 0 683,480 PLEASE NOTE:We have calculated our budget differently this year using a budget generated by our National Office, as we feel those submitted previously did not reflect the true program operating costs. The American National Red Cross uses a budget allocation model to draft Chapter Budgets. Chapter Budgets include"locally incurred costs"and "centrally incurred costs"combined in line items. Direct costs remain comparable to expenses in previous years. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 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, 2023 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. 1/20/2022 • Signature of Authorized Person Date Michael Jordan/Division VP Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 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 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: E If no conflicts exist, check here. Division Vice President 1/20/2022 Signature of Authorized Person (specify title) Date Arts & Sciences Center ASC Community Learning Program 13 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:Arts&Sciences Center Contact Person: Gail Clarke Contact Email: ascpuna@gmail.com Contact Phone: 808 938-2933 Program Information Program Name:ASC Community Learning Program Program Years in Operation: 10+ Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Kalapana, Kapoho, Kea'au, Kurtistown, Leilani Estates, Mountain View, Nanawale Estates, Orchidlands Estates, Pahoa, Pohoiki,Volcano, Puna and East Hawaii Program Target Audience:Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts,Youth,Aged Amount Applying For:$40000 Arts&Sciences Center-ASC Community Learning Program I Page 1 Program Details Organization Mission:The Arts &Sciences Center provides outstanding support and infrastructure for community based learning, rooted in Puna, Hawaii. Program Overview:ASC programs vary greatly in terms of size, style, and length of commitment. Ongoing cumulative courses include Hawaiian Culture & Language (established February 2020) and Business Development for local entrepreneurs (pilot course was Fall 2021, will run again in April). Our biannual community festivals have been adapted for virtual platforms, offering both vendors and participants engagement opportunities from the safety of their home. The Art is Life festival featured local Artists every day throughout November 2021, and Tropical Living will feature agricultural education in early 2022. Growing Artists launched in January 2022 as an ongoing series of'a la carte' bimonthly workshops featuring business tips specifically for Hawaii Artists to succeed. The main expenses related to virtually-focused programs include virtual expansion (website, social media advertisements, virtual conferencing platforms, and labor to facilitate), and program facilitator fees. Program Objectives & Performances Resources Needed:As ASC shifted to virtual spaces, our required resources have shifted. We formerly considered janitorial supplies, labor, and infrastructure for gathering, but now require online applications (i.e., Zoom, Google Business Suite,SquareSpace, social media promotions, etc.) and technological equipment (GoPro camera,video editing laptop)to support our programs,facilitators, and participants. Resources for the individual programs have also shifted, as physical materials and supplies are no longer practical or necessary. However, diverse facilitators who are community experts are needed, and they necessitate compensation for their valuable time. We're utilizing staff to support our administrative tasks and overall organizational growth as we develop these programs. With the virtual model proving to be scalable,we've increased our number of programs and will continue to seek and utilize resources in the form of online applications, equipment, staffing, and professional fees. Major Activities to be Completed: Participants of our ongoing Hawaiian Language &Culture program not only learn 'Olelo Hawai`i, but also chants, stories, cultural protocols, and geography.They participate in outings at historically and culturally significant sites, experience hands-on cultural practices, and observe and participate in traditional ceremonies. Arts&Sciences Center-ASC Community Learning Program I Page 2 are familiarized with business Local entrepreneurs who attend our 12 week Business Developmentclass basics and walk away with a business plan, organizational chart, data analysis system, process documentation practices, and an industry-proven meeting agenda. Prior to the COVID-19 pandemic, local vendors were featured at our community festivals. Now,they are given exposure via promotions on our social media and website. Our online following has grown to support these local organizations, artists, or businesses. Finally, a growing group of local Artists follow our Growing Artists program, which shares relevant information from a guest speaker twice a month. Outputs to be Completed: Our Hawaiian Language &Culture class will serve—15 students/4-mo session via 2 unique classes, and 10 cultural workshops or excursions. Two dozen local businesses are projected to be served by two more rounds of our 12-week Business Development course in 2022. Growing Artists will hold 24 sessions; highlighting 12 unique Hawaii Artists and an additional 12 topics relevant to operating an art business. ASC estimates each session drawing an average audience of 10, resulting in 240 participants. Attendance fee donations average $5 per participant, which will result in $1,200 of revenue. Of our two annual festivals,Tropical Living is scheduled virtually for the Spring. Given data generated by our last virtual festival (November 2021),we anticipate this to reach approximately 10,000 individuals and result in 1,000- 2,000 engagements,with 30 vendors or organizations featured. Our fall festival (Art is Life) may replicate this model or be held in person with different outputs. Measurable Outcomes:The long-term commitment and resiliency of Leialoha Ilae-Kaleimamahu to continue teaching her Hua 'Aina classes throughout the COVID-19 pandemic has bolstered dozens of individuals across East Hawaii in their connection to and understanding of the Hawaiian language and culture. Entrepreneurial individuals, families, or small groups are supported in their business endeavors by our partnership with Sage Business Solutions in hosting our 12-week business development course. Furthermore,this partner is featured regularly in our Growing Artists program to share practical business tips (alternating with inspirational real-life stories of their industry peers). Finally, our two annual festivals promote individuals, small businesses, and organizations in the community.Traditionally,vendors and participants have benefitted from these gatherings in person, but virtual platforms are proving to have an even greater reach beyond a one-day event. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Arts&Sciences Center-ASC Community Learning Program I Page 3 Arts&Sciences Center-ASC Community Learning Program I Page 4 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Arts & Sciences Center Program Name: ASC - Community Learning Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 40000 40000 Applicant organizational budget: 0 0 Individual contributions 1000 0 1000 Membership fees 0 0 0 1 Earned income 1000 0 1000 Current cash assets 0 6000 0 Other funding sources (list below): tbd 4,467 4,467 4,467 HCF-West HI 4,284 4,284 4,284 Total Cash Income 42,000 6000+ 48,000 IN-KIND CONTRIBUTION Anticipated Committed Total wages, fees, operations, supplies 1,000 as needed 1,000 Total In-Kind Contributions 1,000 1,000 1,000 TOTAL PROGRAM INCOME 42000 6000+ 48,000 Appendix D--Budget Sheets (Page 2 of 2) 'Project Budget Form: Expenses ........ .... County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 `Organization Name: Arts & Sciences Center Program Name: ASC - Community Learning Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 12000 4,460 6000 18000 Professional Fees 250 0 750 1000 Operations 250 2,037 750 1000 Supplies 500 2,400 500 1000 Equipment 0 0 0 0 Program Expense Activity: Festivals, Website Resources 5000 5000 Activity: Classes, Courses,Workshops 18000 0 18000 Activity: Youth/STEAM JrMstr Gardner 4000 4000 SUBTOTAL 40,000 8,897 8000 16,794 TOTAL PROGRAM BUDGET 8,897 8,897 0 48,000 County of Hawai‘i Nonprofit Grant Application FY 2022-23 c/i.,e/1(z,S CP-Aqi-eir Agency Name: Program Name: A - COI() "10 n t 1-9-4 iti v r v1/ 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.ehavvaii.gov, complete the easy_step-by-step process, and pay the annual registration fee online using a credit card. If awarded a :rant from the Count of Hawaii I we understand and will corn with the re.uirement to submit a ygar-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. County of '^' Nonprofit Grant ApplicationFY 2022-23 ~-�� ^�' Agency Name: /r| ' -�� {��' ^^��_ �~ ^" . '- ' ^ 624,0( Program Name: A'S C., - y- ,1ill J4'� 14�� 'r ' Prcdi �n�M | - \.� ORGANIZATION�� A°��2�UK�_� DISCLOSURE FORM ._..`~. ..~.�~ ~. .~~.~ .~~�.~. ~~.,~, . .-..~-. P|easedisdoseanyconfUctuorpotent(a| conflictsofinterestthatanyboardrnennber,offcer, d|rector, 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, reqardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflinterest, ofincluding 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 E 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 direc 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: • 1 If no conflicts existcheck here. � �� ' �»^ ~/ � ^ � ��/ � �^' ��l, l ~ x° ' ignature of Authorized Person (specify title) Date Arts and Science Center Villages 14 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Arts and Science Center Contact Person: Robert Golden Contact Email: rgolden46@gmail.com Contact Phone: 808-965-9270 Program Information Program Name:Villages Program Years in Operation: 5 years Other County grants/agreements: No Previously received County GIA: No Program Geographical Reach: Pahoa Program Target Audience:Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth,Aged Amount Applying For: $10000 Arts and Science Center-Villages I Page 1 Program Details Organization Mission:The mission of the website Puna Rising (www.punarising.com) is to connect, inform, and inspire the people of Puna to work together collaboratively,to identify markets for their goods and services,to explore new opportunities and to build a stronger and robust community ethos. We envision ourselves as the 21st century commons that engages and uplifts all members of the community. Program Overview: Puna Rising is seeking this grant to expand the use of Villages, an alternative currency,to help people in Puna do what they love by exchanging their gifts, talents and resources with each other to strengthen our self-reliance. Many of us struggle with the contradiction between what we want to do, and what we need to do to earn money to live. With the digital technology of Villages, we can create a system of interconnected, overlapping economic villages, where personal relationships take precedence over market relationships, and each person is supported in following their passion. Instead of using US$to facilitate an exchange of goods and services,Villages enables us to connect with each other and use Village Hours to exchange what we need and want from each other. Historically, other communities around the world have successfully used abundant local money to increase the production and consumption of local goods and services. Program Objectives & Performances Resources Needed:The digital infrastructure of Villages has been built and updated for the past five years.The purpose of the grant is to expand the program beyond its current level of 150 members who live in Puna, 300 in the state of Hawaii, and 1500 around the world. This will require hiring at least two individuals who will work on a part-time basis to organize an outreach program, including launching a local not-for-profit community development organization and support the ongoing tech/administrative and customer support.They will have a responsibility for having a presence at local markets on a weekly basis, maintaining a presence on social media, conducting community informational events and answering questions posed on the Puna Rising website. Other resources that will be needed include updating Villages, building a smartphone app, purchasing a pop-up tent, a banner, tables and chairs and promotional material. Major Activities to be Completed:There are two distinct but related strategies to expand Villages as an alternative currency in Puna: The first strategy will be directed at educating the community about how Villages works and how an alternative currency program is a safe, secure and legal way to exchange goods and services and to build a self-reliant community. As mentioned above, outreach will take place through educational booths at farmer markets throughout Puna, weekly posts on social media sites, community informational events, and contacting and supporting newly enrolled members of Villages. Arts and Science Center-Villages I Page 2 The other major strategy to change the current economic system is to set up a not-for-profit organization that would a) apply for grants and b)grant/gift Village Hours to businesses and individuals to create and expand local small businesses without an obligation on the part of those businesses to pay back that money.The money remains forever in circulation. Outputs to be Completed: 500 families/individuals will be exchanging goods and services through Villages in Puna,"an increase from the current 120 members. 25 new small businesses will be created that were first started within Villages 250 households or individuals with access to services they couldn't afford previously 200 people "employed" or relieved from unemployment 52K Villages Hours generated ( 780K US$) 10 economical opportunities granted to community members via Villages 1500 individuals reached with educational information on Villages via outreach efforts 1 not-for-profit organization to to grow and enhance the common wealth of Puna Measurable Outcomes: More Individuals and families are food secure. Residents are exchanging their talents,gifts and resources with other local residents. People report higher levels of community engagement and connection with their use of Villages. More new small businesses are registered. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Arts and Science Center-Villages I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Program Name: CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Total Cash Income IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Arts and Science Center Program Name: Villages • Expense Description Nonprofit Other In-Kind TOTAL (Waiwai) Cash Contribution. Grant Source Salary Wages $7200 7200 Professional Fees Operations $600 600 Supplies $1200 1200 Equipment Administrative cost of grant to ASC 1,000 1000 SUBTOTAL 10000 TOTAL PROGRAM BUDGET 10000 County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: vci s 6eAnt'eir Program Name. M OC rColovn n 1 rvt7 " ra. ti Certification of Un i'erstand g (Page 1 of 2 COO/ 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. • t (we) understand that applications will not be reviewed by County personnel receiving ourCounty 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 Fawai'i Com1nliance Express and be compliant prior to receiving payment(s). To register, go to http•//vendors ehawraii. ov,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 rant 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 time! corn,lete and accurate .ear-end re'ort using the tem'late g rovided will im'act the evaluation o our,ra,ram's oraenc 's uture undin reg uests. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: Certificati.n 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 rant funds received durin,_ the ::rant .eriod must be refunded to Coun , 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 30,2023 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 ri, Y - _ Sig4/01-4 /--,,g 5 -2.2_ ature of Authorized Person Date g /€o . be? livia sj Title/Position of Authorized Person VQ yet 1/,31/22 4___,..,..•...,.. ,rdeit___. t..."..."........,.... ' 11-4.-b. s. �l%...v.) (-* 3 r — 1.1...., County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: A>1 Y tri ce.5 _ Program Name: /�5 G � _AA r � Pro / ORGANIZATION CONFLICT DISCLOSURE FORM LI 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 conlist 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 El Staff appointed by a member of the Council • The Mayor [l 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 LA)!�1� Pit, /)Wm) Vi )/age6PboJ Kj If no conflicts exist,check here. , ``-_ I j l/2✓ .1 4 r it, 0. g9- zz pignature of Authorized Person (specify title) Date Big Island Mediation, Inc. Community Mediation and Outreach 15 County of FCawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Big Island Mediation, Inc. Contact Person: Eric Paul Contact Email: epaul@whmediation.org Contact Phone: 808-885-5525 Program Information Program Name: Community Mediation and Outreach Program Years in Operation: 32 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, Captain Cook, Hawi, Holualoa, Honalo, HOnaunau-Napo'opo'o, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kealakekua, Kuki'o, Miloli'i, Ocean View, Puako, Waikoloa Village, Waimea Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Needs of the poor, Public health and welfare of the people and the environment, Aged,Victims of Crimes,Victims of Health or Social Crises Amount Applying For:$15000 Big Island Mediation, Inc.-Community Mediation and Outreach! Page 1 Program Details Organization Mission: Founded in 1988, West Hawaii Mediation Center(WHMC) is a 501(c)(3) nonprofit organization that has served the conflict resolution needs of the West Hawaii community for over 30 years.Through mediation, conflict resolution education, peer mediation, and restorative justice practices, we create space to transform relationships in order to build a culture of peace in West Hawaii. Our Mission is simple:to help people resolve conflict. Program Overview:The Community Mediation and Outreach (CMO) program remains our principal program and primary mode of fostering conflict resolution for West Hawaii neighbors. CMO works on a referral process, both from the courts and from community sources (whether individuals, workplaces, or community organizations). Mediation is a voluntary enterprise.We only mediate if both parties agree. This mechanism helps strengthen any agreements that might come from the session. Mediations are conducted by professionally trained volunteers, who work as neutral facilitators.They hold space for the parties to discuss what outcomes might work best for them. Mediators do not give legal advice or act as a type of arbitrator.This also strengthens any agreement that may result. We mediate custody, separation, divorce, landlord/tenant, civil rights, automobile, property disputes, condo agreements, and many more challenges that routinely occur in West Hawaii. Program Objectives & Performances Resources Needed:The primary resources needed to effectively meet the community's need are as follows: Staff Personnel: Our Case Manager(full time) and Intake Specialists (part-time) hold the primary responsibility for the everyday operation of our mediation program -from intake to scheduling, from volunteer management to training logistics; they make the program run effectively.Salaries/wages and benefits are the largest percentage of our budget. Volunteers:the mediation program relies on the work of well-trained community mediators. In the past year,we have utilized 37 volunteer mediators who have volunteered 1,825 hours. Office/mediation Space: We need both office space and mediation rooms in order to connect with clients.This includes phone lines and internet service in both Kona and Waimea (our geographic reach is 100 miles). Professional Trainers: In order to maintain high quality effective mediators, we offer basic and in-depth mediation trainings to the community and our volunteers. Major Activities to be Completed:There are four major activities that take place throughout the fiscal year: Intakes: we receive referrals from community members and the court system.We conduct safety screens and assess the appropriateness for mediation. Scheduling: if both parties agree to mediation,we begin scheduling for the parties involved as well as two mediators. Big Island Mediation, Inc.-Community Mediation and Outreach I Page 2 Mediations:The mediations are held via zoom (though hopefully face-to-face soon) and last between 2- 3 hours on average. Surveys are conducted when the mediation concludes. If court referred, a court form is sent to the courts. Trainings: We offer an annual Basic Mediation Training (four day training) in order to recruit and train new volunteers. We offer Nonviolent Communication training for the community, conflict resolution workshops/webinars, and exclusive trainings for our volunteers: domestic,TRO, and landlord tenant trainings. Outputs to be Completed: 650 Clients served 1 Basic Mediation Training 12 Community Outreach events 175 mediations conducted In Fiscal year 2020-21,WHMC served 279 cases. Of those cases, 52%of cases mediated reached an agreement.Agreement outcomes literally changed the way people conduct their lives-creating time sharing plans for previously estranged parents with children, debt reduction or forgiveness, homes saved, or extended housing opportunities (to name a few). For cases that didn't reach agreement, participants learn ways to communicate and navigate difficult challenges and models of conflict resolution.This is shown by 71%of participants who felt mediation was a satisfactory enterprise, while 81%of participants, regardless of a reached agreement, said they would recommend mediation to others in their community. Measurable Outcomes: Goals for Outcomes: 55% agreement rate for mediations 75%satisfaction rate for participants 12 new volunteers 50%goal of clients who make less than $42,000 a year. Mediation literally changes the way people manage relationships.Through mediation, custody can be determined, disputes around property boundaries or worker's compensation can come to a hard agreement, and plans for how to care for elderly family members can be made. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Big Island Mediation, Inc.-Community Mediation and Outreach I Page 3 Program Budget Form: Income County of Hawai'i • Nonprofit Grant-in-Aid (Waiwai Grant)—Fiscal Year 2022-2023 Organization Name: West Hawaii Mediation Center Program Name: Community Mediation CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 15,000 Applicant organizational budget: 182,086 182,086 Individual contributions 20,000 10,000 Membership fees Earned income Current cash asset; Other funding sources (list below): Mediation Fees 25,000 Grants (Mediation) 17,500 Grants (unresistricted) 18,000 18,000 Judiciary Contract 39,000 Fundraising Events 30,000 Total Cash Income 183,500 IN-KIND CONTRIBUTION Anticipated Committed Total Volunteers 188,000 Auction Item Donations 36,000 Total In-Kind Contributions 224,000 TOTAL PROGRAM INCOME 407,500 Appendix D--Budget Sheets (Page 2 of 2) Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: West Hawaii Mediation Center Program Name: Community Mediation CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 15,000 Applicant organizational budget: 266,895 266,895 Individual contributions 35,000 15,000 Membership fees Earned income Current cash assets Other funding sources (list below): Mediation Fees 25.000 Mediation Grants (other) 17,500 Unrestricted Grants 56,000 18,000 Peer Mediation Grants 47,000 Fundraising 32,000 Judiciary Contract 39,000 Total Cash Income 266,500 IN-KIND CONTRIBUTION Anticipated Committed Total Volunteers 188000 Auction Item Donations 36,000 Total In-Kind Contributions 224000 TOTAL PROGRAM INCOME 490,500 Appendix 0--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: West Hawaii Mediation Center Program Name: Community Mediation Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 10,000 134,586 143,586 Professional Fees 1,000 5500 6,500 Operations 2,000 11,000 13,500 Supplies 500 1000 1500 Equipment 3000 3000 Training and Outreach 1,500 5500 7000 Mileage 500 500 Advertising and Promotion 6500 6500 SUBTOTAL 15,000 167,086 TOTAL PROGRAM BUDGET 15,000 182,086 • Project Budget Form: Expenses County of Hawaiic, Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: West Hawaii Mediation Center Program Name: Community Mediation T Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant [Salary Wages 10,000 134,586 143,586 ,Professional Fee., 1,000 5500 6,500 }Operations 2,000 11,000 13,500 Supplies 500 1000 1500 Equipment 3000 3000 Training and Outreach 1,500 5500 7000 Mileage 500 500 Advertising and Promotion 6500 6500 SUBTOTAL 15,000 —167.086 TOTAL PROGRAM BUDGET 15,000 182,086 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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 andability 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. County of Hawai`i. Nonprofit Grant Application FY 2022-23 Agency Name: Big island Mediation, Inc.DBA West 1-lawaii Mediation Center Program Name: Community Mediation and Outreach 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.hawaiicount ..-ov fn=non.rofit-;rant-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, 2023 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. -' 1/25/22 Signature of Authorized Person Date Executive Director Title/Position of Authorized Person County of Havvai`i Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name: Community Mediation and Outreach 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 Hawaiii. 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: lloleka Inaba POSITION: County Conned Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): X Member or members of the Council Staff appointed by a member of the Council The Mayor ri The Managing Director II 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: Council Member Holeka Inaba is the current Board President of West Hawaii Mediation Center. He has reef:sett himself from insight,advice,voting,or development of any County GIA grants submitted by%Vest Hawaii Mediation Center. fl If no conflicts exist, check here. ) 1/25/22 Signature of Authorized Person (specify title) Date Big Island Mediation, Inc. Youth Conflict Resolution Education 16 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Big Island Mediation, Inc. Contact Person: Eric Paul Contact Email: epaul@whmediation.org Contact Phone: 808-885-5525 Program Information Program Name:Youth Conflict Resolution Education Program Years in Operation: 10 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, Captain Cook, Hawi, Holualoa, Honalo, Honaunau-Napo'opo`o, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kealakekua, Kuki`o, Ocean View, Puako, Waikoloa Village, Waimea Program Target Audience:School Age (6-11),Adolescence (12-17) Services/Activities Provided: Educational concerns, Culture and the arts,Youth, Physical/Emotional Disabilities,Victims of Health or Social Crises Amount Applying For:$10000 Big Island Mediation, Inc.-Youth Conflict Resolution Education I Page 1 Program Details Organization Mission: Founded in 1988, West Hawaii Mediation Center(WHMC) is a 501(c)(3) nonprofit organization that has served the conflict resolution needs of the West Hawaii community for over 30 years.Through mediation, conflict resolution education, peer mediation, and restorative justice practices,we create space to transform relationships in order to build a culture of peace in West Hawaii. Our Mission is simple: to help people resolve conflict. Program Overview:WHMC seeks funding to support our Peer Mediation and youth conflict resolution (CR) education program.We have relationships with 7 West Hawaii public and private schools, as well as partnerships with youth based community organizations. Conflict resolution education entails teaching youth about the nature of conflict and the typical ways people respond to it, recognizing and managing difficult emotions, learning communication skills, and understanding and respecting differences.Youth use these skills to resolve conflict among their peers in a school setting. Developing these important social-emotional learning skills is integral to strengthening youth relationships. Our Conflict Resolution training develops communication and problem-solving skills needed for youth to assist in conflict resolution with their peers.They learn the processes and protocols in resolving conflict, whether on the playground or dealing with rumors, gossip, and conflict arising from social media interaction. Program Objectives & Performances Resources Needed:The primary resources needed to effectively meet the community's need are as follows: Staff Personnel: Our Peer Mediation Coordinator(part time) holds the primary responsibility for the everyday operation for youth engagement-offering support to teachers and DOE admin, conflict coaching, assessing our curriculum, direct service trainings, and establishing new partnerships. Volunteers:the mediation program relies on the work of mentor mediators and key site coordinators at each school. Office/Utilities:We need both office space, computer, internet, phones, and transportation. As our geographic reach is 100 miles on the West side, our coordinator travels from community to community. Community Partnerships: We rely on communities with pre-existing relationships or spaces that engage youth.We partner with the Dept. of Education, Aloha Teen Theatre, Impact Yoga, Prince Dance Institute, and others to provide services. Major Activities to be Completed:This program serves youth through Education, Conflict Intervention, and Peer Mediation programming. Activities include: Interactive webinar content lead by our Peer Mediation Coordinator. In-Person Peer Mediation Training (8 hour training for elementary, 12 hrs for middle school). Implement Spring/Summer Peace Camp for youth Assessments of teacher needs throughout the year to integrate CR education. Developing the protocol and training manual for online CR education. Big Island Mediation, Inc.-Youth Conflict Resolution Education I Page 2 Teaching peace through various art modalities. Mediation services-facilitating conflicts toward resolutions that work for all involved Update Peer Mediation Manual to better reflect our cultural milieu in Hawaii Seek and establish new partnerships with youth organizations. Outputs to be Completed:These programs promote and instigate healthy dialogue and social-emotional learning techniques.We gather our data,through surveys of students and teachers/administrators. Our outputs are as follows: #of students trained (80 goal) #of mediations held (50 goal) #of partner schools (8 goal) #of community youth partnerships (goal of 3 annually) #of youth Engagements outside of school context Measurable Outcomes: By providing essential mediation and conflict resolution services to community members,WHMC understands that we are all responsible for creating healthy communities by strengthening the bonds between us; this includes establishing and promoting healthy ways of dealing with conflict.With this aim, we measure the following outcomes: of students who use their training outside of school (goal of 60%) of mediation referrals that come from students, rather than teachers or administrators.This allows us to gauge their growth in understanding conflict and needing to manage it. #of agreements that stem mediations held #of schools who continue Peer Mediation programming year after year Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Big Island Mediation, Inc.-Youth Conflict Resolution Education I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: West Hawaii Mediation Center Program Name: Youth Conflict Resolution Education CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 10,000 8,897 Applicant organizational budget: 50,550 0 50,550 Individual contributions 4,000 0 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets 0 0 0 Other funding sources (list below): 4,467 Grants 35,000 4,284 4,284 Fundraising 1,550 Total Cash Income 50,550 17,648 17,648 IN-KIND CONTRIBUTION Anticipated Committed Total 1,000 1,000 Total In-Kind Contributions 1,000 1,000 TOTAL PROGRAM INCOME 50,550 18,648 18,648 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: West Hawaii Mediation Center Program Name: Youth Conflict Resolution Education Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 8000 25,500 0 33,500 Professional Fees 0 Operations 1500 12,000 0 13,500 Supplies 250 250 0 500 Equipment 0 0 Training and Outreach 500 Mileage 250 550 800 Printing 250 Year End Event 1500 SUBTOTAL 10,000 0 16,794 TOTAL PROGRAM BUDGET 10,000 8,897 0 50,550 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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. County of 1-lawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Big Island mediation, Inc.MIA West Hawaii Mediation Center Program Name: 11::-:_-.7...::::::= ,.....,.._-_,..::: ::: Youth Conflict Resolution Education 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 Hawail 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.hawalicounty.govfin-nonprofitjirant-formsL 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, 2023 must be returned to the County of Hawail 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. 10 Z----- 1/25/22 Signature of Authorized Person Date Executive Director Title/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Mediation, Inc. DBA West Hawaii Mediation Center Program Name ' . - - : :. : , . - Youth Conflict Resolution Education 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: Holeka Inaba POSITION: County Council Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): .7K Member or members of the Council 1 , Staff appointed by a member of the Council _ The Mayor I 1 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: Council Member Holeka Inaba is the current Board President of West Hawaii Mediation Center. He has recused himself from insight,advice,voting,or development of any County CIA grants submitted by West Hawaii Mediation Center. If no conflicts exist, check here. 1 .. -1- -":—. ---7-' Z. • 1/25/22 . 1 Signature of Authorized Person (specify title) Date 1 . • Big Island Resource Conservation and Development Council Hawaii Ulu Cooperative:Youth Education to Increase Local Staple Crop Production & • Consumption 17 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Big Island Resource Conservation and Development Council Contact Person: Brandi Milare, Program Manager Contact Email: bircdl@gmail.com Contact Phone: 808-217-7234 Program Information Program Name: Hawaii Ulu Cooperative: Youth Education to Increase Local Staple Crop Production & Consumption Program Years in Operation: 5.5 years Other County grants/agreements:No Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, HOnaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki`o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'dkala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa`ikou, Pauka'a, Pepe`ekeo, Pohoiki, Puako, Pualaa, 'Umikoa,Volcano,Waikoloa Village, Waimea, Wainaku,Wai`ohinu,Weloka Program Target Audience: PlayAge (3-5),School Age (6-11),Adolescence Services/Activities Provided: Educational concerns, Culture and the arts, Public health and welfare of the people and the environment,Youth Amount Applying For: $25000 Big Island Resource Conservation and Development Council-Hawaii Ulu Cooperative:Youth Education to Increase Local Staple Crop Production &Consumption I Page 1 Program Details Organization Mission:The Mission of Big Island RC&D Council 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 RC&D Council is to conserve, enhance, and promote the economic, cultural, and natural environment of Hawaii. Program Overview: HUC's mission is to revitalize 'ulu as a viable crop and dietary staple for Hawai'i by empowering farmers as change makers in the food system.The proposed program builds upon HUC's education work to increase appreciation and consumption of culturally-significant local staples by: 1) Disseminating a value-chain video series for four crops (lulu, kalo, 'uala, and pala'ai)to schools and families along with recipe-ready meal kits, 2) Developing remote-friendly curriculum to accompany video series, and 3) Collecting and analyzing impact metric data to assess program effectiveness and inform future efforts. Bringing together voices from food system stakeholders- including farmers, chefs, cultural practitioners, manufacturers and cafeterias- into a virtual-friendly curriculum, HUC will help students of all backgrounds from Hawai'i Island gain an increased understanding of local vs.global systems, Hawaiian culture, career opportunities, and environmental stewardship through agriculture. Program Objectives & Performances Resources Needed:To distribute a value-chain video series for four staple crops along with meal kit boxes and curricula,the proposed program will require HUC staff to coordinate with community stakeholders including farmers, chefs, crop experts,educators, non-profit partners, schools, and families throughout the county. With 5+years' experience developing today's breadfruit industry via education initiatives- including youth-oriented videos,the Kumu 'Ulu Box educational meal kit and packet,the 'Ulu Education Toolkit and more- HUC is poised to lead this effort. Standards alignment will require contracting with a qualified curriculum development specialist. Outreach will require a professional videographer, HUC marketing staff and printing services to/develop user-friendly resources geared to compel and support students,their teachers and/or parents and siblings. Finally, HUC staff will collect and analyze feedback data to inform future efforts. Funds are required to enable the above efforts. Major Activities to be Completed:Videos will be developed with support from a USDA Specialty Crop Block Grant and the proposed program activities will leverage and build upon past community efforts to maximize impact.An accredited educator will review and align content with curriculum standards to create supplemental resources. Local chefs in HUC's network will create keiki-friendly recipes for the four crops to accompany meal kit boxes.To support outreach, the HUC Marketing Manager will design engaging educational materials and HUC will coordinate printing to publish hard-copy resources.A professional videographer will create an instructional video on how to use boxes to share in relevant PDE3 courses. HUC and community partners including Hawai'i Public Health Institute and KOkua Hawai'i Foundation will conduct outreach and liaison with local schools and community groups to increase Big Island Resource Conservation and Development Council-Hawaii Ulu Cooperative:Youth Education to Increase Local Staple Crop Production&Consumption Page 2 awareness and engagement with these resources. HUC administration will collect and analyze feedback data to inform future efforts. Outputs to be Completed:To advance development of Hawai'i Island's burgeoning breadfruit industry, the proposed program will provide cultural, culinary, and nutritional educational resources, expanding public awareness and consumer demand. Deliverables of the proposed program include 4 remote- friendly, ready-to-use, standards-aligned curricula for educators to use in combination with the farm-to- fork video series as well as a video tutorial for how to use the curricula and videos. Nutritious staples will be distributed to 1,140 students, as one class at each of the 38 public and charter elementary schools in the county will receive a meal kit with Hawai'i-grown staples and recipe cards for 30 students. Crucial for food security, 114 Hawaii Island farmers will be supported by marketing their crops to classrooms and families. Collecting and analyzing feedback and impact metric data to assess program effectiveness, HUC will produce a summary report of the program's successes and future improvements. Measurable Outcomes:The proposed program leverages HUC's knowledge, production capacity and connections in the local food system to provide place-based education opportunities for keiki to engage with four staple crops.These objectives align with the interests of the Hawai'i Island community as they will expand the market for culturally significant and environmentally friendly staples, thereby moving toward the county goal of local food system resiliency. In addition,the meal kits and educational resources provided by this program will support the health of Hawaii Island youth and their families. Farm-to-school education has been found to significantly improve attitudes towards school and encourage marginalized students to engage in food and environmental issues in their communities.This work will expose keiki to various professional avenues within the local food system and help instill healthy eating habits-preparing our next generation for success in school,work and life. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Big Island Resource Conservation and Development Council-Hawaii Ulu Cooperative:Youth Education to Increase Local Staple Crop Production &Consumption Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Big Island Resource Conservation and Development Council Program Name:Hawaii Ulu Cooperative:Youth Education to Increase Local Staple Crop Production&Consumption CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $25,000 $25,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets $2,393.95 $2,393.95 Other funding sources (list below): Total Cash Income $27.393.95 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions 0.00 TOTAL PROGRAM INCOME $25,000 $2,393.95 $27,393.95 Appendix D--Budget Sheets (Page 2 of 2) Program Budget Form: Expenses :County of Hawaii • Nonprofit Grants-in-Aid—Fiscal Year 2021-2022 'Organization Name:Big Island Resource Conservation and Development Council Program Name:Hawaii Ulu Cooperative:Youth Education to Increase Local Staple Crop Production&Consumption Expense Description Nonprofit Other Cash In-Kind TOTAL Grant Source Contribution Salary Wages $6,000.00 $0.00 $0.00 $6,000.00 Professional Fees $9,500.00 $1,643.95 $0.00 $11,143.95 Operations $0.00 $0.00 $0.00 $0.00 Supplies $7,000.00 $750.00 $0.00 $7,750.00 Equipment $0.00 $0.00 $0.00 $0.00 Fiscal Sponsor Admin Fee (10%) $2,500.00 $0.00 $0.00 $2,500.00 SUBTOTAL $25,000 $2,393.95 $0.00 $27,393.95 TOTAL PROGRAM BUDGET $27,393.95 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Resource Conservation and Development Council Program Name: Hawaii Ulu Cooperative: Youth Education to Increase Local Staple Crop Production&Consumption 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Resource Conservation and Development Council Program Name:Hawaii Ulu Cooperative: Youth Education to Increase Local Staple Crop Production&Consumption 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, 2023 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. 01/30/2022 Signature of Authorized Person Date Larry M. Komata, President Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Resource Conservation and Development Council Program Name:Hawaii Ulu Cooperative: Youth Education to Increase Local Staple Crop Production&Consumption 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 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. 4/146- Larry M. Komata, President 01/30/2022 Signature of Authorized Person (specify title) Date Big Island Resource Conservation and Development Council Mauna Kea Watershed Alliance 18 County of Hawai=i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Big Island Resource Conservation and Development Council Contact Person: Brandi Milare, Program Manager Contact Email: bircd1@gmail.com Contact Phone: 808-217-7234 Program Information Program Name: Mauna Kea Watershed Alliance Program Years in Operation: 11 years Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Hakalau, Hilo, Honomu, Honoka'a, Laupahoehoe, Pa'auilo, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo,Wainaku, Weloka Program Target Audience:Young Adulthood (18-39) Services/Activities Provided: Educational concerns, Culture and the arts, Public health and welfare of the people and the environment,Youth Amount Applying For:$15000 Big Island Resource Conservation and Development Council-Mauna Kea Watershed Alliance I Page 1 Program Details Organization Mission:The Mission of Big Island RC&D Council 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 RC&D Council is to conserve, enhance, and promote the economic, cultural, and natural environment of Hawai'i. Program Overview:The Mauna Kea Watershed Alliance is one of ten watershed partnerships across Hawaii Pae 'Aina, the Hawaii Association of Watershed Partnerships (HAWP).The HAWP's ten island- based Watershed Partnerships work collaboratively with more than 74 public& private partners on five islands to protect over 2.2 million ac. of vital forested watershed lands.The Mauna Kea Watershed Alliance includes the Department of Land & Natural Resources, Parker Ranch, Department of Hawaiian Home Lands, Hakalau Forest National Wildlife Refuge, Kuka'iau Ranch, Queen Lili'uokalani Trust, & Kamehameha Schools. Affiliate partners are the Pacific Islands Fish &Wildlife Office,The Nature Conservancy, & USDA FS Institute of Pacific Islands Forestry. Partnership lands span 416,000 ac. on Mauna Kea. Alliance staff conduct watershed management that includes workforce development, hosting activities like native seed collection, growing& planting native trees &shrubs in natural areas to increase watershed capacity. Program Objectives & Performances Resources Needed: Currently due to the impacts of COVID-19 to our program that include no camping trips to reduce the risk of spreading COVID-19, increased operational costs to vehicles as well as less time to complete work deliverables, and having reduced to no volunteers for the past two years we are reaching our operational capacity. This is further complicated by a 1-2 year planning process to receive grants funds, most of the grants received in the past two years didn't account for the impacts of COVID- 19. Plants procurement prices have also doubled in the past year.The Mauna Kea Watershed Alliance requests funds to procure native trees and shrubs from local vendors to plant at our management units on the eastern slope of Mauna Kea so that we can shift current funds to pay salaries and fringe for employees, contractors, and temporary hires (provide work for those impacted by COVID-19). Major Activities to be Completed:The MKWA will procure native plants from Hawaii County plant nurseries for out-planting at Management Units on Mauna Kea.These include native trees & shrubs such as Acacia koa (koa), Sophora chrysophylla (mamane), & Dodonaea viscosa (aali'i).These outplants eventually grow to a multi-canopied forest capable of slowing&capturing water from mists & rain. At costs of$2-6 per native plant we will procure 3,000 native plants.As match & part of our workforce development&to assist our community with employment&training due to COVID-19 impacts we will engage at least three youth &young adults in watershed management& support local jobs & internship programs positions.These positions may include summer internships, Hawaii Youth Conservation Corps, &temporary hires. They will assist with caring for the plants while hardening at field sites&with planting, learn skills & receive training, & be connected to conservation networks. Big Island Resource Conservation and Development Council-Mauna Kea Watershed Alliance I Page 2 Outputs to be Completed: Procure 3,000 native plants & shrubs from nurseries in Hawaii County supporting local business, as match engage three local youth &young adults in watershed management providing training,work experience &skills, & networking to conservation organizations.These actions also increase community resiliency&the ability of forests on Mauna Kea to capture &store freshwater for Hawaii communities. Measurable Outcomes:The measurable outcomes include supporting local nurseries to grow native plants, out-planting native plants to increase water capture &storage strategically on Mauna Kea, support local community providing jobs, & provide training &work experience for local jobseekers. If volunteer programs are operational (COVID-19 protection protocols impact ability to host volunteers) engaging volunteers to plant native trees on Mauna Kea &work with government agencies.These place- based approaches and actions support local communities at a grass roots level. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Big Island Resource Conservation and Development Council-Mauna Kea Watershed Alliance I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Big Island Resource Conservation and Development Council Program Name: Mauna Kea Watershed Alliance CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 15,000 15,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Total Cash Income 15,000 15,000 IN-KIND CONTRIBUTION Anticipated Committed Total Salary Wages 30,000 30,000 60,000 Total In-Kind Contributions 30,000 30,000 60,000 TOTAL PROGRAM INCOME 45,000 30,000 75,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses ;County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ;Organization Name: Big Island Resource Conservation and Development Council Program Name: Mauna Kea Watershed Alliance Nonprofit Expense Description (Waiwai) Other Cash In-Kind TOTAL Source Contribution Grant Salary Wages $30,000 $30,000 $60,000 Professional Fees Operations Supplies $13,500 $13,500 Equipment Fiscal Sponsor Admin Fee (10%) $1,500 $1,500 SUBTOTAL $15,000 $30,000 $30,000 $75,000 TOTAL PROGRAM BUDGET $75,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Resource Conservation and Development Council Program Name: Mauna Kea Watershed Alliance 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Resource Conservation and Development Council Program Name: Mauna Kea Watershed Alliance 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, 2023 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. • 49-: ; ter 01/30/2022 Signature of Authorized Person Date Larry M. Komata, President Title/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Resource Conservation and Development Council Program Name: Mauna Kea Watershed Alliance 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 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: Ix I If no conflicts exist, check here. 4/4._ Larry M. Komata, President 01/30/2022 Signature of Authorized Person (specify title) Date Big Island Resource Conservation and Development Council Nutrition Grown Farming Educational Program 19 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Big Island Resource Conservation and Development Council Contact Person: Brandi Milare, Program Manager Contact Email: bircdl@gmail.com Contact Phone: 808-217-7234 Program Information Program Name: Nutrition Grown Farming Educational Program Program Years in Operation: 3 years Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Open to farmers in any area on Hawaii Island Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59) Services/Activities Provided: Educational concerns, Public health and welfare of the people and the environment Amount Applying For:$15000 • Big Island Resource Conservation and Development Council-Nutrition Grown Farming Educational Program I Page 1 Program Details Organization Mission:The Mission of Big Island RC&D Council 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 RC&D Council is to conserve, enhance, and promote the economic, cultural, and natural environment of Hawaii. Program Overview: Scientific studies show significant losses (up to.70%) of 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"food nutrient values are approximately double as compared to the USDA food nutrient database values. Growing methods are environmentally friendly. These growing methods provide substantially greater yields, better flavor, longer shelf life, increased pest/disease resistance, and improved marketability. We propose to educate five more farmers about Nutrition Grown" methods and to assist them in implementation. The course consists of 19 half-hour teaching videos, pre-and post-comprehensive soil analyses, plant tissue analyses for food nutrient content compared to USDA values, online group calls, on-site consulting and materials. Farmers grow trial plots to compare to their current cropping methods and keep records of crop progression. Data is posted online. Program Objectives & Performances Resources Needed: Dr. Bogs' knowledge of Nutrition Grown."farming conveyed to farmers and their crews through her book, online course, Zoom meetings, one-on-one discussions, and in-person mentoring. Her office with phone and computer/printer equipment, lab equipment (i.e. microscope, scales, dehydrator, etc.), seeds, soil amendments/fertilizers, weighing and mixing equipment,fertilizer spreader, storage room, utilities, and truck for transport. Monetary compensation. Professional soil and plant tissue analyses, and Dr. Bogs' expertise to interpret them, postage. Five excited farmers with their crews,farmable land, irrigation water,farm equipment, computers/phones. Major Activities to be Completed: Recruit farmers for the program through advertising, word-of-mouth, etc.Send them applications. Review the applications and choose farmers based on potential for successful completion of the program and potential impact for the community. Deliver online course and book to students, perform monthly group Zoom meetings for teaching,farm visits by Dr. Bogs to obtain soil samples,soil microbiology analyses by Dr. Bogs, mail soil samples to lab, interpret raw numbers and make recommendations, order soil amendments, make custom soil amendment mixes, order seeds, take amendment mixes/seeds to farmers and help them to apply, farmers care for crops, Dr. Bogs follows up with farmers to make sure they are recording progress and help with problems,farm visits to collect plant tissue and soil for post-trial analyses, photos, compile and interpret data, comparisons to USDA values,write reports, publish online,track and report income and expenses, narrative report. Big Island Resource Conservation and Development Council -Nutrition Grown Farming Educational Program I Page 2 Outputs to be Completed: Five (5) Big Island food producers (plus work crews)taught Nutrition Grown" farming techniques utilizing primarily online methods, but also including on-site, hands-on application education with the following components: • 19 half-hour teaching videos developed by Dr. Bogs delivered to each student farmer • 200-page e-book written by Dr. Bogs delivered to each student farmer • Monthly interactive Zoom teaching meetings led by Dr. Bogs • Nutrition Grown"trial plots on each food producer's land for educational purposes • Comprehensive pre-and post-soil analyses (including microbiology) with interpretation and recommendations by Dr. Bogs • Custom soil amendment/fertilizer mixes and hands=on help with application • Plant tissue nutrient analyses with comparisons to USDA values documented Sharing of information and knowledge gained through written report posted on Dr. Bogs'website and sent to over 1000 subscribers to the blog, and offline resources, i.e. presentations by Dr. Bogs. Measurable Outcomes: Outcomes for Farmers: • More success and satisfaction with crops due to increased yields (past trials showed 33 to 920% increases in yields) and quality, and fewer pests and diseases without the use of toxic chemicals • Greater financial success • Increased food self-sufficiency by growing food they need, right at home Outcomes for the Public: • A sustainable, Nutrition GrownTM food system supplying higher quality, nutrient-rich foods to the community for better health • Greater food security due to more foods available to Hawaii residents from locally-grown sources • Cleaner air,water and soil due to using environmentally-friendly farming methods Attachments Program Budget(Income & Expenses) Certificate of Understanding Conflict Disclosure Big Island Resource Conservation and Development Council-Nutrition Grown Farming Educational Program I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Big Island Resource Conservation and Development Council Program Name:Nutrition Grown Farming Educational Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $15,000 $15,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources(list below): Total Cash Income $15,000 $15,000 IN-KIND CONTRIBUTION Anticipated Committed Total Dr. Jana Bogs/Beyond Organic Consulting $5,000 $5,000 Total In-Kind Contributions $5,000 $5,000 TOTAL PROGRAM INCOME $20,000 $20,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Big Island Resource Conservation and Development Council (Program Name: Nutrition Grown Farming Educational Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $9,800 $9,800 Professional Fees $1,500 $1,500 Operations $1,500 $4,500 $6,000 Supplies $2,200 $2,200 • Equipment $500 $500 SUBTOTAL $15,000 $5,000 $20,000 TOTAL PROGRAM BUDGET $20,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Resource Conservation and Development Council Program Name: Nutrition Grown Fanning Educational Program 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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Resource Conservation and Development Council Program Name: Nutrition Grown Farming Educational Program 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, 2023 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. 10-r 11111111111111111/' 01/30/2022 Signature of Authorized Person Date Larry M. Komata, President Title/Position of Authorized Person • County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Resource Conservation and Development Council Program Name: Nutrition Grown Farming Educational Program 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): Fl 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. Larry M. Komata, President 01/30/2022 Signature of Authorized Person (specify title) Date Big Island Resource Conservation and Development Council Growing Edible Gardens Using Best Management and Sustainable Practices 20 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Big Island Resource Conservation and Development Council Contact Person: Brandi Milare, Program Manager Contact Email: bircdl@gmail.com Contact Phone: 808-217-7234 Program Information Program Name: Growing Edible Gardens Using Best Management and Sustainable Practices Program Years in Operation: 13 years Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Hilo Program Target Audience:School Age (6-11), Adolescence (12-17), Young Adulthood (18-39) Services/Activities Provided: Educational concerns, Public health and welfare of the people and the environment, Youth Amount Applying For: $20000 Big Island Resource Conservation and Development Council-Growing Edible Gardens Using Best Management and Sustainable Practices Page 1 Program Details Organization Mission:The Mission of Big Island RC&D Council 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 RC&D Council is to conserve, enhance, and promote the economic, cultural, and natural environment of Hawaii. Program Overview: One-third of America's 3.4 million farmers are over the age of 65, regarded as retirement age, and nearly a million more are within a decade of that milestone, according to USDA data.The census showed the average age of a Hawaii farmer was 60.1 years. For decades,the aging U.S. farmer has been a cause for concern, expressed in this question: Who will feed America in the future? With the onset of the coronavirus (COVID-19) pandemic in Hawaii, agriculture suffered a setback not only with decreases in amount of food we are producing abut also our human labor. Emerging leaders in agricultural education are key to solving problems of food sufficiency.The development of agricultural leaders still remains a high priority of the College of Agriculture, Forestry and Natural Resource Management (CAFNRM).We aim to achieve this goal by ensuring that each student experience a curriculum packed with activities such as experiential and applied learning coupled with discovery through research. Program Objectives & Performances Resources Needed:The program will organize students from two main courses in CAFNRM: Sustainable Agriculture (AG230) and Introduction to Tropical Horticulture (Hort 262). They will utilize the current campus garden spaces and sites to create their concept sustainable gardens that are carefully planned in the class, critiqued by the members of the class and approved by the professor. The will need materials and supplies such as seeds, organic fertilizers, supplies in making composts and vermicomposts, supplies for photo and video documentation, garden supplies and equipment, laboratory materials and supplies. During earth day, we need to coordinate with the organizing staff of the event to include the gardens for the tours (virtual or in person). We will also be coordinating with the organizers of the Ag symposium on April 14,to feature student presentations highlighting their projects. Major Activities to be Completed:Students in Ag230 and Hort 262 courses will plan and garden using a template provided by the instructor.The template includes details such as: main concept or theme of the garden, design, sustainable ag practices to be implemented in soil and nutrition, insect and disease management and weed management.After presentation and approval,the students will then be assigned to their sites and implement their plants.They will have an allocation of at least 2.5 hours /week to work on their projects.Weekly reports shall be submitted and a final report will be presented orally on the first week of April 2022. Ag symposium will be help on April 14 where selected representatives from each class will be sharing their reports in one venue.This will also be participated by students from all UH campuses system-wide. Big Island Resource Conservation and Development Council -Growing Edible Gardens Using Best Management and Sustainable Practices I Page 2 Outputs to be Completed:The project hopes to produce the following outcomes: 1) 24 Students will be supported in planning and implementing sustainable gardens both on campus and the farm 2) 24 students will be supported in presenting reports by April 4, 2022 3) 10 Students will be selected to present reports at the system-wide Ag Symposium 4) 7 Sites will be supported to develop into sustainable gardens showcasing sustainable practices on campus 5) 10 plots will be supported to develop into sustainable gardens showcasing sustainable practices at the UH Farm 6) 10 volunteers will be supported to work on campus plots 7) 500 students will be supported to participate in gardens tours during earth day celebration Measurable Outcomes:The program will produce the following measurable outcomes to the public: At least 5 -7 gardens on campus established showcasing sustainable practices that promote diversity, enhances soil fertility by application of composts and other recycled organic wastes, alternative source of food and contribute to the reduction of food insecurity on campus and the community.The gardens will offer opportunities for the other members of the community to volunteer in the implementation of the sustainable practices that promote the use of environmentally sound practices such as the use of alternative nonchemical weeds, pest and disease management. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Big Island Resource Conservation and Development Council-Growing Edible Gardens Using Best Management and Sustainable Practices I Page 3 Program Budget Form: Income g g County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Big Island Resource Conservation and Development Council Program Name: Growing Edible Gardens Using Best Management and Sustainable Practices CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $20,000 $20,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources(list below): University of Hawaii $111,000 $111,000 Total Cash Income $131,000 $131,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME $131,000 $131,000 Appendix D--Budget Sheets (Page 2 of 2) ;Project Budget Form: Expenses County of Hawaii • Nonprofit GranNon t-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Big Island Resource Conservation and Development Council Program Name: Growing Edible Gardens Using Best Management and Sustainable Practices Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $111,000 $111,000 Professional Fees $2,000 $2,000 Operations Supplies $18,000 $18,000 Equipment SUBTOTAL $20,000 $111,000 $131,000 TOTAL PROGRAM BUDGET $131,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Resource Conservation and Development Council Program Name: Growing Edible Gardens Using Best Management and Sustainable Practices 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Resource Conservation and Development Council Program Name: Growing Edible Gardens Using Best Management and Sustainable Practices 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-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, 2023 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. jor 101// "'`" 01/30/2022 Signature of Authorized Person Date Larry M. Komata, President Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Resource Conservation and Development Council Program Name: Growing Edible Gardens Using Best Management and Sustainable Practices 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 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. Larry M. Komata, President 01 /30/2022 Signature of Authorized Person (specify title) Date Big Island Resource Conservation and Development Council Big Island Invasive Species Committee Invasive Plant Eradication Program 21 County of Flawai'i • Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Big Island Resource Conservation and Development Council Contact Person: Brandi Milare, Program Manager Contact Email: bircdl@gmail.com Contact Phone: 808-217-7234 Program Information Program Name: Big Island Invasive Species Committee Invasive Plant Eradication Program Program Years in Operation: 22 years Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach:All areas on Hawaii Island Program Target Audience: Infancy(0-3), Play Age (3-5), School Age (6-11), Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Public health and welfare of the people and the environment Amount Applying For:$40000 Big Island Resource Conservation and Development Council-Big Island Invasive Species Committee Invasive Plant Eradication Program I Page 1 Program Details Organization Mission:The Mission of Big Island RC&D Council 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 RC&D Council is to conserve, enhance, and promote the economic, cultural, and natural environment of Hawaii. Program Overview: Invasive plants, animals and disease are the primary threats to forest health, native biodiversity, and watershed function, and local agriculture.The Big Island Invasive Species Committee works to mitigate the impacts of invasive plants across high-priority conservation and ag landscapes on the island of Hawaii, by removing the highest-threat invasive plants in the early stages of invasion. The project will directly support a number of state and county priorities include preserving Water Quality& Quantity; Forest Health; Conservation of Native Biodiversity, and the Productivity of Local Agriculture. The 14 species selected for control have been prioritized using robust, objective risk-assessment critera, which document the risk that each species will significantly impact local resources, and the feasibility of island-wide eradication. Each eradication project is characterized by active collaboration among public and private landowners, government agencies and NGOs, and BIISC. Program Objectives & Performances Resources Needed:The BIISC plant control program is normally staffed by a team of six field crew members (Supervisor, Field leader and four field assistants) and supported by a GIS/Data Analyst, Outreach team, and the BIISC manager,who also work on other program areas. The work requires regular safety and technical training, 4WD vehicles, a rented office and baseyard, sturdy field, camping, and safety gear,tools, herbicide, radios, GPS units, and computer work stations, most of which is in hand and requires only occasional repair and replacement(i.e. our trucks which are over 14 years old!). We receive about 50%of the funding needed to do this work though a competitive grant from the Hawaii Invasive Species Council each year, and seek out other public and private competitive grants to keep the work going year-round. We are requesting a 10%contribution of salary,fringe, and supplies, primarily fuel,from the County to support field staff in getting this important work done. Major Activities to be Completed:After completing the detection, risk and feasibility assessments, and committee approval stages for each target,the GIS Analyst maps out a 200 meter-radius search area around all known target plants. The outreach team develops outreach materials, publicizes weed alerts, solicits reports from the public, and sends out mailings to residents in the search area.The plant crew then canvasses door to door, requesting permission to access each property within the search area. Staff survey along closely-spaced transects to systematically find and control,with herbicide or by hand- pulling, all individuals encountered within the defined search area. A GPS location,the size and age (mature or juvenile) are recorded for each plant encountered, so that the search area can be expanded Big Island Resource Conservation and Development Council-Big Island Invasive Species Committee Invasive Plant Eradication Program I Page 2 or reduced each year.This work must be repeated quarterly to biannually, depending on the species, returning often enough to exhaust the seedbank and prevent emerging keiki from reaching maturity. Outputs to be Completed: BIISC produces an annual action plan detailing benchmarks to be made each year towards the eradication of our 14 eradication target species. Progress is measured by the total number and the density of mature plants (mature plants per square acre) found on repeat surveys. Requested funds, if awarded, will cover approximately 10%of the program costs toward achieving the following: • Conduct surveys of over 1,300 acres surrounding nearly 100 known target species locations • Control over 30,000 mature plants. • Initiate surveys for four new target species prioritized for eradication in 2021 (search areas add an additional 900 acres to the BIISC workload). • Conduct outreach to gain access to an average of 300 private properties per year. • Significantly reduce the density of mature plants year over year. In 2020 seven target species had been reduced to fewer than 2 mature plants per acre, including one that is now eradicated. This is a reduction of 99%or better over ten years. Measurable Outcomes: In one year, BIISC can control 90% of the mature plants in a newly detected invasive plant location, reducing the dispersal rate by 90%, and delaying the felt impact to natural resources or agriculture by ten years.The outcome of the suppression or eradication of each target species depends on its location and the way it impacts our natural resources. For example, devil weed can reduce the productivity of crop & livestock production by 50%or more and increases the frequency and severity of wildfire. One year of work on devil weed now can delay this impact to farms by ten years, giving time for a biocontrol agent to be approved, even if the eradication effort should fail. Last year BIISC removed 190 cotoneaster trees and 3,984 keiki. In previous years, 14,761 mature trees and 38,455 keiki. Without this work, cotoneaster would be more plentiful than ohia or any native plant in the area, overtopping the ohia canopy and crowding out native seedlings. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Big Island Resource Conservation and Development Council-Big Island Invasive Species Committee Invasive Plant Eradication Program I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Big Island Resourc s Conservation and Development Council Program Name:Big Island Invasive Species Committee Invasive Plant Eradication Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 40,000 40,000 Applicant organizational budget: 0 0 Individual contributions 0 0 0 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets 0 0 0 Other funding sources (list below): 130,000 230,000 360,000 Hawaii Invasive Species Council 4,467 160,000 4,467 Hawaii Tourism Authority 90,000 4,284 4,284 US Fish and Wildlife Service 70,000 US Forest Service 40,000 Total Cash Income 170,000 230,000 400,000 IN-KIND CONTRIBUTION Anticipated Committed Total While we don't have a specific $ amount 1,000 1,000 1,000 to attach, over 300 residents participate each year by allowing access to their land, and we received 435 invasive species reports from the public last year-an invaluable contribution! The state and federal government provide $16,000 $16,000 cabins for 20 weeks of remote camping by the crew each year, free of charge. Total In-Kind Contributions 1,000 $16,000 1,000 TOTAL PROGRAM INCOME 170,000 246,000 416,000 Appendix D--Budget Sheets (Page 2 of 2) =Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ;Organization Name:Big Island Resourc s Conservation and Development Council ;Program Name:Big Island Invasive Species Committee Invasive Plant Eradication Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 35,000 240,000 0 275,000 Professional Fees 0 0 0 0 Operations 2,037 15,000 0 15,000 Supplies 1,000 8,000 0 9,000 Equipment 0 23,000 0 23,000 Office & Baseyard rent, utilities,etc 20,000 20,000 Remote camping facilities(cabin,weatherport) 16,000 16,000 10% BIRC&D Administrative Fee 4,000 4,000 UH 5%'Direct/10% Indirect Rate 54,000 54,000 SUBTOTAL 40,000 360,000 16,000 416,000 TOTAL PROGRAM BUDGET 40,000 360,000 16,000 416,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Resource Conservation and Development Council Program Name: Big Island Invasive Species Committee Invasive Plant Eradication Program 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 June 30 of the contractual year to submit a year-end report to the County Council within 60 days after 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Resource Conservation and Development Council Program Name: Big Island Invasive Species Committee Invasive Plant Eradication Program 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, 2023 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. 44.19141101111111.," 01/30/2022 Signature of Authorized Person Date Larry M. Komata, President Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Big Island Resource Conservation and Development Council Program Name: Big Island Invasive Species Committee Invasive Plant Eradication Program 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 ❑ 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: Q If no conflicts exist, check here. ?_ Larry M. Komata, President 01/30/2022 Signature of Authorized Person (specify title) Date Boys & Girls Clubrof the Big Island Daily Meal Support for Income-Challenged Youth and Families 35 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Boys & Girls Club of the Big Island Contact Person: Chad Cabral Contact Email: chad@bgcbi.org Contact Phone: 8089615536 Program Information Program Name: Daily Meal Support for Income-Challenged Youth and Families Program Years in Operation: 70 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Captain Cook, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo`opo'o, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kapoho, Kea'au, Kealakekua, Kurtistown, Leilani Estates, Na'alehu, Nanawale Estates, Ocean View, Orchidlands Estates, Pahoa, Papa'ikou, Pepe'ekeo, Pohoiki,Wainaku, Wai`ohinu Program Target Audience:School Age (6-11),Adolescence (12-17) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth Amount Applying For: $50000 Boys&Girls Club of the Big Island-Daily Meal Support for Income-Challenged Youth and Families I Page 1 Program Details Organization Mission: Boys & Girls Club of the Big Island (BGCBI) mission: "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." Over 70 years, BGCBI has been at the forefront of afterschool youth development services in Hawaii County.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala, Kealakehe, Kahakai, South Kona, Ocean View, & Ulu Wini. Program Overview:This will provide access to nutrition to Hawaii Islands most at-risk&vulnerable populations not able to secure adequate daily nutrition. For some, school lunch is the last meal that they'll have until returning to school the next morning. BGCBI helps to provide an evening meal for these individuals which will satisfy their hunger until their next meal. 62%of families report receiving free/reduced school lunches, a further indication of economic hardship. By providing meals for this population, families &individuals are able to save money&still get a meal provided daily. BGCBI has delivered over 52,952 hot meals &92,930 snacks since 2017. BGCBI staff& parents noticed an increased focus, willingness to learn, & higher respect for others. 89%of youth communicated that the supplementation they received has benefited their daily nutrition needs as a result of the program resources provided.This will increase their access to nutrition & address poverty within these households. Program Objectives & Performances Resources Needed: Kitchen,youth, staff, ingredients, meals, food vehicles, kitchen equipment, kitchen supplies,fuel for vans, utensils, Clubs, community partnershis, data tracking. Major Activities to be Completed: Kitchen staff to prep, cook, pack, and deliver food,youth receiving daily meals,youth and families communicating the meals are enjoyable and are beneficial, delivering meals daily to all BGCBI youth Outputs to be Completed:4 kitchen staff 350 meals served daily 350 youth supported and receiving meals 2 meal delivery drivers 70%of participants will demonstrate that the meals and/or snacks they receive are beneficial to their nutritional supplementation needs 70% of participants communicate that they enjoy the meals &snacks they receive from BGCBI Measurable Outcomes: More food secure families, daily evening meal for free,youth more focused and behavioral changes Attachments Boys&Girls Club of the Big Island-Daily Meal Support for Income-Challenged Youth and Families I Page 2 Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Boys&Girls Club of the Big Island-Daily Meal Support for Income-Challenged Youth and Families I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Boys & Girls Club of the Big Island Program Name:Daily Meal Support for Income-Challenged Youth and Families CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50,000 50,000 Applicant organizational budget: Individual contributions 30,000 10,000 40,000 Membership fees Earned income Current cash assets Other funding sources (list below): SOH GIA Grant 150,000 150,000 Total Cash Income 230,000 10,000 240,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 230,000 10,000 240,000 Appendix D--Budget Sheets (Page 2 of 2) ,Project Budget Form: Expenses :County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name Boys & Girls Club of the Big Island Program Name.Daily Meal Support for Income Challenged Youth and Families Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 23,000 125,211.69 148,21169 Professional Fees 1,000 6,371.45 7,371.45 Operations 21,500 81,401.18 102,901.18 Supplies 3,000 35,714.72 38,714/2 Equipment 1,500 6,000 7,500 SUBTOTAL 50,000 254,699.04 304,699.04 TOTAL PROGRAM BUDGET 50,000 254,699.04 304,699.04 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys &Girls Club of the Big Island Program Name: "Daily Meal Support for Income-Challenged Youth and Families" 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 j/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 lune 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. County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: "Daily Meal Support for Income-Challenged Youth and Families" 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 lune 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.govlfn-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 30,2023 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 Date Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: "Daily Meal Support for Income-Challenged Youth and Families" 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 9 The Mayor ❑ The Managing Director 9 The Director of Finance El 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. LAVUick 31 Signature of Authorized Person(specify title) Date Boys & Girls Club of the Big Island Daily Transport Services of Critical Needs Resources for Income-Challenged Youth, Kupuna, and Families 36 County of Fiawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Boys&Girls Club of the Big Island Contact Person: Chad Cabral Contact Email: chad@bgcbi.org Contact Phone: 8089615536 Program Information Program Name: Daily Transport Services of Critical Needs Resources for Income-Challenged Youth, Kupuna, and Families Program Years in Operation:70 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Captain Cook, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kapoho, Kea'au, Kealakekua, Kurtistown, Leilani Estates, Na'alehu, Nanawale Estates, Ocean View, Orchidlands Estates, Pahala, Pahoa, Papa`ikou, Pepe'ekeo, Pohoiki, Wainaku, Wai'Ohinu Program Target Audience:School Age (6-11),Adolescence (12-17),Young Adulthood (18-39) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth Amount Applying For: $50000 Boys&Girls Club of the Big Island-Daily Transport Services of Critical Needs Resources for Income-Challenged Youth, Kupuna, and Families I Page 1 Program Details Organization Mission: Boys & Girls Club of the Big Island (BGCBI) mission: "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." Over 70 years, BGCBI has been at the forefront of afterschool youth development services in Hawaii County.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala, Kealakehe, Kahakai, South Kona, Ocean View, & Ulu Wini. Program Overview: Daily transportation services (free-of-charge) for income-challenged youth, providing access to BGCBI hosted after school youth development programs that are located in the communities of Hilo, Pahoa, Na'alehu-Ocean View&South Kona. For homeless& poverty-level households residing throughout Hawaii County's spread apart rural area communities, the major barrier to access critical social service resources is transportation access. BGCBI will bring the critical resource to the rural area community& direct to the individual & household location of those needing nutritional supplementation. BGCBI will provide shuttle transport from public&charter schools to site locations. Transport offerings will be targeted to support income-challenged youth that currently do not have transportation access to daily after school youth development resources& are currently going unsupervised after school. Program Objectives & Performances Resources Needed:Vans,fuel, staff to drive, meals,youth, partnerships with schools Major Activities to be Completed: Delivering meals daily to all BGCBI youth, picking up youth from school and taking them to Club sites, dropping off Ocean View youth home after Club Outputs to be Completed:A minimum of 50 income-challenged youth will have a means of accessing essential after school youth development services and resources daily (M-F)throughout the academic school year 70%of youth participants will demonstrate improved study habits, better grades, and greater physical health 70%of youth participants will demonstrate that the meals and/or snacks they receive are beneficial to their nutritional supplementation needs 4-5 drivers daily Measurable Outcomes:Transportation for youth to Club so parents can remain at work,transportation home for youth in Ocean View that live far away from Club, daily evening meal for free Attachments Program Budget (Income & Expenses) Certificate of Understanding Boys&Girls Club of the Big Island-Daily Transport Services of Critical Needs Resources for Income-Challenged Youth, Kupuna, and Families I Page 2 Conflict Disclosure Boys&Girls Club of the Big Island-Daily Transport Services of Critical Needs Resources for Income-Challenged Youth, Kupuna, and Families I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Boys & Girls Club of the Big Island Program Name:"Daily Transport Services of Critical Needs Resources for Income-Challe CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50,000 50,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): SOH GIA Grant 100,000 100,000 Kamehameha Schools 20,000 20,000 Total Cash Income IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 170,000 170,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Boys & Girls Club of the Big Island . .......... . .. ..... Program Name:"Daily Transport Services of Critical Needs Resources for Income-Challe Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 30,264.25 89,854.24 120,118.49 Professional Fees 1,700 2,616.82 4,316.82 Operations 14,874.26 13,809.18 4,200 32,883.44 Supplies 1,600 7,132.98 8,732.98 Equipment 1,561.49 3,859.37 5,420.86 SUBTOTAL 50,000' 117,272.59 4,200 171,472.59 TOTAL PROGRAM BUDGET 50,000 117,272.59 4,200 171,472.59 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name:"Daily Transport Services of Critical Needs Resources for Income-Challenged Youth,Kupuna,and Families" 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 grantfunds,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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys &Girls Club of the Big Island Program Name:"Daily Transport Services of Critical Needs Resources for Income-Challenged Youth,Kupuna,and Families" 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.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 30,2023 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. Olkt ie4 31 Crag. 0aia* Signature of Authorized Person Date Title/Position of Authorized Person • County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys &Girls Club of the Big Island Program Name:"Daily Transport Services of Critical Needs Resources for Income-Challenged Youth,Kupuna,and Families" 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 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 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. c9OZ Signature of Authorized Person (specify title) Date Boys & Girls Club of the Big Island "Academic Tutoring and Homework Support for Income-Challenged Youth" 37 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Boys& Girls Club of the Big Island Contact Person: Chad Cabral Contact Email: chad@bgcbi.org Contact Phone: 8089615536 Program Information Program Name: "Academic Tutoring and Homework Support for Income-Challenged Youth" Program Years in Operation: 70 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Captain Cook, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo`o, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kea'au, Kealakekua, Kurtistown, Leilani Estates, Na'alehu, Nanawale Estates, Ocean View, Orchidlands Estates, Pahala, Pahoa, Papa'ikou, Pepe'ekeo, Pohoiki, Wainaku,Wai'ohinu Program Target Audience:School Age (6-11), Adolescence (12-17) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment, Youth Amount Applying For: $50000 Boys&Girls Club of the Big Island-"Academic Tutoring and Homework Support for Income-Challenged Youth" Page 1 Program Details Organization Mission: Boys & Girls Club of the Big Island (BGCBI) mission: "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." Over 70 years, BGCBI has been at the forefront of afterschool youth development services in Hawaii County.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala, Kealakehe, Kahakai, South Kona, Ocean View, & Ulu Wini. Program Overview: BGCBI's "Academic Tutoring and Homework Support for Income-Challenged Youth" program will provide daily homework support& specialized academic tutoring to BGCBI Club youth identified as homeless or are a part of a low-income and/or poverty level household.This program will increase literacy among challenged youth that BGCBI services through homework, reading, and spelling programs to aid in growing their academic skill set.Tutoring is provided to participants who are struggling academically as revealed through staff observation & report cards that BGCBI is able to obtain. BGCBI's objective is to increase rates of student homework completion while attending Club. Program Objectives & Performances Resources Needed:School supplies,Arts supplies,Sports equipments,Transportation, staff, snacks, water Specialized tutors and staff, school supplies, printers, conducive study spaces, computers, partnerships with schools, daily communication with parents regarding progress Major Activities to be Completed: Daily academic tutoring, daily homework support, increase literacy skills,youth indicate completing their homework more since coming to Club Outputs to be Completed: 50%of participants will show that they complete more of their homework during Club 50% of youth will show an improvement in literacy skills Measurable Outcomes: More youth complete their homework, higher success rate in grade level achievement, partnership with DOE schools, all youth get to accurate literacy and homework levels Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Boys&Girls Club of the Big Island-"Academic Tutoring and Homework Support for Income-Challenged Youth" Page 2 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Boys & Girls Club of the Big Island Program Name:"Academic Tutoring and Homework Support for Income-Challenged Youl CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50,000 50,000 Applicant organizational budget: Individual contributions 10,000 5,000 15,000 Membership fees Earned income Current cash assets Other funding sources (list below): SOH GIA Grant 150,000 150,000 Kamehameha Schools 20,000 20,000 Total Cash Income 230,000 230,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions 230,000 5,000 235,000 TOTAL PROGRAM INCOME 230,000 5,000 235,000 Appendix D--Budget Sheets (Page 2 of 2) (Project Budget Form: Expenses County of Hawaii v Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 `Organization Name:Boys & Girls Club of the Big Island ' Academi " c and Homework Name. ._._. Tutoring Support for Income-Challenged Yout Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 28,246.49 163,821.61 192,068.10 Professional Fees 1,800 3,902.91 5,702.91 Operations 14,415.04 5,378.42 5,600 25,393.46 Supplies 3,200 8,404.37 11,604.37 Equipment 2,338.47 4,989.81 7,328.28 SUBTOTAL 50,000 186,497.11 5,600 242,097.11 TOTAL PROGRAM BUDGET 50,000 186,497.11 5,600 242,097.11 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: "Academic Tutoring and Homework Support for Income-Challenged Youth" 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 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'ii 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. County of JHawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: "Academic Tutoring and Homework Support for Income-Challenged Youth" 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 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 30,2023 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 Date '1;tr ejoi r Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: -Academic Tutoring and Homework Support for Income-Challenged Youth' 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.) a any...A— 31 - qv) ota,P, Signature of Authorized Person (specify title) Date Boys & Girls Club of the Big Island "Public Safety Careers: Workforce Development Program" 38 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Boys&Girls Club of the Big Island Contact Person: Chad Cabral Contact Email: chad@bgcbi.org Contact Phone: 8089615536 Program Information Program Name: "Public Safety Careers:Workforce Development Program" Program Years in Operation: 70 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, Captain Cook, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kapoho, Kea'au, Kealakekua, Kurtistown, Leilani Estates, Na'alehu, Nanawale Estates, Ocean View, Pahala, Pahoa, Papa'ikou, Pepe'ekeo, Pohoiki,Wainaku,Wai'ohinu Program Target Audience:School Age (6-11),Adolescence (12-17),Young Adulthood (18-39) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth Amount Applying For:$50000 Boys&Girls Club of the Big Island-"Public Safety Careers:Workforce Development Program"I Page 1 Program Details Organization Mission: Boys & Girls Club of the Big Island (BGCBI) mission: "To inspire and enable Big Island youth to be productive and responsible citizens, through quality programs in a safe and caring environment." Over 70 years, BGCBI has been at the forefront of afterschool youth development services in Hawaii County.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala, Kealakehe, Kahakai, South Kona, Ocean View, & Ulu Wini. Program Overview: Our"Public Safety Careers" themed workforce development program partners with community safety professionals to bring youth opportunities to explore, experience, & prepare for various public safety careers that are available for them on Hawai'i Island.This specialized workforce development program is for youth ages 15-19, identified as coming from a poverty-level household,that are interested in having a career in: Community Policing (County of Hawaii Police Officer), Fire Fighter, EMT professional, Law Enforcement (FBI, State Sheriff, National Park Ranger, DLNR Officer), or Nursing. The program is free-of-charge,for youth that are accepted. Enrolled youth will be required to maintain a portfolio throughout the program &daily commitment log, documenting their participation in each educational session,workforce development learning opportunity, held training, & career exploration activities that they have attended. Program Objectives & Performances Resources Needed: School supplies,Art and craft supplies, sports equipment, snacks,water, staff Major Activities to be Completed:Study hall, scholarship support, learning computer software,financial literacy classes, internships, physical fitness training, community service, leadership classes Outputs to be Completed: 15 youth supported, 15 youth complete the course, 50%of youth communicate that they have an increased knowledge on their career pathway. Measurable Outcomes:Youth will either attend college or go into the workforce after completion of the course,youth will gain opportunities to work alongside community safety professionals,youth will work or go to college after high school. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Boys&Girls Club of the Big Island-"Public Safety Careers:Workforce Development Program"I Page 2 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Boys & Girls Club of the Big Island Program Name:"Public Safety Careers: Workforce Development Program" CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50,000 50,000 Applicant organizational budget: Individual contributions 10,000 10,000 Membership fees Earned income Current cash assets Other funding sources (list below): SOH GIA grant 85,000 85,000 Kamehameha Schools 20,000 20,000 Total Cash Income 165,000 165,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 165,000 165,000 Appendix D--Budget Sheets (Page 2 of 2) 'Project Budget Form: Expenses `County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 !Organization Name:Boys & Girls Club of the Big Island !Program Name:"Public Safety Careers: Workforce Development Program" Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 29,200 95,848.72 125,048.72 Professional Fees 1,500 4,306.18 5,806.18 Operations 13,300 8,108,80 3,600 25,008.80 Supplies 3,500 9,285.42 12,785.42 Equipment 2,500 2,000 4,500 SUBTOTAL 50,000 119,549.12 3,600 173,149.12 TOTAL PROGRAM BUDGET 50,000 119,549.12 3,600 173,149.12 County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Boys &Girls Club of the Big Island Program Name: "Public Safety Careers:Workforce Development Program" 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. County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Boys& Girls Club of the Big Island Program Name: "Public Safety Careers:Workforce Development Program" 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.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 30,2023 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 Authorize Person Date 144 6J11. t Title/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Boys &Girls Club of the Big Island Program Name: "Public Safety Careers:Workforce Development Program" 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 El 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: • ❑ If no conflicts exist,check here. ta 6.,check herof Authorized Person(specify title) Date Boys & Girls Club of the Big Island "Mentoring for At-Risk Youth on Hawaii Island" 39 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Boys &Girls Club of the Big Island Contact Person:Chad Cabral Contact Email: chad@bgcbi.org Contact Phone: 8089615536 Program Information Program Name: "Mentoring for At-Risk Youth on Hawaii Island" Program Years in Operation: 70 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Captain Cook, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kapoho, Kea'au, Kealakekua, Kurtistown, Leilani Estates, Na'alehu, Nanawale Estates, Ocean View, Orchidlands Estates, Pahala, Pahoa, Papa'ikou, Pepe'ekeo, Pohoiki, Wainaku,Wai'ohinu Program Target Audience:School Age (6-11),Adolescence (12-17) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth Amount Applying For:$50000 Boys&Girls Club of the Big Island-"Mentoring for At-Risk Youth on Hawaii Island"I Page 1 Program Details Organization Mission: Boys & Girls Club of the Big Island (BGCBI) mission: "To inspire and enable Big Island youth to be productive and responsible citizens, through quality programs in a safe and caring environment." Over 70 years, BGCBI has been at the forefront of afterschool youth development services in Hawaii County.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala, Kealakehe, Kahakai, South Kona, Ocean View, & Ulu Wini. Program Overview: BGCBI's "Mentoring for At-Risk Youth on Hawaii Island" program will pair responsible &caring mentors with youth participants who can help to develop emotional bonds, provide support, guidance, &opportunities to help youth succeed in life & meet their goals. BGCBI will provide daily enrichment in the following areas: Project Learn (a BGCA evidence-based program) & Positive Action. Project Learn is utilized with storytelling, Hawaiian culture,Wahi Pana, arts & crafts, & comprehensive discussions.This program aims to increase engagement& connection of mentoring through curriculum &activities.The Wahi Pana program encourages & allows youth members to explore areas of historical Hawaiian landmarks in their community through research, storytelling&art. Youth share their research via video with youth at other sites. Positive Action is a proven systematic educational substance prevention evidence-based program that promotes.interest in learning & encourages cooperation among students. Program Objectives & Performances Resources Needed: School supplies,Transportation, access to internet, art supplies, sports equipment, snacks, staffs Major Activities to be Completed:Youth participate in mentorship classes,youth understand the importance of the Hawaiian culture,youth will succeed in life and learn to meet their goals,youth will participate in Project Learn and Positive Action weekly. Outputs to be Completed: 50% of youth will participate in mentoring classes, 50%will show an increased understanding from mentors,youth will share the things they learn from the mentorship program. Measurable Outcomes:youth will mentor others in the community,youth will use the tools and skills learned in mentorship classes in the community. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Boys&Girls Club of the Big Island-"Mentoring for At-Risk Youth on Hawaii Island"I Page 2 Boys&Girls Club of the Big Island-"Mentoring for At-Risk Youth on Hawaii Islandu I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Boys & Girls Club of the Big Island Program Name:"Mentoring for At-Risk Youth on Hawaii Island" CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50,000 50,000 Applicant organizational budget: Individual contributions 10,000 10,000 Membership fees Earned income Current cash assets Other funding sources (list below): SOH GIA Grant 50,000 50,000 Kamehameha Schools 20,000 20,000 Total Cash Income 130,000 130,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 130,000 130,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses !County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) Fiscal Year 2022-2023 'Organization Name Boys & Girls Club of the Big Island Program Name:"Mentoring for At-Risk Youth on Hawaii Island" Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 28,787.31 55,416.19 84,203.50 Professional Fees 1,200 3,085.20 4,285.20 Operations 15,112.69 13,314.39 28,427.08 Supplies 3,300 5,345.49 8,645.49 Equipment 1,600 3,200 4,800 SUBTOTAL 50,000 80,361.27 130,361.27 TOTAL PROGRAM BUDGET 50,000 80,361.27 130,361.27 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: "Mentoring for At-Risk Youth on Hawaii Island" 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 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. County of FIawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys &Girls Club of the Big Island g Y Program Name: "Mentoring for At-Risk Youth on Hawaii island" 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, 2023 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. 404. c�OVIO, qaeri Signature of Authorized Person Date eSc 1 d , c Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: "Mentoring for At-Risk Youth on Hawaii Island" 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. �� 31 baa Signature of Authorized Person (specify title) Date Boys & Girls Club of the Big Island "Healthy Lifestyles and Sports Programming for Income-Challenged Youth" 40 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Boys&Girls Club of the Big Island Contact Person: Chad Cabral Contact Email: chad@bgcbi.org Contact Phone: 8089615536 Program Information Program Name: "Healthy Lifestyles and Sports Programming for Income-Challenged Youth" Program Years in Operation: 70 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa,Captain Cook, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kapoho, Kea'au, Kealakekua, Kurtistown, Leilani Estates, Na'alehu, Nanawale Estates, Ocean View, Orchidlands Estates, Pahala, Pahoa, Papa'ikou, Pohoiki,Wainaku,Wai'ohinu Program Target Audience::School Age (6-11),Adolescence (12-17) Services Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment, Youth Amount Applying For:$50000 Boys&Girls Club of the Big Island-"Healthy Lifestyles and Sports Programming for Income-Challenged Youth" Page 1 Program Details Organization Mission: Boys & Girls Club of the Big Island (BGCBI) mission: "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." Over 70 years, BGCBI has been at the forefront of afterschool youth development services in Hawaii County.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala, Kealakehe, Kahakai, South Kona, Ocean View, & Ulu Wini. Program Overview:The "Healthy Lifestyles and Sports Programming for Income-Challenged Youth" program objective is to help the keiki to create a Healthy Mindset,to help make Healthy Choices, that help create Healthy Habits, which leads to a Healthy Lifestyle.These steps will help them to understand the importance of Self-Identity to find their place in life. Program Objectives & Performances Resources Needed: School supplies, Arts and crafts supplies, sports equipment, water, water bottles, whistles, sun-screens, masks,jerseys, shoes, snacks, meals, staffs Major Activities to be Completed: Outdoor sports, sports tournaments, healthy eating, classes regarding health, nutrition, home economics, Positive Action, weekly challenges Outputs to be Completed: 50%of youth participate in healthy lifestyles activities 50% of youth communicate that they enjoy the activities at Club Measurable Outcomes:youth will be healthier and have a positive outlook on healthy habits, youth will teach their families the different healthy habits that they learn Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Boys&Girls Club of the Big Island-"Healthy Lifestyles and Sports Programming for Income-Challenged Youth" Page 2 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Boys & Girls Club of the Big Island Program Name:"Healthy Lifestyles and Sports Programming for Income-Challenged You CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50,000 50,000 Applicant organizational budget: Individual contributions 25,000 10,000 35,000 Membership fees Earned income Current cash assets Other funding sources(list below): 85,000 85,000 Total Cash Income 160,000 10,000 170,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 160,000 10,000 170,000 Appendix D--Budget Sheets (Page 2 of 2) 'Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Boys & Girls Club of the Big Island !Program Name:"Healthy Lifestyles and Sports Programming for Income Challenged Yout Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 21,381.97 79,146.31 100,528.28 Professional Fees 1,193.03 4,639.88 5,832.91 Operations 24,125 61,268.46 85,393.46 Supplies 3100 6,704.37 9,804,37 Equipment 200 5,054.28 5,254.28 SUBTOTAL 50,000 156,813.29 206,813.29 TOTAL PROGRAM BUDGET 50,000 156,813.29 206,813.29 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys &Girls Club of the Big Island Program Name: "Healthy Lifestyles and Sports Programming for Income-Challenged Youth" 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. County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: "Healthy Lifestyles and Sports Programming for Income-Challenged Youth" 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.hawaiicoun v.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 30,2023 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. (� . . 31eie4:24\ Signature of Authorized Person Date Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys& Girls Club of the Big Island Program Name: "Healthy Lifestyles and Sports Programming for Income-Challenged Youth" 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. OGYUla Si (fiarN tgoiga Authorize Signature of Person tz (specify title) Date Boys & Girls Club of the Big Island "Child Care and Youth Development Services for Hawaii Island Families" 41 County of Hawai`i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Boys & Girls Club of the Big Island Contact Person: Chad Cabral Contact Email: chad@bgcbi.org Contact Phone: 8089615536 Program Information Program Name: "Child Care and Youth Development Services for Hawaii Island Families" Program Years in Operation: 70 Other County grants/agreements:Yes Previously received County GIA:Yes • Program Geographical Reach: 'Ainaloa, Captain Cook, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kea'au, Kealakekua, Kurtistown, Leilani Estates, Na'alehu, Nanawale Estates, Ocean View, Orchidlands Estates, Pahala, Pahoa, Papa'ikou, Pepe'ekeo,Wainaku,Wai'ohinu Program Target Audience:School Age (6-11),Adolescence (12-17) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment, Youth Amount Applying For: $50000 Boys&Girls Club of the Big Island-"Child Care and Youth Development Services for Hawaii Island Families"I Page 1 Program Details Organization Mission: Boys & Girls Club of the Big Island (BGCBI) mission: "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." Over 70 years, BGCBI has been at the forefront of afterschool youth development services in Hawaii County.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala, Kealakehe, Kahakai, South Kona, Ocean View, & Ulu Wini. Program Overview: "Child Care and Youth Development Services for Hawaii Island Families" will provide homeless children and poverty-level household youth residing in Low/Moderate Census Tract areas through our physically based youth support child care program. Programs (Monday through Friday support services) are based within the rural area communities of Ocean View, Pahala-Ka'u, Pahoa, Hilo, Kea'au, and Kona (Kealakehe, Ulu Wini, and South Kona). Program Objectives & Performances Resources Needed: Arts and craft supplies, school supplies,television,van,van driver, snacks, staffs Major Activities to be Completed: Child care during the after school hours, Homework support, culture learning, physical fitness Outputs to be Completed: 200 youth attend BGCBI programs after school, 75%of parents/guardians communicate that the child care provided by BGCBI allows them to work longer hours, 75%of families share that the child care is beneficial to their family needs Measurable Outcomes: Decrease in juvenile crime,youth attend BGCBI programs during the after school hours, parents/guardians can work longer hours to support their families Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Boys&Girls Club of the Big Island-"Child Care and Youth Development Services for Hawaii Island Families"I Page 2 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Boys & Girls Club of the Big Island Program Name:"Child Care and Youth Development Services for Hawaii Island Families' CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50,000 50,000 Applicant organizational budget: Individual contributions 10,000 10,000 Membership fees Earned income Current cash assets Other funding sources (list below): SOH GIA Grant 50,000 50,000 Kamehameha Schools 20,000 20,000 Total Cash Income 130,000 130,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 130,000 130,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses `County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ,Organization Name Boys & Girls Club of the Big Island `Program Name "Child Care and Youth Development Services for Hawaii Island Families" Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 29,602.06 51,115.98 80,718.04 Professional Fees 1,655.32 2,794.76 4,450.08 Operations 13,542.62 13,957.68 4,200 31,700.30 Supplies 3,200 5,466.24 8,666.24 Equipment 2,000 3,504.12 5,504.12 SUBTOTAL 50,000 76,838.77 4,200 131,038.77 TOTAL PROGRAM BUDGET 50,000 76,838.77 4,200 131,038.77 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: "Child Care and Youth Development Services for Hawaii Island Families" 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 Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http;j/vendors.ehawaii.eov,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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys &Girls Club of the Big Island Program Name: "Child Care and Youth Development Services for Hawaii Island Families" 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 30,2023 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. ad— Oforulk r _.tmc3 Signature of Authorized Person Date Title/Position of Authorized Person County'of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: "Child Care and Youth Development Services for Hawaii Island Families" 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 sinned,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 [l 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. 0 SI r„az.. Signatur of Authorized Person (specify title) Date Boys & Girls Club of the Big Island "Building Income-Challenged Youth to Become Leaders on Hawaii Island" 42 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Boys&Girls Club of the Big Island Contact Person: Chad Cabral Contact Email: chad@bgcbi.org Contact Phone: 8089615536 • Program Information Program Name: "Building Income-Challenged Youth to Become Leaders on Hawaii Island" Program Years in Operation: 70 Other County grants/agreements:Yes Previously received County GIA:Yes - Program Geographical Reach: 'Ainaloa, Captain Cook, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kapoho, Kea'au, Kealakekua, Kurtistown, Leilani Estates, Na'alehu, Nanawale Estates, Ocean View, Orchidlands Estates, Pahala, Pahoa, Papa'ikou, Pepe'ekeo,Wainaku,Wai'ohinu Program Target Audience:School Age (6-11),Adolescence (12-17) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth Amount Applying For:$50000 Boys&Girls Club of the Big Island-"Building Income-Challenged Youth to Become Leaders on Hawaii Island" Page 1 Program Details Organization Mission: Boys & Girls Club of the Big Island (BGCBI) mission: "To inspire and enable Big Island youth to be productive and responsible citizens, through quality programs in a safe and caring environment." Over 70 years, BGCBI has been at the forefront of afterschool youth development services in Hawaii County.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala, Kealakehe, Kahakai, South Kona, Ocean View, & Ulu Wini. Program Overview: BGCBI supplies the resources for youth to utilize and assist in expanding their skills about community resilience. Youth participants are given the tools to see their ideas come to life and put out into the community.This program teaches youth to support projects that impact the community positively.Youth members learn early on the importance of participation and that bringing an idea to life requires teamwork.They learn from first-hand experience what it takes to make a profound difference in the lives of others and even themselves. Program Objectives & Performances Resources Needed: Cleaning supplies, arts and crafts supplies, school supplies, sports equipment,Van driver,Transportation, snacks, staffs Major Activities to be Completed:youth complete one community service per month,youth understand the importance of taking care of the community and giving back,youth build relationships in the community to enhance their life and opportunities. Outputs to be Completed: 50%of youth participate in community service activities once a month, 50% of youth communicate an increased understanding in giving back to the community, 50%of youth communicate a better sense of self after learning about community service Measurable Outcomes:youth will understand the importance of community service and taking care of the community. youth will pass down these traits and knowledge to their families and friends Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Boys&Girls Club of the Big Island-"Building Income-Challenged Youth to Become Leaders on Hawaii Island"I Page 2 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Boys & Girls Club of the Big Island Program Name:"Building Income-Challenged Youth to Become Leaders on Hawaii Islanc CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50,000 50,000 Applicant organizational budget: Individual contributions 10,000 10,000 Membership fees Earned income Current cash assets Other funding sources(list below): SOH GIA Grant 50,000 50,000 Kamehameha Schools 20,000 20,000 Total Cash Income 130,000 130,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 130,000 130,000 Appendix D--Budget Sheets (Page 2 of 2) ;Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 :Organization Name:Boys & Girls Club of the Big Island ;Program Name:"Building Income-Challenged Youth to Become Leaders on Hawaii Islanc Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 28,975 41,441.59 70,416.59 Professional Fees 1,400 2,464.39 3,864.39 Operations 15,181 8,852.44 3,200 27,233.44 Supplies 2,864 6,191.80 9,055.80 Equipment 1,580 2,284.39 3,864.39 SUBTOTAL 50,000 61,234.61 3,200 114,434.61 TOTAL PROGRAM BUDGET 50,000 61,234.61 3,200 114,434.61 County of flawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: "Building Income-Challenged Youth to Become Leaders on Hawaii Island" 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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: "Building Income-Challen•ed Youth to Become Leaders on Hawaii Island" 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 30,2023 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 Date Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys &Girls Club of the Big Island Program Name: "Building Income-Challenged Youth to Become Leaders on Hawaii Island" ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer,director, or administrator of yourorganization 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 on 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 Boys & Girls Club of the Big Island "Social/Emotional Learning & Development for Hawaii Island Income-Challenged 43 County of Hawaii • Nonprofit Grants-in-Aid Program FY 22-23 Organization Information i n Name: Boys&Girls Club of the Big o Island Contact Person: Chad Cabral Contact Email: chad@bgcbi.org Contact Phone: 8089615536 Program Information Program Name: "Social/Emotional Learning& Development for Hawaii Island Income-Challenged Program Years in Operation: 70 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Captain Cook, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kapoho, Kea'au, Kealakekua, Kurtistown, Leilani Estates, Na'alehu, Nanawale Estates, Ocean View, Orchidlands Estates, Pahala, Pahoa, Papa'ikou, Pepe'ekeo, Pohoiki, Wainaku, Wai'ohinu Program Target Audience:School Age (6-11),Adolescence (12-17) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth Amount Applying For:$50000 Boys&Girls Club of the Big Island-"Social/Emotional Learning& Development for Hawaii Island Income- Challenged Page 1 Program Details Organization Mission: Boys & Girls Club of the Big Island (BGCBI) mission: "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." Over 70 years, BGCBI has been at the forefront of afterschool youth development services in Hawaii County.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala, Kealakehe, Kahakai, South Kona, Ocean View, & Ulu Wini. Program Overview:Through this daily program our objective is to help the keiki to create a healthy mindset. BGCBI teaches youth how to do this by encouraging positive choices and habits, which will lead to a healthy lifestyle.Teaching youth participants about their health is beneficial to their futures.This program strives to develop and incorporate daily healthy lifestyle practices for youth that benefits their personal health. BGCBI Staff will conduct social-emotional wellness assessments, providing support resources and referrals for youth impacted by any illnesses or negative feelings. Program Objectives & Performances Resources Needed: Worksheets, arts and crafts supplies, sports equipment, snacks, meal,water, school supplies, staffs Major Activities to be Completed: Gardening Physical activities Dancing Exercising Recreational and organized sports Specialized physical fitness activities Daily healthy nutritional snacks and water Educating youth on how to prepare healthy snacks Social/Emotional wellness checks Good sportsmanship opportunities Health awareness Outputs to be Completed: 50%of youth will understand the importance of their social/emotional health, 50%of youth will show an increased understanding of social/emotional health Measurable Outcomes: By having this program,the community will be impacted because youth will show positive actions and know how to deal with their feelings in a good manner Attachments Program Budget (Income & Expenses) Certificate of Understanding Boys&Girls Club of the Big Island-"Social/Emotional Learning& Development for Hawaii Island Income- Challenged I Page 2 Conflict Disclosure Boys&Girls Club of the Big Island-"Social/Emotional Learning& Development for Hawaii Island Income- Challenged I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Boys & Girls Club of the BigIsland g Program Name:"Social/Emotional Learning & Development for Hawaii Island Income-Chi CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50,000 50,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): SOH GIA Grant 80,000 80,000 Kamehameha Schools 20,000 20,000 Total Cash Income 150,000 150,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 150,000 150,000 Appendix D--Budget Sheets (Page 2 of 2) 'Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 ;Organization Name:Boys & Girls Club of the Big Island `Program Name:"Social/Emotional Learning & Development for Hawaii Island Income-Chi' Nonprofit Expense Description (Waiwai) Other Cash In-Kind TOTAL Source Contribution Grant Salary Wages 29,004.60 76,786.75 105,791.35 Professional Fees 2,200 2,013.90 4,213.90 Operations 13 795.40 18,097.66 31,893.06 Supplies 3,200 7,272.60 10,472.60 Equipment 1,800 1,459.37 3,259.37 SUBTOTAL 50,000 105,630.28 155,630.28 TOTAL PROGRAM BUDGET 50,000 105,630.28 155,630.28 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys&Girls Club of the Big Island Program Name: "SociaUEmotional Learning&Development for Hawaii Island Income-Challenged Youth' 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:/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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: .SociaVEmotional Learning&Development for Hawaii Island Income-Challenged Youth" 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-rant-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 30,2023 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. b a 0 V4' ()),J0 Signature of Authorized Person Date Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: .Social/Emotional Learning&Development for Hawaii Island Income-Challenged Youth" 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): 0 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. ( atr"‘-41"--- 31 -911-4f) , . _ Signature of Authorized Person ( eci sp fy title) Date Boys & Girls Club of the Big Island "Wellness and Mental Health for Income-Challenged Youth and Families" Mental Health 44 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Boys &Girls Club of the Big Island Contact Person: Chad Cabral Contact Email: chad@bgcbi.org Contact Phone: 8089615536 Program Information Program Name: "Wellness and Mental Health for Income-Challenged Youth and Families" Mental Health Program Years in Operation: 70 Other County grants/agreements: Yes Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Captain Cook, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kapoho, Kea'au, Kealakekua, Kurtistown, Leilani Estates, Na'alehu, Nanawale Estates, Ocean View, Orchidlands Estates, Pahala, Pahoa, Papa'ikou, Pepe'ekeo, Pohoiki, Wainaku, Wai'ohinu Program Target Audience:School Age (6-11), Adolescence (12-17) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment, Youth Amount Applying For: $50000 Boys&Girls Club of the Big Island-"Wellness and Mental Health for Income-Challenged Youth and Families" Mental Health! Page 1 Program Details Organization Mission: Boys &Girls Club of the Big Island (BGCBI) mission: "To inspire and enable Big Island youth to be productive and responsible citizens,through quality programs in a safe and caring environment." Over 70 years, BGCBI has been at the forefront of afterschool youth development services in Hawaii County.Annually, BGCBI serves 1,000 youth in the rural communities of Hilo, Keaau, Pahoa, Pahala, Kealakehe, Kahakai, South Kona, Ocean View, & Ulu Wini. Program Overview:The "Wellness and Mental Health for Income-Challenged Youth and Families" program will teach youth the importance of living a happy and meaningful life. Youth learn and grow differently, and it's important that youth know how to mentally deal with the challenges that they're faced with.Youth will learn about the importance of having a healthy mindset which will help them to excel in life. Program Objectives & Performances Resources Needed: School supplies, art supplies, access to internet, sports equipment, snacks, staffs Major Activities to be Completed:Team building, Positive Action, substance and alcohol prevention, mental health classes, cultural learning Outputs to be Completed: 50% of youth will understand the importance of mental health, 50%of youth will communicate an increased understanding of mental health Measurable Outcomes: less juvenile inmates, more positive habits, community filled of positive mental health youth Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Boys&Girls Club of the Big Island-"Wellness and Mental Health for Income-Challenged Youth and Families" Mental Health I Page 2 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Boys & Girls Club of the Big Island Program Name:"Wellness and Mental Health for Income-Challenged Youth and Families CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50,000 50,000 Applicant organizational budget: Individual contributions 15,000 10,000 25,000 Membership fees Earned income Current cash assets Other funding sources(list below): Kukio Community Fund 20,000 20,000 Total Cash Income 85,000 10,000 95,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 85,000 10,000 95,000 Appendix D--Budget Sheets (Page 2 of 2) ;Project Budget Form: Expenses County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Boys & Girls Club of the Big Island Program Name:"Wellness and Mental Health for Income-Challenged Youth and Families; Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 28,975 36,025 65,000 Professional Fees 1,400 2,464.39 3,864.39 Operations 15,181 8,852.44 3,200 27,233.44 Supplies 2,864 6,191.80 9,055.80 Equipment 1,580 2,284.39 3,864.39 SUBTOTAL 50,000 55,818.02 3,200 109,018.02 TOTAL PROGRAM BUDGET 50,000 55,818.02 3,200 109,018.02 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys &Girls Club of the Big Island Program Name: "Wellness and Mental Health for Income-Challenged Youth and Families' 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:1/vendors.ehawoy,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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: 'Wellness and Mental Health for Income-Challenged Youth and Families" 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:fwww.hawaiicountv.gov/fn-nonorofit-erant-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 30,2023 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 Date • - . fi et Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: wellness and Mental Health for Income-Challenged Youth and Families" 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 El Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance El 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 on 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. Jakilw Signature of Authorized Person (specify title) Date Brantley Center, Inc Job Skills Development Program 45 County of Flawai`i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Brantley Center, Inc Contact Person: Dareth Pung Boteilho Contact Email: dboteilho@gmail.com Contact Phone: 8089376079 Program Information Program Name:Job Skills Development Program Program Years in Operation:40 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, Honoka'a, Kapa'au, Kukuihaele, Laupahoehoe, Pa'auhau, Pa'auilo, Papa'aloa, `Umikoa, WaikOloa Village,Waimea Program Target Audience:Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59) Services/Activities Provided: Educational concerns, Needs of the poor, Public health and welfare of the people and the environment,Aged, Physical/Emotional Disabilities Amount Applying For: $25000 Brantley Center, Inc-Job Skills Development Program I Page 1 Program Details Organization Mission: Our mission is to provide quality rehabilitation services that empower people with disabilities to participate independently within his or her community. Program Overview: Brantley Center, Inc receive daily curb to curb transportation both to and from the Center free of charge. While at the Center clients receive a through job skills readiness assessment. Based on assessment results they are given an appropriate service array. These services include job readiness classes, on the job training in the field, competitive employment placement services, and on the job follow up services.At the Center clients have the opportunity to explore different jobs and skills ranging from janitorial, yard maintenance, landscaping, agriculture and hydroponic skills, green house maintenance, car wash and detailing, as well as small craft production. Once the necessary skills are obtained clients are then placed in competitive jobs within the community and continue to receive supportive follow up services for the initial six months of employment. The Job Skills Development staff and clients develop a strong relationship and rapport with community. Program Objectives & Performances Resources Needed: Resources: Staff: initial assessments, skills class,job coaching. Technology: help with the clients to be familiar with daily operations, access to resources Money: clients get paid a wage while working/training Major Activities to be Completed: New Clients Initial client assessments Skills training for specific jobs on the job training job coaching job placement Outputs to be Completed: 12 Clients supported intake 12 clients assessments 12 clients job skills training 12 clients job placements 12 clients NOT 100%solely dependent of government funding Measurable Outcomes: Clients who successfully complete our Job Skills Development Program acquire job skills that will allow them to be independent within his/her own community. and not rely solely on government funding. Measurable outcomes 1. initial job skills assessment Brantley Center, Inc-Job Skills Development Program I Page 2 2.job skills classes..attendence, progress 3.on the job training 4.job placement with job coach Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Brantley Center, Inc-Job Skills Development Program I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Brantley Center, Inc Program Name:Job Skills Development CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 25000 8,897 Applicant organizational budget: 0 0 Individual contributions 0 0 600 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets 0 0 0 Other funding sources (list below): HIUW 8000 4,467 8000 DVR Lawn Service 60000 4,284 60000 Total Cash Income 17,648 17,648 68600 IN-KIND CONTRIBUTION Anticipated Committed Total 1,000 1,000 1,000 Total In-Kind Contributions 1,000 1,000 1,000 TOTAL PROGRAM INCOME 18,648 18,648 68600.00 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses ;County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 :Organization Name:Brantley Center, Inc Program Name Job Skills Development Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 5000 30997 0 7,920 Professional Fees 0 0 0 0 Operations 2,037 ,2,037 0 4,074 Supplies 2,400 2323.01 0 4,800 Equipment 10000 0 0 0 Equipment Repair and Maintenance 10000 Taxes 6000 Permits, Licenses,other 3400 Auto Repairs and Maintenance 5000 Insurance 4000 SUBTOTAL 25000 56720.01 0 81720.01 TOTAL PROGRAM BUDGET 8,897 8,897 0 16,794 • 1' r , County of Ffawai‘i. Nonprofit Grant Appl. ation FY 2022-23 I : , Agency Name: Progratb Name: , 1 Certification of Understandingi 'of of 2)!, -, I (we) have read and understood all of the eligibility requijements;1grant conditions; award procedures; and records, reporting, and fiscal accountability requirernents as Mandated in Article 25,Sections 2- , i, 135—2442.1, Hawaii County Code, relating to AppropriFVp ation of ds to Nonprofit Organizations. I (we)agree to allow the County (the Legislative Auditor,It' he Departil,ment of Finance, designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority 1' to examine and inspect any facility, equipment, property or records pertinent to the grant, contract,or program for which funds were used. 1 11 i I' I (we) hereby certify that information stipolied herein, inluding alli.',tipporting documents, is correct and that I (we) have the authority and ability to fully dMinister the program(s) pursuant to law. 1 i I (we) understand that information supplied herein shall be madei5ublic according to Chapter 92F, Hawai9 Revised Statutes. 1 1; I (we) understand that applications will not be reviewed oy County personnel receiving our County Nonprofit Grant submittal,and that we have full respon4ibilityto i;nsure that ail documents are i 1i conwlete and accurate prior to submittal, IF I (we) understand that all documents requiring a currentsignaturei Must be the ORIGINAL, SIGNED document, Unsigned documents will be disqualified. Faxed or copied documents will not be accepted i i 1 as original documents, • ; 1, If awarded a grant from the County of Hawail, I (we) understand end will comply with the requirement ii to enroll with Hawaii Compliance Expressand be compliant pro iorl: receiving payment(s). TO register, ; I go to httplivendors.ehawan,gov„ complete the easy step-by-stergprocess,and pay the annual registration fee online using a credit card, i 1 1 ;, If awarded a :Trent from the Count of flawan I we undl erstand 'rid miill corn el with the reouirement to to submit a year-end report to the COUtity Council within 60 days 1fter June 30 of the contractual year , for which the grant was awarded. The report, using the teMplate rovided, shall include an explanation of the public benefits derived from the awprdingof She grant(focusing on specific, measurable outcomes),a complete accounting of all expendittireS supported by County of Havvaiii grant funds,and a listing of other funding sources and amounts 64;taineci during the award period,. il Failure,to submit a timely, complete, and accurate Tar-enci re*art usin 0 the tern#lute 0 rovided will ,,, impact the evaluation of your program's or agency's futare funding requests i, i I, !' i i! 1 ! , .1 f ., County of HaWai`i Nonpro-fit Gram ApplIation FY 2022-23 Agency Name: 1 : Program Name: Certification of Understpriding (Page,2 of 2) i If awarded a grant from the County of Hawaiii, I (we) un#rstand thpt a Current Certificate of Liability ' ; i ($1,000,000.general liability,$50,000 each occurrence) niust bei pr vded to the County of Hawari 1 ' ! Finance Department,which specifically and explicitly Indicates thafithe County of Hawaii is an additional insured prior tO receiving any payment(s). I (we) understand that failure to sUbmit the final report iithin 60 ciAys of June 30th shall result in loss of LailriLDAILmds received Awing th&grgyitolis2c1(mte ref jiritiiiylInt and exclusion from future grantparticipatiori,for a minimum ofOne year or until a writterr report is submitted to and accepted by,the council. 1 I (wó)understand there is no provision for further notifiatiopto,Ubrnit the final report. Information . 11 and instructions are available at httn://yyww.hawaiicount , ,av fn-nOprofttLgrant-forrnsi.on or about May 30 of the year the final report is due, :i : 11 As part of this application,you acknowledge that enyfun, s'awarded wil) be restricted for the puepoes stated in the application,except for a maximumaimum ten percent (19%) .1.Tor administrative and overhead -Costs. Any funds unused by June 30, 2023 must be returnecrtb the Founty of Hawaii with the final report. Failure to return these. Unds in a timel manner will Fm iactlihe evaluation a our aienc ls future funding request andrnav result in actions taken.te recover thes:e funds. .' 1 Awards cannot provide funds for(apital Improvements(OA j of instruction,Materiels,insurance . • II ' or securities)on private properties unless otherwise;authorized by law,. : V ; 4 . BY signing below,you are acknowledging that you have rTad and u derStood these requirements. 8 : . Ili H .S. P.71111,6,k 1 1 ! . Ma ' 401 ; 8 . 2.11%. . Signature of Authorized Person i l ! Date • Trojrawl Precr it 1! : Title/Position of Authorized Person II ' i I : . IL 1 i ' ll . 1 i - '1 ! . , . i . 1 , County of Hawaii Nonprofit Grant AppliklatiOn FY2022-23 i . 11 1 Agency Name: grattelill CeritCY trk, it : ' Program Name ,s30‘) c„..W:A4 Dieve Apyy*-1 : ORGANIZATION CONFLICT DISCLOSUREFORM ti. 1 . FiPlease disclose any conflicts or potential conflicts of interest that ay board member, Officer, director, or administrator of your organization may have with the County ofifiawari, Only these listed below need to be disclosed.One form per person with a conflict iS'neededi. If T110 conflicts exist, one form for it the organization,with the "No Conflicts exist"option che ked t neeaS to be submitted. Please duplicate i t 1 as needed to fully disclose. All disclosure forms must.be laned, lardless of whetheria conflict exists. NAME: POSITION: I 1! May have a conflict or potential conflict of interest, inctuti ilng any familial relationship,With any of the following(check all that apply): El •Member or members of the Cooncil E Staff appOinted by a member of the Council E The Mayor • The Managing Director The Director of Finance 1 i 1 ' . 1 : 1 The Corporation Counsel,the Assistant Corporation i,tatinSel,or a Deputy Corporation ,. : COunsel , I 1 . t , Conflict of interest,is defined as:a substantial probability that,cictla taken by ai ndividual will result in MeaSill'Oble direct benefits accrciing to the.individati 1as aPpwc4ta benefits accruing.in eperaka.404 instry. } ' 11 Pleawspecifyany and all mitigation measures to avoid, ir,fct Or aPearance, any Onflictor potential conflicts of interest: . . , . I 1 i 1 . :t ! 11 i ,4 If no conflicts exist, the . PCk here ..._. * ti ,,, , , !„.,* - : P. , tom D-IveciTY 11 Signature'•,- :' othorized Person (SpeCify title) i! Date it 1 i I i I . i t : i t I i i t : I i 1 11 ' Bridge House, Inc. Clean &Sober Living Program 46 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Bridge House, Inc. Contact Person:Andi Pawasarat-Losalio Contact Email: director.bridgehouse@gmail.com Contact Phone: 808-322-3305 • Program Information Program Name: Clean &Sober Living Program Program Years in Operation: 15 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Captain Cook, Holualoa, Honalo, Kailua-Kona, Kealakekua, Keauhou Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Needs of the poor, Public health and welfare of the people and the environment, Physical/Emotional Disabilities,Victims of Health or Social Crises Amount Applying For: $50000 Bridge House, Inc.-Clean &Sober Living Program I Page 1 Program Details Organization Mission: 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. Origin Mission: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. Program Overview:This clean &sober living program provides supportive housing services and caring treatment for 14 individuals for up to 6 months. Clients complete a Sober Living Assessment to help staff determine needs. Clients receive an array of substance abuse continuum of care services and participate in activities that support client needs.This array includes educational and support group services, care coordination,transportation, smoking cessation education, communicable disease education/testing, Vocational Skills Building, substance abuse treatment, health & nutrition education, access to community support group meetings, acupuncture,gardening, cultural activities, community service opportunities, other support services and referrals if needed. Each client is assisted to develop and maintain a healthy support system that fosters a positive transition back into the family and community. Program Objectives & Performances Resources Needed: Houses, land,vehicles for transportation,fuel/oil, staff, continuing education training for staff, insurances, water, electricity, office equipment, stamps, office supplies, Internet, computers,security system, telephones, cell phones, bedding, pest control, personal care items, all regularly used items/supplies to support any household,food, seed, soil, water,water tanks, items needed to support gardens and planting, specialty contractors, cultural specialists, kupuna, and money to pay for all of these.Volunteers to help with program and to serve as board members, connections to other community support organizations, mentors, funding sources and oversight. Major Activities to be Completed: Clients complete a Sober Living Assessment to assist with the creation of a Health &Wellness Plan, receive continuum of care services and activities that support client needs such as educational and support group services including transportation, smoking cessation education, communicable disease education and testing,Vocational Skills Building, access to treatment, health & nutrition education, access to community support group meetings, acupuncture, gardening, cultural activities, community service opportunities, assistance with planning for future housing as well as other care coordination support services. Staff makes referrals to external services for clients in need of additional supports. Each client is assisted to develop and maintain a healthy support system that fosters a positive transition back into the family and community. Outputs to be Completed:45-60 clients served, 3 agencies will volunteer to assist our program, 8-10 people will volunteer around 400 hours, practicum students will volunteer 2000 hours, 20-30 people Bridge House, Inc.-Clean &Sober Living Program Page 2 from community support groups will volunteer their individual times with clients, clients will volunteer 25 or more hours in the community Measurable Outcomes:Approx. 45 adult men &women will be served; and of those completing the program: 90%will be employed or in a school/training program; 90%will attain legal documents/ID At 6-months post-discharge: Clients who have completed the program will be employed and/or participating in school/training program; report no new arrests; report no relapse; maintain safe sober housing: 75%of graduates will make these marks at 6-month follow-up Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Bridge House, Inc.-Clean&Sober Living Program I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Bridge House, Inc. Program Name: Clean & Sober Living Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $50,000.00 8,897 Applicant organizational budget: 0 0 Individual contributions 0 0 0 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets 452,231.32 0 0 Other funding sources (list below): ADAD 50,000.00 4,467 4,467 4,284 4,284 Program Fees 28,000.00 Judiciary 60,000.00 ADAD - OPT 122,480.00 Total Cash Income 17,648 17,648 17,648 IN-KIND CONTRIBUTION Anticipated Committed Total 1,000 1,000 1,000 Total In-Kind Contributions 1,000 1,000 1,000 TOTAL PROGRAM INCOME 310,480.00 18,648 18,648 Appendix D--Budget Sheets (Page 2 of 2) !Project Budget Form: Expenses ;County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Bridge House, Inc. !Program Name: Clean & Sober Living Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 20,500.00 94,500.00 0 115,000.00 Professional Fees 4,000.00 5,000.00 0 9,000.00 Operations 17,013.00 130,787.00 0 147,800.00 Supplies 2,400.00 7,100.00 0 9,500.00 Equipment 0 0 0. 0 Payroll Taxes & Benefits 4,387.00 19,793.00 24,180.00 Staff Training 1,200.00 1,300.00 2,500.00 Travel 500.00 2,000.00 2,500.00 SUBTOTAL 50,000.00 260,480.00 0 16,794 TOTAL PROGRAM BUDGET 8,897 8,897 0 310,480.00 -. .,•-) -- l" 11.' .*". 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P* • co 0 1..1 n Z -* c N., . :"{ rt C CL -• (D ::;,' es• -,, eD '4,4 .:" 2.. 1 41 en ft 15 C) -4 49 0 • s,'j C -• ro ,4" , m. g < 1 County of Hawai`i Nonprofit Grant Application FY 2022-23 trk AgencyName: Program Narne: LE A IN-) So b6P-- Li I to V r-062P--hrt\ Certification of Understanding (Page lot 2) If awarded a grant from the County of Hawail,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 liawari 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 30't'shall result In lois of all grant funds r-ceive. duri • : ant period Imust 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 h:s1pAwww.hawaiicounty.gov/tr-nonorafit:grant-forrnsi 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 30,2023 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 Date D FRS 47. --e)--.11— 'rifle/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name. Program Narr:e...-3e-IZPiejS'):11P-.--PN)(-111 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. Ali disclosure 'orms must be si'fled re*ordless of whether a con id 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): 11 Member or members of the Council El Staff appointed by a member of the Council El The Mayor Lni 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:a SabsUmtlai probability that action taken by on intliwidunt will result in measurable direct benefits accruing to the indioduoi as opposed to benefits accruing in gene,a1 to on industry. Please specify any and all mitigation measures to avoid,in fact or appearance,any conflictor potential conflicts of interest: If no conflicts exist,check here. PrA4P—P PkOhr,e-7.)-1— -.2, ...7ignature of Authorized Person(specify title) Date Bridge House, Inc. Vocational Skills Building Program 47 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Bridge House, Inc. Contact Person:Andi Pawasarat-Losalio Contact Email: director.bridgehouse@grnail.com Contact Phone: 808-322-3305 Program Information Program Name:Vocational Skills Building Program Program Years in Operation: 25 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Captain Cook, Holualoa, Honalo, Kailua-Kona, Kealakekua Program Target Audience:Young Adulthood (18-39), Middle Adulthood(40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment, Physical/Emotional Disabilities,Victims of Health or Social Crises Amount Applying For: $20000 Bridge House, Inc.-Vocational Skills Building Program I Page 1 Program Details Organization Mission: Current: Guided by our values of Pilina (connection),Aloha `Aina (love of the land), Lokahi (unity), Maluhia (peace), and Pono (virtue) we work with the client's best interest at heart to create a supportive environment during the recovery process. Origin Statement:The Bridge House mission is 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. Program Overview: The VSB program's primary objective is to prepare clients to enter/re-enter the workforce and maintain values that promote a clean and sober lifestyle.As a result of their addiction most individuals have disengaged from mainstream society(e.g.: loss of values, 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 secures employment and begins 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. We expect all graduates to have secured employment prior to leaving Bridge House and to report still being employed at 6 months post-discharge. Program Objectives & Performances Resources Needed: Land & building to operate program our of and on,vehicles for transportation, fuel/oil, staff, continuing education training for staff, insurances, water, electricity, office equipment, stamps, office supplies, internet, computers, security system,telephones, cell phones, seeds,soil, water, water tanks, items needed to support gardens and planting, specialty contractors, cultural specialists, kupuna, and money to pay for all of these.Volunteers to help with program and to serve as board members, connections to other community support organizations, mentors,funding sources and oversight, connections with community for volunteering and educational experiences. Major Activities to be Completed:Vocational Assessment of clients, orientation, education and use of tools, learning to work together in a group and as an individual, learning about accountability and how what one does impact others, literacy education for those in need, attaining legal documents and ID, assistance with higher education and specific vocational training, education in planting and propagation of plants, learning to harvest and prepare plants for sale, preparing items for donation, nutrition education, making a connection with land and understanding of aloha 'aina, mock interviews and preparation for work, assistance with job applications, assist in securing employment,transportation to apply for work and interviews. Providing access to mentorship. Life skills development such as scheduling, time management, and budgeting. Providing community service volunteer work with the community college, local parks, schools and the Food Basket. Bridge House, Inc.-Vocational Skills Building Program I Page 2 Outputs to be Completed: 45-60 clients served,4 staff, 7-acres of land, 3 gardens, 3-4 mentor volunteers for 40 hours, practicum students will volunteer 2000 hours, clients will volunteer 25 or more hours in the community 25 hours x 10 clients/staff= 250 hours of community volunteer work, at least 2,500 pounds of local produce will be grown for sale through a local community supported agricultural program and produce supplier, at least 200 pounds of food will be donated to the community, on-site compost dirt will be made instead of being trucked in. Measurable Outcomes: Approx. 45 adult men &women will be served; and of those completing the program: 90%will be employed or in a school/training program; 90%will attain legal documents/ID At 6-months post-discharge: Clients who have completed the program will be employed and/or participating in school/training program; report no new arrests; report no relapse; maintain safe sober housing: 75%of graduates will make these marks at 6-month follow-up Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Bridge House, Inc.-Vocational Skills Building Program I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Bridge House, Inc. Program Name: Vocational Skills Building Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $20,000.00 8,897 Applicant organizational budget: 0 0 Individual contributions 0 0 0 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets 0 0 0 Other funding sources (list below): HIUW 40,000.00 4,467 4,467 HCF-West HI 4,284 4,284 4,284 ADAD - OPT 17,500.00 Program Fees 6,400.00 AG Sales 8,400.00 Judicary 19,559.00 Total Cash Income 17,648 17,648 17,648 IN-KIND CONTRIBUTION Anticipated Committed Total 1,000 1,000 1,000 Total In-Kind Contributions 1,000 1,000 1,000 TOTAL PROGRAM INCOME 111,859.00 18,648 111,859.00 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Program Name:Vocational Skills Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 10,000.00 33,000.00 43,000.00 Professional Fees 2,400.00 10,600.00 13,000.00 Operations 3,000.00 31,000.00 34,000.00 Supplies 1,510.00 8,490.00 10,000.00 Equipment 900.00 1,900.00 2,800.00 Equipment Repair 1,000.00 2,400.00 3,400.00 Staff Training 800.00 800.00 Payroll Taxes & Benefits 1,190.00 3,669.00 4,859.00 SUBTOTAL 20,000.00 91,859.00 TOTAL PROGRAM BUDGET 111,859.00 •slsanbai buipunj aimnis7luabo JO 5,tuaJbai8 Jr1V.Jo tionorticna RtiJ;:tr3dt.or illm 44Diciwai aq2 buifir-poriai a;0.1f13.71?pit) 'apidWoJ 'Aiawq o yaws a,i ainllo Toped pieme e4-4 SulJnp patengo siunowe pue sa .rnos Ou!punj aulo oguRsn e pue'spun 4 4uer2 memem Jo Alurvel Aq pitivocidns sa.trqipuadxa tie 4.0 Suguntme nalduscr e (saweolno eiqeAnseiiu..1 `31p7ads uo fluiswo4)we-4 a& o Suw.teme 344 U10.4 panpap slipuaq 3n4nd ato o uopeueltha ue apnpur netts'paputoid neldtvezaq un'pada,aqi-papAeme seM;uelar au;',plum Jc iraA tettpe_rwco au4 4o of am 4a14,e sAep og u!LI1rAk:taunO:j•Alun au;oft:coal pua-AeaA e ittuqns ; luatur*ibai au;ulteA/WM/0 ity‘ok pue puelvapurt Cam] I '1,temeH. o A4unc53 ai4;Luoil uei e papleme Tie,;man e Butsn auttuo aal uot4e4sdai terkuue auz Aed pue`ssaloid ds-Aq-ds Asea at..4 Nati:Kum `Aow'llemeua-siopuanfiam cn o js)luaulAed o Jotid luettclu.AG aq pue 1OxjasUetiettUoD merAeH twm o4u luautaitnbaiaq ultm AiduJOD pue puelvaptin (aM) I fhtemeil .o Alum:0 tuoil r papieMe .swatunDop teut2oo se paulaape aq 1&J sluounnop patdop.4o paxei-payienbsip aq ttlm cluaLunaop pauEtsuct luaLunDop 03NDIS '11010910 a41 q 1Snu.t airtleu5tuenne Sup!nbai sw8u2roop eleql.pue;sJapun(am) •tellit.uqns o;Jotid aleinan pue alaidulaD sluatuniop tie eq aJnsua o;Avitcusuodsa I tin;aneu am;eq;pue lel.;!Luqns lueiD lijciduoN Alunoa Jno 31eARDai tavuosJad A;unop Aq paAckatAaa aq loU sUORemcide leu;puelsaapun tam)I •salme;s pas!Aa 1,temel-1 jz6 Jaleleuo o;5utploa3e quqnd apew aq tieqs utaaaLt paiiddnsUOFeWJO4Ut et 4 puelsJapun(am)! 'met of luensind(s)weaaid au;ialstutEupe Attn1 o;A;mqe pue Alt-104 n e at Aet4(am) t leu;pue Is.=Si isluatunaop flunJodeins tie Sutpnput'utaJaq paticidns uollettuoitu eq Acia-taq(em) .pasn alatit SpUfl tp!um Jo;Wald Jo 'pe.quoz luea au;o;luaup_lati spiopal o `AlJadogi luawctinba Alllpe;Aue padsui pue 7,1Ufwexa o Aluot.gne pue ssome papiilsalun pue 'au; (Aaue0e 1,421siaAppu!puadxa.10'ontleluasaJda) purioo paletalsap'metnj to luaurvedao `Jolipnv aroeistSai Aluno:,N atti mtone opai5e(;)m) •Suotleztueillo 1014:Wats'O spuno uonepdoiddv o Supe ) 'app.)A.Tunoj!Aemei-{ sEt -z suopas'sz app.iv u! pa4epuew se sivatuallnbal Amciewnone leps9 pue`Au!i_lodai pue fsainpapoJd pieme suoillpuop we.t2 4nopla ato jo poo;siapun pue peai arte4(GM) (Z10 T aged' 2u muelsiapun 30 u0ile399,1aD 9 jw (1-1 S , 7Q \ :aweN welNold _ 9(:1 )4a :auveN rcpuo.ov Z: A-I uopuoliddy ltrako pjoicluoN 1,!ilmt1{Jo County of Hawaii Nonprofit Grant Application FY 2022-23 14-6 0 56: iNe Agency Name: Program Name toc,A t B Certification of Understanding (Page 2 of 2) If awarded a grant from the County of liawari, (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 shell result in loss of all grant funds received citsrin: the •nt .erio• ust be re n• • t. Countyl 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. t(we)understand there is no provision for further notification to submit the final report Information and instructions are available at httpity,ww.nawaijcounty.govfin-ncnprofit-grant-forrns/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 30,2023 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 fun Tho request and may result in actions token 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 taw. 8y signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person Date 'BOAr — Title/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: BP-ID ° 561 N ( Program Name: tx.-Pctt 0 5 ILLS Bu i.-1)/104, 0644401. ORGANIZATION CONFLICT 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. Ail disclosure figrms 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): E Member or members of the Council Staff appointed by a member of the Council fl Th Mayor fl The Managing Director n The Director of Finance El The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:o stib5tOntiol probability thor ecrl'on taken by on Individual will result in measurable direct 1-enefits accruing to he individual as opposed to benefits accruing in general to on industry. P!ease specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: if no conflict:,ex;st, check here. . 0k0 efrilc7ii-i Signature of Authorized Person(specify title) Date • _ _ • Bridge House, Inc. Care Coordination 48 County of Hawai`i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Bridge House, Inc. Contact Person:Andi Pawasarat-Losalio Contact Email: director.bridgehouse@gmail.com Contact Phone: 8083223305 Program Information Program Name: Care Coordination Program Years in Operation: 2 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Captain Cook, Honalo, Honaunau-Napo'opo'o, Kahalu`u-Keauhou, Kailua- Kona, Kalaoa, Kealakekua, Miloli`i, Ocean View, Waikoloa Village Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Needs of the poor, Public health and welfare of the people and the environment, Physical/Emotional Disabilities,Victims of Health or Social Crises Amount Applying For:$5000 Bridge House, Inc.-Care Coordination I Page 1 Program Details Organization Mission: Current: Guided by our values of Pilina (connection),Aloha 'Aina (love of the land), Lokahi (unity), Maluhia (peace), and Pono (virtue) we work with the client's best interest at heart to create a supportive environment during the recovery process. Origin Statement:The Bridge House mission is 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. Program Overview:At the beginning of the pandemic,we quickly realized that clients who left our housing program were suffering with lack of support in the community. Many social service agencies had either shutdown or had limited services availability.This included probation supervision & drug testing. Many clients during the onset of the pandemic relapsed, reoffended, lost housing and ended up back in jail. Our response to this crisis was to expand our Care Coordination to have staff meet clients in the community, as well as offer support by phone, or video conf., and assist with linkage to services needed.This included drug testing, providing paperwork, assisting with technology use, scheduling appointments, speaking with service providers to access care, attainment of documents, and help with needed supplies. We have seen a dramatic turnaround in client outcomes. It showed us that the additional support showed positive outcomes by increasing protective factors and decreasing barriers. Program Objectives & Performances Resources Needed: 2-3 staff,vehicle, insurance, drug testing supplies, cell phone, paperwork, access to supply needs for clients, computer, printer, Internet, paper, printer, mentors, money for program and needed items for client Major Activities to be Completed:The objectives for Care Coordination is to improve overall health and wellbeing of men and women suffering from a substance use disorder by reducing readmissions to substance abuse treatment and referrals for residential treatment, reduce emergency medical visits, reduce arrests, increase compliance with judicial system, increase protective factors of client where client feels supported, and improve communication among client's providers. Outputs to be Completed: 2 -3 staff,45-60 clients, $500 worth of donated items for clients Measurable Outcomes: Program Performance Outcomes (Short-Term Outcome Measures outlined in Logic Model) at Program letion Discharga/ p g Com ram 70% no new arrests 70% no emergency room visits/hospitalizations 80% compliance with legal issues 90% clients report feeling supported & life and health have improved Bridge House, Inc.-Care Coordination I Page 2 Program Performance Outcomes (Short-Term Outcome Measures outlined in Logic Model) At 6 Months Post Discharge Follow-Up for clients Completing Program: 95% clients report care coordination resulted in an improved life 70%clients report continued positive outcomes Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Bridge House, Inc.-Care Coordination I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Bridge House, Inc. Program Name: Care Coordination CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $5,000.00 8,897 Applicant organizational budget: 0 0 Individual contributions 0 0 0 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets 452,231.32 0 0 Other funding sources(list below): HCF-East HI 4,467 4,467 4,467 ADAD-OPT 28,000.00 4,284 4,284 JUDICIARY 8,920.00 PROGRAM FEES 2,000.00 Total Cash Income 17,648 17,648 17,648 IN-KIND CONTRIBUTION Anticipated Committed Total 1,000 1,000 1,000 Total In-Kind Contributions 1,000 1,000 1,000 TOTAL PROGRAM INCOME 43,920.00 18,648 43,920.00 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Bridge House, Inc. Program Name: Care Coordination Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 4,460 4,460 0 40,000.00 Professional Fees 0 0 0 0 Operations 2,037 2,037 0 4,074 Supplies 2,400 2,400 0 4,800 Equipment 0 0 0 0 Payroll Taxes & Benefits 3,920.00 SUBTOTAL 8,897 0 16,794 TOTAL PROGRAM BUDGET 8,897 8,897 0 16,794 uOSJ0d1 paZt1044TIV jo uOt1tsOdianti oleo uOSJacd pazootllny#n aJnleu2i5 .sluawa,rtnbal asa l puulsiapun pue peas z►rietl noA lain ifu18pe1moualae .e nbA.mulaq Zulu Is A 'Me)AR pazotone astismatoo ssajun sal adu.id alenl.td us(samo as Jo aotlesfsul's e%Jaleut'+ctolPt uc 'Iso )stua.uan udwl Iel#d IN spurt;.0pinord lcauuea sptemv 'VW?)aat{l JaA aJ tioOlstiCtipti Lig lfn AwW porn asanbai ntupurrJ ,mlffj SAjtiabblt1OA f u0OviittMa acp.` rrawt"fpM JaUUr W AtauW! 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Uo!WZc1ddV IUUUD lijoiduoN 1,FA . . a k Ufl a County of Hawaii Nonprofit Grant Application FY 2022-23 1.\)) Agency Name: 13 lia.( 4 Pro:ram Name: Q. 41, 6 r j ?kJ AT( tk) 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 Hawall 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 he stoned, regardless of whether o 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): FJ Member or members of the Council n Staff appointed by a member of the Council 0 The Mayor LI The Managing Director The Director of Finance fl 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 on 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" RVAleP PRZ-5/0EN 7 - Signature of Authorized Person (specify title) Date Center for Getting Things Started Farm to Family 49 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Center for Getting Things Started Contact Person: Koh Ming Wei Contact Email: mingwei@c4gts.org Contact Phone: 8084439231 Program Information Program Name: Farm to Family Program Years in Operation: 1.5 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Island wide Program Target Audience: Infancy(0-3), Play Age (3-5), School Age (6-11),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Public health and welfare of the people and the environment Amount Applying For:$50000 Center for Getting Things Started-Farm to Family' Page 1 Program Details Organization Mission: Center for Getting Things Started (C4GTS) is an incubative makery serving the Pacific Region with sustainable education curriculum design, development and implementation,teacher professional development, and research into island food systems. Since 2020, C4GTS has been partnering with Hawai'i Food Basket Inc. and the Farm to Keiki project in developing nutrition education resources and trainings targeted at families to encourage the consumption of locally produced and harvested foods. Program Overview:Our team with support from Keiki Heroes, has collaboratively developed the first of three nutrition education booklets targeted at families and early child care providers https://dabux.org/keiki-corner.The booklet draws on food as a local funds of knowledge, and engages families as educators.There are fun activities to do with local foods along with simple and healthy recipes, and virtual trainings to support families and providers in using the booklet.This model is especially crucial with the pandemic, disruptions in the school year, and more families turning to homeschooling.The goal of Farm to Family is to provide opportunities for the keiki to meet the foods so that they will eat the foods.The team has funds to develop two more booklets and conduct several virtual trainings on the booklets. However,there are not enough funds to print the three booklets for a county-wide distribution. We only have enough for a small group of selected families and early child care providers. Objectives & Performances Program � Resources Needed: Food Basket's distribution network-staff and volunteers. Funds for personnel - program management and distribution staff coordination. Honorariums for expertise consultants- nutrition education, agriculture education, STEAM education, early literacy, and guest speakers at trainings. Funds to contract artwork, graphics and layout for the booklets. Funds for printing- booklets and stickers. Funds for distribution - postage, envelopes. Connections to early childcare providers- home-based, county or state-run, etc. Major Activities to be Completed: 1. Design and develop 2 more booklets. Booklet one is found on https://dabux.org/keiki-corner. 2. Print all three booklets-2,000 each = 6,000 3. Coordinate the distribution of the booklets 4. Distribute the 6,000 booklets to families and early care providers (note that these providers may work with 5-20 students) 5. Conduct training webinars on all three booklets and accompanying resources (such as videos) Center for Getting Things Started-Farm to Family' Page 2 6. Evaluate effectiveness of the booklets and accompanying resources to meet the goal of encouraging more families with keiki to eat local foods. Outputs to be Completed: 6,000 booklets printed and distributed. 6 training webinars on how to use the resources.Two trainings per booklet.These webinars will be recorded and posted on FaceBook for accessibility. 2,000 families supported in getting their keiki to try and eat local foods. 500 early childcare providers supported in getting their students to try and eat local foods (note that these providers may work with 5- 20 students). II Measurable Outcomes: Children who love to eat local food. Local produce -fruits and vegetables-which are in the DaBux program is bought and eaten. Local produce in the Food Basket and DaBox program is not wasted, and integrated with other distributed ingredients for healthy meals. Families who know how to prepare simple, healthy snacks and meals using locally grown and harvested produce from Food Basket. Families and early childcare providers are engaging with food as a local fund of knowledge for STEAM. Attachments Program Budget(Income & Expenses) Certificate of Understanding Conflict Disclosure Center for Getting Things Started-Farm to Family Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Center for Getting Things Started Program Name:Farm to Family CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50,000 8,897 Applicant organizational budget: Individual contributions 0 0 0 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets 0 0 0 Other funding sources (list below): HCF-East HI 4,467 4,467 4,467 HCF-West HI 4,284 4,284 4,284 Total Cash Income 17,648 17,648 17,648 IN-KIND CONTRIBUTION Anticipated Committed Total Center for Getting Things Started 1,000 13,000 1,000 Hawai'i Food Basket 32,900 Farm to Keiki 13,000 Total In-Kind Contributions 1,000 1,000 1,000 TOTAL PROGRAM INCOME 50,000 58,900 108,900 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ;Organization Name:Center for Getting Things Started `Program Name:Farm to Keiki Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 4,460 4,460 26,000 26,000 Professional Fees 0 0 15,000 15,000 Operations 5,000 2,037 0 5,000 Supplies 2,400 2,400 10,400 10,400 Equipment 0 0 0 0 Booklets + stickers 30,000 30,000 Distribution Envelopes 12,000 12,000 Postage 3,500 3,500 Honorariums (10 x$300) 3,000 3,000 Family/provider support 4,000 4,000 SUBTOTAL 50,000 8,897 58,900 16,794 TOTAL PROGRAM BUDGET 8,897 8,897 0 108,900 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Center for Getting Things Started Program Name: Farm to Family 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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Center for Getting Things Started Program Name: Farm to Family 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, 2023 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 1/25/2022 Signature of Authorized Person Date Executive Director Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Center for Getting Things Started Program Name: Farm to Family ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that anyboard 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: ❑ If no conflicts exist, check here. Executive Director i i4.4446 i /27/2022 Signature of Authorized Person (specify title) Date Child and Family Service Alternatives to Violence 51 County of Flawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Child and Family Service Contact Person:Amanda Pump Contact Email: cfscontracts@cfs-hawaii.org Contact Phone: (808) 681-3500 Program Information Program Name:Alternatives to Violence Program Years in Operation: 17 years Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: `Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki`o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli`i, Mountain View, Na`alehu, Nanawale Estates, Ninole, Ocean View, 'O'okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa`aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, 'Umikoa,Volcano, Waikoloa Village,Waimea, Wainaku, Wai`ohinu,Weloka,All areas on Hawaii Island will be served through CFS' Hilo and Kona offices. Program Target Audience:School Age (6-11),Adolescence (12-17), Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided:Victims of Crimes,Victims of Health or Social Crises Amount Applying For: $50000 Child and Family Service-Alternatives to Violence I Page 1 Program Details Organization Mission:The Alternatives to Violence (ATV) program perpetuates Child and Family Service's mission of"Strengthening Families and Fostering the Healthy Development of Children" by helping to break the cycle of domestic violence and ultimately improve community safety. The program has been offering services to increase access to safety for survivors and their children, and intervention to those who batter, since 2005 on Hawaii Island. In fiscal year 2021,the program served 596 individuals. Program Overview:The ATV program asks for$50,000 to increase staffing to meet the needs of individuals and families impacted by domestic violence. ATV provides increased access to safety for survivors of domestic violence, and intervention to those who batter to break the cycle of domestic violence. Services for survivors include, assistance with applying for a Temporary restraining order; court advocacy, safety planning/and referrals to community resources to increase safety, such as,the CFS Domestic Abuse Shelter. Intervention services are aimed at preventing further violence and include, case management; groups to provide education and increase understanding of domestic violence and learn positive coping strategies; and assistance with developing a relapse prevention plan. Program Objectives & Performances Resources Needed: 1)Additional staffing to reduce wait time for individuals accessing services. Specifically, we need to hire two staff, at 12 hours per week, one to provide services in Hilo and one in Kona. Staff will assist with providing TRO's, court advocacy, safety planning, community referrals, domestic violence intervention groups and case management. 2) Two Laptop computers for staff to assist participants with all ATV services. 3) Funding to assist program participants with basic needs such as transportation. Major Activities to be Completed: 1) Survivors will be assisted with applying for a TRO 2) Survivors will be provided the tools to complete a safety plan and understand the court process 3) Survivors will be connected to at least one community resource to enhance their safety 4) Survivors will be provided with pre-court follow-up to answer questions about TRO court hearings and a safety check to provide suggestions for maintaining safety at the courthouse 5) Survivors will receive court accompaniment and advocacy 6) Survivors will be given a survey post services to assess program effectiveness 7) Batters will receive case management(comprehensive assessment, service planning and referral to community resources) 8) Batterers will receive group psycho education for 26 weeks 9) Batterers will receive support to complete a relapse prevention plan 10) Batterers will receive program impact survey every quarter 11) Batters will take a program pre and post survey to assessknowledge increased as a result of program services Child and Family Service-Alternatives to Violence I Page 2 Outputs to be Completed: Funding from COH will support staffing that will assist with completing the following outputs: 1. 500 survivors will be assisted with completing a TRO application. 2. 80 Batterers will receive domestic violence intervention services 3. 1000 Court advocacies/assists will be provided to survivors. Measurable Outcomes: Funding from the COH will support the following outcomes: 1. 80%of batterers will complete the curriculum 2. 90% of batterers will self-report that the services made a positive impact on their life 3. 80%of survivors will report they have a better understanding of the TRO process after receiving AN services. 4. 80%of victims will be connected to at least one community resource to enhance safety. 5. 80% of victims will self-report that they have the tools needed to create a safety plan. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Child and Famil Service-Alternatives to Violence I Page 3 Y Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Child and Family Service Program Name: Alternatives to Violence CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) S50,000 550,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): State Judiciary $454,816 $451,816 Total Cash Income $504,816 $0 $504,816 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME $504,816 $504,816 Appendix D--Budget Sheets (Page 2 of 2) ;Project Budget Form: Expenses ;County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 !Organization Name: Child and Family Service Program Name: Alternatives to Violence Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $34,535 $304,577 $339,112 Professional Fees $200 $200 Operations $3,526 $59,379 $62,905 Supplies $844 $3,285 $4,129 Equipment $2,000 $0 $2,000 Participant Assistance $600 $500 $1,100 Mileage $600 $3,345 $3,945. Indirect Cost $7,895 $83,530 $91,425 SUBTOTAL $50,000 $454,816 $0 $504,816 TOTAL PROGRAM BUDGET $50,000 $454,816 $0 $504,816 County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Child and Family Service Program Name: Alternative to Violence 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, pro ertY. or 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Child and Family Service Program Name: Alternative to Violence 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, 2023 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. 1/31/2022 Signature of Authorized Person Date Karen Tan, President & CEO Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Child and Family Service Program Name: Alternative to Violence 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. l Karen Tan, President & CEO 1/31/2022 Signature of Authorized Person (specify title) Date Child and Family Service Domestic Abuse Shelters (DAS) 52 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Child and Family Service Contact Person:Amanda Pump Contact Email: cfscontracts@cfs-hawaii.org Contact Phone: (808) 681-3500 Program Information Program Name: Domestic Abuse Shelters (DAS) Program Years in Operation: 17 years Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, HOnaunau-Napo'opo`o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa`ikou, Pauka'a, Pepe'ekeo, Pohoiki, PuakO, Pualaa, 'Umikoa, Volcano, Waikoloa Village,Waimea, Wainaku,Wai'ohinu,Weloka,All areas on Hawaii Island will be served through CFS' Hilo and Kona offices. Program Target Audience:School Age (6-11), Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided:Victims of Crimes,Victims of Health or Social Crises Amount Applying For: $50000 Child and Family Service-Domestic Abuse Shelters(DAS)! Page 1 Program Details Organization Mission: Since 1899 CFS's mission of'Strengthening Families & Fostering the Healthy Development of Children" focuses on helping individuals/families address life's serious situations like violence & safety. CFS's Domestic Abuse Shelters are family-centered,full-service sites offering to transform safety risks and sustain positive gains as proven by data and results. Our vision is that our mission results in healthy,thriving individuals and families building strong, multicultural communities. Program Overview:The DAS program asks for$50,000 funding to add the HMIS access to the CES database &the staff hours to assist survivors & children of DV enrollment that prioritizes DV survivors for homelessness prevention. The Hawaii island CAP has developed this organized system under HUD federal regulations including VISPDAT assessment of vulnerability and scope of need giving DV survivors prioritized rank to receive the first open, safe housing referrals. Despite nine access points on Hawaii island, survivors of DV are federally protected on identity&safety but fear disclosure of their locations by leaving the shelter to enroll. DAS locations with survivors' confidentiality and safety make them a logical entry point for this population. Family Centers nearby provide an additional secure location for access to desired services.Services include entry into the system & assistance in ensuring that participants are "document ready," documents lost in flight to DAS shelters for safety/protection. Program Objectives & Performances Resources Needed: CFS seeks funds for fees of HMIS/CES &staff at both DAS as budgets pay only one staff/shift/location making it difficult to meet all needs, cover the hotline &give access to services. DAS services are any time, unlike offices like Vital Records or SNAP are open within a weekday time only. DAS staff assist survivors anytime with applications, document orders, & housing searches for time efficiency with access to working internet/computer--equipment that the survivor will likely not possess. DAS also provides public education dispelling the myths about DV in our communities—that survivors "want"to go back to their perpetrators, "violence only takes place in poor families," or that survivors should stay in danger, not to burden others. Performance data is collected quarterly/at exit in our Results Based Accountability data collection and client surveys.The measures will be: #of survivors served of survivors who exited to safe housing of survivors connected to CES through HMIS Major Activities to be Completed:The major activities are that all DV survivors will be screened for access to expedited affordable housing,with all qualifying survivors enrolled into the CES through HMIS made possible by the payment of fees required for CFS to access the system. The two part-time DVS II staff for Hawaii Island will be hired, trained in basic domestic violence services. Also, access fees for the HMIS will cover two part-time staff to be trained in the system, entry & assessment processes of the HMIS CES software enabling ranked enrollment of victims into the CES. Child and Family Service-Domestic Abuse Shelters(DAS)I Page 2 Survivors receive the needed services from CFS staff to be 'document ready' to accept any suitable available housing and all seekers will get expedited access to their housing status to make prompt decisions about their needs. Victims are assisted directly and through the available technology to do housing searches,job applications, enroll in available community resources, transportation, childcare options, and other critical services. Outputs to be Completed: 150 clients are served yearly per DAS site. In FY 21 per site, 24% accessed safe housing. Of those 24%, only 23%exited to available units &75% resorted to housing with family members/friends.These have safety risks as batterers find their victims quickly through known locations &via "stalking." Lack of safe housing results in clients & children returning to perpetrators or homeless conditions (in vehicles or the beach) at discharge from DAS. HMIS/CES access and trained staff to input data provides outcomes befitting the community: 1) Staff trained to work HMIS/CES lessens clients' need to exit the site minimizing their potential exposures to COVID-19. 2) CES system for clients promotes safety for all. Clients leaving the property risk encountering batterers &/or persons searching to determine the survivors' location. 3) Trained staff in CES would expedite updated housing status; staff on sites improves the process for all and enhances services related to housing needs. Measurable Outcomes: Funding gives: 1) 100%of clients (150/site/year) enter CES/HMIS with security maintained; 2) 100%of qualified clients placed in the CES; 3) 100%of clients in 'document ready' status & links with community resources. CFS's access to CES/HMIS improves the exit to safe housing providing hope, reducing a return to the perpetrator, or the hazards of rooming with family/friends . CFS expects no survivor/child becoming homeless, exposed to additional crimes, or loss of life via batterers. Staff assist victims with their needs/connections to resources. DV trauma effects shrink as survivors/families experience less incidents. Safety increases two ways: 1) reduction of the need to leave the safety of DAS, less exposure of survivors/children to stalking by batterers; 2) reduction of the exposure to COVID as needed services will be on site. CFS/County collaborations impact CHANGE goals of increasing housing security; self sufficiency; &the reduced effects that DV adds to childhood poverty. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Child and Family Service-Domestic Abuse Shelters(DAS)I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Child and Family Service Program Name: Domestic Abuse Shelters CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $50,000 $50,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): DHS - State $690,500 $690,500 Total Cash Income $50,000 $0 $50,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME $740,500 $0 $740,500 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Child and Family Service Program Name: Domestic Abuse Shelters Nonprofit Expense Description (Waiwai) Other Cash In-Kind TOTAL Source Contribution Grant Salary Wages $34,535 $450,271 $484,806 Professional Fees $675 $675 Operations $1,446 $120,144 $121,590 Supplies $5,056 $5,056 Equipment Participant Assistance $4,081 $5,385 $9,466 Membership $1,620 $200 $1,820 Mileage $570 $1,170 $1,740 Indirect Cost $7,748 $107,599 $115,347 SUBTOTAL $50,000 $690,500 $740,500 TOTAL PROGRAM BUDGET $50,000 $690,500 $740,500 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Child and Family Service Program Name: Domestic Abuse Shelters 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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Child and Family Service Program Name: Domestic Abuse Shelters 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, 2023 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 takento 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 , 1/31/2022 Signature of Authorized Person . Date Karen Tan, President & CEO Title/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Child and Family Service Program Name: Domestic Abuse Shelters 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 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. 144-12M-- J Karen Tan, President & CEO 1 /31 /2022 Signature of Authorized Person (specify title) Date East Hawaii Cultural Council Young at Art 2023 53 County of Flawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: East Hawaii Cultural Council Contact Person: Marisa Miyashiro Contact Email: mmiyashiro@ehcc.org Contact Phone: 808-895-1715 Program Information Program Name:Young at Art 2023 Program Years in Operation: 34 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli`i, Mountain View, Na'alehu, Nanawale Estates, NTnole, Ocean View, 'O'okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa`ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, 'Umikoa,Volcano, Waikoloa Village, Waimea, Wainaku, Wai'ohinu,Weloka,YAA is island-wide.All children can participate. Program Target Audience: School Age (6-11), Adolescence (12-17) Services/Activities Provided: Culture and the arts,Youth Amount Applying For: $10000 East Hawaii Cultural Council-Young at Art 20231 Page 1 Program Details Organization Mission: Our mission is to give voice to the cultural and artistic expressions of our island's diverse communities.We have served E. Hawai'i since 1967; some of our programs are 30+years old. We have 3 pillars: 1) Gallery exhibits accompanied by a lecture series; (2) Performing arts including plays, music and multimedia, with a pandemic-friendly outdoor stage; and (3) Arts education targeted primarily to youth that offers after-school classes, day camps,workshops, and print and ceramics studios. Program Overview:Young at Art (YAA) is an annual juried exhibition that celebrates Youth Art Month by recognizing the excellence, creativity and originality of Hawai'i Island's K-12 students. Currently in its 34th year, YAA was originally developed by the Department of Education but has become a key program of the East Hawai'i Cultural Center(EHCC). Our vision is to expand its impact and accessibility while maintaining a strong connection to its traditional homebase in Hilo. By creating a community-based art experience,we aim to reach those who may not otherwise have participated in or visited the exhibit. In 2022, we are taking the first step by having satellite exhibits at Hilo Public Library and Mokupapapa Discovery Center. In 2023, we plan to broaden into public libraries around the island, while also creating displays throughout Downtown Hilo.We hope this shift will help to promote exploration of our community, as well as increase awareness and appreciation of our keiki artists. Program Objectives & Performances Resources Needed: • We will need support from Downtown Hilo businesses and the County to allow the display of artworks.We have established commitments from the Hilo Public Library, Mokupapapa Discovery Center, and Hawaii Science and Technology Museum • Volunteers will be needed to help oversee the curation of satellite exhibits throughout the island. Donkey Mill Art Center has committed to help with West Hawai'i locations. • We have a team of app developers who are willing and able to design an app to guide people to satellite locations. • Website to host information, online gallery, awards video • Coordinators to oversee the program logistics • Funding for supplies for mounting and displaying artworks, and reproducing outdoor artworks. • Advertising materials (programs, informational signs, banners, newsletter, etc.) • Transportation to satellite exhibit locations • Support from DOE for announcements to teachers • Social media outreach Major Activities to be Completed: • Collaborate with businesses and libraries around Hawai'i Island for satellite exhibits • Collaborate with Donkey Mill Art Center to provide convenience and support to all participants and satellite locations • Call for entries through DOE, email list, social media • Solicit donations for awards East Hawaii Cultural Council-Young at Art 20231 Page 2 • Recruit three (3)judges for the competition, who will also provide instructional workshops to facilitate development of the award-winning artists • Reproduce artworks that will be displayed outdoors • Collect, organize, select, distribute, and install artworks at satellite locations with informational signs and materials to increase awareness and education re: YAA and Youth Art Month • Develop app • Create map of locations • Create online gallery and awards video/announcements • Publicize the exhibit • Offer art workshops to YAA participants • Remove, collect, and return artworks at end of exhibit; donate vinyl prints to Upcycle Hawai'i • Thank your and acknowledgements Outputs to be Completed: • 100+ keiki artworks in satellite displays in 3+ locations outside of Hilo • 20 award-winning keiki artworks in locations around Hilo • 100 downloads of the app to locate artworks (for an approximate of 200 visitors) • 3 keiki art workshops by YAA judges (local artists) • 1 artwork purchased for the EHCC permanent collection • 1 artwork chosen as the design for the annual YAA t-shirt Measurable Outcomes: Short-range: Increased awareness and attendance of YAA exhibit (to be determined by app usage, informal survey of locations and participants). Increased art education opportunities for keiki (workshops). Medium-range: Increased participation in YAA from rural areas/other schools. Increased art education opportunities at schools and other locations throughout Hawai'i Island. Long-range: Generalized art accessibility and appreciation -art does not always have to be in a gallery or museum.Art can be in our everyday lives. Economic impacts through increased creative thinking and design principles fostered in our keiki as well as increased employment opportunities for local artists. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure East Hawaii Cultural Council-Young at Art 20231 Page 3 Program Budget Form: Income County of Hawae Nonprofit Grant-in-Aid(Waiwai Grant)-- Fiscal Year 2022-2023 Organization Name:East Hawaii Cultural Council Program Name:Young At Art 2023 CASH Anticipated Committed Total County Nonprofit Grant in-Aid(Waiwai Grant) 10SX)0 10,11 Applicant organizational budget; individual contributiortS1000 0 1000 - Membership fees 0 0 0 Famed income 0 0 0 Current cash assets 0 1500 /500 Other funding sources(list below): 1111111111.11M 1111111111111111 Total Cash Income 150) 11,500 CONTRIBUTION Anticipated Committed Total Salanes&Wages 0 640 640 pretessional fees 0 475 475 111111111111111111 aim 11.11 Total in-Kirtd Contributions 0 1115 1115 TOTAL PROGRAM INCOlvIE 11,# 2615 13615 Appendix 0—Budget Sheets(Page 2 of 2) Budget Expenses County of H W np fiGrant-in-Aid(Waiwai Grant)a Fiscal 2023 Organization Name:East Hawaii Cultural Council. Program Name:young 2023 ExpenseOther Cash In-Kind TOTAL i eft " . Source - Contribution Grant Salary wages 5900 Professional Fees 750 1500 4Th 2725 Operations Supplies 2450 i 1000 0 3450 Equipment ;,..., uu , mss...;, alliMi MEI. wiffititistaaim =MUM , SUB .m I�� p� �1lI�IllUll * .1. 10.000 2500 1150 13615 TOTAL ' -.i.i BuDGEr 10,000 2500 1150: .. .. ..: 13615 County of Hawai‘i Nonprofit. Grant ApplicationFY 2022-23 Erks+ Havie:t, CLaturcti C.4 Agency Name: Program Name: Yoe pt at Art .a.O.L,D Certif 2 - ; n f Understanding (page aat'2) . I we have read and understood all of the eligibility requirements; r nt coitions;award procedures; and records, reporting,and fiscal accountability requirements >mandated in Article 25,. ectiris 2-- 135— -13%—24421, Hawari County Code,relating to Appropriation of Funds to Nonprofit Organizations, I agree to allow the unty(the Legislative Aa it r,the Deparunent 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, r, program for which funds were used, I w hereby certify that information supplied herein,in lu in all sup log documents, is correct t and that l(we)have the authority and ability,to fully administer the program(s)pursuant to law ! . understand that information supplied herein snail he made public according to t r , Hawaii Revised Statutes. i (we)understand that applications will not he reviewed y County personnel receiving our County Nonprofit Grant submittal,and that we have full responsibilityto ensurethat 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., ns ` documents will be disqualified,Faxed orcopied documents will ,„ t be accepted as original documents, If awarded grant from the unt H . r i'i,l(we)understand and will comply with the requirement to enroll with Haw:iii Corn•fiance Ex i ress and be compliant prior to receiving parent s . To register, gotot.t e d rim :Ler„complete the easy step-by-step process,and pay the annual registration fee online using credit card; if awarded a ant from the Cent of Hawaii. lwe odd will comply with the requirement t *_ rl a It a year-end resort to the Count Council within°°:dola.._ alter June the contractual year r which the -rant was aware .The re. ,,using mplate provided, in <'an explanation of tha public benefits derived from the awardingthe o measurable outcomes),a completeaccounting -an expert.' res supported by un Hawaii grant funds,and a listing of r -r fundingsources and amounts obtained<during the period. Failure to submit dm- cornMete, and accurate t ear-end e t ILSIn the tern&Wprovided will ire f act the evaluation a Oar 4tr, rarres iv a enc=$$,uture nein, re uests. County olHawai'i Nonprofit Grant Application FY 2.072-23 Agency Name: En-af /-16\v\tc"*'Ll Program Name: \ioorer,ct Ar 13 Certification of Understanding ( age2 of 2) If awarded a grant from the County of Hawelil, (we)understand that a current Certificate of Liability ($2,000,000 general liability.$50,000 each occurrence)must be provided to the County of Hawaii Finance.Department which specifically and explititly indicates that the County of Hawaii is an additional insured prior to receiving any Payment(5). (we)understand that failure to submit the final report within 60 days of June 30th shaft result in loss of ali grant funds regehtesiAurin: the ;rant -nod must be refunded to County)and exdusion from future ;rant .artici ation for a minimum of one ear or until a writt-n r ort is submitted to,and the coursed. (we)understand there is no provision for further notification to submit the final report. information lid instructions are available at nilririfpv,sx,hay.,airciar a.ry In-riertracrit eran -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 prirpose.s stated in the application,except for a maximum ten percent(10%)for administrative and overhead costs,Any funds unused by June 30,2023 must be returned to the County of Rawer)with the final report:wore to return these urids in a time manner will im act the gyatuation of your agency's ['lure fundint re uest ond mo in actions taken to recover these ands, Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on pe • 4.- prOpertien unless otherwise authorized by law. ity signing below,you are acknowledgingthat you have read and understood these requirements. dct Acylvetry Signature of Authorized Person Date Clooa Title/Position of Authorized Person County of Nonprofit Grant Application FY 2022-23 AgencyC4.,, Name: 17 col/4°A i. a COO OCA Program Name: \lockri lat." Art ,z2-45c23 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, Al/disclosure cans must be si tried regardless of whether o 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): fl Member or members of the Council 0 Staff appointed by a merriber of the Council n The Mayor O The Managing Director O The Director of Finance O The Corporation Counsel, the Assistant Corporation Counsel,or a Deputy Corporation Counsel Cwillict of interest i defined as;,'athstonfivi p/obability that 4vion taken by an individual will result in nicougabld dkert benefits accruing 10 the I:Wit/Moot os opposed to benzfirs accruitv irgencrot to on itnittSW Please specify any and ail wiitigation measures to avoid,in fact or appearance,any conflicts or potential conflicts of interest If no conflicts exist,check here. &Are tasi_Of e" "it e 7a, (2,0 sici.(4041-41 i79W a Signature of Authorized Person (specify title) Date East Hawaii Cultural Council Hawaiian Translation Project 54 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: East Hawaii Cultural Council Contact Person:Jordy Jones Contact Email:jjones@ehcc.org Contact Phone: 808-769-9893 Program Information - Program Name: Hawaiian Translation Project Program Years in Operation: 0 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'Okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, 'Umikoa,Volcano,Waikoloa Village,Waimea, Wainaku, Wai'ohinu,Weloka, EHCC is open to all Big Island residents and our digital materials are easily accessed from anywhere. Program Target Audience:School Age (6-11),Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Culture and the arts Amount Applying For:$5000 East Hawaii Cultural Council-Hawaiian Translation Project I Page 1 Program Details Organization Mission: Our mission is to give voice to the cultural and artistic expressions of our island's diverse communities. We have served E. Hawai'i since 1967; some of our programs are 30+years old. We have 3 pillars: 1) Gallery exhibits accompanied by a lecture series; (2) Performing arts including plays, music and multimedia, with a pandemic-friendly outdoor stage; and (3)Arts education targeted primarily to youth that offers after-school classes, day camps,workshops, and print and ceramics studios. Program Overview:Through Ka Papa Hana Unuhina 'Olelo Hawai'i (the Hawaiian Translation Project*), the East Hawai'i Cultural Center proposes to celebrate `Olelo Hawai'i and better serve the community by expanding opportunities to study, read and speak Hawaiian. In the upcoming year, we will translate key public documents such as signage, our mission and vision statements, and our non-discrimination policy into 'Olelo Hawai'i. We will also adopt a policy of issuing materials generated in the future (such as program announcements, artist statements, and reports that are circulated via our website, social media, and e-mail blasts) on a bilingual basis. Advanced language students will work under the direction of well known and respected teacher Kumu Kaliko Beamer-Trapp, who will review all translations for accuracy. (*Note—as funders in Hawai'i often recommend,we are omitting diacritical marks in this proposal as they may not be supported by submission portals.) Program Objectives & Performances Resources Needed:Administrative support to coordinate deadlines, send and track assignments, issue payments, manage bookkeeping, coordinate development of the coloring book,etc. Student translators Expert linguistic oversight Printing of signage and coloring books Major Activities to be Completed:Advanced students of Hawaiian will translate EHCC materials and public signage from English to Hawaiian. All translations will be reviewed for accuracy by Kumu Kaliko Beamer-Trapp of UHH, who will integrate translations that are not time-sensitive into classroom assignments and discussion.Translation of artists' statements, press releases and other temporary texts will be ongoing.Text that is part of the classroom experience will be unpaid. EHCC will pay for materials needing quick turn-around (for example, announcing sign-ups for an art class) or when classes are not in session, so that individuals are compensated for work that goes beyond classroom assignments. EHCC will also produce an educational children's coloring book in 'Olelo Hawai'i and will host a lecture on 'Olelo Hawai'i through its lecture series (specific topic TBD but it will most likely look at historic suppression of'Olelo Hawai'i, survey contemporary writings in `Olelo Hawai'i, or describe its linguistic roots). Outputs to be Completed:A minimum of 10 student translators, especially youth and elders, will be supported financially. East Hawaii Cultural Council-Hawaiian Translation Project I Page 2 All public signage indicating bathrooms, exits, hours, etc. (a minimum of 6 signs) at EHCC will be made bilingual. At least 4 gallery exhibitions will include bilingual explanatory material such as artist statements, program guides, and titles of artwork. A minimum of 30 announcements (classes, EHCC news, position openings, upcoming gallery exhibitions, performances, etc.)will be digitally distributed in a bilingual format. A minimum of 50 copies of an 'Olelo Hawai'i coloring book will be distributed free to children participating in EHCC art programs. One lecture will be produced and made available on YouTube, attracting a minimum of 150 views within 3 months of posting. Measurable Outcomes:This project will promote the normalization of'Olelo Hawai'i in everyday life. It will offer opportunities for keiki who are being raised either'Olelo before English and/or in immersion school environments to see their language and culture given equal weight outside of family and school, enhancing pride in their culture and associated feelings of self-esteem. Kupuna, many of whom are Kanaka learning their heritage language for the first time as older adults, will be supported, in contrast to their experience of being discouraged from speaking 'Olelo Hawai'i as young people. Students of the language who are financially rewarded for their studies will have renewed commitment and enthusiasm for mastering and using the language.The message that'Olelo Hawai'i is a viable,vigorous and living language will be reinforced among tourists, new residents, and all of Hawaii's multiethnic communities. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure East Hawaii Cultural Council-Hawaiian Translation Project I Page 3 Program Budget Form: income County of Hawaii. • Nonprofit Grant-in-Aid (Waiwai Grant)—Fiscal Year 2022-2023 Organization Name:East Hawaii Cultural Council Program Name:Hawaiian Translation Project CASH Anticipated Committed Total County Nonprofit Grant-in-Aid(Waiwai Grant) 10,000 10,000 Applicant organizational budget: Individual contributions 500 0 500 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets 0 125 125 Other funding sources(list below): Total Cash Income 5,500 125 5625 IN-KIND CONTRIBUTION Anticipated Committed Total Admin support 0 5250 5250 Total In-Kind Contributions 0 5250 5250 TOTAL PROGRAM INCOME 5,500 5,375 10,875 Appendix 0—Budget Sheets(Page 2 of 2) sth'o i- £39 `5 SZ9 000'5 Jasane WYSSONd 1v1oi 9/2'01-, dss`S 9Z9 000'9 1Vi t1S IIIIMRIII 111.1111111111111111111111111111111111111 111111 _ al 111U , am 111111111111111111111.1111111 IIIIIIIIIIIIIIIMIMIIIIIIIIIIIIIIIIIIIIIIIIINIIIIIIIIIIIMIMNIIII l awdrnb saliddris 009 0 009 0 suog adO' 91_1.3 099 SZ1. 000'9 saai leuO!ssaJO)d L. °OWL 0 saem Metes' ueJ9 uO f UlUO) aainos 7vio1 Iemle.M} uond nsao asuadx3 pum- t %Sep Jatilo4goid o N loefoid uogeisuma. a eH:awe N .rle) of 3UfO JRW a,! MeH ma:auueN uo ez!ue o ,SZOZ-ZZOZ leadk leosti- luei9 to leM) PiV-ut-quelp l . , UoN • Y ,e eH JO Alunop sas 3 :11.1i0j 1,92pnga of County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: tAs— rca Cbtknc't Program Name: 140..v.i a.'t7t. -frox\SNogi Certification of Understanding (Page 1 of 2) (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 fadlity,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 abilityto 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 ta 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 Hawari,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.chavvii.gay,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 tmr; for which the grant was awarded.The reports 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 a1% , . of other funding source,s and amounts fined 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 progrpm's or agency's future funding requests. County of Hawai‘i Nonprofit Grant Application FY 202223 Agency Name: E fkawaLi. adfikirejj Courtc 1 I Program Name: Vkaviaiiet.r‘ 1-7-47o.ricsioi.;0 yn, 'Pro- e.Cl" 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 EFLAtirt funds received during the grant period(must be reftsnded to County)and exclusion from future ,.1 .nt . ..rtici. tion 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 httpAmvw,hawaiicomty.Povitn-non*tofit-1 rant-forrng on or about May 30 of the year the final report is due. 1 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 1 costs.Any funds unused by June 30,2023 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 uture undin 0 reouest and rn o result in actions token to recover these nds. Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless otherwise authorized by law, ay signing below,you are acknowledging that you have read and understood these requirements. 4 C th e of Authorized Person „2. Sign tirJainktekr1 0..6.2a., Date ... Vi te_ 0,14CiC _ Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 1. E1054- akt+u, Agency Name: ro-1 Counc; ProgramName NaWatIanI ran 51 0-11.. 0c' 1r ecr ORGAN IZATION CON Fucr 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 Hawari.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. Ail disclosure orms must be si‘ned re.ardiess o whether a con hit exists. NAME: POSMON: 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 O Staff appointed by a member of the COUnCil O The Mayor tj 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 parbability 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: 4* CI If no conflicts exist,check here. ‘0 et)Alks-si... ice Ctick:t c c2Lt tiowevrct QoaQ Signature of Authorized Person(specify title) Date East Hawaii Cultural Council EHCC Out of Doors 55 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: East Hawaii Cultural Council Contact Person: Larry Reitzer Contact Email: Ireitzer@ehcc.org Contact Phone: 323-203-4556 Program Information Program Name: EHCC Out of Doors Program Years in Operation:4 months (first performance November 2021) Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nana-wale Estates, Ninole, Ocean View, 'O'okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, `Umikoa,Volcano,Waikoloa Village,Waimea, Wainaku,Wai`ohinu,Weloka,This program will have a virtual component,therefore it will be available to all areas of Hawai'i Island. Program Target Audience: Play Age (3-5),School Age (6-11),Adolescence (12-17),Young Adulthood (18- 39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Culture and the arts,Youth, Aged Amount Applying For: $20000 East Hawaii Cultural Council-EHCC Out of Doors I Page 1 Program Details Organization Mission: We are an inclusive platform for the expression of the rich and complex cultural diversity that defines our communities through exhibitions, performances, education, and creative inquiry. Program Overview:We will expand the EHCC Out-of-Doors Program that transformed an unused area next to our music studio into a 100-seat (or 50 socially distanced seat)theatre space, providing an opportunity for EHCC and partner organizations to present low-cost or free theatre, dance, music, hula, poetry, readers-theatre, and lectures in an accessible location that capitalizes on our warm climate and allows us to perform outdoors year-round, which is so important during pandemic conditions. In addition to performances at EHCC,the modular stage has been designed so that it can be dismantled and transported to various neighborhood locations to create "Culture on Demand." The Out of Doors program is overseen by EHCC's Resident Theatre Director Larry Reitzer,who worked on Broadway for 10 years as a Company Manager of such shows as "Les Miserables" and "Phantom of the Opera," and in Hollywood for 20 years as a television writer. His expertise and vision inform all of EHCC's performing arts programming. Program Objectives & Performances Resources Needed:After a successful launch, which included a visit from our Mayor, Mitch Roth as well as several outdoor performances and visits to multiple nursing homes,the hope is to continue the program and expand in-person and online programming which will take more volunteers, more paid production staff, additional stage equipment(lighting,sound, projector, rigging), office equipment (computer, printer), camera equipment, office supplies, wardrobe/costume essentials and marketing/advertising expenses. Major Activities to be Completed: In addition to online capabilities and expanding our reach of programming and education,this year we plan to produce six full scale concerts in the park(that run for two nights). These free-to-low-cost-concerts will be fully directed, choreographed and have the highest production values including sets, lights, costumes and have different themes that will appeal to a wide range of audiences. For example: 1)An evening of Hawaiian music and dance, 2) Family sing-along-night featuring music from Disney classic films, 3)A LGBTQ themed concert that coincides with Pride Month, 4) The Music of Jersey Boys, 5) Hamilton in Concert, 6)The Music of Phantom of the Opera.These will be larger full-out productions than those we have done in the past and will encourage people to pack a picnic basket, a blanket,their ohana and join us in the park for an evening of song and community under the stars.This like all of our future programming will be livestreamed over the two-performance run. Outputs to be Completed:A program like this includes hundreds of volunteers, paid technicians, and performers as well as 1000s of audience members. Larry recently produced/directed BEAUTY AND THE BEAST, which sold out its run prior to opening.This demand for tickets coupled with the reaction received from the Mayor's office, our community,the young people who saw it and the cast of over East Hawaii Cultural Council-EHCC Out of Doors I Page 2 one-hundred performers proves the demand for audience-building and arts opportunities. Providing low-to-no-cost outdoor programming can not be underestimated.Ten volunteers work for two weeks prior to each event, a minimum of four hours a day-five days a week.That is 400 volunteer hours for a program that just did 5 events (in a pandemic) and plans to do at least 10 events per year. This breaks down as at least five full-scale concerts performed twice over a weekend. Paid performers, crew members and staff equal about 10 per show and audience reach should be over 1,500 in-person and that does not include online viewers. Measurable Outcomes:When arts and culture interweave in the fabric of a community, it helps cities rebuild and heal, something we greatly need after the two years we have lived through.Arts programming attracts people of all ages, economic barriers and race. It also attracts tourism, brings about innovation and grows the economy. Everybody in the ecosystem benefits from the arts. Individuals and communities benefit from the arts on both physiological and psychological levels.Art, as a form of expression and release, has been used to combat depression and reduce stress. Moreover, exposure to creative endeavors makes people more open and tolerant of other people's views and opinions. Using of arts can be an effective way of uniting individuals of contrasting cultures and improving their understanding of and communication with one another. Attachments Program Budget(Income & Expenses) Certificate of Understanding Conflict Disclosure East Hawaii Cultural Council-EHCC Out of Doors I Page 3 Progr Budget Form: Inc. , ie County of Hawai`i 0 Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: East Hawaii Cultural Council Program Name:EHCC Out of Doors CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 20,000 20,000 Applicant organizational budget: Individual contributions 2,500 0 2,500 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets 0 0 0 , Other funding sources (list below): Total Cash Income 22,500 0 22,500 IN-KIND CONTRIBUTION Anticipated Committed Total 0 10,750 10,750 Total In-Kind Contributions 0 10,750 10,750 TOTAL PROGRAM INCOME 22,500 10,750 33 250 Appendix D--Budget Sheets (Page 2 of 2) Project Budget For a: Expenses County of Hawaii G Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:East Hawaii Cultural Council Program Name:EHCC Out of Doors Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 5,500 2,500 5,750 13,750 Professional Fees 12,500 0 0 12,500 Operations 0 0 5,000 5,000 Supplies 700 0 0 700 Equipment 1,300 0 0 1,300 SUBTOTAL 20,000 2,500 10,750 33,250 TOTAL PROGRAM BUDGET 20,000 2,500 10,750 33,250 County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: 'E-0-5`1^ kava i lk-hc-( C ,,,-,61 Program Name: .E.NC.G ocA of 7:1)60(5 C- on i f Und 'rstandrng (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 unrestrictedaccess 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, l"(we) understandand will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receivingpayment(s). To register, go to htt 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 suppo' ed 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 County of Hawaii Nonprofit Grant Application FY 202/-23 Agency Name: 1:-.A1-- Ci-Aurc-1-% Program Name: cx of D6ors Certification d Underst•indiEng (Page 2 of 2) If awarded a grant from the County of Hawari, 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 rant funds received =curin: the :rant 'eriod must be refunded to Coun. , and exclusion from future grant participation for a :urn 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 sub =:It the final report Information and instructions are available at http://www.hawaiicanatia9v/fn-nosprofit-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 30,2023 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. Cadt-t-e (4) WeStiz),_ col oayy Signature of Authorized Person •Date • ay-AA r Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: \--ko.‘atu C-Ak-u-re-%-\ Co cc- Program Name: E-OCC Ook- c Door-5 RGANIZATION CONFLICT !DISCLOSURE FOR:‘ 1 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): 0 Member or members of the Council 0 Staff appointed by a member of the Council 0 The Mayor 0 The Managing Director 0 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. • conflicts olenafsliectsofnte specifyinterest:rneysta:nd all mitigation measures tp avoid, in fact or appearance, any conflicts or potential • If no conflicts exist, check here. . . . . . • . • East Hawaii Cultural Council EHCC Lecture Series 56 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: East Hawaii Cultural Council Contact Person: Lawrence Butler Contact Email: (butler@ehcc.org Contact Phone: 240-988-2367 Program Information Program Name: EHCC Lecture Series Program Years in Operation: 1 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo`o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki`o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O`okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, PuakO, Pualaa, 'Umikoa, Volcano, Waikoloa Village,Waimea, Wainaku, Wai'ohinu,Weloka,Since lectures are posted on YouTube they can reach everyone,wherever they live. Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Culture and the arts, Public health and welfare of the people and the environment, Physical/Emotional Disabilities Amount Applying For:$5000 East Hawaii Cultural Council-EHCC Lecture Series I Page 1 Program Details Organization Mission: Our mission is to give voice to the cultural and artistic expressions of our island's diverse communities. We have served E. Hawaii since 1967; some of our programs are 30+years old. We have 3 pillars: 1) Gallery exhibits accompanied by a lecture series; (2) Performing arts including plays, music and multimedia, with a pandemic-friendly outdoor stage; and (3) Arts education targeted primarily to youth that offers after-school classes, day camps,workshops, and print and ceramics studios. Program Overview: EHCC gives public lectures related to our gallery programming approximately 1x/month. Most are offered via Zoom to enable live participation despite the pandemic. Others, such as gallery walk-throughs with artists/experts, are videotaped and edited. All lectures are uploaded to YouTube so that the public can enjoy them on demand.The lectures have 3 goals:to enrich our gallery program by giving exhibiting artists a forum; to contextualize EHCC's gallery, music, and education programs through historical lectures; and to give community partners and cultural activists a forum to discuss their relationship to the arts. If pandemic restrictions end, we will host future events with in- person audiences, but will continue to record and upload the lectures.Through this program we connect the arts to larger societal concerns—Hawai'ian cultural activism,the environment, and access to the arts for the disabled. We add a historical dimension to our activities through art history lectures. Program Objectives & Performances Resources Needed: Program management to identify and schedule lecturers with topics that dovetail with other EHCC activities. Participation by artists and experts in the community to deliver lectures. Funds to offer honoraria to speakers Administrative support to arrange Zoom meetings,take sign-ups, send links, upload material to YouTube, etc. Skilled manpower to videotape and edit recorded lectures Computer, camcorder, software and related peripherals to enable production of high quality videos Funds to pay for skilled editing Major Activities to be Completed: EHCC will conduct a lecture series through Zoom meetings, recorded videos, and (if pandemic restrictions ease) with in-person audiences. If in-person events resume, these will be recorded, so that all lectures are available on demand through YouTube.The core program will consist of talks with artists exhibiting in the EHCC gallery. However,the availability of funds to pay honoraria will enable EHCC to expand its offerings to cover a wider range of speakers.We will focus on inclusive programming, featuring speakers who represent Native Hawaiian, other ethnic, women, and LGBTQ communities, and persons with disabilities.We will publicize upcoming events through our digital mailing list of nearly 1,000 names (and growing). While our main focus is art and culture,we will East Hawaii Cultural Council-EHCC Lecture Series I Page 2 seek out speakers who can relate this focus to contexts such as environment, community development, social justice, and history. Outputs to be Completed:A minimum of 8 lectures by paid speakers A minimum of 4 lectures by volunteers A minimum of 12 lectures uploaded to YouTube A minimum of 30 views per lecture within 1 week of posting A minimum of 600 total views (a number that will continue to climb indefinitely) by the end of the project period Measurable Outcomes: Outcomes will include increased knowledge about specific art-related topics. Members of groups to whom we give voice will feel an increased sense of pride in their culture and will feel acknowledged by the wider community. Because the program will give speakers an outlet to share their original thoughts, it will result in the research and development of art and cultural ideas. Presentations by lecturers from a variety of backgrounds will help individuals from different communities to respect and value the contributions of others. Attachments Program Budget(Income & Expenses) Certificate of Understanding Conflict Disclosure East Hawaii Cultural Council-EHCC Lecture Series Page 3 Program Budget For: income County of Hawai'i m Nonprofit Grantin-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:East Hawai'i Cultural Council ProgramName:8D18:LeOtUD3Seri8S CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 5'000 5.800 Applicant organizational budget: Individual contributions O 0 0 Membership fees 0 0 0 Earned income ' 0 0 0 Current cash assets ` 0 600 660 Other funding sources (list below): Total Cash Income 5,000 660 5660 IN-KIND CONTRIBUTION Anticipated . Committed Total 0 6,840 6,840 Total In-Kind Contributions 0 8,840 8`840 TOTAL PROGRAM INCOME 5'000 7.500 12,500 Appendix D--Budget Sheets (Page 2 of 2) Project 1: udget Form: Expenses County of Hawai'i 0 Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: East Hawai'i Cultural Council Program Name:Lecture Series Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 0 0 4440 4,440 Professional Fees 400 2,400 4,800 Operations 0 140 0 140 Supplies 0 0 0 Equipment 3,000 120 0 3,120 SUBTOTAL 5,000 660 6,840 12,500 TOTAL PROGRAM BUDGET 5,000 660 6,840 12,500 County of Hawai'i Nonprofit Grant Application FY 2022-23 Agency Name: ‘5*: 0,-AA/6-( CA-A.(11 rCocrJe, Program Name: e e s Cer t ification sf Underst.inding (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 Hawail, lqwe)understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to receivingpayment(s). To register, go to litt: vendors.ehawaii.:ov 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 a,. arding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Slawaill grant funds,and a listing of other funding sources and amounts obtained during the a vard period. Failure to submit a timely, complete, and accurate year-end report, usinqthe template provided, will impact the evaluation of your program's or agency's future funding requests. County of Hawai'i Nonprofit Grant Application FY 2022-23 Agency Name: (vs H ‘Al I:" et-t-':h'1"r(d Program Name: s +Was. Alait=ix CerlificArion of ' 'dersta: (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 ail 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 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 30,2023 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 aaency'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. ;a1-- Lk-Kr ,To a Signature of Authorized Person Date V • Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: L.---o.sk- haw k' CAIWurcu\ a 0 n Program Name: Le_d-w-e__ .3(.--!,v--.1e ORGANO 1,u,T1i*N CONFLOCT DOSCLOSUE 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 Hawaiii.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 0 Staff appointed by a member of the Council 0 The Mayor El The Managing Director • 0 The Director of Finance El 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 Io avoid, in fact or appearance, any conflicts or potential conflicts of interest: LT If no conflicts exist, check here. atx.ir g.7.- JAI/tau-Li Doa Sigalure of Authorized Person (specify title) • Date Educational Services Hawaii Foundation dba EPIC Foundation Imi 'Ike Learning Center at Hilo 57 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Educational Services Hawaii Foundation dba EPIC Foundation Contact Person: Kathie Ann Awaya Contact Email: k_awaya@epicfoundhawaii.org Contact Phone: 8089556100 Program Information Program Name: Imi 'Ike Learning Center at Hilo Program Years in Operation: On Hawaii Island for 3 years Other County grants/agreements: No Previously received County GIA: No Program Geographical Reach: 'Ainaloa, Fern Forest, Hakalau, Hawaiian Beaches, Hilo, Honomu, Honoka'a, Kalapana, Kea'au, Laupahoehoe, Mountain View, Pa'auilo, Pahoa, Papa'ikou, Pepe'ekeo, 'Umikoa,Wainaku,Weloka Program Target Audience: Play Age (3-5), School Age (6-11), Adolescence (12-17), Young Adulthood (18- 39) Services/Activities Provided: Educational concerns, Culture and the arts,Youth, Physical/Emotional Disabilities,Victims of Health or Social Crises Amount Applying For: $50000 Educational Services Hawaii Foundation dba EPIC Foundation-Imi 'Ike Learning Center at Hilo I Page 1 Program Details Organization Mission: Established in 2004, we are singular in our mission, and that is to ensure that all children,youth,young adults have equal access to a quality education that opens doors to a purposeful future.We accomplish this through a complement of services including intensive instruction and tutoring in all academic areas, out of school time intersession and after school programs, mentoring and advocacy.Outcomes are focused on improving academic skills,graduation rates and post high school opportunities Program Overview:The Project provides a proven approach to implementing an out of school learning environnment to a targeted popluation of learners--students aged 4 years through college currently or formerly in foster, kinship, shelter or residential care. Our highly skilled and qualified tutors and instructors understand the social and emotional needs of each individual student within the context of his/her life histories and current situations.The academic instruction,available both in-person and virtually, is individualized for that particular student's need and is paced accordingly. Instruction is informed by baseline standarized assessment in both reading and math and the development of an individualized educational plan. Interim assessments of targeted skills are administered routinely. A post test is administered annually or when learning goals are achieved.Enrichment activities and intersession programs supplement the academic instruction.Satisfaction surveys provide feedback to the Project. Program Objectives & Performances Resources Needed:The following resources are necessary to carry out the goals and objectives of the 'Imi 'Ike Learning Centers: -A physical primary learning center -Satellite learning centers - Highly qualified and trained staff that includes Project Director, Educational Coordinator, tutors and instructors -Staff training and professional development opportunities -Focused and evidence based curriculum -Educational website subscriptions -Testing licenses -Database -Program specific supplies -Maintenance supplies -Telecommunication systems -Equipment for student use -Equipment for learning center use -Transportation (van or chartered bus)for place-based learning for students -Insurance -Adequate funding Educational Services Hawaii Foundation dba EPIC Foundation-Imi 'Ike Learning Center at Hilo I Page 2 --Collaboration with stakeholders --Student enrollment Major Activities to be Completed: --Educational Coordinator(EC) and Project Director(PD) will outreach into the communities for recruiting students, will establish and upkeep a fully operational leaning center that includes furnishings and technology conducive to student achievement, will develop satellite sites as the need arises, will maintain an efficient database to capture all relevant data including student demographics, attendance, testing, progess,group activities,family engagement activities, all ouput and outcome measures particularly as related to grantor specifications and reporting.--EC will enroll and do orientation to the Project with all students and their caregivers and schedule tutoring sessions.--EC and staff tutors will tutor students a minimum of twice per week,design educational plans, administer pre and post tests, interim assessments, record data, maintain communication with caregivers.-Instructors will design and implement enrichment and intersession programs to supplement tutoring. Outputs to be Completed: 1 fully equipped/operational learning center; satellite sites as needed in the community to increase accessibility;50 students, ages 4 to college, currently or formerly in foster, kith, kinship, residential, shelter care enrolled and participating in Project services;40 orientation sessions with students and caregivers;100 baseline and post standards based assessments to measure progress in targeted skills;50 individualized educational plans;200 interim assessments of targeted skills to to inform instruction and determine progress toward measureable objectives; Minimum 2500 tutoring hours (intensive instruction in reading, writing, math and/or course content); in-person or virtual; 4 half day project based intersession programs.Fall &Spring--1 week; Winter--2 weeks and Summer-4 weeks; 6 four session enrichment classes, Saturdays or after school; 50 Project satisfaction surveys completed by students and 45 by caregivers.; 100 written progress reports disseminated to caregivers Measurable Outcomes:-95%of students who participate in Project services will be promoted to the next school grade by the end of the school year or by the end of the summer of that same school year. -95%of students who participate in academic tutoring will demonstrate after 32 hours of instruction an increase in the identified academic skill,typically reading, writing, math based on curriculum based measurements. -100%of students in their senior year will graduate on time. -100%of students enrolled within the first 6 months of the Project and seeking to complete an alternative high school credential such as GED and HiCore will do so by the end of the Project year. -95%of students who participate in enrichment classes and intersession programs will show improvement in targeted skill develpment based on pre and post assessments, portfolio or activity specific rubrics. Educational Services Hawaii Foundation dba EPIC Foundation-Imi 'Ike Learning Center at Hilo Page 3 Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Educational Services Hawaii Foundation dba EPIC Foundation-Imi 'Ike Learning Center at Hilo I Page 4 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Educational Services Hawaii Foundation dba EPIC Foundation Program Name:'Imi 'Ike Learning Center CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50,000.00 50,000.00 Applicant organizational budget: 15,000.00 15,000.00 Individual contributions Membership fees 00 00 Earned income 00 00 Current cash assets 00 00 Other funding sources (list below): Office of Hawaiian Affairs-Solicitation in March 2021 40,000.00 40,000.00 Friends of Hawaii Charities-proposal submitted 5000.00 5,000.00 Total Cash Income 95,000.00 15,000.00 110,00.00 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 95,000.00 15,000.00 110,00.00 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses `County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Educational Services Hawaii Foundation dba EPIC Foundation ;Program Name:'Imi'Ike Learning Center at Hilo Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 39,200.00 47,200.00 86,400.00 Professional Fees 00.00 00.00 00.00 Operations 10,800.00 10,800.00 21,600.00 Supplies 00.00 2,000.00 2000.00 Equipment 00.00 00.00 00.00 SUBTOTAL 50,000.00 60,000.00 TOTAL PROGRAM BUDGET 110,000.00 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Educational Services Hawaii Foundation Program Name: 'Imi 'Ike Learning Center at Hilo 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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Educational Services Hawai`i Foundation Program Name: 'Imi 'Ike Learning Center at Hilo 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, 2023 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. 1/27/2022 Signature of Authorized Person Date Executive Director Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Educational Services Hawai`i Foundation Program Name: 'Imi 'Ike Learning Center at 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 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: Kathie Awaya 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 n 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: ❑ If no conflicts exist, check here. 1/27/2022 Signature of Authorized Person (specify title) Date Five Mountains Hawaii On-Board Psychologist 61 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Five Mountains Hawaii Contact Person: Claren Kealoha-Beaudet Contact Email: clarenk@aol.com Contact Phone: 8089377171 Program Information Program Name: On-Board Psychologist Program Years in Operation: 8 years Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, Hawi, Honoka'a, Kailua-Kona, Kapa'au, Kuki'o, Kukuihaele, Laupahoehoe, 'O'okala, Pa'auhau, Pa'auilo, Puako, 'Umikoa,Waikoloa Village,Waimea Program Target Audience: Play Age (3-5), School Age (6-11), Adolescence (12-17),Young Adulthood (18- 39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Physical/Emotional Disabilities, Victims of Crimes,Victims of Health or Social Crises Amount Applying For: $50000 Five Mountains Hawaii-On-Board Psychologist I Page 1 Program Details Organization Mission: Five Mountains Hawaii Inc, dba Kipuka o ke Ola (KOKO), is a 501c3 non-profit. Mission Statement: KOKO provides cultural, spiritual, medical, and psychological services to all residents of North Hawai'i with a special emphasis for the Kanaka Maoli (Native Hawaiians). Vision Statement: The Native Hawaiians living in North Hawaii will enjoy the highest quality of comprehensive healthcare from prenatal to end of life. Program Overview: Due to significant shortages in behavioral health providers and their related services KOKO would like to hire a full-time Psychologist. Since COVID's emergence in March 2020,the increased demand and immediate need for additional mental health services has grown exponentially.The most troublesome shift our healthcare providers regularly manage now is the distress in the family systems- seeing increasingly unhealthy, escalating, and even violent outcomes within families;the increase in domestic violence, child abuse and neglect, substance abuse, poor academic performance, loss of employment and financial security, depression, and anxiety are all well documented, locally and nationally. KOKO currently has two part-time Psychologists with full caseloads and carry substantial patient waitlists. Adding a full-time psychologist KOKO would in effect be doubling KOKO's capacity to provide mental health services to North Hawaii and the island. Program Objectives & Performances Resources Needed: Administrative time to recruit, interview and on-board a new Clinical Psychologist. Provide a budget for relocation expenses should that be required. Advise HR company and put together benefits package for new hire. Purchase computers,furniture and equipment appropriate for a Behavioral Health Office. Purchase a Battery of Psychological Assessment Tests. Print and social media communication to effectively reach out to community and advise of new Behavioral Support available to community. Approximately$80,000 in capitol to cover initial ramp up cost of salary and start up expenses before medical insurance reimbursables are sufficient enough to sustain full time provider employment. Major Activities to be Completed:The on-boarded clinical psychologist will incrementally build a patient panel over the course of eight months until reaching full capacity.At full-capacity,the clinical psychologist will be conducting 35 clinical sessions per week, with approximately 250 patients on their patient panel. This will help to address the shortage currently experienced in the community. Outputs to be Completed: 250 community members between the ages of 5 and beyond in need of mental health services. Those receiving mental health services will hopefully impact the stability and well being of their individual family systems, places of employment, and over all communities. The goal is to help provide stabilization of community post COVID. Five Mountains Hawaii-On-Board Psychologist I Page 2 Measurable Outcomes: Prior to each behavioral health session,the patient completes an industry standard brief depression screen (Patient Health Questionnaire-9) and an anxiety screen (Generalized Anxiety Disorder-7).The results of these screens are tabulated and tracked over the course of treatment. The goal is to help patients attain a non-clinically elevated scale on the symptoms of Anxiety and or Depression which generally underlies all mental health conditions. Attachments Program Budget(Income & Expenses) Certificate of Understanding Conflict Disclosure Five Mountains Hawaii-On-Board Psychologist Page 3 Program Budget Form: Income County of Hawaii ® Nonprofit Grant-in-Aid (Waiwai Grant)—Fiscal Year 2022-2023 Organization Name: jc, MovAtin5 .4-b4AAAAL Program Name: Ov't e'? ' 'i *5 CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) c , ' 1, " , pa 03 Applicant organizational budget: Individual contributions Membership fees Earned income r 4 C1, )� ll k 'R Current cash assets Other funding sources (list below): c i I DV, V. n MAO tti I n D1 >t cT F kf , 1.111. 7?1- ) '713ti 4-0 � C < 1 . i � t; A. m t 7)c, trDia ' { Sr t , 2 . 7.x ) , � 1l Total Cash income 11" ' ,r I 1. t. l gli,q12 - - 21101/ !Win IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME " , 411 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawai`i * Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Program Name: Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 50/t -Trik-INt 05,702)4 - Professional Fees Operations / Oilthcifj 6100 • if‘k) ( 0(i )-4 Supplies S Equipment SUBTOTAL tet- fl) 4 tti ;70.i24. TOTAL PROGRAM BUDGET 1743/10". 4" County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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:J/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. County of Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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. 1 (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.govifn-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, 2023 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. 941 gifSignature of Authorized Person Date ( O - LLI.rt4W l? • Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23olcat,o q Agency Name: +-i V Program Name: z; a `"� • RGANIZATION 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 I The Director of Finance U 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: 171 If no conflicts exist, check here. 660 f3fi Signature of Authorized Person (specify title) Date Friends of the Children's Justice Center of East Hawaii Special Needs, Enhancement, Support, Education &Training 64 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Friends of the Children's Justice Center of East Hawaii Contact Person: Robin Benedict Contact Email:fcjceh@fcjceh.org Contact Phone: 808-935-8755 Program Information Program Name: Special Needs, Enhancement, Support, Education &Training Program Years in Operation: 32 years Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Honoka'a, Kalapana, Kapoho, Kaueleau, Kea'au, Kurtistown, Laupahoehoe, Leilani Estates, Mountain View, Na'alehu, Nanawale Estates, Ninole, `O`okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, 'Umikoa,Volcano, Wainaku,Wai'ohinu, Weloka, Our service area is East Hawaii- from Honokaa to Pahoa, N and S Hilo, & part Ka'u Program Target Audience: Infancy (0-3), Play Age (3-5), School Age (6-11), Adolescence (12-17) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth, Physical/Emotional Disabilities,Victims of Crimes,Victims of Health or Social Crises Amount Applying For: $7500 Friends of the Children's Justice Center of East Hawaii-Special Needs, Enhancement,Support, Education& Training Page 1 Program Details Organization Mission: 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. Program Overview:The Friends serve child victims of abuse, residing in East Hawaii, between the ages of Oto less than 18, and up to 21 who attend high school and are in voluntary foster care. Components of the program: "Special Needs and Enhancement" is designed to help child victims develop positive self-worth. Funds are used to provide basic essentials (i.e. clothing, hygiene items, beds, bedding), special needs (i.e. school supplies, correspondence courses, remote learning tools,therapeutic tools) and enhancement support(i.e. sports, music, dance lessons, art). "Center Support" ensures the safety and comfort of the children that come to the Children's Justice Center for interviews, with toys, games and snacks. "Prevention and Education" plans events promoting awareness and prevention of child abuse. "Training" helps to support the attendance of various professionals at seminars and conferences to learn state-of-the-art interviewing techniques. Program Objectives & Performances Resources Needed:The program has seen a significant shift in office operations, since the beginning of COVID.The Program requires a full-time staff person, 6 volunteers, 10 Board of Directors, and the need to hire an additional part-time staff person. Staff and volunteers run program administration, data collection and outreach activities. Virtual meeting partnerships for community outreach events to bring awareness to child abuse prevention. Community projects that solicit public participation, in an activity that supports child abuse victims, and brings child abuse prevention awareness. Ongoing communication avenues to network with partner agencies to build positive relationships, and to encourage submittal of"Special Needs Requests". Foundation grants, corporate donations, and special event income to supply funding to run our program,fill special needs requests, and promote child abuse awareness. Major Activities to be Completed: Provide funds for clothing, hygiene items, bed/mattress and other necessities for children in emergency or relative foster placement. Provide funds for tutoring, correspondence courses or summer school to allow a child to graduate or progress to the next grade level. Provide funds for children to participate in supervised spring and winter intersession activities, or summer camps. Friends of the Children's Justice Center of East Hawaii-Special Needs, Enhancement,Support, Education& Training Page 2 Pay for fees, equipment and supplies needed for extracurricular activities Provide funds for holiday or birthday gifts when a child would otherwise not receive a gift. Pay for event fees to give a student a chance to participate in school functions. Support the training of professionals to keep up to date with the latest investigative techniques. Provide privacy, comfort and safety at the Children's Justice Center. Participate in community education activities to increase child abuse awareness. Outputs to be Completed:The FCJCEH currently has a 10 member, all volunteer Board of Directors, a full-time Program Coordinator and 6 volunteers to implement the Emergency and Special Needs, Support, Education &Training Program.Through multiple grants, the Phantom mail-out, and donations, funds and staffing will be available to fill requests for abused and neglected children. In 2021 the Friends filled 931 request for 429 unduplicated children Due to the uncertainty of the COVID-19 pandemic,the Friends anticipate our output to remain the same,filling approximately 930 requests that support approximately 430 child victims of abuse. Outcome evaluation data is anticipated at 98% participant participation, as our request form has been updated to capture this information. Participants will report an increase in self-esteem, positive impacts on physical & mental health, increased school performance, and reduced family stress. Measurable Outcomes:The Friends of the Children's Justice Center of East Hawaii (FCJCEH) utilize outcome measurement data to evaluate the impact of our program and to solicit feedback from our fund recipients,their foster parents/families and referring professionals,to find out how funding impacted children. The FCJCEH requests evaluation response data with each processed request. In 2021 the top five most widely selected categories of impact on a child's life were "Self Esteem and Self Confidence", "Physical Health", "Family Stress", "Mental Health", and "School/Academic Performance". In 2022 outcome data and comment will be collected on the special need request form. Feedback from participants is important to us. In addition to the above information received through the evaluation data, we also receive notes from children and their families throughout the year. It is rewarding to know that the Friends is fulfilling our mission by successfully helping child victims of abuse. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Friends of the Children's Justice Center of East Hawaii-Special Needs, Enhancement,Support, Education& Training Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)—Fiscal Year 2022-2023 Organization Name:Friends of the Children's Justice Center of East Hawaii Program Name:Special Needs, Enhancement, Support, Education & Training Program CASH Anticipated Committed - Total County Nonprofit Grant-in-Aid(Waiwai Grant) 7,500 7,500 Applicant organizational budget: Individual contributions 36,550 36,550 Membership fees 0 0 Earned income 0 0 Current cash assets 10,350 10,350 Other funding sources(list below): Foundations 100,000 100,000 Corporate donations&grants 15,400 15,400 Special Events 40,000 40,000. HIUW 5,000 5,000 Total Cash Income 214,800 - 214,800 IN-KIND CONTRIBUTION Anticipated Committed Total Total in-Kind Contributions 0 0 0, TOTAL PROGRAM INCOME 214,800 0 214,800. Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)—Fiscal Year 2022-2023 Organization Name:Friends of the Children's Justice Center of East Hawaii Program Name:Special Needs, Enhancement, Support, Education &Training Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 67,200 67,200 Professional Fees 10,600 10,600 Operations 750 13,350 14,100 Supplies Equipment 0 Special Needs Request 3,750 115,750 119,500 CJC Center Support 500 0 500 Education&Community 2,000 100 2,100 Volunteer Expense 500 300 800 SUBTOTAL TOTAL PROGRAM BUDGET 7,500 207,300 . 0 214,800 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Ft v ds QA 1 \e' Ch'16jet ns 3`v s+ + c v\i l g Y Program Name: _ecial kkids,Enbanurnvnt S rF, atcykijonlcpIrccintnal 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 Fund: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 pubic according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County per sonnel 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. County of Hawai`i N nprofit Grant Application FY 2022-23 Agency Name: t=-r-ercls o� - �- Chila �eXs Tug s -Hv c �►i Program Name:G?eC+oal Weds, ink ncarl,eAlt, sport-, Fsitkco4ion Trci- ni n9 I 455 la Certification of Understanding (Pav,2 of 2) If awarded a grant from the County o`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 receivinc any payment(s). I (we) understand that failure to sul:.. 1;t the final report within 60 days if June 30th shall result in loss of all grant funds received during tl-se 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. 1 (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at httpJ'i:ayra.f.ri w.Vali:o°,,nz . o).119_nonEoi`i_ rant-iorrn1 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, 2023 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. • / aG z0�z Signature of Authorized Person Date lR tS‘bck Title/Position of Authorized Person • County of flawai‘i Nonprofit Grant Application FY 2022-23 Fr c &(-• .Agency Name: - I r Program Name: ec-'143- (iS ED1-)041ce.ftmten ,7(),192(,),r h Er.uc1 Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, (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 indicatesthat 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 -rant funds received during the :rant zeriod must be refunded to Count and exclusion from future grant particioation for a minimum of one year or until a written re.ort is submitted to and accepted by,the council. 1 (we) understand there is no provision for further notification to submit the'final report. Information and instructions are available at htt)://www,Fla%,w;iicf:J>Jttty,2cvlin-ricitipmfit- iorny2Z 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, 2023 must be returned to the County of Hawaii with the final report. Failure tcII-etuatiselocis in a timely manner will impact the evaluation of your agency's future fundina 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. , N Signature of Aut orized Person Date Title/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Ti-�ends o-C -+her Cha�dret-�s 4 ►c Ce 4e►— -st ( Program Name: Weec s; EbharxsmQn}'> 5 off, mn Trr,nn n 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: MA}RCIA M Ppc g POSITION: 30Arkb csax / 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 ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substartJal 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. coq �R �phi //2,e, 2ozZ- S,,nature o Authorized Person (specify title) Date County of Hawaii Nonprofit Grant Application FY 2072-23 „, On\IAA-Qv-1's. Cc— art e-r— —440,ANc----u. • Agency Name: v. , . r Program Nanie:`-------717e4°1 fl --721 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 Hawaiii. 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): ri Member or members of the Council Staff appointed by a member of the Council 0. The Mayor [J 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 on individual will result in measurable direct benefits accruing to the individual os 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: 19--- If no conflicts exist, check here. V e 2020 Signature of Authorized Person (specify title) Date Friends of the Palace Theater Annual Musical 66 County of Hawrai`i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Friends of the Palace Theater Contact Person: Phillips Payson Contact Email: phillips.payson@gmail.com Contact Phone: 808-934-7120 Program Information Program Name:Annual Musical Program Years in Operation: 19 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Hilo Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Culture and the arts Amount Applying For: $10000 Friends of the Palace Theater-Annual Musical I Page 1 Program Details Organization Mission: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. Program Overview:The Annual Musical is the signature event and biggest fundraiser of the year for the Palace Theater. Proceeds from this event provide operational funding to the Palace Theater for several months each year. Each year for the last 19 years,the Palace Theater has presented a professional - quality Broadway Musical Theater production lasting over 3 weekends. Staff, Board members and volunteers dedicate months to preparation and rehearsal for the production. Excitement about the event increases over these months, as the news spreads by word of mouth. This popular event attracts the residents of East Hawaii, along with visitors from the mainland, who frequently make their vacation plans around the Annual Musical.The Palace Theater is an excellent venue for this kind of production, and the event provides an opportunity for local artists to highlight the local talent and vibrant arts community in East Hawaii. Program Objectives & Performances Resources Needed: Board members and Staff to decide which musical will be presented. Musical rights-must be acquired and paid for Technology experts-for lighting, sound, and Livestreaming Equipment-for lighting, sound, and Livestreaming Professional fees for Director and technicians, plus funds for sets, costumes, printed marketing material Volunteers to help design sets and costumes, help to market the event, and to be ushers and cafe workers during the event Funds to maintain operations during the planning and production of the event Major Activities to be Completed:The production of the Annual Musical is a collaboration among Board members, office and technical staff, and volunteers. Board members and the Executive Director decide on the musical to be presented, and the rights then have to be acquired.Volunteers are sought to build the sets and design the costumes.Auditions for each part are held over several weeks. Rehearsals are then held several times a week. Marketing materials are prepared, and volunteers assist with the distribution of flyers.The event is promoted on social media, on the radio, and newspapers. Businesses in the local community are approached to become sponsors. During the event,volunteers staff the theater's cafe, and act as ushers. Board members greet patrons before and after the show to solicit feedback. Outputs to be Completed: $10,000 increase in annual revenue from ticket sales Increase in audience participation from targeted marketing to potential patrons outside of the local area. = 60 patrons Friends of the Palace Theater-Annual Musical I Page 2 20 new performers added to pool of local talent 5 new community organizations that rent the theater as a result of seeing it as a venue for large events 2 new local businesses that sponsor the event 60 volunteers with 240 hours served 10% increased efficacy of virtual platform for theater events Measurable Outcomes: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. The common theme for all Palace productions is the preservation of Hawaiian culture through the encouragement and support of local artists.The Musical at the Palace Theater provides an opportunity for artists to highlight the vitality of the talent and the arts scene in Hilo, . Another outcome desired is for the Palace Theater to continue to be an economic driver of the health of the downtown business area, attracting more patrons and business activity through its diverse programs, like the Annual Musical..These outcomes are measured quantitatively by tracking attendance and monitoring uptakes on social media and the website, and qualitatively through surveys and direct discussions with patrons and performers. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Friends of the Palace Theater-Annual Musical I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Friends of the Palace Theater Program Name:Annual Musical CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 10,000 10,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets 5,000 5,000 Other funding sources (list below): Box Office 11,000 11,000 Sponsor Donations 5,000 5,000 Cafe/Bar 2,000 2,000 Total Cash Income 23,000 10,000 33,000 IN-KIND CONTRIBUTION Anticipated Committed Total In-kind marketing 1,000 1,000 Total In-Kind Contributions 11,000 TOTAL PROGRAM INCOME 23,000 11,000 34,000 Appendix D--Budget Sheets (Page 2 of 2) !Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Friends of the Palace Theater Program Name:Annual Musical Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 5000 5000 Professional Fees 3000 3000 Operations 3000 3000 Supplies 2500 2500 Equipment Musical Rights 3500 3500 Live Streaming equip/operator 1000 4000 5000 Sets, Props and Costumes 2500 2500 Sound/Lighting Equip/Technician: 3500 3500 Marketing 5000 1000 6000 SUBTOTAL 10,000 23,000 1,000 34,000 TOTAL PROGRAM BUDGET 10,000 23,000 1,000 34,000 -53s.?nrfai ,u!pun Y./Ivry 5, xraor•JQ Y,wfxr•Qi• J 0 uurprituna 430,WI Him .papytaly, 41iatua4 ato Yu's:7'210J 0.1(1D-.10011 atzunxv PUC'a.lafOrtuo,-mawg ptuclos 01 Wa1101 -poyad pieme 04upop pau!elqo slonatue pue saJitios ilutpurqiaqlo jo ifupsij e pue'spunj weal, memeti 1,0 Alunop Aq poddns sairmpuadxahR o 2upunopae alaidtuo)e IsaLuonno eigeolseatu a)upd s uo Itutsn3o1)wet! 44 jo2ulpiemeatflwoJj paAtsap sagettaq 3llqnfl aqt jo uogeuerixa ue epnpu!iteqs paplAcud1Wa442tqsn Et/octal aqi-papieme SeNN 01.0 tpp-im TO1 3-05.74.lenpelluo3 4144 jo OEaunt Jaile ep 09 u!qi!m unoj a qz o Uodzu pua-JeaA e 41.uqns luawa)giOril-affq4!m,Aidtuo ULM pue persiapun(am) 1,ierviefi jo Alunco aqi VJOAj greS57-1 'puez."it,pao e auf,sn auquo aaj uone.u.siZal ienuue 44 Aed pue 1ssaawd dari-Aq-chw Asea aq4 Naiduloa.•Ao*!tv.metio'-.j pt,a,',„/:,:441.1 olo2 ‘Jalsi9a;01, -(s)luaulAed 2ulAtaaalo Jotid 4uelidtuo)aq pue ssaJox3 aauelidtuoj LtemeH quit%licuua 4uatuaitnba3;41 qmAA.Aidusoa pue puelsiapun(am) jo AzunoD aqi.11404 lueJS e papier .sluaturoop ieuppo se pdlddazle zq t1 wm 5ittewt-pop peK10:,„It)paxe -paunenbslp aq sluaLun3op pau2!suri'auaturoop cos IVNI9IVO 041 dq Isnuu aunleutip lualfro e gup!nbaJ sik.tauimop tie 4eqt pue4.s.lapun(am) leilltuqrts ol Jopd aIe3n3De pue a;alduJo) sJC sluaLunuop fie leql a.insuaoi 4 qsuodsa ijnaAeu; wtl pue leutwqnslue.0 lijoiduoN Alunop Jr10 2uteitaaad lauttosiad Alunop Aq pamagAal aq 20U UVpm suoge-mdde pueiveptin (CM) t •selmeis pas!Aeli '.4Z5 ialdeup o 1.11„ra.t000e atiqdd apew eq lieqs tqe,lett paftddns tiot4euilo/ut 4241 puelsiapurc(am)i -met olluerts)dd(s)kuogoid aqz JaIslutuipe Anja4 Amqe pue Aipoqzne aq-laAeq(am)i4eul pue pallop 'sluawroop 2upoddns lie 2utpripu! cuplau pauddas uogetuiolu!leq1.49.1aa Aqe)aq(Cm) .pasn aidlok spun;qa!qm.JOJ we,t5oid JO(1324110D')„ue..0 ato oluaupiad spAoaa,ic AVadoid lluatudoba 'fLivej due padsuf pue.aup.uexa A;poqine pue ssaDe palap1Sam,an pue {Auk 4q2qs-tar\oputpuadxa JO'amieluasaida.4 paunoD paie.urzap'a3ueut4 jo luaLupedaa at.p.'Jollpnv amleispai aul)AlunoD attl mow aafie(am) 'suorjezpie2J0 luoaduoN olspuni jo uogeydo,iddv o poj Awno !,lemeH —SET -z suopnas'5z apipv tJ pazepuew se sluawaJulbai A.Ingielunope ieasq pue'Suivodai'spit:11a)pue fsasnpaao.id pieme Lsuompuoo luck-:sluatha.o.nbai Alwqi8na auijo Ijpoois.lapun pue pea;aAel]OM/ (z oT aNed) ufpuel.siapun o uage3111pap :attleN 111U.TOid jmi o )(v3i.X..):aluEN ADuaBv EZ-ZZOExj olluoliddy ltivao TIJOICILK)ts,t !,I.13ANUI I JO /Clunop County of HawaiI Nonprofit, Grant Application FY 2022-23 Agency Name: frd NC5 o 'ME Rrx XL:7 Program Name: p icic 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.„C40,000 general liability,$50000 each occurrence)must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawari is an additional insured prior to receiving any dayrnent(s). (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(era minimum of one year or until d written r =ort-is submitted to and accented b the council. I(we)understand there is no proViSibri for further notification to submit the final report. Information and instructions are available at http://ww,%- iiçtrn.. ;,..).-iSii.,7grant,fa mil 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 30,2023 must be returned to the County of Hawai'i with the final report.Failure to return these funs in a trmelv manner will impact the evaluation of vow'Ogences future'undin re vest and may reMitt in act taken to recover these nds, Awards cannot provide funds for Capital improvements(cost of Construction,materials,insurance or securities)on Ovate properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. January 22. 2022 Signature of Authorized-Person Date Executive Director t lolPosition of Authorized Person County of Ilawai'i Nonprofit Grant Application FY 2022-23 Agency Name: FP.),5",2)s (-7,r- Program Name: i.giliviit_ imi).-s/(2 CIL_ 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. Al!disciontrre orcliess. vherherci conflict exists. NAME: POST tION: 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 O Staff appointed by a member of the Council O The Mayor Ej The Managing Director O The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of interest is defined as:o.)ubstontiof probability that asbnei token by 61T indivAiltal wif 1 rest in encostimbte direct benefit5 otrxtting to the inditolatioi as opposed to benefits occo....ino.in gener01 k an inOustry. Please specify any and all mitigation measures to avoid,in fact or appearance,any conflicts or potential conflicts of interest; Lii If no conflicts exist,check here, 7--- . January 22, 2022 C.- . A-,,,,--,--7 ret,...... --` EC:VT.11E- -TIrr/ccro.i.Q., • ry Signature of Authoriied Person(specify title) Date • Friends of the Palace Theater Hawaiian Roots Festivals of Talent 67 County of Flawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Friends of the Palace Theater Contact Person: Phillips Payson Contact Email: phillips.payson@hilopalace.com Contact Phone: 808-734-7120 Program Information Program Name: Hawaiian Roots Festivals of Talent Program Years in Operation:4 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Hilo Program Target Audience:Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Culture and the arts Amount Applying For: $15000 Friends of the Palace Theater-Hawaiian Roots Festivals of Talent' Page 1 Program Details Organization Mission: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." Program Overview: The 'Hawaiian Roots' program will consist of 5 concert events that will include headlining solo acts from top tier entertainers like Jake Shimubuku, a 3-day music festival to provide opportunities for lesser- known artists to showcase their talents, and a special "Home for the HiloDays" Christmas concert. These concert events will be a hybrid of in-person and virtual performances. A new virtual platform developed in 2020 has allowed presentation of"Live from the Empty Palace", a series of pre-recorded performances that are released weekly on the website.This series will continue to provide both established local talent and up-and-coming artists a professionally-produced video to use as a calling card. "Live from the Empty Palace" has been picked up by PBS, and will be broadcast on PBS Hawaii as well as streamed on their platform, accessible from around the world. Program Objectives & Performances Resources Needed: Staff to book and coordinate the artists Artists for the performance schedule;funds for artist fees Funds for Sound Engineer/videographer and equipment Volunteers for front of house management-cafe workers, ushers, etc. Funds for marketing Major Activities to be Completed:The Executive Director starts reaching out to artists at the beginning of the fiscal year. Once a potential line up is available, it is reviewed by the Board of Directors to ensure balance between well-known and up and coming artists. Travel arrangements are made for each artist, and dates scheduled,with an eye to maximizing attendance by scheduling during events that usually bring lots of patrons into the city. Marketing starts early in the fiscal year, -flyers and concierge cards are distributed through out the island. Each performance is videographed and live-streamed. Evaluation of each concert is undertaken by monitoring audience numbers and 'hits' on social media and the website. Outputs to be Completed: Outputs include: -10 new performers in the series Friends of the Palace Theater-Hawaiian Roots Festivals of Talentj Page 2 -10 new performers book playing gigs using their"Live from the Empty Palace" session as a reference -50 new patrons due to targeted marketing of each event -release of episode 100 of"Live from the Empty Palace" Measurable Outcomes:There is a wealth of talent in the Hilo area, and the Palace Theater is dedicated to preserving this for veteran performers, as well as for the up and coming arts students who have been inspired to follow in their footsteps. 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. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Friends of the Palace Theater-Hawaiian Roots Festivals of Talent I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Friends of the Palace Theater Program Name:Hawaiian Roots Festivals of Talent ................ CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 15,000 15,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Box Office 22,000 22,000 Cafe Sales 2,000 2,000 Total Cash Income 39,000 39,000 IN-KIND CONTRIBUTION Anticipated Committed Total In-Kind Marketing 1,000 1,000 In-kind Artist Travel Expenses 2,000 2,000 Total In-Kind Contributions 3,000 3,000 TOTAL PROGRAM INCOME 39,000 3,000 42,000 Appendix D--Budget Sheets (Page 2 of 2) ;Project Budget Form: Expenses County of Hawaii e Nonprofit Grant-in-Aid (Waiwai Grant) Fiscal Year 2022-2023 !Organization Name:Friends of the Palace Theater =Program Name:Hawaiian Roots Festivals of Talent Nonprofit Other Cash In-Kind Expense Description (Waiwai) r TOTAL Source Contribution Grant Salary Wages 3,500 3,500 Professional Fees Operations ' Supplies 1,500 1,500 Equipment Sound technician 2,500 2,500 5,000 Video/livestream/equiprrment/operE 1,500 3,500 5,000 Marketing 1,000 8,000 1,000 10,000 Artists fees/travel/accommodatior 10,000 5,000 2,000 17,000 SUBTOTAL 15,000 24,000 3,000 42,000 TOTAL PROGRAM BUDGET 15,000 24,000 3,000 42,000 Counts,' of HaweiNonprofit Grant Application FY 202%23 Agency Name: v1714-49c5 1 w Program Name: orlbq AS Rc:<,--P5 F7.6 1;144 65' -2714JEArr Certification of g fpno.a of 2) (we)have read and understood all of the eligibility requirements;grant conditions;award procedures; and records,reporting and fiscal accountability requirements as randated In Article 25,Sections 2- 135 135—2-142,1,Hawaii County Code,relating to Appr x ietion of Funds to NonprofitOrganizations_ I agree e to allow the County(the Legislative Auditor,the Department of Finance,designated Council representative,or expendingloversight agency)full, free,and unrestricted access and authority to examine and inspect any facility,equipment,property,or records pertinent to the: rant: 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 r the prograndsj pursuant to law, e understand that infor tin supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes, I(we)understand that applications will not be reviewed 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 subr i -l. I(wej understand that all documents requiring a current signature must bethe ORIGINAL„l.,SIGNED document.Unsigned documents will be disqualified,Faxed or copied documentswill not be accepted as original duen. If awarded rded grant from theCount r of Hawaii,I(we)understand and will comply with the rectuirement to enroll with Hawaii Compliance Fxpress and he compliant prior to receiving aaytent , To register, o to i cel oM :l -1,I,7, complete the easy step- .step process,and pay the annual registration fee online using credit card.. ifa�a ..�,grant fromthe Ro att ofHawaii I ,tee:understand and WillCOMOhe with the requirement to su r' _ r-end $,fo ; to the County Coundi within 60 clays after„lune 30 the contractual year for which the: ,,nt was awarded. re report,using the template provided,shall include an anation of e public benefits derived from awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures sup= by . of Hawaii grant funds,and a listing of other funding urces and amounts obtained during -e award period. Failure ta submit a rinieitspmplere, and.accurate . f-'nd re •rt' LtSi t he template pr id _o ll impact the evaluation� ti program's or t enc 's:uture funding reauests, • • • umed paztuoulniele LiO4r$CIdia4u, 4./7 , Oleo UOVAd pulustmv.10,s,uneuIS oe -szttawaitnba,4 psoto poo4kepue pe pew aAem tloklet.42-uPpaimouve Pie noot-rmoeci rkuluais Ntel q potikitme asiNumpo oseturt sotuodold alommi uo(sommos Jo eette,tnsui tiettezetu tuopenlisuOap 3S03)swoulattsmkut ieude3 spun).appieuti 4ouutO spieffimi 'spettj, Jai10:,,,e/.04.L144174 YCIOIPCP 41-1 4117.5a0 pu .4"tr. i"won.;wall .4na .o uopantatio aq.4,43.:4.w.imeti-Jouutau .10449 aJispu turtp916;W luotitt leuU,a44.414m.LtameHjo Autno3q4 olt-powniat q nut Etat tE aunt/kg peenun epurtt Amy'5.4soe p040 Pue aAP,e4sPntupe Jo;(7,AN) eel tuntutxeut e rn4deuxe''uotzeqcfds egg.ut pawls sesodlnd exp..ioj.pia J fitm papa sputt4 Au .10tp,.apaitpouli pelt Impsalidds situ p/Jed s np potiaJ tett";etp.issA atfuo.0E Ina,/ jo 77qolgenemae suogen4sut pu tiop.eUtiolut .3,JotiaJ jeu9 etr4.uutqns o usgseimou latipinl JOJuOismold su omilptitmaptin(am) ipUtlee 010.' :TN polio= pue pout lusaat ual;whve pun Jo isere-ii6ptureutulut 14117/614.6 tuTtuj.uotsrt.!.;xa pu um) paputois aq mut)pogtw . eta paitipai scturtl Ile pe sset ul linsw netts 440E atinf sAup 09 ultiwAlioda.,11 leuu,etpltugnso empej. pue4sJapun(aAA) 1s)pletuAsd Au s 9upgapat o loud painsut le uppippe uct t,tetAoH 4e-A4uno,utp leg;seltrutput Atha pue Alleuveds 14:11iim lueuipedaa eotteuii UIMH Jo Alum)st41 OpaptAcud as snut(eauatirtalo tpea 00Coss"Ameq leJotioa 000'000ft$) Almgen p aleat4pueo,wellnu e 4etp puelsispun(0.%)I LlemsH p hum°aq ut04 itie22 poi:memo It (Z 10 Z 02e4) utpuelsiapun o uogeawilaD :aLueN 1...tteawd :attiew Satiagy Ez- oz Ad uoilaa-Ifddy lump lijoaduoN jo ./Clunop County of Hawaii Nonprofit Grant Application i FY 202?-73 Agency Name:r /. 25- 0;''' -1-P:-: ,...1,7 c•,.././?c,.. 1,7-7'641-47.-,t, 1 • -,,, ,. ...,.._---- - _ _..... ,„ ,--. --, -,r-7-4 r-, - Program Name: 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 Hawaill 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 sit ned rewordiess o whether a con Uct egists, NAME: POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the followin(check all that apply): O Member or members of the Council O Staff appointed by a member of the Council ED The Mayor El The Managing,Director 0 The Director of Finance O The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:osubstonttat probabligy that action mken by on itrrfividual wit/resit in treasurable direct benefirr,accruing to the f-Pdividael q5 OPPosed to beftereSOCCran0 in Weir)/to w inct4stry. 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. Eel" "----) 7..,----Th 7 4 ,, ( , A--------, J c . ,,E,-i.---—, 4ikao--;:;;,,-r 7.44.,..:,7e5r,--, -----i wit's?:,4 ..-72,4; () i Signature of Authorized Person (specify title) Date om...i.... ..mF, „_,..„, .. , ,., — — ,.,............,. ..... .........,d..arv..,— ., Friends of the Palace Theater Youth Theater Program 68 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Friends of the Palace Theater Contact Person: Phillips Payson Contact Email: phillips.payson@hilopalace.com Contact Phone: 808-934-7120 Program Information Program Name:Youth Theater Program Program Years in Operation: 3 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Hilo Program Target Audience:School Age (6-11), Adolescence (12-17) Services/Activities Provided: Culture and the arts,Youth Amount Applying For:$10000 Friends of the Palace Theater-Youth Theater Program I Page 1 Program Details Organization Mission: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." Program Overview: This program involves a full-scale musical-theater presentation of a beloved children's theater classic, such as Beauty and the Beast. It involves acting, singing, dancing and stagecraft featuring up to 100 young performers from the age of 5 to 18.. Classes in audition technique, scene study, improv, singing, dancing and design are held for 2 weeks leading up to auditions for the cast.This is followed by a full production, with 6 weeks of rehearsals and 6 shows over 2 weekends. The program is overseen and directed by Larry Reitzer, a Board member with over 20 years experience touring, writing, producing and working on Broadway and in television for such shows as Spin City, and Ugly Betty. 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. Program Objectives & Performances Resources Needed:Staff and Board members to choose the Broadway performance to be presented Lighting and sound technicians and funds for their equipment Board members and staff to assist with auditions volunteers to oversee front of house activities during rehearsals and live shows Funds for marketing, honorariums for director and choreographer Major Activities to be Completed:The first step is to decide on the Broadway show to be presented. This is typically an agreement between staff, Board and Larry Reitzer, the Director and the local choreographer. Once a date is closen, participants are solicited via advertising, and auditions take place over the course of several weeks. Rehearsals are scheduled, and marketing is organized. Dress rehearsals take place with the sound and lighting technicians. Front of house staff and volunteers are engaged and ready for the live performances. Evaluation of the presentation is accomplished by direct Board contact with patrons, and via social media and website input. Outputs to be Completed: Outputs include: -up to 100 youth participating in the program -50-100 new youth engaged in the theater program -50-75 new patrons (families,friends,teachers, etc.) -90%satisfaction with the program and desire to continue it ( as judged by direct feedback from patrons, and via social media input. Friends of the Palace Theater-Youth Theater Program I Page 2 Measurable Outcomes: An understanding of arts and culture among youth plays an essential role in promoting sustainable social and economic development for future generations. Promoting creativity, collaborative effort, and motivations is a priority to finding solutions to today's challenges. The Youth Theater Program not only creates new opportunities for a broader engagement of children and their parents, but also serves to 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. Inspiring and encouraging the building of capacity in acting, dancing and singing as well as in the technical disciplines like lighting and sound, we will assure that there is the local talent necessary to sustain a robust and professional theater scene in Hilo for generations to come. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Friends of the Palace Theater-Youth Theater Program I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Friends of the Palace Theater Program Name:Youth Theater Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 10,000 10,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Box Office 10,000 10,000 Cafe Sales 1,000 1,000 Donor-designated funding 5,000 5,000 Total Cash Income 21,000 5,000 26,000 IN-KIND CONTRIBUTION Anticipated Committed Total In-kind marketing 2,000 2,000 Total In-Kind Contributions 2,000 TOTAL PROGRAM INCOME 21,000 7,000 28,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Friends of the Palace Theater Program Name:Youth Theater Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 3,000 3,000 Professional Fees 3,000 4,000 7,000 Operations 2,000 2,000 Supplies 3,000 3,000 Equipment Sets, costumes and props sound/lighting technicians and eq 5,000 5,000 Advertising and marketing 2,000 4,000 2,000 8,000 SUBTOTAL 10,000 16,000 2,000 28,000 TOTAL PROGRAM BUDGET 10,000 16,000 2,000 28,000 County 4Hawai'i Nonprofit Grant Application FY 2022-23 Agency Name: �p-g 1 p aSg Program Name: -3„ t -er 1 Cie-11;1?-411 Certification of Understd o Image i of I(we)have read and understood all of the eligibility napuircments;grant conditions;award procedures; and records,reporting,and fiscal arcountability requirements as mandated in Article 25,Sections tri 2-142.1,Hawaii County Code,relating to Appropriation of Funds to Nonprofit Organizations, (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'(w have the authority and ability to fully administerthe 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 thatapplications 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. It awarded a gram from the County of Newel,I (we)understand and will comply with the requirement to enroll with t4awai'i Corapjlance Express and be compliant prior to receiving payment(s). To register, otea' s a r�r r 4, complete the easy step-by-step process,and pay the annual registration fee online using a credit card, If awarded a t.ant from the CoOtu ,of Hawaii I=we understand and will ; 11, e requirement to submit a ear-end re,irt to the Count Council wi°bin 60 da after June 30 of the contractal leal for which the grant was awarded.The report,using the template provided,shalt include an explanation f the public benefits derived from the awarding of the grant sing on specific, measurable outcomes),acomplete accounting ail expenditures suppcirted by County of i'a ai'i grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely cum flew and accurate ,ear-end ref er-; sin the tern glace crovided will impar the e'pfuation of your Ito sram's or oien:, s future "undin. recti st; . County oil . wai' Nonprofit Urant Application Fly, 2022-23 Agency Name: 611 Program Name -r fj4i, 31 ri Certification of Understanding (Page 2 of if awarded a grant from the County of Hawaii,I(we)understand that a current Certificate of liability ($1,000,000 general liability,350,000 each occurrence)must be provided to the my of Hawaiq Finance Department,which specifically and explicitly indicates that the County f la ai i is an additional insured prior to receiving any payment(s).. I(we)understand that failure to submit the final report within 60 days of June 302'snail result in los of ill nt funds received due 1.the$rant ...od must be refunt.bd to n end Sinn from. future :rant iortici .tion for a minimum of on w tear or until a written amort, bm� ed t a act., ed b tfz l understand there is no provision for further notification t mit the final report,Information and instructions are available at e t ��.g- a .. i . n st ,, £t ri i 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 wed for the purposes stated in the application;except for a maximum ten percent(10%)for administrative and overheadtOsts .Any fends unused by June 30,2023 mustt he returned to the County of iia iii with the final report.Failure to return these fps in a timely manner ner wil impact the e 4 italtibri a 'our 0,en ris future fundina /west opi may result le actions token to recover th.s, .s rads, Awards cannot provide funds for Capital Improvements(Cost of Construction,materials,insurance or securities)on private properties unless 'se authorized by law. By signing below,you are acknowledging that you have read and understood thew requirements. Signature of Authorized Person Date Title/Position Authorized person County of Flawa 'l Nonprofit Grant Application FY 2022-73 Agency Name: rli ,:e.',1.3.):)< '4-14 ¶i- Program Name: 0 c.irk 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 rto conflicts exist,one form for the org-anization,with the"No conflicts eNist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure •rim must be5i ,ed relardieSS L'Vhether a COn.1 exists. NAME: POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(chedt all that apply); Member or members of the Council D Staff appointed by a member cif the Council The Mayor 0 The Managing Director D The Director of Finance 0 The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of interest is Ofined as:a substantial proboblOy that avian token by on inifivin'uol rousit in rneosurobte(Vert benefits “ruing to the indisndtiol os opposed to benefits ortrofrrg in weal to On industry, Please specify any and all mitigation measuresto avoid,in fact or appearance,any conflicts or potential conflit.t, of interum: 114 If no conflicts exist,check here. < Signature of Authorlie4yerson(specify title} Date • .„„ Full Life Renaissance of Inclusion 69 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Full Life Contact Person:Jim Kilgore Contact Email:jim@fulllifehawaii.org Contact Phone: 808-322-9333 Program Information Program Name: Renaissance of Inclusion Program Years in Operation: 10 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: `Ainaloa, Captain Cook, Hawi, Hawaiian Acres, Hawaiian Paradise Park, Hilo, Holualoa, Honaunau-Napo`opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kapa'au, Kapoho, Kea'au, Kealakekua, Kurtistown, Nanawale Estates, Ocean View, Pa'auilo, Pahala, Pahoa, Papa'ikou,Waikoloa Village,Waimea,Wainaku • Program Target Audience:Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth,Aged, Physical/Emotional Disabilities Amount Applying For:$15000 Full Life-Renaissance of Inclusion I Page 1 Program Details Organization Mission: Full Life is a Hawai`i Island non-profit that works to empower people with developmental disabilities to live self-determined and full lives in the community. We provide services to support community inclusion, independence in the home, employment, and opportunities for people with developmental disabilities to develop and exhibit artistic talents. In the past 20 years, Full Life has provided over 1.75 million direct service hours supporting independence, self-determination, and inclusion. Program Overview: Full Life's Renaissance of Inclusion program supports inclusion for people with developmental disabilities in the life of our community.The program is used to enhance the core services provided by Full Life. It includes access to the arts, associated costs for self-determination, Aktion Club, and arts based adult day health programing. Collaborative Art Programming: inclusive art classes and festivals for people with all abilities including Pua Na Pua (Kona),Abled Hawai'i Artists (Hilo/Puna), Live Aloha Art Festival (Hilo), and more. Associated Costs for self-determination: provide funds to people with disabilities supporting inclusion and their individual goals for independence. Aktion Club: A service project club in partnership with Kiwanis that is led by awesomely abled adults. Arts based Adult Day Health Program: Inclusive adult day health program at Alii Gardens Marketplace that showcases art and supports entrepreneurship in the arts for awesomely abled adults and teens. Program Objectives & Performances Resources Needed: In order to implement and carry out the Renaissance of Inclusion Program Full Life requires staffing for organizing art programs and festivals, staffing to support the Aktion Service Club, staffing to support participants in art-entrepreneur retail activities, money to hire local teaching artists, volunteers for community-based inclusive activities, supplies for art programs,technology for art programs, money for participant expenses related to inclusion and their self-determined goals, transportation for adult day health programs, and equipment for art programs, equipment and training for staff and volunteers. Major Activities to be Completed: • People with different abilities develop artistic talents and become awesome artists. • Program participants have opportunities to earn income with their artistic work. • Program participants lead a service club and contribute to improving their community • Volunteers support community inclusion activities. • An inclusive retail operation is developed to showcase the work of program participants and other community members of all abilities. • The community participates in inclusive art festivals. • Program participants have support with expenses that help the achieve self-determined goals: community activities, items to help them remain independent in their homes, supplies and items related Full Life-Renaissance of Inclusion Page 2 to securing and maintaining customized employment, items that support development of hobbies and other social valued roles. Outputs to be Completed: • 20 people with special abilities attend art classes. • 10 awesome artists earn income by selling their work. • 25 people are supported with expenses that support the achievement of self-determined goals. • Hold at least 2 inclusive community art festivals. • 200 community members attend art festivals. • 40 participants are satisfied with community inclusion programming. • 40 families are satisfied with the growth in community inclusion for their loved ones. • 4 service projects led by people with developmental disabilities are achieved. • 40 community inclusion activities including ocean activities, music, sports, social, and accessing community resources and events. • 15 program participants will be supported to access public transportation through the many recent improvements of the hele-on system. Measurable Outcomes: • Communities are engaged and people with developmental disabilities are included in all aspects of community life. • People of all abilities bring joy to others by sharing their unique abilities and socially valued roles. • People of all abilities contribute to the well-being of the community through service. • Families are stronger because all their family members can live more independently and access a variety of community resources. • The community will experience greater awareness and appreciation of people with all abilities through a renaissance of inclusion.This results in more opportunities for all in all aspects of life:family, relationships, employment, education, sports, and leisure pursuit. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Full Life-Renaissance of Inclusion I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Full Life Program Name: Renaissance of Inclusion CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 15,000 15,000 Applicant organizational budget: Individual contributions 5,000 5,000 Membership fees 0 0 Earned income 5,000 5,000 Current cash assets 0 0 Other funding sources (list below): Other Grant Funding 15,000 15,000 Total Cash Income 420,889.00 263,321.00 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 40,000 40,000 Appendix D--Budget Sheets (Page 2 of 2) `Project Budget Form: Expenses `County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ;Organization Name:Full Life 1Program Name:Renaissance of Inclusion Nonprofit Expense Description (Waiwai) Other Cash In-Kind . TOTAL Source Contribution Grant Salary Wages 8,000 12,000 20,000 Professional Fees 2,000 2,000 4,000 Operations 2,000 3,000 5,000 Supplies 1,500' 3,000 19,822.00 4,500 Equipment 1,500 5,000 6,500 SUBTOTAL 15,000 25,000 116,000.00 40,000 TOTAL PROGRAM BUDGET 15,000 25,000 40,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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 hitt ;//y,w v,l awaiic €i ter on nonprofit-grant-for ms/,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, 2023 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. Sig :ture of Authorized Perso / Date Ore v4;te-L Title/Position of Authorized Person County of Hawai'i. Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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 Hawari. 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: ' yr/ If no conflicts exist, check here. I , I .0-24„.. ature of Authorized Pe .:on (specify title) Date Going Home Hawaii Reentry and Recovery Housing 71 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Going Home Hawaii Contact Person: Kimi Palacio, Programs Administrator Contact Email: kimi.goinghomehawaii@gmail.com Contact Phone: 808-491-2437 Program Information Program Name: Reentry and Recovery Housing Program Years in Operation: 5 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, 'Umikoa,Volcano,Waikoloa Village,Waimea, Wainaku, Wai'ohinu,Weloka Program Target Audience:Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth, Physical/Emotional Disabilities,Victims of Crimes,Victims of Health or Social Crises Amount Applying For: $50000 Going Home Hawaii-Reentry and Recovery Housings Page 1 Program Details Organization Mission: Incorporated in 2015, Going Home Hawai'i's (GHH) mission is to assist justice- involved Hawai'i Island men, women and youth with reintegration into community life through employment, education, housing and appropriate services.These efforts help increase public safety, reduce costs to our public systems, and heal individuals,families and communities. GHH operates 4 facilities with a total capacity of 84 beds islandwide, and partners with the diverse members of the Going Home Consortium. Program Overview: Individuals face the greatest difficulties immediately after release from incarceration, so GHH coordinates with key partners like the Dept. of Public Safety during incarceration, and connects people with reentry and recovery housing upon point of release. In contrast to the Housing First model, GHH's program meets the needs of those struggling with addiction, in treatment, or under court orders to avoid such behavior. An abstinence-focused, structured environment with accountability facilitates the longer stays of 12 - 18 months needed to accomplish meaningful goals like recovery. Every participant works with a case manager and is matched with a mentor with similar life experiences, who are both trained in evidence-based practices such as motivational interviewing. Participants are referred to services through GHH's broad network, and can also participate in GHH programs such as courses in sustainable agricultural and Hawaiian cultural values, and services for pregnant women. Program Objectives & Performances Resources Needed: COMMUNITY PARTNERSHIPS 80+ public and private organizations and community members,together with a network of over 500 local, state and national partners through the Going Home Consortium. MOAs with strategic partners, including the Department of Public Safety and the Judiciary. FUNDS Program fees,foundation grants, government grants and contracts, donations (cash and in-kind). STAFF Chief Executive Officer, Programs Administrator, 3 Intensive Case Managers, Mentor Coordinator, Facility Manager(West HI), Finance Officer, 30 Volunteer Community Mentors, 5 Residential Monitors, and Special Program Cultural Practitioners. FACILITIES Reentry& recovery housing (84 beds): 1 coed facility (63 beds) &office in Kailua-Kona, and 1 residence for women (8 beds) and 2 for men (9 and 4 beds) in Hilo. Main office in Hilo. Internet access. APPROACH Evidence-based reentry&recovery housing approach. Proven training and educational curricula from partners such as Blueprint for Change. Going Home Hawaii-Reentry and Recovery Housing Page 2 Major Activities to be Completed: Staff provide clean, safe and functioning living space that is abstinence-focused and includes accountability measures such as regular on-site drug tests and peer support. Intensive Case Managers and project team coordinate with the Dept. of Public Safety and others to ensure eligibility requirements, meet participants at point of release, develop Individual Service Plans (ISPs) and work with participants to complete all ISP objectives (such as obtaining employment, housing, and healthcare), and advocate with parole/probation officers. As part of the project team,the Mentor Coordinator recruits, screens, matches, trains, and monitors Community Mentors with participants. Volunteer mentors provide participants with encouragement, guidance, and a support system to hold them accountable through weekly meetings. Staff and instructors provide and support development of culturally informed workforce development opportunities in sustainable agriculture and agricultural technology. Outputs to be Completed: 150 referrals received 50 new participants enrolled and provided with case management/care coordination 75 total participants received reentry and recovery housing and supportive services 30 participants received permanent supportive housing 15 new volunteer mentors recruited 40 total volunteer mentors trained and matched with 35 total participant mentees 6 Special Program sessions providing 120 instructional hours to participants Measurable Outcomes:SUCCESSFUL PARTICIPANT OUTCOMES Within 1 year of their release from incarceration: Less than 30%will be rearrested for new crimes or reincarcerated For those successfully completing the program: 80%engage mental health treatment services 70% receive positive mentoring services 50%enroll in OR complete any type of secondary or vocational training program 80%obtain employment within 6 months of release from incarceration 60% maintain their employment for 6 months post-hire 60%obtain stable permanent housing or appropriate transitional housing 100%enroll in Medicaid RECIDIVISM RATE County of Hawaii: 61.6% GHH: 39.2% GHH's overall recidivism rate, based on 163 discharges between October 2018 and March 2021 is 39.2%. The County of Hawaii's rate is from the ICIS "2018 Recidivism Update" (June 2020). COST PER DAY PER PERSON For the Dept. of Public Safety to incarcerate an inmate: $219 For GHH to provide reentry and recovery housing and services: $66.70 Savings: 69.5% Going Home Hawaii-Reentry and Recovery Housing I Page 3 Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Going Home Hawai'i-Reentry and Recovery Housing' Page 4 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Going Home Hawai'i Program Name:Reentry and Recovery Housing CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $50,000.00 $50,000.00 Applicant organizational budget: Individual contributions $3.500.00 $0.00 $3,500.00 Membership fees Earned income $142,560.00 $0.00 $142,560.00 Current cash assets Other funding sources (list below): Hawai'i State Grant-in-Aid $287,500.00 $0.00 $287,500.00 Program Fee Income $145,920.00 $0.00 $145,920.00 Hawai'i Community Foundation $50,000.00 $2,530.00 $52,530.00 Hawai'i County Council Contingency Relief Funds $30,000.00 $0.00 $30,000.00 Total Cash Income $709,480.00 $2,530.00 $712,010.00 IN-KIND CONTRIBUTION Anticipated Committed Total Mentorship Activities $24,000.00 $0.00 $24,000.00 Supplies: Personal Protective Equipment $4,000.00 $0.00 $4,000.00 Total In-Kind Contributions $28.000.00 $0.00 $28,000.00 TOTAL PROGRAM INCOME $737,480.00 $2,530.00 $740,010.00 Appendix D--Budget Sheets (Page 2 of 2) =Project Budget Form: Expenses ,County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ;Organization Name:Going Home Hawai'i Program Name:Reentry and Recovery Housing Nonprofit Other Cash In-Kind. Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $14,172.00 $307,937.00 $322,109.00 Professional Fees $10,567.00 $10,567.00 Operations $10,712.00 $227,987.00 $238,699.00- Supplies $13,616.00 $7,050.00 $4,000.00 $24,666.00 Equipment $2,530.00 $2,530.00 Other: Cultural Practitioners $4,000.00 $4,000.00 Other: Administrative Costs $7,500.00 $37,500.00 $45,000.00 Other: Utilities $44,279.00 $44,279.00 Other: Events and Activities $2,500.00 $2,500.00 Other: Mileage and Gas $3,160.00 $3,160.00 Other: Mentorship Activities $24,000.00 $24,000.00 Other: Repairs and Maintenance $15,000.00 $15,000.00 SUBTOTAL $50,000.00 $658,510.00 $28,000.00 $736,510.00 TOTAL PROGRAM BUDGET $50,000.00 658,510.00 $28,000.00 $736,510.00 County of Hawaii Nonprofit Grant Application FY 2022®23 Agency Name: (s20 1 NJ-C -O} E HAAAJA I Program. Name: 1t,c-6,-I'D t_..Cod 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 thatinformation 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 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, usingthe template provided, will impact the evaluation of your program's or agency's future funding requests. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: -,,t 1r,J6 C-k0'YriE A ) - _ e� Program Name: C`c Certification of Understanding (Page 2af'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 htto://www.hasvaiicounty.gov/fn-nonprofit-granr-forms/on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awardedwill 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, 2023 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) onprivate properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. e.-0/7-&b 01/27/2022 Signature of Authorized Person Date Chief Executive Officer Title/Position of Authorized Person County of.Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: (Dy1--V-0C MAM Program Name: feC- -r 4 (?e..ov - eke 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 ❑ 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. 01 /27/2022 Signature of Authorized Person (specify title) Date • Going Home Hawaii Hawaii Island Going Home Consortium (HIGHC) 72 County of IHawai`i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Going Home Hawaii Contact Person: Kimi Palacio, Programs Administrator Contact Email: kimi.goinghomehawaii@gmail.com Contact Phone: 808-491-2437 Program Information Program Name: Hawaii Island Going Home Consortium (HIGHC) Program Years in Operation: 18 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: `Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, 'Umikoa,Volcano,Waikoloa Village,Waimea, Wainaku, Wai'ohinu, Weloka Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth, Aged, Physical/Emotional Disabilities, Victims of Crimes,Victims of Health or Social Crises Amount Applying For: $40000 Going Home Hawaii-Hawaii Island Going Home Consortium (HIGHC)I Page 1 Program Details Organization Mission: Established in 2004, the Hawai'i Island Going Home Consortium's (HIGHC) mission is to assist justice-involved Hawai' i Island men, women, and youth with reintegration into community life, under the guiding light of No New Crimes, No New Victims. Members draw from sectors including criminal justice, employment, healthcare, social services, education and housing. Our efforts also contribute to increasing public safety and community wellness and reducing recidivism and public costs. Program Overview: HIGHC is a fluid, grassroots entity serving all of Hawaii County whose members volunteer their time to participate in monthly meetings, awareness events, and individual committee activities to promote successful outcomes for our target population. Committees include the West Hawaii Coalition, Career Pathways, Cultural Competency, Faith-based, Health and Wellness, Housing, and Justice Partners. Mini-grants support committee-led projects, such as restorative justice training materials. HIGHC alsoY romotes employment b recognizing employers hiring our target population and p assisting with job fairs. This grant year HIGHC will strengthen its focus on mobilizing members to facilitate diversion of resources from incarceration to community reentry efforts in the County.This will include clarifying measurable outcomes in committee areas and engaging in outreach and education through member networks,the community, and decision makers at the County and State levels. Program Objectives & Performances Resources Needed: COMMUNITY PARTNERSHIPS 80+ public and private organizations and community members,together with a network of over 500 local, state and national partners through the Going Home Consortium, including the American Job Center, Workforce Development, Maui Economic Opportunity, ACLU and Blueprint for Change. MOAs with strategic partners, including the Department of Public Safety,Judiciary, HI County Police Dept., and HI Paroling Authority. Consortium committees. FUNDS Government grants, donations STAFF Chief Executive Officer, Programs Administrator, 3 Intensive Case Managers, Mentor Coordinator, Facility Manager(West HI), Finance Officer. VOLUNTEERS SUPPLIES Audio-video production equipment and facilities; resource materials such as media kits, social media assets and platforms (website, Facebook, etc.) and banners; and volunteer supplies such as t-shirts and signs. FACILITIES Public meeting spaces,Zoom capabilities, multi-media room. Going Home Hawaii-Hawaii Island Going Home Consortium (HIGHC)I Page 2 Major Activities to be Completed: GHH staff and HIGHC committee chairs and members strengthen the structure and function of the Consortium and committees to increase the focus on our collective impact through general, committee and other meetings. HIGHC outreaches to and educates decision makers and the general public at the State and County levels around reentry issues and community-based responses. HIGHC introduces and supports bills in the State legislature that support County reentry efforts. Committee members request and use mini-grants to support activities. HIGHC holds an employer recognition event to promote employment of justice-involved individuals. Outputs to be Completed: 12 monthly Consortium meetings, plus 25 sub-committee meetings,with Consortium membership comprising 80 HI County nonprofit organizations, government agencies, and others,participating in the Consortium, and 20 from other Counties, and 10 from beyond Hawaii State $4,000 in mini-grants 1 Employer Recognition event 4 State legislative bills introduced/supported 1 White Paper on Reentry in HI County 1 Countywide Coalition Plan 9 Hawaii County Council members and 20 State Senators and Representatives engaged through personal meetings, resource materials, and events Measurable Outcomes: Strengthened and more effective County community-based reentry efforts as a result of additional State resources and more focused coalition actions. Decreased County recidivism rate and increased public safety. Alleviated overcrowding at Hawai'i Community Correctional Center and decreased criminal justice system costs. • Greater understanding of and concrete support for reentry issues by the general public and decision makers. Decreased stigma and barriers and greater public voice for justice-involved individuals and families. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Going Home Hawaii-Hawaii Island Going Home Consortium (HIGHC)I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Going Home Hawai'i Program Name:Hawai'i Island Going Home Consortium CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $40,000.00 $40,000.00 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Total Cash Income $40,000.00 $0.00 $40,000.00 IN-KIND CONTRIBUTION Anticipated Committed Total Professional Fees $500.00 $0.00 $500.00 Consortium Activities $24,000.00 $0.00 $24,000.00 Total In-Kind Contributions $24,500.00 $0.00 $24,500.00 TOTAL PROGRAM INCOME $64,500.00 $0.00 $64,500.00 Appendix D--Budget Sheets (Page 2 of 2) `Project Budget Form: Expenses ;County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 'Organization Name:Going Home Hawai'i !Program Name:Hawai'i Island Going Home Consortium Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $7,458.00 129,258.00 $7,458.00 Professional Fees $12,000.00 16,812.00 $500.00 $12,500.00 Operations $1,739.00 59,312.00 $1,739.00 Supplies 3,000.00 18,357.00 19,822.00 41,179.00 Equipment Other: Consortium Activities $24,000.00 $24,000.00 Other:Marketing and Informational Material $3,303.00 $3,303.00 Other: Mini Grants $4,000.00 $4,000.00 Other: Events and Activities $5,500.00 $5,500.00 Other:Administrative Costs(15%) $6,000.00 $6,000.00 SUBTOTAL $40,000.00 $0.00 $24,500.00 $64,500.00 TOTAL PROGRAM BUDGET $40,000.00 $0.00 $24,500.00 $64,500.00 County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: - 1 ikO '. ' t Program Name: (-11-AltAct) t LIV\i ) .-A et l rin 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, relatieig 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 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 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 Havvai'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 httn://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 orapency's future fundinq requests: County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: t,O G t em G 1ck1kk.AJA, Program Name: A-- \1A) Cli L-A-1,-lb. C1,0 n---)C, . omt Cc 6Na;09--1-1 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, 2023 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. ,1rr' 01/27/2022 Signature of Authorized Person Date Chief Executive Officer Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: 0lJ C- V- rt Program Name: ItAkvki1 t. .; C,o t IL,) 4...1 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: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. " 01/27/2022 Signature of Authorized Person (specify title) Date Goodwill Industries of Hawaii Ola I Ka Nana Youth Program 73 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Goodwill Industries of Hawaii Contact Person: Emily Lau Contact Email: elau@higoodwill.org Contact Phone: 808-836-0313 Program Information Program Name: • Ola I Ka Hana Youth Program Program Years in Operation: • 17 years —since 2005 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Eden Roc, Fern Acres, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Kalapana, Kea'au, Kealakekua, Kurtistown, Laupahoehoe, Leilani Estates, Miloli`i, Mountain View, Na'alehu, Nanawale Estates, Ocean View, Orchidlands Estates, Pa'auilo, Pahala, Pahoa, Papa'ikou, Pepe'ekeo, Pohoiki, Volcano,Waimea,Wainaku Program Target Audience:Adolescence (12-17),Young Adulthood (18-39) Services/Activities Provided: Educational concerns, Youth Amount Applying For: $30000 Goodwill Industries of Hawaii- • Ola I Ka Hana Youth Program I Page 1 Program Details Organization Mission: Goodwill's mission is to "help people with employment barriers to reach their full potential and become self-sufficient." We have served low-income and vulnerable people, including opportunity youth, since 1959; and currently operate over 20 human services programs, 11 retail stores, and 27 donor centers. Last year, we served over 10,800 individuals, successfully placing 619 into jobs, statewide.We support the local Big Island community with a variety of employment and training services. Program Overview: Ola I Ka Hana exclusively serves low-income youth aged 14-24.This well-established program has operated on Hawaii island for 17 years and last year, served 108 local youth. A coordinated service focus develops each youth for continuing educational achievement, successful transition to adulthood, and sustained,self-sufficient employment. Priority is given to opportunity youth, including high school dropouts, runaway and homeless youth,youth in or aged out of foster care, court involved youth, children of incarcerated parents, and migrant youth. Goodwill's innovative curriculum addresses: Outreach,Assessment, and Individual Plan Development; Life Skills; Mentoring and Tutoring; Computer Literacy;Academic Support: Career Training; and Employment and Job Placement.The proven, evidence-based program design reflects the unique needs of the focus population and empowers youth to develop positive behaviors for a healthy, safe life, and achievement of success. Program Objectives & Performances Resources Needed: Resources needed to carry out the proposed services: * Staffing: Staff will carry out various important functions of the program including outreach to recruit potential participants,teaching, coaching, mentoring, counseling, contacting vocational training institutes, coordinating exploration activities, etc. * Technology such as computers, software, internet access, mobile phone:This program uses Odysseyware (educational software) which requires annual subscriptions. * Assessments: CASAS, interest and other skills assessments. * Student and Teacher Workbooks: Basic Skills Enrichment Math & Reading; GED/ HiSET. * General Supplies for staff and youth. Major Activities to be Completed: Major activities to be completed include: *-Tutoring and Alternative Secondary School Offering * One-on-one or group tutoring • Basic Skills Enrichment; HiSET/GED Preparation * Webinars/Virtual Training * Comprehensive Adult Student Assessment System (CASAS) -1 Leadership Development Opportunities * Employment Explorations/Career Pathways * Exposure to Post-Secondary School Offering Goodwill Industries of Hawaii-• Ola I Ka Hana Youth Program I Page 2 -Adult Mentoring * Group or individual activities * Goal planning and setting * Life Skills Sessions—decision making, healthy relationship behaviors,time management, etc. -Employment preparation * Work experience * Volunteering *Job readiness training * Vocational training Outputs to be Completed:The expected outputs of the program include: - Number of participants completed intake—30 - Number of assessments completed—30 - Number of participants enrolled in Basic Skills Math—20 - Number of participants enrolled in Basic Skills Reading—20 - Number of participants enrolled in HiSET/GED (Diploma Track)—20 - Number of participants identified a Career Pathway-30 Measurable Outcomes: Outcomes of the program are listed below: For the youths attending program - o Increased math and reading proficiency levels. o Successful graduation from High School (High school diploma and/or equivalency. o Positive and healthy growth and development in a supportive environment. o Development of future leaders. o Successful transition to higher education such as college or vocational school. o Attainment of credential that leads to higher earnings. o Successful transition to adulthood. o Attainment of sustainable employment. For the Hawaii Island community— o Increased high school graduation rate. o Reduced truancy rate. o Provision of quality workforce. o Developed future leaders. Attachments Program Budget (Income & Expenses) Certificate of Understanding Goodwill Industries of Hawaii-• Ola I Ka Hana Youth Program I Page 3 Conflict Disclosure Goodwill Industries of Hawaii-• Ola I Ka Hana Youth Program I Page 4 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Goodwill Industries of Hawaii, Inc. Program Name:Ola I Ka Hana Youth Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $30,000 $30,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): County of Hawaii -WIOA fund $399,419 $399,419 Total Cash Income $429,419 $429,419 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions 0 0 TOTAL PROGRAM INCOME $274,000 $274,000 Appendix D--Budget Sheets (Page 2 of 2) `Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ,Organization Name:Goodwill Industries of Hawaii, Inc. Program Name:Ola I Ka Hana Youth Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $30,000 $286,459 $316,459 Professional Fees 16,812.00 16,812.00 Operations 7,000.00 $98,156 $98,156 Supplies 3,000.00 $3,964 19,822.00 $3,964 Equipment $1,000 $1,000 Client Assistance (Support Services) $3,840 $3,840 Client Tuition Assistance (Voc Training) $6,000 $6,000 SUBTOTAL $30,000 $399,419 116,000.00 $429,419 TOTAL PROGRAM BUDGET $429,419 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Goodwill Industries of Hawaii,Inc. Program Name: Ola I Ka Hana Youth Program 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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Goodwill Industries of Hawaii,Inc. Program Name: Ola I Ka Hana Youth Program 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.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 30,2023 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. 11-211'7-1,Signature of of Au rized Person Date Katy Chen,President/CEO Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Goodwill Industries of Hawaii,Inc. Program Name: Ola I Ka Hana Youth Program 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 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: X❑ If no conflicts exist, check here. yi .- President/CEO 112 Ltklt) ?/Y Signature of horized Person (specify title) / f Date • Goodwill Industries of Hawaii Career Services— Employment Services for low-income and reintegrating individuals 74 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Goodwill Industries of Hawaii Contact Person: Emily Lau Contact Email: elau@higoodwill.org Contact Phone: 808-836-0313 Program Information Program Name: Career Services—Employment Services for low-income and reintegrating individuals Program Years in Operation: 20 Year Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honomu, Honoka'a, Kailua-Kona, Kalaoa, Kea'au, Kealakekua, Kurtistown, Laupahoehoe, Leilani Estates, Mountain View, Nanawale Estates, NInole, Ocean View, Orchidlands Estates, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Volcano, Waikoloa Village,Waimea, Wainaku Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Needs of the poor, Public health and welfare of the people and the environment Amount Applying For: $35000 Goodwill Industries of Hawaii-Career Services—Employment Services for low-income and reintegrating individuals! Page 1 Program Details Organization Mission: Goodwill's mission is to "help people with employment barriers to reach their full potential and become self-sufficient." We have served the people of Hawaii since 1959. Currently, we operate over 20 human services programs, 11 retail stores, and 27 donor centers statewide. We support the local Big Island community by providing a variety of employment and training services. Last year, we served over 10,800 individuals with employment barriers, successfully placing 619 into jobs, statewide. Program Overview:The program is a multi-faceted program incorporating many supports and education to assist low-income and reintegrating participants to work towards the ultimate goal of sustained independent community living via gainful employment and increased financial stability, and to avoid recidivism.All participants access: 1. Individualized services to empower them for independent living and successful reintegration. 2. Evidence-based programs--specifically, robust employment services, basic computer instruction, vocational training opportunities, access and referrals to community resources.This year, we plan to strengthen financial literacy training to help develop skills for budgeting,financial management, saving, asset building, and building good credit. Referral to a financial coach will be facilitated, as needed. 3. Post-employment follow up for 6 months helps "graduates" navigate their new work environment and community. 675 people have received services in the past 5 years. Program Objectives & Performances Resources Needed: Resources needed to carry out the proposed services: 1. Designated staff: Staff will carry out various important functions of the program including outreach to recruit potential participants,job readiness training, coordinating vocational training with training providers,financial literacy training,job development with potential employers, making referrals to support services, career counseling, and job retention support to both the participants and employers. 2.Technology such as computers, software, internet access, mobile phone:Technology is required to support all activities such as training, case management, outreach etc.Technology also supports communication and virtual training. 3. Curriculum: Evidence-based curriculum for Job Readiness training and financial literacy training will enhance skills development. 4. Money: Money allows us to hire qualified staff, purchase technology, and provide tuition support. Major Activities to be Completed: Major activities to be completed include: 1. Comprehensive assessments to identify an individual's,strengths, abilities, and barriers that may affect employability. Goodwill Industries of Hawaii-Career Services—Employment Services for low-income and reintegrating individuals! Page 2 2. Individualized program plan development to set desired employment goals and objectives, and determine activities and needed supports.This plan will outline their road map to success and self- , sufficiency. 3.Job Readiness training to develop skills to find and maintain gainful employment. 4.Vocational training to teach new job skills and to help obtain credentials that will lead to higher paying job opportunities. 5. Financial literacy training to build financial management skills, savings, assets, and wealth. 6. Support services and referrals to provide holistic support and ensure family needs are met. 7. Post-employment services/job retention supports for at least 30 days to assure participants' acclimation to their new job environment and that they are meeting job requirements Outputs to be Completed:The expected outputs of the program include 1. Intake/Comprehensive Assessment 100 individuals served 2. Job Readiness Training 90 Individuals served 3. Job Placement 75 Individuals achieved 4. 30-day retention 60 Individuals achieved 5. Completion of financial Literacy 50 Individuals achieved • Measurable Outcomes:The program will provide vital supports to low-income residents in Hawaii County.The program's many outcomes include: 1. Families are financially stable and self-sufficient 2. Ex-offenders have a second chance and are better able to reintegrate 3. Individuals and families increase financial management skills to build assets and wealth. 4. Hawaii Island families attain a higher quality of life 5. In-demand occupations are filled by people who complete vocational training 6. Hawaii County businesses have lower vacancy rates 7. An improved Hawaii Island economy due to an increased quality workforce and higher individual spending power through increased earnings Additionally, we aim to improve participant self-esteem through their acquiring skills, knowledge, change behaviors, and community supports. With our robust evidence-based employment and training services and supports, we empower participants to establish and maintain a stable, productive, independent life in our community Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Goodwill Industries of Hawaii-Career Services—Employment Services for low-income and reintegrating individuals! Page 3 Goodwill Industries of Hawaii-Career Services—Employment Services for low-income and reintegrating individuals Page 4 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Goodwill Industries of Hawaii, Inc. Program Name:Career Services -Employment Services for low-income and Reintegrating Individuals CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $35,000 $35,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Office of Community Services $189,000 $189,000 Department of Public Safety $50,000 $50,000 Total Cash Income $274,000 $274,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions 0 0 TOTAL PROGRAM INCOME $274,000 $274,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Goodwill Industries of Hawaii, Inc. Program Name:Career Services - Employment Services for Low-income and Reintegrating Individuals Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $35,000 $184,762 $219,762 Professional Fees 16,812.00 16,812.00 Operations 7,000.00 $25,072 $25,072 Supplies 3,000.00 $1,526 19,822.00 $1,526 Equipment $3,040 $3,040 Client Assistance (Support Services) $3,000 $3,000 Client Tuition Assistance (Voc Training) $21,600 $21,600 SUBTOTAL $35,000 $239,000 116,000.00 $274,000 TOTAL PROGRAM BUDGET $274,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Goodwill Industries of Hawaii,Inc. Program Name: Career Services-Employment services for low-income and reintegrating individuals 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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Goodwill Industries of Hawaii,Inc. Program Name: Career Services-Employment services for low-income and reintegrating individuals 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.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, 2023 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. 1/2- /2"--e Signature of A/horized Person Date Katy Chen,President/CEO Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Goodwill Industries of Hawaii,Inc. Program Name: Career Services-Employment services for low-income and reintegrating individuals 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. I 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 ❑ 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: X❑ If no conflicts exist, check here. 6,/,.......n._ President/CEO "/2_ / —o, Signature o Authorized Person(specify title) Date Goodwill Industries of Hawaii Ho'olana Educational and Arts Program 75 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Goodwill Industries of Hawaii Contact Person: Emily Lau (VP of Mission Svcs) Contact Email: elau@higoodwill.org Contact Phone: 808-836-0313 Program Information Program Name: Ho'olana Educational and Arts Program Program Years in Operation: • Ho'olana program has been in operation in Hawaii Island for over 20 years. Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Kea'au, Kurtistown, Mountain View, Orchidlands Estates, Pahoa, Papa'ikou, Pepe'ekeo, Wainaku, Keaukaha and Piihonua Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts,Youth,Aged, Physical/Emotional Disabilities Amount Applying For: $50000 • • Goodwill Industries of Hawaii-Ho'olana Educational and Arts Program I Page 1 Program Details Organization Mission: Serving Hawaii since 1959, Goodwill's mission is to "help people with employment barriers to reach their full potential and become self-sufficient." With over 20 human services programs statewide, we serve low-income persons, immigrants, people with disabilities, homeless persons, ex-offenders, and those with substance abuse issues.The Ho'olana program serves people with development/intellectual disabilities, helping them build skills, develop relationships, and become independent. Program Overview:The Ho'olana Educational &Arts Program will provide opportunities for people with an intellectual and/or developmental disability to become entrepreneurs by exploring Hawaiian culture and their own ancestral heritage.They will connect with members of the community and local artists to showcase their talents and abilities in the world of art. Additionally,they will learn the importance of creating a business based on community needs, how to sustain a business, and how to sell and earn a sustainable income, independently. Participants will be afforded educational insights into the varied cultures and experiences of Hawaii Island. They will use tools--such as embroidery machines, computer programs, and software--to create original art pieces.They will utilize the Ancestry Club to define where they came from, explore their ethnic background/s, and further research their family histories. Funds will support staffing, cultural site admission, and purchase of equipment and supplies Program Objectives & Performances Resources Needed:The following are resources needed to carry out this program: Staffing: Staff will carry out various important functions of the program including teaching, coaching, researching, coordinating with businesses and cultural sites, and supporting the varied needs of people with disabilities. Technology: Computers, special software etc.We will need to purchase approximately 10. computers for participants to use to learn basic reading and math skills, create art designs for embroidery, Glow forge, and heat presses. - Equipment and supplies: Embroidery machine, office supplies, safety and sanitation supplies. - Transportation: Wheelchair accessible vehicles. Funding: To pay for and provide access to cultural sites;museums, and National Parks. Major Activities to be Completed: Here are the major activities to be completed: - Purchase of approximately 10 desktop/laptop computers for participants to use while attending the program. Staff will teach and coach participants to use the computers to learn basic skills such as reading and mathematics, and take training in art skills such as creating art designs for embroidery, Glow forge, and/or heat presses. Staff will teach and coach participants to make art pieces and to use the embroidery machine. Goodwill.Industries of Hawaii-Ho'olana Educational and Arts Program! Page 2 • We will develop an ancestry club, and participants will use computers to explore cultural heritage. Our program will allow participants to tour around the island and explore cultural and historical sites. They will also learn about Hawaiian and other ethnic cultures. Participants will visit museums and National parks. Participants will be given ample opportunities to connect with local artists, learn skills, and showcase talents and abilities. Outputs to be Completed:The expected outputs of the Ho'olana Arts and Education program include: 1. Arts/craft education: 34 persons served 2. Educational literacy: 14 persons served 3. Promotion of Hawaiian/ethnic cultures: 20 persons served 4. Increase earning potential: 10 persons served 5. Opportunities to participate and practice arts and culture: 34 persons served Measurable Outcomes:The Ho'olana Arts and Education program will achieve the following outcomes: 1. Benefits to participants with developmental/intellectual disabilities: Increase access to the community—improving community inclusion is a focal point. Participants and families will be able to spend more time in the wider community. Gain and build skills that will lead to a career and long-term sustainable living. - Develop better relationships that will help increase quality of life. - Build self-confidence and value, and become a member that contributes to the community. - Expand understanding of cultural diversity. Increase happiness so they and their families can enjoy life. 2. Benefits to the Hawaii County community: - Build a vibrant community through program funds being used to reinvest in the local economy, through the purchase of passes and supplies. Increase inclusiveness with people with disabilities becoming more involved in different aspects of the community. Attachments Program Budget(Income & Expenses) Certificate of Understanding Conflict Disclosure Goodwill Industries of Hawaii-Ho'olana Educational and Arts Program I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Goodwill Industries of Hawaii, Inc. Program Name:Ho'olana Education and Arts Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $50,000 $50,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Department of Health $150,000 $150,000 Total Cash Income $200,000 $200,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions 0 0 TOTAL PROGRAM INCOME $200,000 $200,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 iOrganization Name:Goodwill Industries of Hawaii, Inc. Program Name:Ho'olana Education and Arts Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Grant Source Contribution Salary Wages $37,000 $103,353 $140,353 Professional Fees 16,812.00 16,812.00 Operations 7,000.00 $44,716 $44,716 • Supplies $2,000 $931 19,822.00 $2,931 Equipment $10,000 $0 $10,000 Client Assistance (service activities) $1,000 $1,000 $2,000 SUBTOTAL $50,000 $150,000 116,000.00 $200,000 TOTAL PROGRAM BUDGET $200,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Goodwill Industries of Hawaii,Inc. Program Name: Ho'olana Education and Arts Program 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.sov, 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'sor agency's future funding.requests. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Goodwill Industries of Hawaii,Inc. Program Name: Ho'olana Education and Arts Program SIMSMal 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, 2023 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. s f l -a-11 Signature of A orized Person Date Katy Chen,President/CEO Title/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Goodwill Industries of Hawaii,Inc. Program Name: Ho'olana Education and Arts Program 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 ❑ 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. /0144,9-erhiu, President/CEO I / -(0/D-0 Signature of Authorized Person (specify title) Date Hawai'i Children's Action Network Hawaii Diaper Bank (a fiscally sponsored program of Hawaii Children's Action Network) 85 County of Fiawai`i • Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hawaii Children's Action Network Contact Person:Jessica Histo Contact Email:jessica@hawaiidiaperbank.org Contact Phone: (808)731-6611 Program Information Program Name: Hawaii Diaper Bank (a fiscally sponsored program of Hawaii Children's Action Network) Program Years in Operation: 3 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, NInole, Ocean View, 'O'okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, PuakO, Pualaa, 'Umikoa,Volcano, Waikoloa Village,Waimea, Wainaku, Wai'ohinu, Weloka Program Target Audience: Infancy (0-3), Play Age (3-5) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment, Youth, Physical/Emotional Disabilities,Victims,of Crimes,Victims of Health or Social Crises Amount Applying For: $30000 Hawaii Children's Action Network-Hawai'i Diaper Bank(a fiscally sponsored program of Hawaii Children's Action Network)I Page 1 Program Details Organization Mission: Hawai'i Diaper Bank's mission is to serve and support the keiki of Hawai'i by providing diapers, wipes, and other essentials to organizations that assist low-income families with young children.We are a fiscally sponsored program of Hawai`i Children's Action Network (HCAN), a 501(c)(3) nonprofit organization. Hawai'i Diaper Bank(HDB) is the only diaper bank on Hawai`i Island, and we are committed to eliminating diaper need for the 1 in 3 families that experience its detrimental effects. Program Overview: Funds from this grant would be used to support HDB's growing program and operations. HDB accomplishes its mission by collecting diapers, wipes, and other essentials through community drives and events, as well as through corporate donations and low-cost bulk purchasing. HDB's volunteer program ensures donations are efficiently sorted, organized, and ready for distribution. Low-income families receive our donations through 16 partner organizations (nonprofits/community- based organizations)that provide additional services, resources, and support. HDB's partners may make monthly bulk requests for diapers and wipes and/or Makana Packs. Makana Packs are for special occasions (like birthdays) and include diapers, wipes, blankets, books, clothing, hygiene products, and toys. In 2021,we distributed more than 420,000 donations, including 450 Makana Packs, serving an average of 323 children per month. Program Objectives & Performances Resources Needed:To carry out HDB's program, we will need staff, volunteers, and funds.Jessica Histo is the founder and president of HDB. Mrs. Histo manages the day-to-day operations, community engagement, and social media for the organization. Ms. Histo is supported by two volunteer staff members, Hannah London and Jennifer Evangelista. Mrs. London provides oversite and guidance on day-to-day operations, budgeting, strategic planning, and program development. She also manages all in-kind donation data. Mrs. Evangelista is instrumental in helping to distribute donations. HDB's team is supported by a robust volunteer program and our growing network of partner organization, community drop-off locations, and donation drive hosts.We will also need funds to pay rent for HDB's office/warehouse, as well as utilities costs and costs for telecommunications services. Funding is also needed to produce marketing materials and maintain HDB's website. Major Activities to be Completed: To meet our objectives, HDB will identify new strategies for increasing incoming donations, including a modified marketing and social media plan to gain more engaged followers and supporters.Additionally, HDB will enhance our volunteer program to help keep our space and donations organized,thereby increasing our capacity and operational efficiency. We will use a new volunteer platform which will provide targeted outreach, streamlined registration, and appreciation tools. Further, HDB will onboard new partners to help meet the needs of more low-income families. We will frequently gather feedback and provide training for partners on a regular basis to ensure an efficient distribution process. Hawaii Children's Action Network-Hawai'i Diaper Bank(a fiscally sponsored program of Hawaii Children's Action Network)! Page 2 Outputs to be Completed: HDB will complete the following: (a) Donations Collected & Distributed: This fiscal year, we are on track to collect and distribute 600,000 donations. Next fiscal year, we anticipate that we will be able to collect and distribute 800,000 donations. (b) Volunteers &Volunteer Hours: This fiscal year, we will receive at least 600 volunteer hours from our most dedicated supporters. Next fiscal year,we anticipate another 1,000 volunteer hours and a much more diverse volunteer base. (c) Number of Clients Receiving Diapers, Wipes, and/or Other Essentials:This fiscal year, we expect to provide donations to more than 2,000 children (unduplicated). Next fiscal year, we anticipate that we will provide donations to more than 2,500 children (unduplicated). Measurable Outcomes: HDB's program alleviates diaper need,which significantly reduces the cost of living for Hawaii Island's families in need. Diaper need contributes to the cycle of poverty for low-income families. For instance, at most childcare centers, a supply of six to eight diapers is required to drop a baby off.Without childcare, parents are unable to work and financially support their families. Additionally, HDB's program elevates community engagement by providing opportunities to volunteer and give back. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Hawaii Children's Action Network- Hawai'i Diaper Bank(a fiscally sponsored program of Hawaii Children's Action Network)I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Hawaii Children's Action Network (HCAN) Program Name: Hawaii Diaper Bank, a fiscally sponsored program of HCAN CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 30,000 30,000 Applicant organizational budget: Individual contributions 45,000 0 45,000 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets Other funding sources (list below): Corporations 6,000 0 6,000 Foundations & Grants 5,000 0 5,000 Other 13,000 0 13,000 Total Cash Income 99,000 0 99,000 IN-KIND CONTRIBUTION Anticipated Committed Total Diapers, Wipes, & Essentials (Program; 140,000 0 140,000 Volunteer Time 14,000 0 14,000 Other 5,000 0 5,000 Total In-Kind Contributions 159,000 0 159,000 TOTAL PROGRAM INCOME 258,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses !County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 'Organization Name: Hawaii Children's Action Network (HCAN) Program Name: Hawaii Diaper Bank, a fiscally sponsored_program of HCAN Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 13,000 17,000 0 30,000 Professional Fees 3,000 6,900 0 9,900 Operations 0 9,975 0 9,975 Supplies 0 600 0 600 Equipment 0 400 0 400 Program 0 19,375 0 19,375 Rent 13,000 14,000 0 27,000 Utilities, Phone, & Internet 1,000 750 0 1,750 SUBTOTAL 30,000 69,000 0 TOTAL PROGRAM BUDGET 99,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Hawaii Children's Action Network (HCAN) Program Name: Hawaii Diaper Bank, a fiscally sponsored program of HCAN 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Hawaii Children's Action Network (HCAN) Program Name: Hawaii Diaper Bank, a fiscally sponsored program of HCAN 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, 2023 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. 1/30/2022 Signature of Authorized Person Date Vice President and Executive Director Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Hawaii Children's Action Network (HCAN) Program Name: Hawaii Diaper Bank, a fiscally sponsored program of HCAN 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 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. ec E e i rec VP and Executive Director 1/27/2022 ` � ''' Signature of Authorized Person (specify title) Date HAWAII ISLAND ADULT CARE, INC. Hilo Adult Day Center 93 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: HAWAII ISLAND ADULT CARE, INC. Contact Person:Tanya Aynessazian Contact Email: execdir@hawaiiislandadultcare.org Contact Phone: 808-961-3747 x107 Program Information Program Name: Hilo Adult Day Center Program Years in Operation: 46 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Hilo Program Target Audience: Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment, Aged Amount Applying For: $30000 HAWAII ISLAND ADULT CARE, INC.-Hilo Adult Day Centers Page 1 Program Details Organization Mission: We provide high-quality day care for elders,frail and challenged adults and support for their families and caregivers in order to ensure continued living at home - aging in place. Program Overview: Our Adult Day Care program is a safe and socially active program for kupuna and challenged adults,who have a medical or safety necessity to attend day care. Our program provides a structured daily schedule six days a week and includes varied activities to aid in mental, physical, creative and memory stimulation. Over 80%of our participants are over 80 years old, and over 60% have moderate memory care needs; almost a quarter are diagnosed with some form of dementia. Our tuition assistance program supports kupuna who require daytime supervision and socialization who do not qualify for Medicaid-paid services,yet who cannot afford to pay full-time cost of day care out of pocket, or who may qualify for Medicaid but who have not yet applied. Many times, caregivers are caught off guard when mom/dad falls, lands in the hospital and rehab for an extended stay, and is never the same to remain at home alone.We work to assist these folks who require adult day supervision and care immediately. Program Objectives & Performances Resources Needed:We have systems in place, a beautiful 3-year-old facility, dedicated/compassionate staff and volunteer board, and generous support from our community stakeholders. Yet we still rely on government and foundation funders to close the needs gap on the$180k needed each year to accommodate the low income kupuna who want to attend.The resources needed primarily rests with helping those without the income or savings to pay for services. By providing tuition assistance needed for lower income kupuna to attend, we can focus on our day care program and minimizing Covid risks. Meeting Covid challenges comes with additional direct and indirect costs: the costs of PPE, sanitizing, extra staff, Covid rapid tests, quarantining of potentially exposed staff or participants etc. to ensure the safety of the entire HIAC 'ohana. Our goal is to minimize risks associated with serving the most vulnerable population with robust Covid protocols that are continuously adapted as new information becomes known. Major Activities to be Completed: Our program is comprised of meaningful social activities with specific times for movement/exercise, creative/art/music time, group activities, meals, celebrations and rest time. We create a meals and activity plan for our caregivers in a newsletter on a monthly basis. On the health coordination side, our staff RN and Care Coordination team update care plans and goals for each kupuna. Our bi-annual survey was sent out in December 2021, and will be sent again in June 2022, for review of our services and caregiver/participant satisfaction. We are enhancing our monthly calendar to include new memory care activities, more activities for men, and movement and creative activities in smaller groups to minimize the awkwardness kupuna feel by social distancing. Our 2022 tuition assistance application will be mailed out in May for awarding tuition assistance beginning July 1, 2022. We anticipate the 2022-23 budget for tuition assistance to be similar to 2021. HAWAII ISLAND ADULT CARE, INC.-Hilo Adult Day Centers Page 2 Outputs to be Completed:We are requesting$30,000 to provide a minimum of 25 kupuna to receive tuition assistance through this grant; this equates to $1,200 per kupuna per year, which is roughly twelve days of assistance per person per year depending on their care level.Total estimated days of tuition assistance that$30k will provide is 300 days of attendance. By assisting 25 kupuna, indirectly the County is assisting a minimum of 25 families, and approximately 62 primary, secondary and emergency caregivers. Some of our tuition assistance funders have demographic restrictions on who can receive assistance such as women only, must live alone, minimum age, etc. We recognize the generosity of the County and are thrilled that we have a few grant opportunities such as this one that do not specify demographic restrictions. Measurable Outcomes: Measurable outcomes/key evaluation factors include 1) Kupuna continue to attend; they enjoy getting up and are motivated to attend our program each day 2) Noticeable improvement of mental attitude and self-care as noticed by families and our staff 3) Getting involved in activities, staying engaged 4) Caregiver/family respite and satisfaction 5) Bi-annual anonymous survey results and comments reported by program participants and caregivers 6) Caregivers able to continue employment or business. Through weekly progress reports recorded by staff observation of each participant in their care plan, anonymous surveys, attendance records, comments from other agencies supporting same participant, concerns of caregivers, participants' attitudes and behaviors, discharge data, we determine success. Noting improvements in participant interest levels and emotional behavior in the first few weeks of attending is an additional factor in determining successful outcome. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure • HAWAII ISLAND ADULT CARE, INC.-Hilo Adult Day Center' Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Hawaii Island Adult Care Inc Program Name:Hilo Adult Day Center CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 30,000 � � � � 30,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Day Care Tuition and Fees 1,340,000 1,340,000 Hawaii Island United Way(Tuition Assistance) 20,000 20,000 Other Tuition Assistance grants 70,000 60,000 130,000 Fundraising and Events 106,710 106,000 USDA 60,000 60,000 Add govt/provider grant 34,000 34,000 Operational assistance grant 66,000 66,000 Total Cash Income 1,726,710 60,000 1,786,710 IN-KIND CONTRIBUTION Anticipated Committed Total Golf prizes and certificates 6,000 0 6,000 Total In-Kind Contributions 6,000 0 6,000 TOTAL PROGRAM INCOME 1,732,710 60,000 1,792,710 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii m Nonprofit Grant-in-Aid (Waiwai Grant)- Fiscal Year 2022-2023 . Organization Name:Hawaii Island Adult Care, Inc. ;Program Name:Hilo Adult Day Center Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 20,000.00 816,000 816,000 Professional Fees 19,100 19,100 Operations 7,000.00 59,312.00 66,312.00 Supplies 3,000.00 18,357.00 19,822.00 41,179.00 Equipment Taxes and Benefits 326,000 326,000 Direct Client/Tuition Assistance 30,000 150,000 180,000 Software/IT Services 18,000 18,000 Program Supplies, Meals & Transport 83,534 83,534 . Occupancy 36,884 36,884 Occupancy- Utilities 38,580 38,580 Fundraising and Events 27,000 6,000 33,000 Staff Support& Development 33,828 33,828 Insurance 32,5611 32,561 Program Support 34,490 34,490 Other Expense 56,428 56,428 Depreciation (non-cash) 82,305 82,305 SUBTOTAL 30,000 1,759,710 6,000 1,792,710 TOTAL PROGRAM BUDGET 1,792,710 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Hilo Adult Day Center 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:J/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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name:, 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:,l/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 30,2023 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. k/2„.41 Sig .ture of 'utho i Person Date Cbotv Title/Position of Authorized Person i County of Hawai`i Nonprofit Grant Application FY 2022-23 , Agency Name: Hawaii Island Adult Care, Ince Program Name: Hilo Adult Day 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 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: If no conflicts exist, check here. I. a of Authorized Person (specify title) Date Hawaii Island Home for Recovery, Inc HIHR Permanent Supportive Housing Program 96 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hawaii Island Home for Recovery, Inc Contact Person: Rita Sandi Palma Contact Email: admin@hihrecovery.org Contact Phone: 808 640 9442 Program Information Program Name: HIHR Permanent Supportive Housing Program Program Years in Operation: 11 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Hilo Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Needs of the poor, Public health and welfare of the people,and the environment, Aged, Physical/Emotional Disabilities,Victims of Crimes,Victims of Health or Social Crises Amount Applying For: $30000 Hawaii Island Home for Recovery, Inc-HIHR Permanent Supportive Housing Program I Page 1 Program Details Organization Mission: Aid Single Adult Homeless Population with mental illnesses, substance abuse, dual diagnosis with physical, health and other disabilities, prioritizing Chronically Homeless. Achieve goals not limited to obtaining and maintain Transitional, Supportive Permanent and long-term Permanent Housing. Improving life skills, income, self-determination, pursuing goals and dreams. Provide Housing with Evidence-Based and Low Barrier Service Models, Coordinated Entry System,VI- SPDAT and Housing First Model. Program Overview: HIHR provides Homeless Shelter Services since 2002, adding 2006-Transitional Shelter Housing, 2011-Permanent Supportive Housing, and 2008 Kitchen/Pantry Food Programs. A facility serving Single Adult Homeless Population with mental illnesses, substance abuse, dual diagnosis with physical, health and other disabilities, prioritizing Chronically Homeless. QBP financial system subcontracted, to prof. Bookkeeper, and CPA auditing and tax returns. High aid expertise assisting Homeless dazed multiple barriers to self-sufficiency. Assess and create Individual Service Plans-ISP/Case Mngt, substance abuse/mental health treatment, healthcare, living skills,financial training, education, jobs, housing resources, entitlements, parenting, domestic violence, recreational activities, holistic, social services,food, and pantry. Restore mind, body and spirit, to live independently, adding unmet needs. Coordinate resources with community, county, state, federal, public and private providers. Program Objectives & Performances Resources Needed: Last pre-COVID-19 pandemic Point-In-Time Count on 2020 revealed 1% rise in homelessness from 1,995 in 2019 to 2,010 in 2020. Attributed to an increase of 16% on the island of Hawaii, and 5% in unsheltered homelessness to 1,304 compared to 1,237 in 2019. and Unsheltered homelessness climbed 17%. Pool of PIT data is affected by COVID however, multiple indicators across the Nation show these homeless issues have greatly and harshly increase. Consequences not addressing these extensive and complex issues of homelessness, affordable housing, hunger, and poverty are and will be devastating. These injustices must be managed, improve with real solutions for the well-being of our communities. County,State and Federal funds and policies are required. HIHR is ready and well position to continue help our community address these and other issues pressing and shocking our society, when funds available HIHR will keenly be part of organizations providing solutions easing our needed Communities. Major Activities to be Completed:Align internal resources and local community, private, public, and institutional partners,to work obstacles to stable housing, health, income, food, recreation, financial obligations, entitlements,Jobs, education, and unmet needs. Create goals and objectives by Individual Service Plans-ISP with bi-weekly individual and team meetings,follow-up activities and teamwork with, health/medical, probation officers, mental health, substance abuse, and multiple social services, general assistance, social security benefits,section 8, housing authorities, realtors, landlords. Individual and group life skills trainings, as part of their support system.Also, meals and food bags are provided.All Hawaii Island Home for Recovery, Inc-HIHR Permanent Supportive Housing Program I Page 2 initiatives with goal to enhancing well-being and strengthening their ability to live healthier in balance and independently. Restitution of a sound and unblemished mind, body, and spirit to better handle the multiple barriers to the Homeless conditions in our society. Outputs to be Completed: • Comprehensive assessments and Individual Service Plan (ISP). • Case Manager craft strategic goals and objectives to overcome Homelessness recurrence cycles. • Health, mental health, substance Abuse and other as need treatment services. • Multiple areas of Life skills trainings in house and as well with other partners in the community. • Provide serve hot meals as need and as per available funds. • Provide bag meals as need and as per available funds. • Pursue and secure additional funding sources. • Provide a wholesome living environment promoting and encouraging the restitution of individuals to an unblemished mind, body, and spirit. • Maintain housing at HIHR and at exiting programs to obtain and maintain permanent Housing in the community. Measurable Outcomes: • 100% of residents received and implemented Individual Service Plans- ISP with program goals and objectives. • 100%of residents through HIHR and community providers received treatment services and trainings in multiple areas,gaining life skills that improved their income, living and housing conditions, helping them increase and maintain overall well-being. • 100%of residents received hot cook meals and food bags as need and as per available funds. • 95%exited residents assisted to obtain and maintain permanent housing for six months and longer. • Total annual average number of persons indirectly assisted not housed at HIHR, and those housed surpassed over 530 persons. • Resources and funding again were secure with HUD-CoC, SHI-DHS-HPO, HIUW, HICTY, and Other minor donors. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Hawaii Island Home for Recovery, Inc-HIHR Permanent Supportive Housing Program I Page 3 Program Budget Form: Income FY 2022-2023 County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name:HIHR Permanent Supportive Housing Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 30,000.00 30,000.00 30,000.00 Applicant organizational budget: 766,749.00 448,428.00 448,428.00 Individual contributions Membership fees Earned income Current cash assets 32,000.00 Other funding sources (list below): HUD-COC_PHS 345,860.00 345,860.00 345,860.00 Program Fees 64,500.00 40.500.00 40,500.00 Hawaii Island United Way- EFSP 25,750.00 16,168.00 16,168.00 Hawaii Island United Way -CIPGP 21,000.00 9,000.00 9,000.00 Other Revenue 11,000.00 6,900.00 6,900.00 Hawaii County Non-Profit 80,000.00 30,000.00 30,000.00 Total Cash Income 580,110.00 448,428.00 448,428.00 IN-KIND CONTRIBUTION Anticipated Committed Total Care Hawaii Inc. Adult Services 163,400.00 102,600.00 102,600.00 Project Vision Hawaii 68,800.00 43,200.00 43,200.00 United Ohana Coordinated Services 27,900.00 17,500.00 17,500.00 Rotary Club 94,600.00 27,000.00 27,000.00 Other Voluntiers 12,900.00 5,400.00 5,400.00 Total In-Kind Contributions 367,600.00 195,700.00 195,700.00 TOTAL PROGRAM INCOME 947,710.00 644,128.00 644,128.00 Appendix D--Budget Sheets (Page 2 of 2) - Project Budget Form: Expenses FY 2022-2023 County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Hawaii Island Home for Recovery, Inc. HIHR Program Name:HIHR Permanent Supportive Housing Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 20,000.00 179,543.00 178,420.00 377,963.00 Professional Fees 23,350.00 23,350.00 Operations 7,000.00 160,957.00 167,957.00 Supplies 3,000.00 38,410.00 33,448.00 74,858.00 Equipment SUBTOTAL 30,000.00 402,260.00 211,868.00 644,128.00 TOTAL PROGRAM BUDGET 30,000.00 402,260.00 211,868.00 644,128.00 County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Permanent Supportive Housing Program. 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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Hawaii Island Home for Recovery, Inc. HIHR Agency Name: Program Name: HIHR Permanent Supportive Housing Program 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 berefunded 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, 2023 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. 1/27/2022 Signat re of Authorized Person74f44714°' Date Executive Director Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Permanent Supportive Housing Program AISSZSZNICIZZESW 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 I The Managing Director I I 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. Executive Director1/27/2022 Signature of Authorized erson (specify title) Date Hawaii Island Home for Recovery, Inc. HIHR Kitchen & Pantry Outreach Programs 97 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hawaii Island Home for Recovery, Inc. Contact Person: Rita Sandi Palma Contact Email: admin@hihrecovery.org Contact Phone: 808 640 9442 Program Information Program Name: HIHR Kitchen & Pantry Outreach Programs Program Years in Operation: 14 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Hilo Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Needs of the poor, Public health and welfare of the people and the environment, Aged, Physical/Emotional Disabilities,Victims of Crimes,Victims of Health or Social Crises Amount Applying For: $20000 Hawaii Island Home for Recovery, Inc.-HIHR Kitchen& Pantry Outreach Programs 1 Page 1 Program Details Organization Mission:Aid Single Adult Homeless Population with mental illnesses, substance abuse, dual diagnosis with physical, health and other disabilities, prioritizing Chronically Homeless. Achieve goals not limited to obtaining and maintain Transitional, Supportive Permanent and long-term Permanent Housing. Improving life skills, income, self-determination, pursuing goals and dreams. Provide Housing with Evidence-Based and Low Barrier Service Models, Coordinated Entry System,VI- SPDAT and Housing First Model. Program Overview: HIHR provides Homeless Shelter Services since 2002, adding 2006-Transitional Shelter Housing, 2011-Permanent Supportive Housing, and 2008 Kitchen/Pantry Food Programs. A facility serving Single Adult Homeless Population with mental illnesses, substance abuse, dual diagnosis with physical, health and other disabilities, prioritizing Chronically Homeless. QBP financial system subcontracted, to prof. Bookkeeper, and CPA auditing and tax returns:High aid expertise assisting Homeless dazed multiple barriers to self-sufficiency. Assess and create Individual Service Plans-ISP/Case Mngt, substance abuse/mental health treatment, healthcare, living skills,financial training, education, jobs, housing resources, entitlements, parenting, domestic violence, recreational activities, holistic, social services,food, and pantry. Restore mind, body and spirit,to live independently, adding unmet needs. Coordinate resources with community, county, state,federal, public and private providers. Program Objectives & Performances Resources Needed: Last pre-COVID-19 pandemic Point-In-Time Count on 2020 revealed 1% rise in homelessness from 1,995 in 2019 to 2,010 in 2020. Attributed to an increase of 16% on the island of Hawaii, and 5% in unsheltered homelessness to 1,304 compared to 1,237 in 2019. and Unsheltered homelessness climbed 17%. Pool of PIT data is affected by COVID however, multiple indicators across the Nation show these homeless issues have greatly and harshly increase. Consequences not addressing these extensive and complex issues of homelessness, affordable housing, hunger, and poverty are and will be devastating. These injustices must be managed, improve with real solutions for the well-being of our communities. County, State and Federal funds and policies are required. HIHR is ready and well position to continue help our community address these and other issues pressing and shocking our society, when funds available HIHR will keenly be part of organizations providing solutions easing our needed Communities. Major Activities to be Completed:Align internal resources and local community, private, public, and institutional partners,to work obstacles to stable housing, health, income, food, recreation,financial obligations, entitlements,Jobs, education, and unmet needs. Create goals and objectives by Individual Service Plans-ISP with bi-weekly individual and team meetings,follow-up activities and teamwork with, health/medical, probation officers, mental health, substance abuse, and multiple social services,general assistance, social security benefits, section 8, housing authorities, realtors, landlords. Individual and group life skills trainings, as part of their support system. Also, meals and food bags are provided.All Hawaii Island Home for Recovery, Inc.-HIHR Kitchen &Pantry Outreach Programs I Page 2 initiatives with goal to enhancing well-being and strengthening their ability to live healthier in balance and independently. Restitution of a sound and unblemished mind, body, and spirit to better handle the multiple barriers to the Homeless conditions in our society. Outputs to be Completed: • Provide serve hot meals as need and as per available funds. • Provide bag meals as need and as per available funds. • Provide a wholesome living environment promoting and encouraging the restitution of individuals to an unblemished mind, body, and spirit. • Pursue and secure additional funding sources. Measurable Outcomes: • 100%of residents received and implemented Individual Service Plans- ISP with program goals and objectives. • 100%of residents through HIHR and community providers received treatment services and trainings in multiple areas,gaining life skills that improved their income, living and housing conditions, helping them increase and maintain overall well-being. • 100%of residents received hot cook meals and food bags as need and as per available funds. • 95% exited residents assisted to obtain and maintain permanent housing for six months and longer. • Resources and funding again were secure with HUD-CoC, SHI-DHS-HPO, HIUW, HICTY, and Other minor donors. Attachments Program Budget (Income & Expenses) • Certificate of Understanding Conflict Disclosure Hawaii Island Home for Recovery, Inc.-HIHR Kitchen &Pantry Outreach Programs I Page 3 Program Budget Form: Income FY 2022-2023 County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Hawaii Island Home for Recovery, Inc. HIHR Program Name:HIHR Kitchen & Pantry Outreach Programs CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 20,000.00 20,000.00 20,000.00 Applicant organizational budget: 766,749.00 1,000.00 1,000.00 Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): HIHR Kitchen & Pantry Food Outreach Programs 1,000.00 1,000.00 1,000.00 Hawaii Island United Way 3,000.00 3,000.00 3,000.00 Total Cash Income 24,000.00 24,000.00 24,000.00 IN-KIND CONTRIBUTION Anticipated Committed Total Rotary Club 94,600.00 51,600.00 51,600.00 Other Volunteers 12,900.00 4,300.00 4,300.00 Total In-Kind Contributions 107,500.00 55,900.00 55,900.00 TOTAL PROGRAM INCOME 131,500.00 79,900.00 79,900.00 Appendix D--Budget Sheets (Page 2 of 2) ;Project Budget Form: Expenses FY 2022-2023 County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ;Organization Name:Hawaii Island Home for Recovery, Inc. HIHR Program Name:HIHR Kitchen & Pantry Outreach Programs Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 2,000.00 2,000.00 55,900.00 59,900.00 Professional Fees 16,812.00 16,812.00 Operations 2,000.00 2,000.00 4,000.00 Supplies 16,000.00 18,357.00 19,822.00 16,000.00 Equipment SUBTOTAL 20,000.00 4,000.00 55,900.00 79,900.00 TOTAL PROGRAM BUDGET 20,000.00 4,000.00 55,900.00 79,900.00 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Kitchen & Pantry Outreach Programs 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 onspecific, 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Hawaii Island Home for Recovery, Inc. HIHR Agency Name: Program Name: HIHR Kitchen & Pantry Outreach Programs 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, 2023 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. .40.4 fah.740, 1/27/2022 Sig ature of Authorized Person Date Executive Director I Title/Position of Authorized Person Hawaii Island Home for Recovery, Inc. HIHR Transitional Shelter Program 98 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hawaii Island Home for Recovery, Inc. Contact Person: Rita Sandi Palma Contact Email: admin@hihrecovery.org Contact Phone: 808 640 9442 Program Information Program Name: HIHR Transitional Shelter Program Program Years in Operation: 20 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Hilo Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Needs of the poor, Public health and welfare of the people and the environment, Aged, Physical/Emotional Disabilities,Victims of Crimes,Victims of Health or Social Crises Amount Applying For: $30000 • Hawaii Island Home for Recovery, Inc.-HIHR Transitional Shelter Program I Page 1 Program Details Organization Mission: Aid Single Adult Homeless Population with mental illnesses, substance abuse, dual diagnosis with physical, health and other disabilities, prioritizing Chronically Homeless. Achieve goals not limited to obtaining and maintain Transitional, Supportive Permanent and long-term Permanent Housing. Improving life skills, income, self-determination, pursuing goals and dreams. Provide Housing with Evidence-Based and Low Barrier Service Models, Coordinated Entry System,VI- SPDAT and Housing First Model. Program Overview: HIHR provides Homeless Shelter Services since 2002, adding 2006-Transitional Shelter Housing, 2011-Permanent Supportive Housing, and 2008 Kitchen/Pantry Food Programs.A facility serving Single Adult Homeless Population with mental illnesses, substance abuse, dual diagnosis with physical, health and other disabilities, prioritizing Chronically Homeless. QBP financial system subcontracted,to prof. Bookkeeper, and CPA auditing and tax returns. High aid expertise assisting Homeless dazed multiple barriers to self-sufficiency. Assess and create Individual Service Plans-ISP/Case Mngt, substance abuse/mental health treatment, healthcare, living skills, financial training, education, jobs, housing resources, entitlements, parenting, domestic violence, recreational activities, holistic, social services,food, and pantry. Restore mind, body and spirit, to live independently, adding unmet needs. Coordinate resources with community, county, state, federal, public and private providers. Program Objectives & Performances Resources Needed: Last pre-COVID-19 pandemic Point-In-Time Count on 2020 revealed 1% rise in homelessness from 1,995 in 2019 to 2,010 in 2020.Attributed to an increase of 16%on the island of Hawaii, and 5% in unsheltered homelessness to 1,304 compared to 1,237 in 2019. and Unsheltered homelessness climbed 17%. Pool of PIT data is affected by COVID however, multiple indicators across the Nation show these homeless issues have greatly and harshly increase. Consequences not addressing these extensive and complex issues of homelessness, affordable housing, hunger, and poverty are and will be devastating. These injustices must be managed, improve with real solutions for the well-being of our communities. County,State and Federal funds and policies are required. HIHR is ready and well position to continue help our community address these and other issues pressing and shocking our society, when funds available HIHR will keenly be part of organizations providing solutions easing our needed Communities. Major Activities to be Completed:Align internal resources and local community, private, public, and institutional partners,to work obstacles to stable housing, health, income,food, recreation, financial obligations, entitlements,Jobs, education, and unmet needs. Create goals and objectives by Individual Service Plans-ISP with bi-weekly individual and team meetings, follow-up activities and teamwork with, health/medical, probation officers, mental health, substance abuse, and multiple social services,general assistance, social security benefits,section 8, housing authorities, realtors, landlords. Individual and group life skills trainings, as part of their support system. Also, meals and food bags are provided.All Hawaii Island Home for Recovery, Inc.-HIHR Transitional Shelter Program I Page 2 initiatives with goal to enhancing well-being and strengthening their ability to live healthier in balance and independently. Restitution of a sound and unblemished mind, body, and spirit to better handle the multiple barriers to the Homeless conditions in our society. Outputs to be Completed: • Comprehensive assessments and Individual Service Plan (ISP). • Case Manager craft strategic goals and objectives to overcome Homelessness recurrence cycles. • Health, mental health, substance Abuse and other as need treatment services. • Multiple areas of Life skills trainings in house and as well with other partners in the community. • Provide serve hot meals as need and as per available funds. • Provide bag meals as need and as per available funds. • Pursue and secure additional funding sources. • Provide a wholesome living environment promoting and encouraging the restitution of individuals to an unblemished mind, body, and spirit. • Maintain housing at HIHR and at exiting programs to obtain and maintain permanent Housing in the community. Measurable Outcomes: • 100%of residents received and implemented Individual Service Plans- ISP with program goals and objectives. • 100% of residents through HIHR and community providers received treatment services and trainings in multiple areas, gaining life skills that improved their income, living and housing conditions, helping them increase and maintain overall well-being. • 100% of residents received hot cook meals and food bags as need and as per available funds. • 95% exited residents assisted to obtain and maintain permanent housing for six months and longer. • Total annual average number of persons indirectly assisted not housed at HIHR, and those housed surpassed over 530 persons. • Resources and funding again were secure with HUD-CoC, SHI-DHS-HPO, HIUW, HICTY, and Other minor donors. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Hawaii Island Home for Recovery, Inc.-HIHR Transitional Shelter Program I Page 3 Program Budget Form: Income FY 2022-2023 County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Hawaii Island Home for Recovery, Inc. HIHR Program Name:HIHR Transitional Housing Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 30,000.00 30,000.00'' 30,000.00 Applicant organizational budget: 766,749.00 263,321.00 263,321.00 Individual contributions Membership fees Earned income Current cash assets 32,000.00 Other funding sources (list below): SHI-DHS-HPO TSP 186,639.00 186,639.00 186,639.00 Program Fees 64,500.00 24.000.00 24,000.00 Hawaii Island United Way- EFSP 25,750.00 9,582.00 9,582.00 Hawaii Island United Way -CIPGP 21,000.00 9,000.00 9,000.00 Other Revenue 11,000.00 4,100.00 4,100.00 Hawaii County Non-Profit 80,000.00 30,000.00 30,000.00 Total Cash Income 420,889.00 263,321.00 263,321.00 IN-KIND CONTRIBUTION Anticipated Committed Total Care Hawaii Inc. Adult Services 163,400.00 60,800.00 60,800.00 Project Vision Hawaii 68,800.00 25,600.00 25,600.00 United Ohana Coordinated Services 27,900.00 10,400.00 10,400.00 Rotary Club 94,600.00 16,000.00 16,000.00 Other Volunteers 12,900.00 3,200.00 3,200.00 Total In-Kind Contributions 367,600.00 116,000.00 116,000.00 TOTAL PROGRAM INCOME 788,489.00 379,321.00 379,321.00 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses FY 2022-2023 County of Hawaii• Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Hawaii Island Home for Recovery,,Inc. HIHR ,Program Name:HIHR Transitional Housing Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 20,000.00 129,258.00 105,760.00 255,018.00 Professional Fees 16,812.00 16,812.00 Operations 7,000.00 59,312.00 66,312.00 Supplies 3,000.00 18,357.00 19,822.00 41,179.00 Equipment • SUBTOTAL 30,000.00 223,739.00.. 116,000.00 379,321.00 • TOTAL PROGRAM BUDGET 30,000.00 223,739.00 116,000.00 379,321.00 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Transitional Shelter Program 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 gear 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Transitional Shelter Program 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, 2023 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. akz,to. 1/27/2022 Signature of Authorized Person Date Executive Director Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Hawaii Island Home for Recovery, Inc. HIHR Agency Name: Program Name: HIHR Transitional Shelter Program 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): I I 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: If no conflicts exist, check here. 74 fa"e* Executive Director1 /27/2022 Signature of Authorize Person (specify title) Date Hawaii Rise Foundation Together We Can 100 County of Fiavvai`i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hawaii Rise Foundation Contact Person: Breeani Sumera-Lee Contact Email: Breeani@Hawaiirisefoundation.com Contact Phone: 808-557-0880 Program Information Program Name:Together We Can Program Years in Operation: 3 Other County grants/agreements: Yes Previously received County GIA:Yes Program Geographical Reach: Hakalau, Hawi, Hilo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kailua- Kona, Kalapana, Kea'au, Kurtistown, Laupahoehoe, Mountain View, Pahoa, Papa'ikou, Volcano, Waimea, We want to serve the entire island if possible and be able to reach as many communities as possible. Program Target Audience: Infancy (0-3), Play Age (3-5), School Age (6-11), Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment, Youth, Aged, Physical/Emotional Disabilities Amount Applying For: $50000 Hawaii Rise Foundation-Together We Can I Page 1 • Program Details Organization Mission:The Hawaii Rise Foundation's mission is to create opportunities for vulnerable, or moderate and low-income families, children and elderly by providing educational services, programs and support. Program Overview: Our program is called,Together We Can. We partner with a variety of local farmers to create fresh local boxes for our Kupuna. We rotate and do island-wide deliveries with communities and we want to continue creating these wonderful CSA boxes in partnership with the County of Hawaii, OK Farms, and over 25 local farmers.and their'Ohana. We hope to continue to grow together and support one another through these hard times.The program aims to help make healthy food accessible to our community members.The program fosters supporting our local farmers and their farm to table initiatives.The program helps to take food to rural communities and to places where the people do not have reliable transportation, preventing them from access to these healthy foods in their life.The boxes also have informational packets about different things happening in the community so that elders can be up to date and informed.This program creates long term sustainable relationships within the community. Program Objectives & Performances Resources Needed: We currently work with OK Farms,who has access to the many farmers. (List of these farmers attached) We do have 2 staff that helps to manage the weekly deliveries, budget and data collection. We also have an accounting to pay for the produce. Makana Raw Kawamata Farms Rincon Family Farms Johnson Family Farms Ano'ano Farms Hamakua Forest Farm Sweet Cane Cafe Hamakua Mushrooms Hawaii Farming Teos Sweet Potatoes Dam Fine Farms Olakino Hawaii Mother Nature's Miracle Ahuimanu Farm Tarring Ohana Farms OK Farms Hamakua Macadamia Nut Company Buddhist Temple Wood Valley Daniel Nguyen Hawaii Rise Foundation-Together We Can I Page 2 Tai Nguyen Sue Kim Seung Le Martine Gonzalez Major Activities to be Completed: Kupuna boxes will be distributed to fourteen (14) different locations island-wide; ranging from different parts of Hilo, Hamakua, Kohala, and Kona.These Community boxes will be packed by OK Farms and delivered weekly in the communities. The community hubs have staff/volunteers to deliver to the Kupuna and there are volunteers who also deliver directly to Kupuna as well. Outputs to be Completed:We will support over 30 local farmers, and help over 1000 families by providing local produce. Measurable Outcomes:We would like to survey our elderly community members and help address their other immediate needs. Some elderly have expressed the need for transportation, help with preparing meals, household chores, bathing, vaccination accessibility, dental work,financial struggles, and a request to provide a master list of services offered for the elderly. We are able to build a relationship with our communities, farmers, and Kupuna by communicating and being more involved and engaged. We are using this community box as a communication tool as well to gather information and make better decisions on where we can be most impactful in leveraging all of our resources. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Hawaii Rise Foundation-Together We Can I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Hawaii Rise Foundation Program Name:Together We Can CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50,000.00 Applicant organizational budget: Individual contributions 1,000.00 Membership fees Earned income Current cash assets Other funding sources (list below): Total Cash Income 51,000.00 51,000.00 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 51,000.00 51,000.00 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Hawaii Rise Foundation Program Name: Together We Can Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 15,000.00 10,000.00 25,000.00 Professional Fees 2,000.00 3,000.00 Operations 33,000.00 Supplies .1,000.00 Equipment SUBTOTAL 51,000.00 10,000.00 61,000.00 TOTAL PROGRAM BUDGET 51,000.00 10,000.00 61,000.00 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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-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, 2023 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 23,2022 Signature of Authorized Person Date Executive Director,Hawaii Rise Foundation Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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 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: �If no conflicts exist, check here. January 23,2022 Signature of Authorized Person (specify title) Date Hawaii Society of Obstetricians and Gynecologists Hawaii County OB/GYN Resident Program 2022-2023 101 • County of Flawai`i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hawaii Society of Obstetricians and Gynecologists Contact Person:John K. Uohara Contact Email: obgyn96720@hotmail.com Contact Phone: (808) 937-3600 Program Information Program Name: Hawaii County OB/GYN Resident Program 2022-2023 Program Years in Operation:Three (3) Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo`o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, NTnole, Ocean View, ((Takata, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, `Umikoa,Volcano,Waikoloa Village, Waimea, Wainaku, Wai`ohinu,Weloka Program Target Audience: Infancy (0-3), Play Age (3-5),School Age (6-11), Adolescence (12-17), Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment,Youth, Aged Amount Applying For: $50000 Hawaii Society of Obstetricians and Gynecologists-Hawaii County OB/GYN Resident Program 2022-20231 Page 1 Program Details Organization Mission: Hawaii Society of Obstetricians & Gynecologists (HSOG) is a nonprofit 501(c)3 formed in 2018. Our mission and vision: create an advocacy for quality comprehensive women's health care for the State of Hawaii, with emphasis on rural and underserved areas.The Board represents decades of experience in academic medicine, non-profit boards, private and group medical practices. We have been supportive and been deeply involved with the Hawaii County Ob/Gyn Resident Rotation since inception in 2019. Program Overview: Engagement: collaborate with UH School Of Medicine's OB/GYN physician resident's one-month Hilo rotation for exposure to office practices &surgical procedures at Hilo Medical Center. Residents will experience rural medicine and have opportunities to live, eat and play among the people of Hilo for exposure to rural life. Awareness: host the 2nd Annual Statewide Conference on Rural Medicine to bring awareness on the medical needs of underserved communities. Invitees: undergrads, medical students, resident and practicing physicians, hospital administrators, and insurance providers to increase awareness--the catalyst for change. Opportunity:with the Hawaii Residency Program, host the 1st medical job fair focusing solely on rural areas. Invitees: medical students, resident physicians, and allied health professionals along with employers from rural areas and neighbor islands. This will be Hawaii's first medical job fair to include medical students and residents from all training programs Program Objectives & Performances Resources Needed: ENGAGEMENT: The physical resources, medical facilities, and personnel for the 12 resident physicians to rotate to Hilo are in place. Funds are needed to house residents. AWARENESS: For the statewide medical conference, IMUA: WOMEN'S HEALTH, a poster session will be included to create awareness among students, residents, and the medical community. Funds are needed for facility rentals, air transportation, printing, and food and refreshments for 80 attendees. Food/refreshments are essential as sessions will be held during meal periods to maximize conference time; refreshment breaks provide participants with the opportunity to network and form connections. OPPORTUNITY: HSOG will host the State's 1st Rural Medicine Job Fair.All training programs and specialties including primary care will be involved. A volunteer force of 30+ physicians and 20+ non- physicians and 100 attendees is expected. Funding for the areas described above is essential as this is a non-revenue generating event. Major Activities to be Completed: ENGAGEMENT: HSOG expects a total of 12 residents (six 3rd-year and six 4th-year)to complete a month long rotation to Hilo.The resident physicians are also expected to interact and be involved with the Family Medicine residents at Hilo Medical Center. AWARENESS: IMUA: WOMEN'S HEALTH is expected to involve 80 physicians in June 2023. This continuing medical education event in conjunction with Hilo Medical Center will have volunteer speakers who will discuss practice challenges in rural settings. Hawaii Society of Obstetricians and Gynecologists-Hawaii County OB/GYN Resident Program 2022-20231 Page 2 OPPORTUNITIES: Our Rural Health Jobs Fair is expected to involve more than 100 resident physicians from all training programs in the State (Tripler, Kaiser, Hawaii Island Family Residency and Hawaii residency program). Medical students from JABSOM will also be invited. The attendees will include physicians in all medical specialties as well as primary care. Outputs to be Completed: ENGAGEMENT: HSOG expects 12 resident physicians to rotate to Hilo during the 12 month period. Resident physicians will average 40 outpatient contacts per week for a total of 2,000 patient contacts per week. Residents will also average a total of 10 surgical procedures per week and 500 procedures for the year.The numbers are estimates and may vary considerably pending the COVID-19 pandemic. AWARENESS: IMUA: WOMEN'S HEALTH, our medical conference in June 2023, is estimated to involve up to 80 participants. We will also invite 20 guests from allied fields. We anticipate at least 30 volunteer physicians and 10 others. OPPORTUNITIES: HSOG's Rural Jobs Fair is expected to have more than 100 attendees from various medical specialties. We will attempt to unite employers from rural areas with potential employees. We anticipate at least 30 volunteer physicians and 20 others. Measurable Outcomes: ENGAGEMENT: The average physician's career is 30 years and the average patient contacts per day is a minimum of 20 patients (pts). Impact of a single physician: 20 pts/day x 5 days/week x 50 weeks/year= 5,000 pts contacts/year. 5,000 pts contacts/year x 30 years= 150,000 pts contacts Excludes baby deliveries, surgeries, emergency room visits or hospital consultations. The quantitative effect will be felt for many generations. AWARENESS:The rural medical conference will inform and create a platform for discussions by future physicians.The conference is designed to provide the knowledge needed to bring about change. OPPORTUNITIES: The Rural Health Job Fair will help to create opportunities for employers to recruit new • physicians for our community. HSOG has received a non-profit County Grant in 2020-2021 and 2021-2022, engaged 24 residents and retained two physicians, now practicing in Hilo and Kona. HSOG needs the County's continued support and is eager to expand these efforts Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Hawaii Society of Obstetricians and Gynecologists-Hawaii County OB/GYN Resident Program 2022-20231 Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Hawaii Society of Obstetricians and Gynecologists Program Name:Hawaii County OB/GYN Resident Program 2022-2023 CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $50,000 $50,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Total Cash Income IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME $50,000 $50,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Hawaii Society of Obstetricians and Gynecologists Program Name:Hawaii County OB/GYN Resident Program 2022-2023 Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages Professional Fees 1,300 1,300 Operations Supplies Equipment Insurance 1,400 1,400 ---ENGAGEMENT--- - - Resident housing 18,000 18,000 Resident start-up stipend 3,600 3,600 ---AWARENESS-IMUA WOMEN'S HEALTH CONFERENCE--- — — Rental of venue 4,000 4,000 Stipends for speakers 1,000 1,000 Audio visual rental 500 500 Posterboard stands - rental 350 350 Posterboard stands - supplies 100 100 Stipends-neighbor island students(airfare,ground transportation.M&IE) 4,000 4,000 Printing of conference materials 400 400 Services Agreement - secretarial 500 500 Services Agreement-conference coordinator 1,500 1,500 Services Agreement-web design and IT support 1,500 1,500 ---OPPORTUNITY-RURAL JOB FAIR--- - - Rental of venue 4,000 4,000 Meals and Refreshments 2,000 2,000 Travel(airfare,ground,M&IE)-president recruitment trips to neighbor islands 2,000 2,000 Printing of job fair materials 350 350 Services Agreement- secretarial 500 500 Services Agreement-conference coordinator 1,500 1,500 Services Agreement- web design and IT support 1,500 1,500 SUBTOTAL TOTAL PROGRAM BUDGET 50,000 50,000 County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Hawaii Society of OB/GYN Program Name: Hawaii County OB/GYN Resident Program 2022-23 Certification of Understanding (Page 1 oft) 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, l (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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Hawaii Society of OB/GYN Program Name: Hawaii County OB/GYN Resident Program 2022-23 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, 2023 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/b/C,(-Cd4.4r-u\ January 21,2022 Signature of Authorized Person Date Yesicf P_,r� Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Hawaii Society of OB/GYN Program N ame: Hawaii County OB/GYN Resident Program 2022-23 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 neeaed 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 Member or members of the Council n Staff appointed by a member of the Council The Mayor Li The Managing Director j_ 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 token by on 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. );Zi -G«r - President January 21,2022 signature of Authorized Person (specify title) Date Heart Ranch Heart Ranch 103 County of Hawai`i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Heart Ranch Contact Person: Fronda Harris Contact Email: fronda@heartranch.org Contact Phone: 808-937-9717 Program Information Program Name: Heart Ranch Program Years in Operation: 10 years Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Hilo Program Target Audience:School Age (6-11), Adolescence (12-17), Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Public health and welfare of the people and the environment, Youth, Physical/Emotional Disabilities, Victims of Crimes, Victims of Health or Social Crises Amount Applying For: $25000 Heart Ranch- Heart Ranch I Page 1 Program Details Organization Mission: Heart Ranch strives to develop strong and resilient individuals and communities across Big Island. Rooted in an ethic of providing unconditional love and support, Heart Ranch provides unique ranch experiences that challenge and encourage growth in children, families,Veterans, and volunteers. Specifically, Heart Ranch creates a safe environment where individuals encounter and overcome adversity.Through these challenges, individuals develop confidence and bond with others. Program Overview:Over the last ten years, Heart Ranch has built confidence, developed leadership, and encouraged personal growth in over 600 children, their families, and Veterans from every corner of Big Island. On a small ranch in Hilo,volunteer mentors foster personal growth at the start of every session.They talk with participants about the importance of setting boundaries, using body language, and communicating clearly with a 1,000-pound animal; horses naturally seek leadership, so participants must learn to lead, or the horse will step in to fill the role. Volunteers coach and mentor each participant throughout the session, enabling participants to build confidence as they learn how to effectively lead and connect to their horse. Families are encouraged to stay during the session to watch their loved ones learn and grow. In addition to serving participants, Heart Ranch staff invest heavily in the development of their volunteers, conducting training sessions two to three times per month. Program Objectives & Performances Resources Needed:Volunteers are the lifeblood of Heart Ranch. With such labor-intensive operations and no paid staff, Heart Ranch would not be able to operate without its many volunteers. Next, Animal feed costs remain the biggest budgetary item each year. With the low-quality nutrition in the grass in our area, all our animals need to be subsidized daily with additional feed and supplements. Additionally, many of Heart Ranch's horses are older and have physical or psychological health problems. Heart Ranch maintains a close relationship with its veterinarian, and focuses on preventative care. Maintaining the health and welfare of the ranch animals is essential, and an increasing cost, as Heart Ranch seeks to acquire more horses, expand its operations, and serve more members of the community. As Heart Ranch expands this year, it plans to hire paid staff for the first time. Extra staff will be vital to develop new programs and reach more individuals in the community. Major Activities to be Completed: Heart Ranch maintains almost 30 animals on over 15 acres, requiring daily care.This work is largely completed by Heart Ranch staff, with the help of volunteers. Aside from routine ranch upkeep, the largest time-demand is the planning, coordination, and execution of Heart Ranch's Youth Mentorship. In preparation for each term Heart Ranch staff must analyze their ever- growing wait-list of over 200 participants, and pair each with volunteer"mentors." These mentors will work one-on-one with each participant and a horse for an hour and a half session, each week, for six weeks. Staff lead a volunteer training session every term, and provide extra mentorship and training to youth volunteers every other week. Additionally, Heart Ranch staff coordinate and facilitate Equine Assisted Psychotherapy sessions for Veterans with PTSD, foster groups, and individuals. Staff work with local therapists to create personalized lesson plans to meet individual's needs. Heart Ranch-Heart Ranch I Page 2 Outputs to be Completed:This year, Heart Ranch will conduct five "terms" of Youth Mentorship. Each term lasts six weeks, running three days a week, with two 90-minute sessions per day. Each session averages three to four participants, averaging about 20 participants per term. This year, we aim to serve over 100 participants for 900 session-hours. We also measure success by the development of our volunteers, and the engagement of our families.Volunteers mentor participants, connect with families, assist with ranch maintenance, and ensure ranch safety. While volunteering, they develop their own leadership, confidence, and interpersonal skills.This year, volunteers will spend over 3,000 hours at Heart Ranch. Many families arrive early, stay late, and connect with other families. We expect families to spend about 1,000 hours at the ranch, enriching our community. Additionally, Heart Ranch will provide over 200 hours of Veterans services and other Equine Assisted Psychotherapy. Measurable Outcomes: We measure successful outcomes by the desire of Heart Ranch's alumni to return to the program, and the strength of the community that we have built. We have served over 600 individuals in the past ten years, and most sign back up as soon as they can. Most volunteers are alumni, looking for any way to give back to Heart Ranch. Our community shows its strength by consistently inviting others to attend the program; despite having never advertised, we consistently maintain a waiting list of over 200 potential participants.Additionally, our community supports us with generous donations of time and money. Our volunteers annually contribute about 3,000 volunteer hours, with eight of them weekly commuting from Kona and Waikoloa during terms. Individual donations account for over 80%of the program's income; Heart Ranch is the recipient of tithes and percentages of local business' profits; it has been written into wills and it receives a constant stream of thank you letters and calls. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Heart Ranch-Heart Ranch I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name Heart Ranch Program Name:Heart Ranch CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $25,000 $25,000 Applicant organizational budget: Individual contributions $35,000 $35,000 Membership fees Earned income Current cash assets Other funding sources (list below): EAP Programs $8,000 $8,000 Total Cash Income $68,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME $68,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses 'County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Heart Ranch E Program Name:Heart Ranch Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $18,850 0 0 $18,850 Professional Fees $3,700 $3,700 Operations $3,950 $3,950 Supplies $29,500 $29,500 Equipment $12,000 $12,000 SUBTOTAL $68,000 $68,000 TOTAL PROGRAM BUDGET $68,000 $68,000 County of awai`i Nonprofit Grant Application FY 2422-23 Agency Name: Heart Ranch Program Name: Heart Ranch Certification of Understanding (Page t 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) understandandwill comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior toreceiving payment(s). To register, go to httmilveitdur ,ehawaiLatw,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. County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Heart Ranch Program Name: Heart Ranch Certification of nderstanding (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 i /L ,, tri Ali cf vil>il ,? ,} _ z i - f 1 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, 2023 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;42. Signature of Authorized Person Date ?c't t Title/Position of Authorized Person County" of awai`i Nonprofit Grant Application FY 2022-23 Name: Heart Ranch Agency Ma Program Name: Heart Ranch "GANIZATION 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 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 IT Staff appointed by a member of the Council n The Mayor The Managing Director E The Director of Finance I 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 / 1 Signure of Ault orized Person (specify title) Date Hilo Community Players 45th Annual Shakespeare in the Park Festival 104 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hilo Community Players Contact Person: Rachel Klein Contact Email: HiloCommunityPlayers@Gmail.com Contact Phone: 8088956042 Program Information Program Name:45th Annual Shakespeare in the Park Festival Program Years in Operation:44 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Hawaiian Acres, Hawaiian Paradise Park, Hilo, Kea'au, Kurtistown, Mountain View, Ninole, Pa'auilo, Pahoa, Papa'ikou, Pauka'a, Pepe'ekeo,Volcano,Waimea,Wainaku Program Target Audience:Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and,the arts,Aged Amount Applying For:$10000 Hilo Community Players-45th Annual Shakespeare in the Park Festival I Page 1 Program Details Organization Mission:The mission of the Hilo Community Players is to educate, enrich, and inspire the Big Island community through quality theatrical productions,workshops, and activities for children, teens, and adults. Program Overview:The 45th Annual Shakespeare in the Park Festival program provides opportunities for children,teens, and adults of all ages to participate in the production process of a full-length Shakespeare play.This year's program will be special, incorporating a renaissance faire into the event in addition to the Shakespearean literature education workshops and stage play presentation.The program is put on at no cost to our audience or participants so that families of all socio-economic backgrounds may enjoy together.This program promotes a sense of community and access to the arts by creating opportunities both for participation and enjoyment for all. In recent years,this program has produced Hamlet, Othello and Romeo &Juliet, which were all very Y well attended and received by our community.This project draws island-wide participants and large, diverse audiences. It creates educational opportunities for all that attend and exposure to various elements of the arts process. Program Objectives & Performances Resources Needed:This program requires monetary support that will provide supplies such as lumber for set building,fabric for costume creation and paint for scenic art.The staff and volunteers necessary for this program to be executed total 75 positions,with not less than 3 drama instructors highly skilled in Shakespeare specific text who will earn wages from the program. Outdoor event supplies such as tents, tables and chairs will be needed to create opportunities for small business and artists to participate in the faire.We will also need sound and lighting equipment, a projector and lighting truss which can all be rented to supplement our current supply. Major Activities to be Completed: In this full program,there will be educational workshops,the production of stage play and presentation of a full renaissance faire, including a food distribution. Outputs to be Completed: Outputs expected: 1,500 members of the public served, 60 volunteer performers/artists/businesses (with 200 hours offered per volunteer), 15 technical skills volunteers (with 200 hours offered per volunteer), 2 educational workshops offered, 11 performances offered for the community. Measurable Outcomes: Outcomes: Engaged community participation, improved literacy, increased access to the arts and arts education, and significant workforce development Attachments Program Budget (Income & Expenses) Certificate of Understanding Hilo Community Players-45th Annual Shakespeare in the Park Festival I Page 2 Conflict Disclosure Hilo Community Players-45th Annual Shakespeare in the Park Festival I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Hilo Community Players Program Name:45th Annual Shakespeare in the Park Festival CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 10,000 10,000 Applicant organizational budget: Individual contributions 4,000 4,000 Membership fees 2,500 2,500 Earned income Current cash assets 2,500 2,500 Other funding sources(list below): Project Specific Fundraising 2,000 3,000 5,000 Total Cash Income 12,000 12,000 24,000 IN-KIND CONTRIBUTION Anticipated Committed Total Salary Wages 10,000 10,000 Equipment Storage 2,000 2,000 Total In-Kind Contributions 2,000 10,000 12,000 TOTAL PROGRAM INCOME 14,000 22,000 36,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii ® Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Hilo Community Players Program Name:45th Annual Shakespeare in the Park Festival Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 2,500 3,500 10,000 16,000 Professional Fees 1,000 1,500 2,500 Operations 1,000 2,500 3,500 Supplies 2,500 3,500 6,000 Equipment 2,000 2,000 4,000 Equipment Storage 1,000 1,000 2,000 4,000 SUBTOTAL 10,000 14,000 12,000 36,000 TOTAL PROGRAM BUDGET 10,000 14,000 12,000 36,000 County of favvai`l Nonprofit Grant �� icati {n FY 2022_-73 Agency N am e: HHo Communy Players Program Name: 45th Annual Shakespeare in the Park Festiv Certification of Understanding (Page 1 of 2) (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. signature gnozurpnouotbctheOR|G|NALSUGNED 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 Havvei 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 Hawail, 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, anaccurate year-end report, us/ng the tr/np/otap0ov/ded, will impact the evaluation of your pro qram's or aqency's future fundinq requests. County of t Iawai'i. Nonprofit Grant Application FY 2022-23 Agency Name: Hila Community Players Program Name; 45th Annual Shakespeare=n the Park Festival 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 durin the :rant ;•eriod 'must be refunded to Count and exclusion from future grant participation fora minimum of one year or until a written report is submitted to, and accepted by,the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at ht�E tty,tvn,h ,t rdiico;uritv,,gov/fn-r7o nprc�f t- ;tarsi-sorrns%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, 2023 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 agencyL's future fundinq 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 /15/2022 iatur,( Auth d Person Date Board President Title/Position of Authorized Person County ol Hawai‘i Nonprofit Grant Application FY 2022-23 Agency Name: Hi'.o Con-gnu-10y Players P rogran Name: 45th Annual Shakespeare in the Park Festival 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 mustbe 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 j] Staff appointed by a member of the Council [] The Mayor The Managing Director The Director of Finance 1 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: • (1 If no conflicts exist, check here. -,-�. Board President 1/15/2022 igna .fie Authorized Person (specify title) Date Hilo Community Players Na Mea Hawaii Theatre 105 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hilo Community Players Contact Person: Dr. Rachel Klein Contact Email: HiloCornmunityPlayers@Gmail.com Contact Phone: 80889560042 Program Information Program Name: Na Mea Hawaii Theatre Program Years in Operation: 9 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Kalapana, Kapoho, Kea'au, Kurtistown, Laupahoehoe, Leilani Estates, Mountain View, Nanawale Estates, Ninole, Pahoa, Pauka'a, Pepe'ekeo, Volcano,Wainaku Program Target Audience: Play Age (3-5),School Age (6-11),Adolescence (12-17),Young Adulthood (18- 39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts,Youth,Aged Amount Applying For: $7500 Hilo Community Players-Na Mea Hawaii Theatres Page 1 Program Details Organization Mission:The mission of the Hilo Community Players is to educate, enrich, and inspire the Big Island community through quality theatrical productions,workshops, and activities for children, teens, and adults. Program Overview: Na Mea Hawai'i Theatre is a program of agency that we dedicate to the perpetuation and education of Hawaiian culture, language and history.This program works toward a production and series of educational classes involving these Hawaiian themes and local works. Our Na Mea Hawai'i program cannot be done without kokua from our volunteers and a focus on our keiki. For some keiki,this program may be their first experience learning kuleana and the importance of ho'omau, having the confidence to persevere through obstacles on their own.This program functions to promote local artists, preserve Hawaiian culture, amplify local voices and perpetuate Hawaiian stories. In past years,this program has presented works such as"The Trial of Lil 'uokalani" by Maurice Zimring, and "The Last Princess" by Jackie Prell.This program was established under the guidance of Jackie Pualani Johnson and Dr.Justina T. Mattos, and often works in collaboration with UHH and East Hawaii Cultural Center. Program Objectives & Performances Resources Needed:Volunteers, staff, performers, funding, building tools, building supplies, paint, lumber, storage space, costumes, stage properties,tents, paper, printing,technology, speakers, sound equipment,wireless microphones, lighting, light boards, performance spaces, rehearsal spaces, • classroom spaces, marketing tools. Major Activities to be Completed: Production is selected and royalties for the local playright are paid to the local artist, rehearsal space and dates are arranged, performance space and dates are arranged, advertising is distributed to community to generate awareness of the project. Educational workshops are offered for the elements involved in storytelling, such as hula, ukulele, and 'Olelo Hawai'i.Volunteer performers as well as artistic staff and technical skills volunteers begin crafting the production through numerous rehearsals and meetings. Costumes are designed and created. Props are designed and created. Stage and scenic elements are designed and built. Stage is painted and scenic elements and stage properties are created by artists to set the stage for the story.Technical skills volunteers and staff design, build and execute sound system and lighting equipment systems to enhance audience's ability to consume the art.The final production is presented 6-12 times and filmed for future presentation as well. Outputs to be Completed: 30 volunteers participating, 200 hours per volunteer provided, 6 local artists employed, 6 staff employed, 2 workshops offered, 1,000 community participants/audience members educated. Measurable Outcomes:The East Hawai'i community learns about Hawaiian culture, history and language.The program is supported by the public after the experience and we are encouraged to Hilo Community Players-Na Mea Hawaii Theatre I Page 2 continue efforts in Hawaiian education. Keiki are confident and leave the program knowing more about their'aina, its people and its culture. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Hilo Community Players-Na Mea Hawaii Theatre I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Hilo Community Players Program Name:Na Mea Hawai'i Theatre CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 7,500 7,500 Applicant organizational budget: Individual contributions 4,000 4,000 Membership fees 2,500 2,500 Earned income Current cash assets 2,500 2,500 Other funding sources(list below): Project Specific Fundraising 2,000 1,500 3,500 Total Cash Income 9,500 10,500 20,000 IN-KIND CONTRIBUTION Anticipated Committed Total Salary Wages 12,000 12,000 Workshop, Rehearsal & Performance Space 4,000 4,000 Total In-Kind Contributions 16,000 16,000 TOTAL PROGRAM INCOME 9,500 26,500 36,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Hilo Community Players !Program Name:Na Mea Hawai'i Theatre Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 2,500 2,500 12,000 17,000 Professional Fees 2,500 2,500 Operations 1,000 2,000 3,000 Supplies 1,000 2,500 3,500 Equipment 2,000 2,000 4,000 Workshop, Rehearsal& Performance Space 1,000 1,000 4,000 6,000 SUBTOTAL 7,500 12,500 16,000 36,000 TOTAL PROGRAM BUDGET 7,500 12,500 16,000 36,000 County of Hawai`i. Nonprofit Grant Application FY 202?-23 Agency Name: Hilo Community Players Program Name: Na Mea Hawai'i Theatre 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 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. County Qf `^' N ^ Application ' FY2Q22_23 Agency Name: Hilo Community Players Program Na088^ NMea B i'iIbcatre Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'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 eplicitly 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 :rant funds receiveddurim: 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. | �xxe\ understand |rtherno� � submit Information . . and instructions are available at awaiicIUntysAuv/fn'nouroN-grant-fn/ms/onorabout 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, 2023 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 u[ogency's future fundinq 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. 1/1 5/2022 �o ____ /�gnatune ~/Au horized Person Date Board U��'��f President .�.�..�.�, .� Title/Position of Authorized Person County of Fl.awai`i Nonprofit Grant Application FY 2022-23 Agency Name: thin Commuity Players Program Name: Na Mea Hawaii Theatre. 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 I I Staff appointed by a member of the Council The Mayor f l The Managing Director 7 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: [x1 If no conflicts exist, check here. Board President 1/15/2022 Signa�iire of Authorized Person (specify title) Date Hilo Community Players Kid-Shakes! 106 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hilo Community Players Contact Person: Dr. Rachel Klein Contact Email: HiloCommunityPlayers@Gmail.com Contact Phone: 8088956042 Program Information Program Name: Kid-Shakes! - Program Years in Operation: 8 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Hawaiian Acres, Hawaiian Paradise Park, Hilo, Honoka'a, Kalapana, Kea'au, Kurtistown, Laupahoehoe, Nanawale Estates, Ninole, Pahoa, Papa'ikou, Pauka'a, Pepe'ekeo, Volcano, Wainaku Program Target Audience: Play Age (3-5), School Age (6-11),Adolescence (12-17),Young Adulthood (18- 39) Services/Activities Provided: Educational concerns, Culture and the arts,Youth Amount Applying For:$5000 Hilo Community Players-Kid-Shakes! Page 1 Program Details Organization Mission:The mission of the Hilo Community Players is to educate, enrich, and inspire the Big Island community through quality theatrical productions,workshops, and activities for children, teens, and adults. Program Overview: Kid-Shakes is an annual program our agency began 8 years ago to make the literature of Shakespeare more accessible to keiki.This is a program in which an original adaptation of a Shakespeare play designed to educate and entertain young audiences.The production is performed by and for children.The program offers our younger community members the opportunity to participate in every aspect of mounting a production, and is an excellent way to introduce them to Shakespeare's rich literary world in an appropriate, accessible,family-friendly format.The scripts are designed to appeal to young audiences and to begin to introduce the complex topics covered by the writing of William Shakespeare.The program is presented free of charge to participating keiki,their families and the community. Program Objectives & Performances Resources Needed:Volunteers, staff, performers, funding, building tools, building supplies, paint, lumber, storage space, costumes, stage properties,tents, paper, printing,technology,speakers, sound equipment,wireless microphones, lighting, light boards, performance spaces, rehearsal spaces, marketing. Major Activities to be Completed: Production is selected, rehearsal space and dates are arranged, performance space and dates are arranged, advertising is distributed to the community to generate awareness of the project. Keiki,volunteer performers as well as artistic staff and technical skills volunteers begin crafting the production through numerous rehearsals and meetings. Costumes are designed and created. Props are designed and created.Stage and scenic elements are designed and built. Stage is painted and scenic elements and stage properties are created by artists to set the stage for the story.Technical skills volunteers and staff design, build and execute sound system and lighting equipment systems to enhance audience's ability to consume the art.The final production is presented 5-9 times, starring our keiki participants,for an audience of children and families. Outputs to be Completed: 20 children participating, 10 adult volunteers participating, 200 hours per volunteer provided, 6 staff employed, 500 community participants/audience members entertained Measurable Outcomes: Enriched community of tomorrow's leaders and artists, an audience leaves also feeling enriched and aware of the performing arts opportunities in their local community for youth. Educated participating keiki in the literature of Shakespeare and inspired them to pursue performing and leadership opportunities. Hilo Community Players-Kid-Shakes!I Page 2 Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure • Hilo Community Players-Kid-Shakes!I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Hilo Community Players Program Name:Kid-Shakes! CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 5,000 5,000 Applicant organizational budget: Individual contributions 2,000 2,000 Membership fees Earned income Current cash assets 3,000 3,000 Other funding sources (list below): Total Cash Income 5,000 5,000 10,000 IN-KIND CONTRIBUTION Anticipated Committed Total Salary Wages 5,000 5,000 Workshop, Rehearsal & Performance Space 2,000 2,000 Total In-Kind Contributions 7,000 7,000 TOTAL PROGRAM INCOME 5,000 12,000 17,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses ;County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Hilo Community Players Program Name:Kid-Shakes! Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 2,000 1,000 5,000 8,000 Professional Fees 1,000 1,000 Operations 500 500 Supplies 1,000 1,500 2,500 Equipment 1,000 1,000 Workshop, Rehearsal& Performance Space 1,000 1,000 2,000 4,000 SUBTOTAL 5,000 5,000 7,000 17,000 TOTAL PROGRAM BUDGET 5,000 5,000 7,000 17,000 County of Hawjai`i. Nonprofit Grant Application FY 2022-23 . Agency Name: Hilo Community Players Program Name: Kid-Shakes! 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, cornplete the easy step-by-step process,and pay the annual registration fee online using a credit card. If awarded a ,rant from the Count of Hawaii I we understand and will corn.1 with the re•uirement 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. County of '^ ` Nonprofit Grant Application FY 2029-23 Agency Name: Bj|oCnmcnooiiy Players Program Name: Kid-Shake ! 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 :rant funds received dunn: the :rant seriod must be refunded to Count 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 onty,go«/fn'o gran1'fonns/ onorabout 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, 2023 must be returned to the County of.Hawari with the final report. Failure to return these funds in a tfrnely manner will impact the evaluation of your oqency'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. fi � /� ��y��^�^� y / n ^��z�� natureViku horized Person Date Board K��^��Mf �- . ==��J=. .� Title/Position of Authorized Person County Q, fi awai^^ Nonprofit Grant Application FY 2022_23 Agency Name: Hilo Commuity Players Program Name: Kid-Shakes! ORGANIZATION ��KU�� 8��U �� K� CONFLICT �°"~°"~��."��=~- FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, mradnninishatorofyoVrorganizationrnayhaveVviththeCountyofHavvai^|. Onk/those |/stedbe|oxV need to he 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 siqned, reqard/ess of whether a conflictt 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 —1 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: 7 If no conflicts exist, check here. ' ~ -10 Board President 1 /15/2022 3ignaJtrp of Authorized Person (specify title) Date Hilo Community Players Rising Stars 107 County.of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hilo Community Players Contact Person: Dr. Rachel Klein Contact Email: HiloCommunityPlayers@Gmail.com Contact Phone: 8088956042 Program Information Program Name: Rising Stars Program Years in Operation:4 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Kea'au, Kurtistown, Laupahoehoe, Leilani Estates, Mountain View, NInole, Orchidlands Estates, Pahoa, Papa'ikou, Pauka'a, Pepe'ekeo,Volcano,Wainaku Program Target Audience:School Age (6-11),Adolescence (12-17) Services/Activities Provided: Educational concerns, Culture and the arts,Youth Amount Applying For: $10000 Hilo Community Players-Rising Stars I Page 1 Program Details Organization Mission:The mission of the Hilo Community Players is to educate, enrich, and inspire the Big Island community through quality theatrical productions,workshops, and activities for children, teens, and adults. Program Overview: Rising stars is a children's musical theater educational program.The Rising Stars program has previously presented a musical theater summer camp of drama, dance and music classes that culminated with a musical theater performance by children ages 5-17 which was a production written, rehearsed and performed by the children with the guidance of local artists and instructors.This year, we hope to expand this summer program to a year-round program. Program Objectives & Performances Resources Needed:Volunteers, instructors, students,funding, stage properties, rehearsal space, performance space, paper, printing. Major Activities to be Completed: Instructors and volunteers educate students about theater by presenting classes in arts topics, culminating in final performances by the children presented to families and/or the general public. Outputs to be Completed: 40 children participating, 5 adult volunteers participating, 100 hours per volunteer provided, 5 staff employed, 200 community participants/audience members entertained Measurable Outcomes: Enriched community of tomorrow's leaders and artists, an audience leaves also feeling enriched and aware of the performing arts opportunities in their local community for youth. Educated participating children in the arts and inspired them to pursue performing and leadership opportunities. Attachments Program Budget(Income & Expenses) Certificate of Understanding Conflict Disclosure Hilo Community Players-Rising Stars I Page 2 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Hilo Community Players Program Name:Rising Stars CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 10,000 10,000 Applicant organizational budget: Individual contributions 1,000 1,500 2,500 Membership fees 2,000 2,000 Earned income Current cash assets 5,000 5,000 Other funding sources (list below): Program Specific Fundraising 3,000 3,000 Total Cash Income 11,000 11,500 22,500 IN-KIND CONTRIBUTION Anticipated Committed Total Salary Wages 5,760 5,760 Workshop, Rehearsal & Performance Space 2,000 2,000 Total In-Kind Contributions 7,760 7,760 TOTAL PROGRAM INCOME 11,000 19,260 30,260 Appendix D--Budget Sheets (Page 2 of 2) f � ;Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Hilo Community Players :Program Name:Rising Stars Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 5,000 5,000 5,760 15,760 Professional Fees 1,000 1,000 Operations 2,000. 2,000 Supplies 2,000 1,500 • 3,500 Equipment 1,000 1,000 2,000 Workshop, Rehearsal&Performance Space 2,000 2,000 2,000 6,000 SUBTOTAL 10,000 12,500 7,760 30,260 TOTAL PROGRAM BUDGET 10,000 12,500 7,760 30,260 County of Haw'ai'i Nonprofit. Grant Application FY 2022-23 . Name: Hon Community Players Agency tt � 3 Program xm Name Rising Stars 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. 1' 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 htt : 'vendors.ehawaii.:ov 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 ,rant 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. uosaad pazlaaylny to ualllsod/allll TuapisaJd pJeo9 oleo uosaad pazuoy nv aan�eu i �. .. y ��< ZZoZlg •sluewaalnbaa asap pools.apun pue pear aneq noAleq 2uppalMou>pe eue noA 'molaq Oulu is Ag 'me!Aq pazlaogone aslmaagl.o ssalun sal}.adnad alenlad uo (salllanaas acs eaueansul `sleualew `uollanalsuoD Jo 4soo) sluauaanoadual lellde)Jo;spun)apinoad louuea spaennb 'spun]asapp aanOJa_i O. ua.jra,l suor.laO ti! Annul pup.lsanbaai burpunl inn s,Aauabo mn©A JO uo on/Ona ayl pOcIwr Him.aauuaw A/acui.;0 ui spunk asayl umn ixoT a.rnI!o J •uodaa leug at il!m I,!emeH Jo Alunop ail of pawnlaa aq lsnw £z0z `0E aunr Aq pasnun spun}Aud •slsoD peayaano pue anllea;sluiwpe mol(%0T) luailad ual wnwlxew e aoi ldaua `uolle3ildde ay; u! pawls sasodand ay}aol palalalsaa aq 1!!M papaeMe spunj Aue;By;aapaimouope noA `uolleplidde slyl to ped sb •anp sl podaa leUl aq;at?aA ayl Jo 0€ Aelnl lnoge JO uoj itTac� ruaa�i :jl ra'ifiio�� u A07Tuno)�ar�n-1ey rnl r rl c .'i le algellene ale suo!pnalsu! pue uollewao}ul laodaa leul}aql lluagns of uollea!J lou Japan}aol uolslnaad ou sl aaagl puelsaapun (am) I •launoa aql`Aq paldaaae pue `ol pall.lwgns s!laodaa uaallam a Run JO aeeA aua Jo uanualu!w a not .edpllaed luea nlnj uao.J uolsnlaxa pue (AlunoD of papunla.t aq lsnw) polaad luea alp ul.inp pan!aaaa spunk auea&lie}o ssol ul linsaa !legs os aunt Jo sAep 09 u!yliM pada; leuu. au;llwgns of aanllej lull puelsJapun (am) ! •(s)luaLuAed Aue Sulnlaaaa of aoud paansu! leuoliippe ue sl i,!emeH Jo Aluno0 ail lap saleaipu! Alllalldxa pue Alieal}laads Low ';uawlaedajl aueul j !,!emeH 40 Aluno) ayl of pap!noad aq lsnw (aaua.aanaao (pea oo0`0S$ `Allllge1l le.auaa 000`000'L$) Allllgen Jo aleallllaaJ luaaanJ e ley; puelsaapun (am) I '!,!emeH o AlunoJ ayl wauu luea0 e papaeme fl (z fo z aaed) u!pue .siapu f jo uoi eal 1paD s.iar.td A.i!ununuoD ()UN :oLuEN A0Ua V EZ-ZZOZ Ad uoueoncjk ytim.EH County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Hilo commuily Players Program Name: Rising Stars 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 he 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 farms must besigned, 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 ri T- he Mayor [l The Managing Director [1 T- he Director of Finance H 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 genera!to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: IT If no conflicts exist, check here. �rr% �_ Board President 1 /15/2022 Signa i'"re of Authorized Person (specify title) Date Hilo Community Players Disney in the Park 108 County of Hawairi Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hilo Community Players Contact Person: Dr. Rachel Klein Contact Email: HiloCommunityPlayers@Gmail.com Contact Phone: 8088956042 Program Information Program Name: Disney in the Park Program Years in Operation: 1 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Hawaiian Acres, Hawaiian Paradise Park, Hilo, Honomu, Kea'au, Mountain View, Pahoa, Papa'ikou, Pauka'a, Pepe'ekeo,Wainaku Program Target Audience: Infancy(0-3), Play Age (3-5),School Age (6-11), Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Culture and the arts,Youth,Aged Amount Applying For:$5000 Hilo Community Players-Disney in the Park I Page 1 Program Details Organization Mission:The mission of the Hilo Community Players is to educate, enrich, and inspire the Big Island community through quality theatrical productions,workshops, and activities for children, teens, and adults. Program Overview: Disney in the Park,will be a wonderful one day event of music&entertainment in historic Kalakaua Park, in downtown Hilo.This event will be provided free of charge for the East Hawai'i Community.This event will feature a variety of live music and selections form popular Disney plays and movies, with appearances by a variety of princesses and other characters the keiki are sure to love. There will also be a costume dress-up parade, snacks, balloons and other fun activities provided to the keiki. Families will be able to come and enjoy a day in the park together in beautiful Hilo town with free entertainment and engagement for their kids. Leading up to the event, the character performers will be receiving free one-on-one and small group training from professional performing arts instructors. Program Objectives & Performances Resources Needed:To successfully carry out Disney in the Park, Hilo Community Players will need to bring together staff and volunteers to create this event for the Hilo community.We will also need to build a stage for the performers and decorate Kalakaua Park to bring outs the whimsical nature of a Disney event. Lighting and sound equipment (speakers & microphones) will be needed to allow for the best listening experience of the audience. Funding will be needed to pay for staff salary wages & musicians.Tents to potentially deal with Hilo's rain will also be necessary. Disney in the Park will include a variety of performances of live and recorded music. Snacks, balloons w/ helium (for decorations and hanging out to the keiki) and other fun things (ie. stickers or temporary tattoos),will also be needed. Major Activities to be Completed: Casting and character instruction, costume creation, set design and execution, stage construction, marketing for event day must all be executed. Multiple training sessions with volunteers will be held. Public welcomed by Disney characters on event day, with multiple performances.Then, children and their families are entertained and the community is enriched. Outputs to be Completed: Disney in the Park hopes to serve 400 audience members, 25 volunteer performers/participants, 5 technical staff and 5 artistic staff/instructors to create this event.There will also be 80 hours of volunteer hours available for each volunteer. Measurable Outcomes: Number of engaged children increases, high families in attendance, high number of performers receiving training, increase number of performances offered. Attachments Program Budget (Income & Expenses) Certificate of Understanding Hilo Community Players-Disney in the Park! Page 2 Conflict Disclosure Hilo Community Players-Disney in the Park Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Hilo Community Players Program Name:Disney in the Park CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 5,000 5,000 Applicant organizational budget: Individual contributions 5,000 5,000 Membership fees Earned income Current cash assets Other funding sources(list below): Total Cash Income 5,000 5,000 10,000 IN-KIND CONTRIBUTION Anticipated Committed Total Salary Wages 3,000 3,000 Rehearsal & Performance Space 2,000 2,000 Total In-Kind Contributions 5,000 5,000 TOTAL PROGRAM INCOME 5,000 10,000 15,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)- Fiscal Year 2022-2023 Organization Name Hilo Community Players Program Name:Disney in the Park Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 2,000 3,000 3,000 8,000 Professional Fees 500 1,000 1,500 Operations 500 500 Supplies 1,000 1,000 Equipment 500 500 1,000 Rehearsal & Performance Space 500 500 2,000 3,000 SUBTOTAL 5,000 5,000 5,000 15,000 TOTAL PROGRAM BUDGET 5,000 5,000 5,000 15,000 County of:Hawai`i Nonprofit Grant Application FY 2022-21 Agency Name: Hilo Community Players Program Name: Disney in the Park 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 4.2-142.1, 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 htt : vendors,ehawaii,gnv,-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 import the evaluation of your program's or agency's future funding requests, County of Hawaii Nonprofit Grant Application FY 202?-?3 Agency Name: Hilo Community Players Program Name: Disney in the Park 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 ITi ;l q, astir! h,:V1 i .o,u,rty.govifh nor7J.zrait-hranmsf 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, 2023 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. 1/15/2022 , gnature /Au horized Person Date Board President Title/Position of Authorized Person County of Hawai'i Nonprofit Grant Application FY 2022-23 i Name:Agency aHilo C"ommuity Players Program Name: LBGIQIA-+- Outreach Through Theatre 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 1 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 pny of the following(check all that apply): (0 Member or members of the Council Staff appointed by a member of the Council The Mayor ri The Managing Director fl The Director of Finance [1 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 1 If no conflicts exist, check here. Board President 1/15/2022 Signal re of Authorized Person (specify title) Date Hilo Community Players LBGTQIA+ Outreach Through Theatre 109 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hilo Community Players Contact Person: Dr. Rachel Klein Contact Email: HiloCommunityPlayers@gmail.com Contact Phone: 8088956042 Program Information Program Name: LBGTQIA+Outreach Through Theatre Program Years in Operation: 2 Other Countygrants/agreements:Yes grants/ g Previously received County GIA:Yes Program Geographical Reach: Hawaiian Acres, Hawaiian Paradise Park, Hilo, Honomu, Honoka'a, Kea'au, Kurtistown, Laupahoehoe, Mountain View, Na'alehu, Nanawale Estates, Ninole, Orchidlands Estates, Papa'ikou, Pauka'a, Pepe`ekeo,Volcano, Waimea, Wainaku Program Target Audience:Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts,Victims of Health or Social Crises Amount Applying For:$5000 • Hilo Community Players-LBGTQIA+Outreach Through Theatre! Page 1 Program Details Organization Mission:The mission of the Hilo Community Players is to educate, enrich, and inspire the Big Island community through quality theatrical productions, workshops, and activities for children, teens, and adults. Program Overview:The LGBTQIA+Outreach program provides opportunities in a safe and welcoming environment for teens and adults to participate in the production process of a full-length play with a LGBTQIA+theme, providing access to the arts.This program builds community for the participants and LGBTQIA+awareness for the Big Island community at large. It creates educational opportunities for all that attend and exposure to various elements of the arts process. Program Objectives & Performances Resources Needed: Funds will be used on lumber and fasteners for building a set,fabric and sewing notions for creating costumes, supplies for hair and makeup, paint for scenic design,the rental of lighting and sound equipment, and staff wages. This program will require a minimum of 50 positions to be filled by volunteers and staff. Major Activities to be Completed: LGBTQIA+ and allies volunteer for a performing arts production, under the direction of staff. Skilled technicians and volunteers work with performers in building and designing a set, costumes, and props for the performances. Staff and volunteers are educated about LGBTQIA+ issues.Volunteers and performers are mentored in trade skills.A full-length play will be performed. Outputs to be Completed: Outputs expected: 1,500 members of the community served,40 volunteer performers/artists/businesses (with 200 hours offered per volunteer), 10 volunteer skilled technicians (with 200 hours offered per volunteer), and 11 performances offered for the community. Measurable Outcomes: Outcomes: Engage community participation, increase access to the arts, increase community safety through LGBTQIA+awareness and acceptance, reduction of risk potential for at-risk youth, and workforce development through trade skill mentoring. Attachments Program Budget(Income & Expenses) Certificate of Understanding Conflict Disclosure Hilo Community Players-LBGTQIA+Outreach Through Theatre I Page 2 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Hilo Community Players Program Name:LBGTQIA+ Outreach Through Theatre CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 5,000 5,000 Applicant organizational budget: Individual contributions 2,000 3,000 5,000 Membership fees 1,000 1,000 2,000 Earned income Current cash assets 4,000 4,000 Other funding sources(list below): Total Cash Income 8,000 8,000 16,000 IN-KIND CONTRIBUTION Anticipated Committed Total Salary Wages 10,000 10,000 Rehearsal & Performance Space 2,000 2,000 Total In-Kind Contributions 12,000 12,000 TOTAL PROGRAM INCOME 8,000 20,000 28,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ,Organization Name:Hilo Community Players ;Program Name:LBGTQIA+ Outreach Through Theatre Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 2,000 3,000 10,000 15,000 Professional Fees 1,000 2,000 3,000 Operations 500 1,000 1,500 Supplies 500 2,000 2,500 Equipment 1,000 1,000 2,000 Rehearsal & Performance Space 2,000 2,000 4,000 • SUBTOTAL 5,000 11,000 12,000 28,000 TOTAL PROGRAM BUDGET 5,000 11,000 12,000 28,000 County of Hawai`i. Nonprofit Grant Application FY 2022-23 Agency Name: Hilo Community ylayers Program Name: LBGTQIA+ Outreach Through Theatre 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--2-1.42.1, 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. County of Hawai`i Nonprofit Grant Application FY 2027-73 Agency Name: Hilo Community Players Program Name: LBGTQIA+ Outreach Through Theatre 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 i)t0121;v,rwvr.h Awa icn ; its .Kov(fn-nooprolit-r rant-formsL 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, 2023 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. 1/15/2022 fi:ignature /Au horized Person Date Board President Title/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: nil()Commuity Players Program Name: LBGI'QIA-t- Outreach Through Theatre 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 bya member of the Council 1 The Mayor I The Managing Director l The Director of Finance —1 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: C_ If no conflicts exist, check here. /, '? ► _ Board President 1/15/2022 Signa re of Authorized Person (specify title) Date • Hilo Community Players Dinner With Divas 110 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hilo Community Players Contact Person: Dr. Rachel Klein Contact Email: HiloCommunityPlayers@Gmail.com Contact Phone: 8088956042 Program Information Program Name: Dinner With Divas Program Years in Operation: 0 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Fern Acres, Hawaiian Acres, Hawaiian Paradise Park, Hilo, Honoka'a, Kea'au, Kurtistown, Laupahoehoe, Mountain View, Nanawale Estates, Ninole, Orchidlands Estates, Pahoa, Papa'ikou, Pauka'a, Pepe`ekeo,Volcano, Wainaku Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts,Victims of Health or Social Crises Amount Applying For: $5000 Hilo Community Players-Dinner With Divas I Page 1 Program Details Organization Mission:The mission of the Hilo Community Players is to educate, enrich, and inspire the Big Island community through quality theatrical productions,workshops, and activities for children, teens, and adults. Program Overview: Funds obtained for this program will support starting a line-up of 8-10 drag shows for the local community.This program will support much needed exploration of gender identity through the art of drag and incorporate levels of representation for Trans, Non-Binary and Mahu culture. Our intentions with these shows are to create more LGBTQIA+safe spaces that the community can feel free to be free in. We also want to create a safe space where drag artists can consistently perform, inspire new talent and bring the community together. Program Objectives & Performances Resources Needed:This program requires monetary funds to obtain various materials to make these shows possible including lumber for set pieces,fabric for costumes and various stage props, educational books, and stage makeups.The expected number of staff and volunteers making these events possible is 25 persons including 1-3 professional drag performers and choreographers who will earn wages from the program. Major Activities to be Completed:Artistic staff will hold multiple training sessions for volunteers, volunteers will perform for an audience. Food will be purchased and provided by a partner restaurant, which the staff coordinates.Audience members achieve representation and become more comfortable in their community. Outputs to be Completed: 2 small businesses supported, 20 volunteers trained, 100 hours available per volunteer, 3 artistic staff employed, 6 technical staff employed, 2,000 audience lives entertained and enriched. Measurable Outcomes: Improved community engagement and acceptance, increased participation in performance opportunities, increased number of trained arts professionals available in the community, future artists inspired. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Hilo Community Players-Dinner With Divas I Page 2 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Hilo Community Players Program Name:Dinner with Divas CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 5,000 5,000 Applicant organizational budget: Individual contributions 3,000 3,000 6,000 Membership fees Earned income Current cash assets 5,000 5,000 Other funding sources (list below): Total Cash Income 8,000 8,000 16,000 IN-KIND CONTRIBUTION Anticipated Committed Total Salary Wages 8,000 8,000 Rehearsal & Performance Space 2,000 2,000 Total In-Kind Contributions 10,000 10,000 TOTAL PROGRAM INCOME 8,000 18,000 26,000 Appendix D--Budget Sheets (Page 2 of 2) !Project Budget Form: Expenses County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Hilo Community Players 'Program Name Dinner with Divas Nonprofit Expense Description (Waiwai) Other Cash In-Kind TOTAL Source Contribution Grant Salary Wages 1,500 4,000 8,000 15,000 Professional Fees 1,300 3,000 Operations 1,000 1,000 1,500 Supplies 1,000 2,000 2,500 Equipment 500 700 2,000 Rehearsal & Performance Space 1,000 2,000 2,000 4,000 • SUBTOTAL 5,000 11,000 10,000 26,000 TOTAL PROGRAM BUDGET 5,000 11,000 10,000 26,000 •sjsanba.i burpun]a.rninJ vtauabo JO s,tualbo d ino/i Jo uor of gwl.a ayl podwr! 1t!m 'paprno.r+ alo1.ural aL? .utsn vn a.r pua-Joa alrunaao pua cuQJ ')aulr.l a Ewgns of irillod •poiaad peme ayl 2uianp paurelgo slunouae pue sau.unos 8uipun;aaw;o 2ulisii e pue 'spun;lue.t2 l,iemeH;o Alunop Aq paaoddns saanlipuadxa tie lo 2uluno33e alalduaol e'(sawoalno aigeanseaua 'Di;bads uo 8uisn3o1) luelS ayl;o 2uipaeme aye uaoa;paAlaap sly;auaq 3iignd mg;o uogeueidxa ue apnpui !legs 'papinoad aleiduaal.aqi Suisn '1.rodaa •papaeme sem ;uea all !alum Jul aeaA lenlaealuoa au;to OE aunt Jaw sAep 09 ululim llaunoJ Aluno3 al;of laodaa pua-aeaA e llwgns o1 uawaalnsal ay; u14m .i.woD !WA pue puelsaapun am' i l,lemey;o luno) au; woa; uc papaeivne�I •plea;mala e Rulsn aulluo aa; uollealsiSaa lenuue aul Aed pue `ssaaoad dais-Aq-da;s Asea au; alaidwoa `noo•ilemeiia•saopuaA8:cllll of od `aalspaa •(s);uawAed Supmaa u of loud ;uelidwoa aq pue ssa.idx3 aaueydwoj Luanne! glum Iloaua of luawaalnbaa au; ullm Aidwoa limn pue puelsaapun (am) ! `i,lemeH jo Alunop ay;woa;luea3 e papaeme •sluawnaop 1e4.4lao se paldaaae aq lou !pm sluawnaop paldoa JO paxej •pal;llenbsip aq !pm sluawnDop pauJlsun •luawnaop CI3N9IS 'IVNIJIUO au; aq lsnw aanleu0ls luaUnD e 9ulalnbaa sluautnaop lie lain pue;saapun (am) I •lelllwgns of loud aleana3P pue alaldwca_a ale sluawnaop lie lett amsua of Allllglsuodsaa lin;anew am leu; pue `lelllwgns lueag 1j4oaduoN Alunop ano 2ulnlaaaa lauuosaad Alunop Aq pamalnaa aq lou lllm suollealidde;Cu; puelsaapun ( ' ) •salnlels Paslnai !,lameH `�Z6 aa;deyj o;8ulpaoaoe alignd apew aq !legs ulaaaq pallddns uoRewao;ul leg; pue;saapun (am) I -mel o;luensand (s)weAoad au;aalslulwpe o1 Alll!ge pue Aluoq}ne au;anew (am) I leg.! pue laaaaoa sl 'sluawnaop cul;aoddns lie 2ulpnpui `ulaaaq paliddns uon;ewao;ul lel;A;llaaa Agamag (am) pasn aaam spun;. gaigm ao;, weaoad JO laealuoa 'lueaau;of luaullaad spaoaaa AO 'Alaadoad 'l uaLudlnba 'Allllae}Aue la3dsul pue aulwex3 al Aluog;ne pue ssaaae palaulsaaun pue 'aaa; `lin; (Aquae lgtlsaano/Sulpuadxa JO 'anlleluas3adaa !Dune) paleu9!sap `aaueu13 ;o luawlaedaa au; `aoppnt'and;eisl al all) Alunoj au;moue of oaa&e (am) I •suollezluegap ll;oaduoN of spun3;o uolleladoaddb o12ullelaa `apop Aluno: !,!erne! 'T'Zb1 Z—SCT -Z suollaas `ssz apjlay ul palepuew se sluawaainbaa Allllgelunoaae least; pue tullaodaa `spaoaaa pue `saanpaaoad paeme 'suollipuoa lueiS :sluawaalnb3a A;tllg101ia au;}o lie poolsaapun pue peal anal (am) (Z 10 I abed) 2uipue saapu f jo uoilea .!paD seA.>(J4 11M LUL21\1 utV.12OJ s.i,)XuIc3. (.11unuiuro') oltT_I :0LLIe4 LCJUO- V • L-ZZOZ, tm– t— Jo Aluno County of FTawai`i. Nonprofit Grant Application FY 2022-23 Agency Name: Hilo Community Players Program Name: Dinner with Divas 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 inance 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 :.rant funds received durin: the :rant •eriod must be refunded to Countand exclusion from future :rant •artici*ation for a minimum of one ear or until a written resort 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 j7wvvw.hawaiico„i tv.gov/fn nonprofit-gran-iorrnf.1 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, 2023 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 -undn re uest and ma 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 1/15/2022 gnature re/Au`horized Person Date Board President Title/Position of Authorized Person County of Hawa `i Nonprofit Grant Application FY 2022-23 Agency Name: I-lil©Commuity Players Program Name: Dinner with Divas 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 ri T- he Mayor ^i The Managing Director The Director of Finance pl 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: x ( if no conflicts exist, check here. ." / ".,11111P,- Board President 1 /15/2022 Signa :"re of Authorized Person (specify title) Date Hilo Community Players Annual Musical Theatre Program 111 County of Flawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hilo Community Players Contact Person: Dr. Rachel Klein Contact Email: HiloCommunityPlayers@Gmail.com Contact Phone: 8088956042 Program Information Program Name:Annual Musical Theatre Program Program Years in Operation: 20 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Hawaiian Acres, Hawaiian Paradise Park, Hilo, Honomu, Kea'au, Kurtistown, Laupahoehoe, Mountain View, Nanawale Estates, Ninole, Orchidlands Estates, Pa'auilo, Pahoa, Pepe'ekeo, Volcano, Wainaku Program Target Audience: Infancy(0-3), Play Age (3-5), School Age(6-11),Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts,Youth,Aged Amount Applying For: $15000 Hilo Community Players-Annual Musical Theatre Program I Page 1 Program Details Organization Mission:The mission of the Hilo Community Players is to educate, enrich, and inspire the Big Island community through quality theatrical productions, workshops, and activities for children, teens, and adults. Program Overview:The Hilo Community Players' annual musical theater productions bring island-wide community members of all ages together for multiple weeks of talent-sharing, skill-building, and hands- on cooperation. Past productions have included 'Next to Normal,' 'bare: a pop opera,' and 'Willy Wonka.'These full-scale productions offer the opportunity for members of the community to learn theatrical and technical skills that spark artistic creativity, inspire young students, and build resumes with experience that translates equally well to the workforce.Audience members enjoy an enriching evening of live theater and experience an expansion of the conversations around cultural activity to which they may not otherwise have access. Program Objectives & Performances Resources Needed:Volunteers, staff, performers, funding, building tools, building supplies, paint, lumber, storage space, costumes, stage properties,tents, paper, printing,technology, speakers, sound equipment,wireless microphones, lighting, light boards, performance spaces, rehearsal spaces, classroom spaces, performance space, marketing tools. Major Activities to be Completed: Production is selected, auditions are held to gain public participation, rehearsal space and dates are arranged, performance space and dates are arranged, advertising is distributed to the community to generate awareness of the project. Educational workshops and training are offered in music, dance and acting.Volunteer performers as well as artistic staff and technical skills volunteers begin crafting the production through numerous rehearsals and meetings. Costumes are designed and created. Props are designed and created. Stage and scenic elements are designed and built. Stage is painted and scenic elements and stage properties are created by artists to set the stage for the story.Technical skills volunteers and staff design, build and execute sound system and lighting equipment systems to enhance the audience's ability to consume the art.The final production is presented 9 times,for public enrichment and enjoyment. Outputs to be Completed: 75 volunteers participating, 200 hours per volunteer provided, 15 staff employed, 2+workshops offered, 2,000 community participants/audience members educated and entertained. Measurable Outcomes:The East Hawaii community learns about musical theatre and has access to enjoy this rich art which they may otherwise not have. Young performers are inspired and trained in the arts.The program is supported by the public after the experience and we are encouraged to continue efforts in musical theatre. Participants gain confidence and leave the program knowing more about Hilo Community Players-Annual Musical Theatre Program I Page 2 themselves and their abilities, having now had training that can help them with school and employment efforts. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Hilo Community Players-Annual Musical Theatre Program I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Hilo Community Players Program Name:Annual Musical Theatre Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 15,000 15,000 Applicant organizational budget: Individual contributions 8,000 5,000 13,000 Membership fees 2,000 1,000 3,000 Earned income Current cash assets 6,000 6,000 Other funding sources(list below): Program Specific Fundraising 6,000 6,000 Total Cash Income 31,000 12,000 43,000 IN-KIND CONTRIBUTION Anticipated Committed Total Salary Wages 12,000 12,000 Rehearsal & Performance Space 2,000 2,000 Total In-Kind Contributions 14,000 14,000 TOTAL PROGRAM INCOME 31,000 26,000 57,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form:'Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Hilo Community Players 'Program Name:Annual Musical Theatre Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 5,000 13,000 12,000 30,000 Professional Fees 2,000 2,000 4,000 Operations 2,000 2,000 4,000 Supplies 3,000 4,000 7,000 Equipment 1,000 4,000 5,000 Rehearsal & Performance Space 2,000 3,000 2,000 7,000 SUBTOTAL. 15,000 28,000 14,000 57,000 TOTAL PROGRAM BUDGET 15,000 28,000 14,000 ' 57,000 Count of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Hilo Community Players Progr0m Name: Annual Musical Theatre Program 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 l (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 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. County of Nawai`i. Nonprofit Grant Application FY 2022-23 Agency Name: Hilo Community Players Program Name: Annual Musical Theatre Program 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). (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all :rant funds received durin: the grant period Imust 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 htipi r' v r w"awaiico ncrv" c fn-noni.Jrafit-grant form5j 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, 2023 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. 1115/2022 4 ;. ignature Auhorized Person , Date Board President Title/Position of Authorized Person County of Hawai°i. Nonprofit Grant Application FY ?02?-23 Agency Name: Hilo Conimuity Players Program Name: Annual.Musical Theatre Program 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 1 The Mayor The Managing Director f l The Director of Finance r1 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: r<1 If no conflicts exist, check here. '/ r,,: Board President 1/15/2022 Signat, re of Authorized Person (specify title) Date Holualoa Foundation for Arts & Culture 114 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Holualoa Foundation for Arts &Culture Contact Person: Maja Grajski Contact Email: maja@donkeymillartcenter.org Contact Phone: 808-322-3362 Program Information Program Name: Program Years in Operation: 18 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Holualoa Program Target Audience:School Age (6-11),Adolescence (12-17),Young Adulthood (18-39) Services/Activities Provided: Educational concerns, Culture and the arts, Public health and welfare of the people and the environment,Youth Amount Applying For: $50000 Holualoa Foundation for Arts&Culture- I Page 1 Program Details Organization Mission:The Donkey Mill Art Center is the home of the Holualoa Foundation for Arts & Culture, serving as a place of convergence for the exploration of arts and culture to inform, inspire and strengthen individual and collective well-being. We provide hands-on classes, exhibitions and events of contemporary visual arts, crafts and culture, on campus and in local public schools. Our 2.6 acre campus includes studios for printmaking, ceramics, metals,fiber arts and gardens, and an exhibition space. Program Overview: Requested grant funds will support our Youth Education and Fibers (YEF) program to address the critical lack of arts education in our region for homeschooled, charter and public school students in West Hawaii.We provide year-round art classes on campus and in area schools to enhance academic and social success for the children in our community, caring for our keiki, the 'aina, and our gardens, informed by the cultural practices of our diverse community. Hawai'i's public school teachers often struggle to incorporate art into their classes because of severely limited public funding and the demands of federal and state education requirements that place an emphasis on testing in core subjects such as math and reading. We are addressing the systemic shortages of available arts programming by providing: 1)year-round youth programs; 2) professional development for public school teachers; and 3) mentorship and employment opportunities for teaching artists. Program Objectives & Performances Resources Needed: Our 2021-2023 Strategic Plan aims to build our capacity as a regional provider of arts education by improving accessibility to arts education for underserved, under-resourced community members and in addressing the systemic shortage of teachers and a lack of employment opportunities for newly trained teachers. Our Youth Education staff and roster of 20+contract teaching artists are among the most qualified in the state in years of experience and training through HSFCA, and continue to gain and sustain the trust of community partners in the DOE, WHCHC and more. In 2021, Gerald Lucena joined our staff as Youth and Fibers Program Coordinator. Growing our staff in this way has increased our capacity to train new teaching artists and collaborate with partner institutions and community groups to promote cultural exchange, deeper understanding of diverse cultures and perspectives, and hone survival skills together as a united community. Major Activities to be Completed: Classes take place year-round on campus and in area public schools, including Teen Workshops, Parent/Child Weekend Workshops, Spring Art Experience and Fall Art Experience for ages 6-11. Summer Art Experience for keiki and teens meets daily for five weeks and culminates in an open house and exhibition at the Mill's gallery curated by the Young Curators Program for Teens with staff curator Mina Elison. The 2022 SAE theme is Pu'uhonua complementing an exhibition of the same name featured in the Donkey Mill's 2022 exhibition schedule. Pu'uhonua offers an examination of places and people of peace and safety.Youth education program curriculum plans will expand upon the featured artists' exploration Holualoa Foundation for Arts&Culture- I Page 2 of the concept of refuge, sanctuary and protection, providing contemporary interpretations of its meaning, with a focus on stories of underrepresented and marginalized voices, reflecting many in our community who find refuge at the Donkey Mill Art Center as a safe place for self expression. Outputs to be Completed: In 2022-23,we will hold 19+youth and fibers workshops and multi-session classes: Beyond the Schools (100-200 students); Fiber Arts (100+students); and In-School Programs (300+) in collaboration with faculty and administration of Holualoa Elementary School as part of HSFCA Artists-in-the-Schools program. Our exhibition schedule, including the Summer Art Experience (SAE) Young Artist Exhibition draws 2000 visitors annually. Highlights include: 2022 Summer Art Experience (SAE): Pu'uhonua (Ages 6-12) SAE: Metals Intensive for Teens SAE: Ceramic Intensive for Teens SAE: Participatory Design Project for Teens Young Curators Program for Teens with DMAC Curator Mina Elison SAE: Young Artist Exhibition Kanaka Maoli/Marshallese Youth: Art&Artifact Workshop After School Program: Mixed Media Mania (Ages 6-11) Keiki Fall Art Experience 2023 Wahi Pana Project with Holualoa Elementary School Grade 5 In-school programs for Holualoa Elementary School, Grades 3 &4 SAE for Ages 6-8, 9-12 &Teens Measurable Outcomes: Now in our 27th year, we measure much of our success by the strength of our partnerships with faculty and administration of area schools; intergenerational and intercultural learning through our Fiber Arts program and gardens with WHCHC and the Wodde Jippel Club of Kona, a Marshallese women's leadership group, and the transfer of indigenous cultural practices from kupuna to younger generations.Youth Education and Fibers programming is a key priority in our strategic plan. Program expansion is a goal that will allow us to serve more youth in our community, both in and out of school; and to provide multiple access points for learning new skills, deepening practice and building community. We keep informed by conducting surveys of students,teachers, parents and members. We are listening more than ever and connecting with the voices of the land, our kupuna, diverse cultural perspectives and the complex histories the land holds to ground and unite us. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Holualoa Foundation for Arts&Culture- Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Donkey Mill Art Center Program Name:Youth Education and Fibers Programming CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $50,000 $50,000 Applicant organizational budget: Individual contributions $25,000 $10,000 $35,000 Membership fees $5,000 $5,000 Earned income $35,000 $35,000 Current cash assets Other funding sources(list below): State of Hawaii GIA Program $100,000 $100,000 Total Cash Income $215,000 $10,000 $225,000 IN-KIND CONTRIBUTION Anticipated Committed Total Gallery Install Support $500 $500 Video/Photo Support $3000 $3000 Classroom Assistant $2000 $2000 Total In-Kind Contributions $5,500 0 $5,500 TOTAL PROGRAM INCOME $220,500 $10,000 $230,500 Appendix D--Budget Sheets (Page 2 of 2) 'Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 .Organization Name:Holualoa Foundation for Arts & Culture dba Donkey Mill Art Center ,Program Name:Youth Education and Fibers Programming Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $40,000 $116,000 $156,000 Professional Fees $5,000 $3,000 $8,000 Operations $20,000 $20,000 Supplies $6,000 $6,000 Equipment Contract Teaching Artists $10,000 $20,000 $2,500 $32,500 Marketing, Printed materials $6,000 $6,000 Utilities $2,000 $2,000 SUBTOTAL $50,000 $175,000 $5,500 . $230,500 TOTAL PROGRAM BUDGET $50,000 $175,000 $5,500 $230,500 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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, 2023 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. • ` 1/27/2022 Signature of Authorized Pers n Date Executive Director Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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 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. Ex-•i aditine, Executive Director,Donkey Mill Art Center 1/27/2022 Signature of Authorized a on,(specify title) Date Holualoa Foundation for Arts&Culture- I Page 4 Holualoa Village `Ghana Holualoa Coffee &Art Stroll 115 County of Hawairi Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Holualoa Village `Ohana Contact Person:Anne (`Antu') Harvey Contact Email: antu.harvey@gmail.com Contact Phone: 808.895.5458 Program Information Program Name: Holualoa Coffee &Art Stroll Program Years in Operation: 26 years Other County grants/agreements:Yes • Previously received County GIA:Yes Program Geographical Reach: Captain Cook, Holualoa, Honalo, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kealakekua Program Target Audience:School Age (6-11), Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Culture and the arts, Public health and welfare of the people and the environment,Youth, Aged Amount Applying For: $2500 Holualoa Village`Ghana-Holualoa Coffee&Art Stroll I Page 1 Program Details Organization Mission:The mission of the Holualoa Village Ohana is to preserve the historical importance of Holualoa to the County and State of Hawai'i and the village multicultural heritage as well as provide opportunities to promote Kona Akau coffee growing heritage, artistic assets, and cultural traditions through the organization's projects and educational community events. Program Overview: Each November, Holualoa village kicks off the Kona Coffee Cultural Festival (KCCF) with the Coffee &Art Stroll.The Stroll highlights the central role coffee farmers have played in Kona's rich history as well as the important role they play in Kona coffee's future. Approximately 30 farms share fresh brewed samples of their Kona grown coffee.This event brings the community together with the large influx of people visiting Kona for the KCCF and provides an opportunity for farmers to educate the public about Kona coffee and coffee production. Attendees are invited to vote in the People's Choice award. All the art galleries are open and HOlualoa Elementary School curates a coffee-based art exhibit by the students at the old Holualoa library. Educational/informational booths are also set up for the event.The Coffee &Art Stroll is an event that celebrates all HOlualoa village has to offer: a rich coffee background, talented artists, and historically significant buildings. Program Objectives & Performances Resources Needed: 1.We need farmers growing coffee! And we appreciate everyone who takes this day each year to set up a tent in the village, (prepare) and serve freshly brewed samples and visit with anyone who shows an interest in learning about their coffee,the Kona Coffee tradition and the community. 2. We need volunteers to plan, liaise with the farmers, prepare, set up, help with parking and safety, greet/host, serve as village ambassadors, and then clean up. It takes a village. 3. We need adequate facilities;tent and strolling space, parking, comfort stations (lua). 4. We need adequate funds to cover out-of-pocket expenses to ensure a safe and fun event. 5. We need community members and visitors to attend and fall in love (again) with Kona coffee and Holualoa. Major Activities to be Completed: 1. Preparations. Holualoa Village 'Ohana volunteers: • Organize the list of participating Kona coffee farmers and collect a small booth fee to supplement expenses not covered by grants. • Coordinates vendor parking and designates farmer booth locations. • Place parking location signs and large orange safety cones along the roadside to protect pedestrians from cars, and place safety guideline signboards in in key locations • Place banners throughout the village, digital Newsletter Blasts and advertise with KCCF and other local News media promoting the event 2. Farmers set up tents and serve samples, conversation. Holualoa Village'Ohana-Holualoa Coffee&Art Stroll I Page 2 3.Volunteers/Ambassadors circulate and talk up Kona Coffee,the School and the student art exhibit, the village history, and KCCF. 4. Chefs sample coffee from each of the coffee farmers' booths. Peoples Choice and Chefs Choice awards are presented. 5. Clean up - HVO volunteers take down banners, signs and orange cones and store them for the following year. Outputs to be Completed: 1. 30 farmers, 5 food vendors, 10 craft vendors, 5 nonprofit organizations supported. 2. 23 volunteers +280 hours served 3. 30 elementary student artists featured 4. Estimated 120 cars find parking in Holualoa Village at a time 5. impacting over 1,000 families/tourists throughout the day from 8:30am -3pm. Measurable Outcomes: 1. Participating farmers get an average of at least 20 leads for new loyal customers 2. Participating Nonprofits(each) get at least 20 new people sign up to volunteer or receive more information 3.At least 50 attendees (keiki and adults) participate in the 'Kona Coffee Knowledge Challenge'. 4. Zero complaints. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Holualoa Village'Ohana-Holualoa Coffee&Art Stroll I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Holualoa Village `Ohana Program Name:Music& Light Festival CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 2200 Applicant organizational budget: Individual contributions Membership fees Earned income 1000 Current cash assets Other funding sources (list below): Sponsorship (named mahalo) 1000 Participating Farm Fees 150 Participating Vendor Fees 1000 Total Cash Income 3150 IN-KIND CONTRIBUTION Anticipated Committed Total Banner, Poster, Media design, production 1500 1500 Event Coordination 1000 1000 Total In-Kind Contributions 2500 TOTAL PROGRAM INCOME 7850 2500 Appendix D--Budget Sheets (Page 2 of 2) ;Project Budget Form: Expenses ;County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 !Organization Name:Holualoa Village `Ohana ;Program Name:Coffee &Art Stroll Nonprofit Expense Description (Waiwai) Other Cash In-Kind TOTAL Source Contribution Grant Salary Wages Professional Fees 1200 2500 3700 Operations 1000 1000 Supplies 500 1000 1500 Equipment 500 1150 1650 SUBTOTAL -(2200) (3150) (2500) (7850) TOTAL PROGRAM BUDGET 2200 3150 2500 7850 County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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. County of lawai`i Nonprofit Grant application FY 2O2 Agency. Name: Program Name: .. Certification of Understanding (Page 2 ot•2i If awarded a grant from the County of hawai`i, { (we) understand that a current Certificate of Liability (51,000,000 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 Hnwai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the Finn)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. (we)understand there is no-provision for further notification to submit the final report. information r n:+r aico rt fax .. �.'' r,� ,,,-t on or about and instr,sctrons are.available at or j . _..:._ � _... --._ May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will he 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 30,2023 must be returned to the County of Hawai`i with the final report,Failure to return these funds ino timely manner will impact the evaluation of your agency's future fundina rearrest and may result in actions token to_recove'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. 25- Signature of Authorized Person Date • President; H©lualoa Village Ohana Title/Position of Authorized Person olea Oim A7pads uosAad pazpoywnb}o yafieuulS a�aq jaaga `islxa slail}uoa oU x :lsa.Jalu,}o spllfucx) le!lualod 3o s.a!tj.uoa Aue°aaue.Jeadde ao 1:}e4 ul`pioAe sa,itiSeCRIA uos e l tut Ile pue Niue ApJeds eSeaid 5 is��• {tir c, iul F ,35 w tt ?3EP WoJ:iac oa pasocielo:s a ion r,;q;po!oto O:d fiu;'(Woo r j uac; aigomsoa a it .:1nc J;/f "=inr1p ipuf o by e:aan,unit:cr,n41 kt goq,o.d lo!ur;sqns c::e pain p sE Isaaa;uE z)alluo ESUtlQJ uosresod.to Alndag e.JU`14sunop uolw.eaodaaD,ueisi,ss,y au7 lasunoD,u0ReJOdscO aqi, , j aaueuli io aopaila yyi jP1 so;3aal€ uleueE�,�algJ 11 JO,Aelikj a11i _t (la°uno)ally)sa.iagLuaw e Act paws.=godde};e15 i.... llauslop dJlil}o saagwow.Ja aagtualt„ €i :(;`.ldrl )1343)Oulniolla} aql!o Aue gilts`d!,,:lbuolte,la;lel;luiel Aue`dulpnlaU;'saja}ulja uo_ leI,utl©ci 1:s!l}uo3 e aleil Ae!"4 :PdOLLISOd ,]wVN '316IXi J'S). ?iO0 .:.a1.17 11,41 Jo SSaipiova) %auti52(. .pines Swwj n upJSip/iv 'asop p AUnJ o}p,3;odau SE .4;ir lldtip as Bald pal;Rugns aq Q.SptaU pq1a1la ucigdc �slXa sill}ucia�,(5 au;q li,A'U0I1ezlueSioaye ;ca}ueloi au()°1slxa °a;ow.uoa ou}I 'papaau St.13 13uo3 n c{1€rA uosaad:ad wit)] auo 'pri opstp aq o paau m°olaq tp-;s eesoLi:3 AluO }o a,';J l:l ACLU Uo:{.e.,que"ijao)ItQ l#o.Joleliswo.upe Jo 'iotas p,aa31}ta`sagW._aaL p eaq Aue Er sa:E.aa,Jalul Jo sa ll}uoa legUa;ud Jo s:iall#uoa Aue a r p.Jp asea d 3 33J€ISOIDSI1 1311:1N°) NOLLVZINV9UO :ouleN to .1.Val d .01.1.WN 1Latr V _.% .() :. 1(J zgoU1 DJjcIdy itip„..19 1,,I.13ry it 4o iclunO) Holualoa Village 'Ohana Holualoa Music & Light Festival 116 County of Hawai`i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Holualoa Village `Ohana Contact Person:Anne ('Antu`) Harvey Contact Email: antu.harvey@gmail.com Contact Phone: 808.895.5458 Program Information Program Name: Holualoa Music& Light Festival Program Years in Operation: 25 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Captain Cook, Holualoa, Honalo, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kealakekua Program Target Audience: Infancy(0-3), Play Age (3-5),School Age (6-11),Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth,Aged Amount Applying For: $2500 Holualoa Village`Ohana-Holualoa Music&Light Festival I Page 1 Program Details Organization Mission:The mission of the HOlualoa Village 'Ghana is to preserve the historical importance of HOlualoa and the village's multicultural heritage as well as provide opportunities to promote Kona Akau coffee growing heritage, artistic assets, and cultural traditions through the organization's projects and educational community events Program Overview: M&L is a holiday family celebration that has grown in popularity over 25 years. In 2020, COVID-19 precautions damped down the event to a display of lights and music for the community as they drove through the village during the holiday weeks. In 2021, the festival was back with fewer performers and attendees appropriately distancedto follow COVID mandates. In 2022,we hope our families can get closer to 'normal'-gather to see neighbors, and celebrate the season with friends old and new, stroll through the village buoyed by cheery light displays and holiday music. Musicians such as John Keawe and Big Island Academy of Music keep alive the tradition of sharing Hawaiian holiday music. Santa cruises through town in a classic car,then settles into his big chair and kindly listens to each child. Every child visiting Santa receives a gift. Holualoa Elementary School participates too-with a student art exhibit that is always highly creative and a highlight of this family-centered event. Program Objectives & Performances Resources Needed: 1.We need lights, lots of lights, musicians, Santa and elves. HVO purchases holiday lights, holiday trees and ornaments to decorate the village, and hires musicians to promote Hawaiiana through cultural music. Santa and elves are hired to listen to the long line of children that wait to tell them their wishes, photo opportunity and leave with a generated by HVO. 2. We need volunteers to plan, prepare, set up, help with parking and safety, serve as village ambassadors, and then clean up, including carefully putting away all the lights and decorations until next year. It takes a village. 3. We need adequate facilities;tent and strolling space, parking, we rent comfort stations (lua) & parking lot safety lights. 4. We need adequate funds to cover out-of-pocket expenses to ensure a safe and enjoyable event. 5. We need community members and visitors to attend and fall in love (again) with each other and HOlualoa. Major Activities to be Completed: 1. Participant and volunteer sign up, layout and logistics, preparations completed. 2. Set up lights, decorations,tents, banners and safety cones 3. Musicians perform,Santa welcomes the keiki, refreshments are made available. 4.Volunteers/Ambassadors circulate and help as needed. 5. Clean up. Outputs to be Completed: 1. 30 musicians and choristers, 5 food vendors. HOlualoa Village'Ghana-Holualoa Music& Light Festival I Page 2 2. 12 volunteers + 120 hours served 3. 30 elementary student artists featured • 4. Estimated 120 cars find parking in Holualoa Village at a time, 5. Estimated 500 attendees throughout the evening from 5- 9pm. Measurable Outcomes: 1. Families linger and enjoy the festival an average of at least one hour each 2. 1,200 smiles are counted, zero complaints 3. Every keiki can talk to Santa and each receives a gift 4.Almost all local galleries and businesses contribute and participate Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure • Holualoa Village'Ohana-Holualoa Music& Light Festival I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Holualoa Village `Ohana Program Name:Holualoa Music & Light Festival CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 2200 Applicant organizational budget: Individual contributions 300 300 Membership fees 300 300 Earned income Current cash assets 250 250 Other funding sources(list below): Vendor Fees 500 Total Cash Income 3550 850 IN-KIND CONTRIBUTION Anticipated Committed Total Banner, Poster, design, media/technology 1000 1000 Total In-Kind Contributions 1000 1000 TOTAL PROGRAM INCOME 4550 1850 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 • Organization Name:Holualoa Village 'Ohana ;Program Name:Holualoa Music & Light Festival Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages Professional Fees 1100 150 1000 2250 Operations 200 200 Supplies 500 500 Equipment 500 200 700 Lua Rental (1 reg. 1 ADA)) 600 600 Safety&Security 300 300 *Pro Fees incl-Musician Honoraria,Pgm Coord. *Ops incl-permit,event insurance, etc. • SUBTOTAL (2500) (1050) (1000) (4550) TOTAL PROGRAM BUDGET 2200 2050 - 4550 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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. County of ^‘' ��D�D]�� Application FY �A77~7` `� ,� ^ ^ °°,,"^ ^ Nonprofit^ ^^~ Grant ^ ��^. � ~.-~_ ~~~ Agency KJ � aTDe: ° � Program Name: _ ___ Certification of Understanding (Page2of2) If awarded a grant from the County of Hawai'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 Haeai'\ � ! ' Finance Departnngncv/hkchs0ecUUcaUyand expUdUyindicates that the County ofHnvvaiiisan additional insured prior to receiving any payment(s). | (v«e) understand that faUurehzsubno�the Mna| repo�w/hhin6Odays ofJune 3Om shall result inloss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant pacipation for a minimum of one year or until a written report is submitted to, and accepted bv the council. I(we) understand there is no provision for further notification to submit the final report. Information . \ and instructions are available at 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, 2023 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 aqency'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. � �' • ��' | ' -e4-1.9,4/ . Signature of Authorized Person Date �\ President, HOlualoa Village Ohana | � Title/Position of Authorized Person � | ' ) County of Hawai'i Nonprofit Grant Application FY 2022-23 Agency Name- • Program Name: ORGANIZAT/ON 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. Al!disclosure forms must be signed, recwrd/ess 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): PI Member or members of the Council • l 1 Staff appointed by a Member of the Council ni The Mayor The Managing Director ri The Director of Finance fl 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 is 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: >7 If no conflicts exist, check here. Signature of Authorized Person (specify title) Date HOPE Services Hawaii, Inc. Sacred Heart Community for Kupuna 122 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: HOPE Services Hawaii, Inc. Contact Person:Sarah Figueroa Contact Email: sfigueroa@hopeserviceshawaii.org Contact Phone: (808) 765-8662 Program Information Program Name:Sacred Heart Community for Kupuna Program Years in Operation: 3.5 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Pahoa Program Target Audience: Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment,Aged, Physical/Emotional Disabilities,Victims of Crimes,Victims of Health or Social Crises Amount Applying For: $20000 HOPE Services Hawaii, Inc.-Sacred Heart Community for Kupuna I Page 1 Program Details Organization Mission: Mission: We bring to life gospel values of justice, love, compassion and hope through service, empowerment and advocacy. Vision: We envision a world where those who face great challenges realize their value and self worth. Program Overview:The Sacred Heart Community for Kupuna (SHC) is a campus in Pahoa serving kupuna, or elderly, experiencing and overcoming homelessness.SHC is inclusive of 1) Sacred Heart Shelter comprising 10 micro-unit emergency shelters and 10 micro-unit single-room occupancy rental units; 2) the Sacred Heart Affordable Housing Program (SHAHP), inclusive of 12 efficiency studio rental units, a new housing development to ensure vulnerable kupuna can age in dignity and community; and 3) the Sacred Heart Resource Center(SHRC), an integrated multi-purpose community space on-site. SHC is the outcome of community collaboration and public-private-philanthropic partnership, most critically in response to the 2018 lower Puna lava eruptions when, in June 2018, more than 200 local businesses and community members came together to construct the Sacred Heart Shelter, providing emergency housing for kupuna displaced by the lava eruptions. SHS remains in place for continued homeless services. Program Objectives & Performances Resources Needed:The resources needed to carry out our program, as requested through this grant application include: staffing (salary/wages,taxes and fringe benefits of direct service staff), program supplies (client supplies, cleaning supplies, program supplies and office supplies), and repairs and maintenance (repairs within units and congregate areas that assure participant safety and security). HOPE regularly and consistently seeks government, philanthropic and private support for all programs. Secured and pending funding (including funding plan and targets)for this program illustrate the need for additional funding to provide the safety, security, and ripple effect of improved health and well-being promised by this program. Major Activities to be Completed:- Providing safe, accessible and functional shelter and housing to kupuna experiencing and overcoming homelessness - Establishing and/or strengthening connection and rapport, including: connecting people experiencing unsheltered homelessness with immediate needs, like hygiene kits,food and water, clothing and shoes, and other items to ensure their immediate safety, along with a connection to housing support services; - Employing trauma-informed approaches and conducting assessments to determine risk and prioritization, identifying needs,working together to identify housing-focused goals - Helping participants become "document ready," ensuring that all documents needed to enter into a traditional lease are accessible -Ongoing support to ensure that homelessness is non-recurring through case management and in collaboration with partner agencies to provide other critical supports significant in improving the health, well-being and stabilization of community members HOPE Services Hawaii, Inc.-Sacred Heart Community for Kupuna I Page 2 Outputs to be Completed:- 12 kupuna households in secured, affordable housing -At least 40 kupuna will resolve their unsheltered homelessness, entering in to secure emergency shelter at SHS - 30%of SHS participants will exit SHS within 90 days to enter permanent housing, thus ending their homeless episode Measurable Outcomes: - Increased economic self-sufficiency and residential stability among vulnerable community members, as measured by shelter entrance, length of stay in homelessness, and entrance to permanent housing - Enhanced social capital, or positive networks of social connections and resources, which can have a positive impact to break the cycle of intergenerational poverty, as measured by program and service enrollment in HOPE and partner provider programs/services Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure HOPE Services Hawaii, Inc.-Sacred Heart Community for Kupuna I Page 3 Program Budget Form: Income 383,264.00 County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:HOPE Services Hawaii, Inc. Program Name:Sacred Heart Community for Kupuna CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 20,000.00 20,000.00 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): State: Homeless Programs Office 229,500.00 229,500.00 Federal: Emergency Solutions Grant 14,560.00 14,560.00 Rental Income 101,440.00 101,440.00 Program Fees 9,300.00 9,300.00 Medical Reimbursements 28,464.00 28,464.00 Total Cash Income 139,204.00 244,060.00 383,264.00 IN-KIND CONTRIBUTION Anticipated Committed Total Community-led volunteerism(donations and volunteer hours) 10,000.00 48,000.00 58,000.00 Total In-Kind Contributions 58,000.00 TOTAL PROGRAM INCOME 383,264.00 Appendix D--Budget Sheets (Page 2 of 2) ,Project Budget Form: Expenses 428,815.00 'County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:HOPE Services Hawaii, Inc. `Program Name:Sacred Heart Community for Kupuna Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 10,000.00 343,000.00 353,000.00 Professional Fees Operations 5,000.00 34,935.00 39,935.00 Supplies 5,000.00 15,036.00 20,036.00 Equipment 15,844.00 15,844.00 SUBTOTAL 20,000.00 408,815.00 TOTAL PROGRAM BUDGET 428,815.00 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: HOPE Services Hawaii, Inc. Program Name: Sacred Heart Community for Kupuna 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 imj act the evaluation of your program's or agency's future funding requests. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: HOPE Services Hawaii, Inc. Program Name: Sacred Heart Community for Kupuna 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, 2023 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. k— DaIIr1�8I2�22 Brandie!duan 25,2022 30:57 I-1571 Signature of Authorized Person Date Chief Executive Officer Title/Position of Authorized Person . County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: HOPE Services Hawaii, Inc. Program Name: Sacred Heart Community for Kupuna 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 n The Mayor Ti 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. AND Brande Menina(Jan 28,202211:42 HST) Chief Executive Officer 01/28/2022 Signature of Authorized Person (specify title) Date Hospice of Kona, Inc. Volunteer Services 123 County of Fiawai`i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hospice of Kona, Inc Contact Person: Laura Varney Contact Email: info@hospiceofkona.org Contact Phone: 8083247700 Program Information Program Name:Volunteer Services Program Years in Operation: 30 Other County grants/agreements: Yes Previously received County GIA:Yes Program Geographical Reach: Captain Cook, Hawaiian Paradise Park, Holualoa, Honalo, Honaunau- Napo'opo'o, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kealakekua, Kuki'o, Miloli'i, Ocean View, Puako Program Target Audience:School Age (6-11), Adolescence (12-17), Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment,Youth,Aged,Victims of Health or Social Crises Amount Applying For: $2500 Hospice of Kona, Inc-Volunteer Services I Page 1 Program Details Organization Mission: Mission: Hospice of Kona provides family centered support, education and care for those approaching end of life. The Medicare Hospice Benefit created in 1983 requires the utilization of trained volunteers as part of our clinical team.The pandemic that began in 2020 has changed how and where we can utilize our volunteers and we have adapted to these temporary changes. We believe our Volunteers are the foundation of our organization and committed to providing excellence in service. Program Overview: Hospice of Kona is seeking funding for our Volunteer Program. The intentional purpose of this program is to increase organization capacity through offering a wide variety of opportunities for volunteerism. Volunteers aged 16 and older from all walks of life seek out the chance to join our Volunteer team. Training classes are held quarterly to bring in new volunteers throughout the year. Opportunities include Board members, patient respite care, office work, medication delivery, event/fund raising support, chores and patient support at Nakamaru Hale hospice residential home), chores, errands and retail support at our two thrift stores (Memory Lane and Memory Lane Too). Maluihi Grief Center also recruits and trains volunteers to support youth participants of our Camp Erin children's grief camp and all activities. The staff of Hospice of Kona join forces annually to show appreciation for our amazing "Stars of Service" volunteers in April during Volunteer Appreciation Week. Program Objectives & Performances Resources Needed:Volunteers Staff to train, provide assignments and support volunteers Administrative Staff to track program progress Funding for training, equipment, meeting food, appreciation Major Activities to be Completed: Recruit-through advertising&social media Staff-train lead volunteers Training events- printed materials, meals & meeting space Post event debriefing with volunteers Volunteer Annual Appreciation events Event debriefing with volunteers Outputs to be Completed: Four volunteer trainings annually 50 volunteers providing in home patient support 75 volunteers for youth bereavement activities 12,000 hours logged annually of direct and indirect volunteer service Hospice of Kona, Inc-Volunteer Services I Page 2 Measurable Outcomes:Volunteers provided the opportunity to join a supportive team Increased program capacity in all departments Increased public relations and referrals to earlier access of hospice services Engaged communities with education on end of life care and resources through HOK Attachments Program Budget(Income & Expenses) Certificate of Understanding Conflict Disclosure Hospice of Kona, Inc-Volunteer Services I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Hospice of Kona, Inc Program Name:Volunteer Services CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 2500 2500 Applicant organizational budget: Individual contributions 1000 1000 Membership fees 0 Earned income 0 Current cash assets 0 Other funding sources (list below): Wallmart 1000 1000 Ironman Foundation 2000 2000 Ohana Fuels 3500 3500 Total Cash Income 10000 3500 10000 IN-KIND CONTRIBUTION Anticipated Committed Total Gooses Edge - gas 500 500 Total In-Kind Contributions 500 500 TOTAL PROGRAM INCOME 10500 10500 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses !County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Program Name: Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 1000 4000 5000 Professional Fees Operations 1000 3000 4000 Supplies 500 500 1000 Equipment • SUBTOTAL TOTAL PROGRAM BUDGET 2500 7500 10000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: 1405 P (;e,. o. or\)A Program Name: Vo I ,„A..ec,r 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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: )-}0 (;)c,e, ©.C- \Lo Program Name: VO v -ter 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, 2023 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. //2 Signature of Authorized Pers Date (C; 0 Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: 1-6p c c Program Name: Volt,4eer 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): 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 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: Al If no conflicts exist, check here. 6.7aitddW2-ef, //..2.S/0,2, Signature of Authorized Pers&(specify title) Date • Hospice of Kona, Inc. Nakamaru Hale, hospice residential care 124 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hospice of Kona, Inc Contact Person: Laura Varney Contact Email: info@hospiceofkona.org Contact Phone: 8083247700 Program Information Program Name: Nakamaru Hale, hospice residential care Program Years in Operation: 9 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Holualoa Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Public health and welfare of the people and the environment Amount Applying For: $20000 • Hospice of Kona, Inc-Nakamaru Hale, hospice residential care' Page 1 Program Details Organization Mission: Mission: Hospice of Kona provides family centered support, education and care for those approaching end of life. Nakamaru Hale is a hospice residential home staffed 24/7 by compassionate caregivers trained to provide the best care possible for up to 5 patients. The caregiving team selected to provide care are taught to treat patients like they would their own loved ones and trained to nurture, give respect for individual beliefs and choices. Program Overview: Nakamaru Hale is a program where up to 5 patients are able to receive care at their ' end of life in a home like setting. Nakamaru Hale accommodates patient's who do not have a loved one at home to care for them and patient's whos family members are in dire need of up to 5 days of respite or much needed rest. End of life care is also available to those who are leaving the hospital in a critically ill state and cannot be cared for at home.The program provides 24/7 medical care and supervision, scheduled RN, Social Worker and Spiritual provider visits, home health aides for their personal care and volunteer services such as companionship, making meals, running errands or providing vigil visits. Nakamaru Hale creates an environment where symptoms can be relieved comfortably,family members and friends can visit and have the quality time with their loved one and most importantly preserving dignity during one of life's most difficult journeys. Program Objectives & Performances Resources Needed:Staff-6 Full Time Employees Training-initial orientation and 12 hours annually per staff member Groceries Cleaning supplies Household items including linen and kitchenware Money- no room and board reimbursement is available for this type of home Major Activities to be Completed: Hospice appropriate referrals for residential care Patient/Family tours of home prior to moving in Individual Care planning by the HOK clinical team Patient/family personal items, favorite foods is applicable and specialty needs Volunteers to increase capacity of staff, provide companionship for patients and help with chores 24/7 Caregiving Technology-to connect patients with families from afar 24/7 care for all activities of daily living(ADL's) Outputs to be Completed: Care to 75-100 patients 1200- 1600 patient days Hospice of Kona, Inc-Nakamaru Hale, hospice residential care l Page 2 90 hours of training to staff and volunteers 2 volunteers plus 416 volunteer hours served Measurable Outcomes: Provide professional hospice and respite care Provide monthly trainings to staff and volunteers Provide monthly staff and volunteer grief support (virtually at this time) Provide virtual tours and informational presentations to referring physicians and Clinical professionals Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Hospice of Kona, Inc-Nakamaru Hale, hospice residential carel Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Hospice of Kona, Inc. Program Name: Nakamaru Hale, hospice residential home CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 20000 20000 Applicant organizational budget: Individual contributions 60000 60000 Membership fees Earned income 100000 100000 Current cash assets Other funding sources (list below): Fund raising events/grants 120000 120000 • Total Cash Income IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 300000 300000 Appendix D--Budget Sheets (Page 2 of 2) 'Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)—,Fiscal Year 2022-2023 ;Organization Name: Hospice of Kona, Inc Program Name: Nakamaru Hale Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 10000 230000 240000 Professional Fees Operations 7500 40500 48000 Supplies 2500 9500 12000 Equipment SUBTOTAL 20000 280000 TOTAL PROGRAM BUDGET 300000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: 4050% C)-c- KOC Program Name: No. ,.,c4a-1e- 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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: '‘Ge,-Dc prq., Program Name: Nxi,x(A. (►rictru 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, 2023 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 Persen Date Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: SP Ce o )(—ore". Program Name: (vG, ,l,.., .o 4-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 ❑ 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: fIf no conflicts exist, check here. Signature of Authorized Person ecify title) Date Hospice of Kona, Inc. Maluihi Grief Center- Bereavement Services 125 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hospice of Kona, Inc. Contact Person: Laura Varney Contact Email: Ivarney@hospiceofkona.org Contact Phone: 808-324-7700 Program Information Program Name: Maluihi Grief Center- Bereavement Services Program Years in Operation: 35 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Captain Cook, Holualoa, Honalo, Honaunau-Napo'opo`o, Kahalu'u- Keauhou, Kailua-Kona, Kalaoa, Kealakekua, Kuki'o, Miloli'i, Ocean View, Puako Program Target Audience:School Age (6-11),Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Needs of the poor, Public health and welfare of the people and the environment, Youth,Aged, Physical/Emotional Disabilities,Victims of Health or Social Crises Amount Applying For: $15000 • Hospice of Kona, Inc:-Maluihi Grief Center-Bereavement Services I Page 1 Program Details Organization Mission: Hospice of Kona provides family-centered support, education and care for those approaching end of life. Maluihi Grief Center exists to meet the bereavement needs in our community and across the ocean. As the only stand alone grief center in the State of Hawaii; our vision is to offer services to participants through technological means and to include Ohana out of our physical reach. Program Overview: Hospice of Kona's Malu'ihi Grief Center (Maluihi meaning to be in a safe peaceful environment,treated with respect to prepare for a sacred peaceful journey safe from Kapu.) is simply a space that allows healing to occur through grief counseling and groups for youth and adults. Bereavement services include our Annual Circle of Remembrance,grief support groups, individual counseling and an annual Youth grief event known as Camp Erin-Hawaii.The pandemic of the past 2 years has increased grief in ways above and beyond anything we could have expected. Loss is everywhere and when the loss of life is added to the loss of work,the loss of home,the loss of normal than the loss must be handled with additional compassion. Our team is trained to provide compassion, sympathy and resources without contact. Our support group clients have adapted to sharing their grief into a camera and watching themselves and others as they come together and stay apart when neccessary. Program Objectives & Performances Resources Needed: Staff Technology Meeting Rooms School counselors Funding for conferences&training Volunteers to make support calls, mailings and office help Specialize support groups Supplies for youth and adult programs Major Activities to be Completed: Individualized grief services Specialized support groups (loss of spouse, loss of child,workplace, school, grief explorations,veterans &suicide support) Youth services Grief workshops for youth & adults (arts, crafts, creative writing, movement &dinner/movie nights) Community collaboration &trainings Annual memorial event(Circle of Remembrance) Camp Erin - Hawaii-50 campers supported by 50 or more volunteers Hospice of Kona, Inc.=Maluihi Grief Center-Bereavement Services I Page 2 Outputs to be Completed: 50 youth &families supported 250 hospice families receiving calls and mailings 13 months post hospice patient death 75 volunteers for youth services 500 hours office volunteer support 2000 hours contact touches to adult clients 5 trained counselors Measurable Outcomes:-Hospice of Kona families and community members will walk away understanding their own unique grief processes. -They will uncover ways to deal with their intense emotions -Realize that grief is a natural process the we all go through -Because of this specialty, people come to us during times of loss, grief, and recovery. If we can continue to address these needs; we can assist with the mental and emotional health of individuals and teach them various coping skills that can also be used outside of grief. -Clients are given the opportunity to begin the healing process from their loss -Clients feel emotional and physical support in a safe and non-judgmental environment -Clients demonstrate coping skills to help through the most difficult days of the grief journey Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Hospice of Kona, Inc.-Maluihi Grief Center-Bereavement Services' Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Hospice of Kona, Inc Program Name:Maluihi Grief Center, Bereavement Services CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 15000 15000 Applicant organizational budget: Individual contributions 0 11000 11000 Membership fees 0 Earned income 50000 50000 Current cash assets 0 Other funding sources(list below): NFL Charities 4000 4000 HIUW 1650 1650 Eluna Network 5000 5000 New York Life 3450 3450 Karakin Foundation 46500 46500 Total Cash Income 68950 67650 136600 IN-KIND CONTRIBUTION Anticipated Committed Total Childhood Bereavement Changemaker Expansion 60000 60000 Costco 450 450 Cal Kona Produce 800 800 Broderson Landscape -venue for camp 10000 10000 Various Camp Erin donations 5000 5000 Total In-Kind Contributions 76250 76250 TOTAL PROGRAM INCOME 145200 67650 212850 Appendix D--Budget Sheets (Page 2 of 2) ,Project Budget Form: Expenses `County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ;Organization Name:Hospice of Kona, Inc Program Name:Maluihi Grief Center, Bereavement Servicez Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 5000 47000 52000 Professional Fees 2500 17500 20000 Operations 2500 24100 26600 Supplies 1500 4500 6000 Equipment Annual Memorial Event 2000 10000 12000 Camp Erin 1500 18500 20000 SUBTOTAL 15000 121600 TOTAL PROGRAM BUDGET 136600 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: 4osp`ce Program Name: r2CJ,Nyam ' 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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: 1c,� 9S\Cort. Program Name:1�. ,itr,,,e 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.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 be returned to the County Any funds unused by June 30, 2023 must 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 Perso Date Title/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Hos f�C,,�, pc- Ko Program Name: 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): ri Member or members of the Council Staff appointed by a member of the Council The Mayor ri 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. Signature of Authorized Peran (specify title) Date Housing and Land Enterprise of Hawaii County, The Community Marketing and Development Outreach 126 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:The Housing and Land Enterprise of Hawaii County Contact Person: Peter Hoffmann Contact Email: petehoffmann@hawaii.rr.com Contact Phone: 8088950834 Program Information Program Name: Community Marketing and Development Outreach Program Years in Operation:4 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo,.Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa`ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, 'Umikoa,Volcano,Waikoloa Village, Waimea, Wainaku, Wai'ohinu,Weloka, any and all not listed within Hawaii County Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of the poor Amount Applying For:$30000 The Housing and Land Enterprise of Hawaii County-Community Marketing and Development Outreach I Page 1 • Program Details Organization Mission: Mission Statement: "To secure and preserve a permanent supply of affordable housing alternatives for the working families of Hawaii County." An affordable housing land trust providing homes for individuals/families who earn 60%- 100%AMI. We have constructed one home in 2021 in Hawaiian Paradise Park and have two more lots waiting for County permits near Volcano village. With further funding, we plan to purchase at least two more lots in 2022 to expand our affordable housing inventory. Program Overview:With this funding, HALE 0 HAWAII will continue to fund the Development- Marketing efforts for 2022. Most of our funding is restricted for other purposes and cannot be used for capacity building activities.A knowledgeable officer is invaluable to navigate available options and efficient use of resources. Funds will be used to provide advertising and promotional materials targeting potential beneficiaries of our mission, potential donors, and volunteers.We will host presentations to assist individuals/families to participate in the selection process for projects. We will host presentations for potential donors and community partners for investment in our affordable housing projects.Through these efforts we will be able to develop databases for donors, partners (including volunteers), and potential homeowners.These efforts will also serve to support building self-sufficiency of our organization,while pursuing our mission to build affordable homes for low-to moderate- income families. Program Objectives & Performances Resources Needed: Marketing-development person Money Strategic partnerships ie: private foundations, government, businesses, individuals Printed fliers&materials Digital creative design resources for print and digital collateral Website developer to expand resources and access to information online Volunteers to help identify and speak with qualifying families and supportive partners in the community Meeting space(s) for in person/zoom events Zoom subscription Community partners including Habitat for Humanity et al affordable home agencies. Hawaii Community Assets, a nonprofit, HUD-approved housing counseling agency building the capacity of low-and moderate-income communities to achieve and sustain economic self-sufficiency. Neighborhood Place of Puna, a nonprofit supporting at-risk and homeless families in Puna,to help identify families that might qualify for the land trust home lottery. HomeStreet bank, mortgage lender,for qualifying prospective buyers. Major Activities to be Completed:Start and add to a database of low to moderate income families including those who qualify for affordable homes. • The Housing and Land Enterprise of Hawaii County-Community Marketing and Development Outreach I Page 2 Staff and board coordinate outreach, including follow-up, to potential community partners, supporters and donors. Four Development Mailings with Four follow-up virtual meetings to discuss support opportunities for affordable projects. Design, print, and identify locations for informational materials in order to target potential homeowners. Design, launch, and manage analytics/ROl for digital advertising and online reach, raising organization presence. Design media marketing campaign targeting news outlets including launch of radio campaign. Promote & Host Four informational island-wide meetings to educate potential homeowners on the community land trust and application process for homeowner lottery to purchase future projects. Identify, negotiate, and fund new affordable home project(s) Outputs to be Completed:Add 500 applications of interested individuals to database Organize at least four presentations islandwide in person and digitally as an informational session to educate 1000 people. Meetings will be available publicly afterwards for additional outreach opportunities. Enhance website with resources and information. Four weeks at twice weekly radio spots across Big Island channels. In East Hawaii we estimate 75,000 person potential reach. Four mailings at 500 each to promote donor(individual and business) outreach, add 100 new donor sources(time,goods/material, or financial) -sustained and one-time support. Add four new strategic partnerships for affordable housing development projects Four new strategic media partnerships for community outreach (ie: Google for nonprofits, Facebook, Pacific Media Group, Pacific Business News, etc.) Measurable Outcomes:A more educated and knowledgeable public of affordable homeownership options including wider acceptance in regards to the benefits of community land trusts. Increased awareness of affordable housing and homeownership resources and options, including Hale 0 Hawaii's community land trust. New investments of national and/or mainland foundations in Hawaii County affordable projects. Investment from New local and statewide donors. Improved website and online presence, generating trust and exposure to those seeking information, application to purchase, donor, or affordable housing project investment opportunities. Engaged community network including volunteers to help share information and identify potential homeowners. Stable, new construction projects identified and funded to move forward. A new database of Big Island families identifying interest, location, and qualification status to purchase low to moderate housing. The Housing and Land Enterprise of Hawaii County-Community Marketing and Development Outreach I Page 3 Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure The Housing and Land Enterprise of Hawaii County-Community Marketing and Development Outreach I Page 4 Program Budget Form: income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Housing and Land Enterprise of Hawaii County. HALE 0 HAWAII Program Name: Development and Marketing CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 30,000 30,000 Applicant organizational budget: Individual contributions 5,000 5,000 Membership fees Earned income Current cash assets 5,000 5,000 Other funding sources (list below): Total Cash Income 40,000 40,000 IN-KIND CONTRIBUTION Anticipated Committed Total - r • Total In-Kind Contributions TOTAL PROGRAM INCOME _ 40,000 40,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Havel Nonprofit Grant-in-Aid (Waiwai Grant)—Fiscal Year 2022-2023 Organization Name: jAolps p Libi\sp t,:+311,77-„Rpfi oF 4 II,* Program Name: z.,-_vE eNT ANA() mpArtt<L7-rikiG., Nonprofit Other Cash in-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 25,000 25,000 Professional Fees Operations Supplies 2,000 2,000 Equipment Radio advertising 5,000 3,000 8,000 Printing materials 5,000 5,000 SUBTOTAL TOTAL PROGRAM BUDGET 30,000 10,000 40,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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. County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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 fora 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://vvww.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, 2023 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. Peter S. Ho mann �AA23 JanuaryrY 2022 Signature of Authorized Person Date Executive Director Title/Position of Authorized Person • County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: RGANk. TION CONFLOCT =e 1SCL*SURE F Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organizationmay 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): C Member or members of the Council Staff appointed by a member of the Council 0 The Mayor [] The Managing Director The Director of Finance D 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. 1)-4- 111' Alf(-Peer S Hoffmann. Executiv r irector 23 January 2022 Signature of Authorized Person (s ecify title) • Date Hui Pono Holoholona Low Cost Spay/ Neuter Clinics 131 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Hui Pono Holoholona Contact Person: Frances Pueo Contact Email: owlitl@gmail.com Contact Phone: 808-769-1128 Program Information Program Name: Low Cost Spay/ Neuter Clinics Program Years in Operation: 15 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Kalapana, Kapoho, Kaueleau, Kea'au, Kurtistown, Laupahoehoe, Leilani Estates, Mountain View, Nanawale Estates, Ninole, Orchidlands Estates, Pahoa, Papa'aloa, Papa'ikou, Pepe'ekeo, Pohoiki,Volcano,Wainaku, Weloka, Big Island cat delivered to Hilo Clinic, address does not deny service Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment Amount Applying For: $25000 Hui Pono Holoholona-Low Cost Spay/Neuter Clinics I Page 1 Program Details Organization Mission: Hui Pono Holoholona founded in 2007, a 501c3 nonprofit services our community by humanely decreasing animal overpopulation through low cost, no cost spay and neuter. We unite dedicated volunteers for our sponsored clinics, provide support to pet owners, caregivers and others caring for lost,fostering, stray, abandoned, abused, and neglected animals. Help towards the cost to spay and neuter, pets, backyard cat colonies, and cats at recycle stations, malls, and other locations. Program Overview: Partnering with Good Karma Clinic is a huge part of the solution towards decreasing animal overpopulation humanely. Dr. Kristina Henricks, PhD, DVM, MS, (formerly with HIHS-Hawai'i Island Humane Society) brings a tremendously needed service to our community"The Good Karma Spay and Neuter Clinic" in Hilo. By appointment spay and neuter for dogs and cats is every Monday, Wednesday and Friday.The highly trained surgical Pandemic Protocol team, are able to service 300 to 400 cats and dogs each month. A huge benefit to continue our S/N services during crowd gathering restrictions preventing mash type clinics. Dr. Henricks has partnered with Hui Pono Holoholona in offering special low rates.Together we have s/n 1,100 felines, and the grand total as of this date is 7,469. such as having animals serviced as soon as possible helps to reduce pregnancies.Another advantage is Dr. Henricks and her team are available post-operative for any complications or follow up if the need should arise. Program Objectives & Performances Resources Needed: For years we held periodic weekend MASH style spay/neuter cat clinics with various visiting Veterinarians. Coordinating dates and venues with the Veterinarians,Volunteers and Participants for these clinics was a major operation. Local veterinarian businesses offered what they could, but very limited, low cost sterilization at their facilities, and were backlogged and reluctant to deal with TNRM-Trap Neuter Release and Managed colony cats. Currently appointments for the Good Karma Clinic spay/neuter are being scheduled about 4 weeks out. Many regular veterinarians have no new client available appointments, and wait time is in weeks to months.The demand for spay and neuter services and for all animal care with the Veterinarian shortage is problematic. When and if Covid precautions are no longer needed our spay/neuter clinics could resume, and these would require more funding and planning. Major Activities to be Completed:All spay/neuter funding will be used as directed.The services are provided by Veterinarians at set prices.The funds we receive determines the number of animals that can be helped at$35 for males and $50 for females.The female and male ratio has been 50/50,which averages the cost per sterilization surgery to$42.50. Every Monday, Wednesday and Friday, 10 appointments per day are scheduled. Good Karma, has been averaging 14 cats per week for Hui Pono Holoholona, 14 cats at$42.50 each is$595 each week. $31,000 would be needed to fully fund free sterilization for those 728 cats( 14 cats x 52 weeks). If left unfixed,those cats can easily reproduce to over 2,500 more cats in just one year! Hui Pono Holoholona-Low Cost Spay/Neuter Clinics I Page 2 Outputs to be Completed: Focusing that animal sterilization is the real solution in preventing unwanted litter births, and reaching out to people unable to afford the cost.With grant funding for 728 cats, a dramatic drop will be in unwanted litter births, and abandonment. One unfixed female cat within a year can produce between 16 to 24 kittens. Each unaltered kitten from the age of four months, is sexually active and will continue to produce and within a year over a hundred unwanted kittens will be born. It is a solvable problem by preventing the births through our efficient and effective humane spay and neuter program. In receiving a call for help for a particular cat colony in a neighborhood,we set up a network of volunteers, connecting them within that area to assist if necessary, in the trapping for Spay and Neuter. We loan out our traps, and teach how to use the traps.Spaying and neutering also helps in preventing certain cancers, reduces roaming,fighting and other undesirable behaviors. Measurable Outcomes: Everyone benefits in the community in striving towards a non-kill society, and there is less abandonment, less animal cruelty, a healthier animal population, less stress on the environment, and bird population. Many island social media posts are questions of where can they get their cats altered, and is there any financial assistance for the spay and neuter. It shows a positive attitude and understanding on the importance to get their animals fixed and communities willing to have their pets spay/neutered, but no funds to do so.We are reaching out to those request through scheduling appointments with Good Karma Spay and Neuter Clinic. Having to just continue to kill adoptable pets because there are not enough good homes is not necessary,when humane "get them fixed" methods exist.Another beneficial effect is that this greatly reduces the number and expansion of cats and cat territory, and that thereby will reduce their need to roam and encroach on Hawaiian Bird recovery areas. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Hui Pono Holoholona-Low Cost Spay/Neuter Clinics' Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant)—Fiscal Year 2022-2023 Organization Name: Hui Pono Holoholona Program Name: Low Cost Spay/ Neuter Clinics CASH Anticipated Committed Total County Nonprofit Grant-in-Aid(Waiwai Grant) 25,000 25,000 Applicant organizational budget: Individual contributions 3,000 3,000 Membership fees Earned income Current cash assets Other funding sources(list below): Foundation Source 1,250 1,250 Susan Kosasa Fund 7,500 7.500 Total Cash Income IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 28,000 8,750 36,750 Appendix D--Budget Sheets(Page 2 of 2) Project Budget Forms Expenses County of Hawaii o Nonprofit Grant-in-Aid (Waiwai Grant)—Fiscal Year 2022-2023 Organization Name: Hui Pono Holoholona Program Name: Low Cost Spay J Neuter Clinics Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages Professional Fees Surgery- 728 cats 22,000 9,000 31,000 Operations Supplies - Flea Medications 2,500 750 3,250 Equipment-Traps j Carriers 2,000 2,000 Insurance - Liability Premium 500 500 SUBTOTAL TOTAL PROGRAM BUDGET 25,000 11,750 36,750 County of HawaK`INonprofit Grant Application FY 2022-23 Agency Name: Hui Pono Holoholona Pro'ram Name: Low Cost S|�� / Neuter Clinics ==ECI==^ 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-l42.1. Haxxai'iCountyCoda, ra|at|ngtoAppnopriatiouufFundatoNonproftO[ganizations' 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 andinspectanyfad|ity,equ/pnoent, property, orrecordspertinenttothegrant,00ntnact, 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 Flawaiti, (we) understand and will comply with the requirement to enroll with Hawail 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 Hawaiii, 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 HawaVi 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 providedwill impact the evaluation of your pro qram's or agency's future funding requests. County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Newel'', 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 Newel 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.hawaiicountv.gov/fn-nonprofltgrantfLnL 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, 2023 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 20, 2022 } Signature of Authorized Person Date Vivian Toellner,Treasurer Title/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Hui Pono Holoholona Program Name: Low Cost Spay / Neuter Clinics ORGANIZATION CONFLICT DISCLOSURE FO 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 Flawai`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): Fi Member or members of the Council n Staff appointed bya member of the Council The Mayor The Managing Director I I The Director of Finance I 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: Xx If no conflicts exist, check here. bee67---VA Vivian Toellner,Treasurer January 20,2022 Signature of Authorized Person (specify title) Date Innovations Public Charter School Foundation Na Kalai Ola - Life Navigators-Wellness Program 132 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Innovations Public Charter School Foundation Contact Person:Julie Nelson Contact Email: leenelson.ipcs@gmail.com Contact Phone: 8087565492 Program Information Program Name: Na Kalai Ola - Life Navigators-Wellness Program Program Years in Operation: 5 - Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Kailua-Kona Program Target Audience:School Age (6-11),Adolescence (12-1.7) Services/Activities Provided: Educational concerns, Culture and the arts,Youth Amount Applying For: $10000 Innovations Public Charter School Foundation-Na Kalai Ola-Life Navigators-Wellness Program I Page 1 Program Details Organization Mission:The mission of Innovations Public Charter School Foundation is to provide support to the West Hawaii Community by helping nurture the bodies, minds and spirits of the children of West Hawaii. The Foundation raises funds, has numerous outreach activities and after-school and in- school support activities for Innovations Public Charter School. Innovations Foundation supports on campus community gardens, sustainability initiatives (recycling/composting), nutrition,STEAM and cultural programs . Program Overview: "Na Kalai Ola - Life Navigators", recognizes the act way-finding youth will need to prepare for their destiny, understand their journey, and build the wisdom and experiences while discovering life's opportunities. "Na Kalai Ola - Life Navigators" is the metaphor for Innovations. 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, music, science, technology, garden, nutrition, cultural and sustainability programs. Over 60 mentors throughout the community are involved with student navigators. With the push for common core achievement, and low per pupil funds, there is little funds available for the arts, music, drama, science,technology,garden, cultural and sustainability programs. These healthy types of activities are paramount to the overall development of our youth. Program Objectives & Performances Resources Needed: "Na Kalai Ola - Life Navigators" is a program that ties all of our extracurricular community outreach and art, music, garden, science,technology cultural and sustainability programs together. Life Navigators key component is community involvement. Innovations relies heavily on support from the community. For this program to be successful,we need over 60+volunteer mentors. Additionally,we need the funds to hire specialized instructors for our students, in core programs such as gardening, sustainability, dramatic arts,visual arts, music, STEAM and cultural arts. Further,we need funds for supplies for the gardens, musical programs, STEAM and cultural activities. Offering all of these programs, leads to lifetime healthy habits for our students. It is so important for our students' social and emotional development to have access to healthy activities at no cost to the student. Funds from the county are so important to help withthestaff and supply costs. Major Activities to be Completed: Healthy extracurricular and mentorship activities are the major activities to be completed. All students will be offered "farm to fork" opportunities with garden class. Students not only learn to grow kale, spinach, eggplant and tomatoes, but also how to prepare vegetables for a healthy future. All students will be able to develop life long passions and a respect for the arts via music, drama,visual and other art resource specialty classes. Further, all students will learn to be effective users of technology through numerous science and technology activities. All 7th and 8th graders will be partnered with community mentors. Innovations Public Charter School Foundation-Na Kalai Ola-Life Navigators-Wellness Program I Page 2 Having mentors for our mostly at-risk and low income students connects students to leaders and role models in the community. Additionally, all students will participate in cultural activities which will tie them to the aina and their community. Outputs to be Completed: 60 Community Mentors to help our young student navigators in their life voyage =72 middle school students having positive mentors. 4 Volunteer Planting and Community Gardening Days, 100 volunteers attendance = 1600 hours of community gardening. 4 Curriculum Shares Incorporating Art, Music, Drama,Sustainability, Culture, Science and Technology- 240 in family, community in attendance= 240 families supported. 4 Community Garden, Sustainability Tours-50 in attendance = 200 community members educated in the aina, local produce, and nutrition. All Students Served with Weekly Garden,Art,Music, Drama, Science,Technology, Cultural and Sustainability Lessons-240 students per week= 240 students having access to healthy extracurricular activities. 1 Culminating Performance of After School Drama Program -900 in attendance over 3 days=900 community members witnessing the talent of our youth. Measurable Outcomes:-Community Mentorship-engaged communities, development of student leaders, gives 72 students adults to look up to, gives 72 students career exploration activities. -Volunteer Planting and Community Gardening Days-engages the community, educates the community about garden programs, educates families about healthy, local and sustainable food opportunities. -Curriculum Shares Incorporating Art, Music, Drama, Sustainability, Garden, Cultural, Science and Technology-Allows students to showcase their work and talents, engages the community -Community Garden,Sustainability Tours- Engages the community, Educates the community. -All Students Served with Weekly Garden, Art, Music,Science, Drama,Technology, Cultural and Sustainability Lessons- Healthy enrichment for at risk students. -Culminating Performance of After School Drama Program -Community engagement, healthy hobbies and students learn to be leaders by sharing talents. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Innovations Public Charter School Foundation-Na Kalai Ola-Life Navigators-Wellness Program Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 10000 10000 Applicant organizational budget: Individual contributions 5000 5000 Membership fees Earned income Current cash assets Other funding sources (list below): REACH Program Grant 12000 12000 UPLINK Program Grant 25000 25000 Innovations Public Charter School 20000 20000 Total Cash Income 72000 72000 IN-KIND CONTRIBUTION Anticipated Committed Total Mentors In-Kind 10000 10000 Total In-Kind Contributions 0 10000 10000 TOTAL PROGRAM INCOME 72000 10000 82000 Appendix D--Budget Sheets (Page 2 of 2) :Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ;Organization Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 10000 50000 10000 70000 Professional Fees Operations Supplies 12000, 12000 Equipment SUBTOTAL 10000 62000 10000 82000 TOTAL PROGRAM BUDGET 10000 62000 10000 82000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program 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, 2023 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 , 2022 Signature of Authorized Person Date Schel Leatherman Board Secretary Title/Position of Authorized Person • County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Innovations Public Charter School Foundation Program Name: Na Kalai Ola - Life Navigators - Wellness Program 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): I I Member or members of the Council I-1 Staff appointed by a member of the Council n The Mayor n The Managing Director LI 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: { x❑ If no conflicts exist,check here. Board Secretary January 11 , 2022 Signature of Authorized Person (specify title) Date Island of Hawaii YMCA Family Visitation Center 133 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Island of Hawaii YMCA Contact Person:Wendy Botelho-Cortez Contact Email: wendy.botelho@islandofhawaiiymca.org Contact Phone: 808-935-3721 Program Information Program Name: Family Visitation Center Program Years in Operation: 27 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau- Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kalapana, Kapa'au, Kapoho, Kea'au, Kuki'o, Kurtistown, Laupahoehoe, Leilani Estates, Mountain View, Nanawale Estates, Ninole, 'O'okala, Orchidlands Estates, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Volcano, Waikoloa Village,Waimea, Wainaku Program Target Audience: Infancy(0-3), Play Age (3-5),School Age (6-11),Adolescence (12-17) Services/Activities Provided: Public health and welfare of the people and the environment,Youth, Physical/Emotional Disabilities,Victims of Crimes,Victims of Health or Social Crises Amount Applying For:$50000 Island of Hawaii YMCA-Family Visitation Center I Page 1 Program Details Organization Mission: Build a strong community; invest in Youth, teach them good health, community involvement&social responsibility. 27+years of operation. Seasoned staff brings a combined 60 years • of experience & knowledge in this field of work, are active participants of& received training by certified DV organizations.YFVC currently serves 142 parents who are either a survivor or perpetrator of domestic violence. 118 infants&youth engage in Supervised Visitation or Safe Exchanges. Program Overview:YFVC is a one-of-its-kind safe, least restrictive, most homelike environment where children come to visit their parent who was removed from the house due to DV.The program is safe because it is staffed with employees who are trained to work with DV situations and procedures in place prevents the adversarial parents to interact. Program services include Intermittent Supervised, Full Direct, One-to-One, Supervised Telephone &Video Supervised visits as well as Safe Exchanges. Court matters involving DV, divorce, and child (abuse) protective (CPS) cases, are referred to the YFVC by Family Court Judges. Most cases involve TRO's. We assess, assist& coordinate type, duration &schedule for the visits. Observation reports of the visits are submitted to Courts. Reports include areas of concern, positive and negative assessments.YFVC always remains a neutral 3rd-party and does not act as a "go- between" adversarial parent.#1 priority is safety of the child during the visit. Program Objectives & Performances Resources Needed: Resources needed to conduct visits is funding for labor/wages for the FVC employees. FVC employees include: FVC Director, FVC Supervisor, FVC Visitation Associate, FVC Safety and Security Officer. iPads are needed for Facetime visits. Laptops,subscription to software such as Microsoft Suite and case tracking systems are needed for communication and input of data. The community has provided donations such as:toys,teddy bears, children's books, snacks and clothing. These donated items make visits at the FVC run smooth. Community fundraisers are used to seek funds that will be used to scholarship parents who cannot afford to pay the fees for the visits. Major Activities to be Completed:The FVC needs a FVC Director to overlook and manage the FVC.The site supervisor is needed to complete assessments and conduct referrals, schedule, and coordinate visits, speak with the children and understand their perception of the situation.The FVC Associate monitors and completes the observations forms, receives, and delivers the children to the visiting/custodial parent,talks, comforts and explains to the child the situation.The security officers maintain the peace, keeps the traffic flowing and keeps the child safe. Outputs to be Completed: 1 each - 1/8-time Director 1 each - 1 full-time Supervisor 5 each—Visitation Associates 2 each—Safety&Security Officers 1 each—1/2 time clerical Island of Hawaii YMCA-Family Visitation Center I Page 2 We will service 200 children on the Island of Hawaii with over 1,500 visits annually. We will complete intakes and assessments for matters referred by the Family Court for over 200 parents. Measurable Outcomes: 1. Visits are pleasant and stress free for the child. 2. Ohana means no one is left behind or forgotten. 3. The child is allowed to form their own opinion of their parents. 4. No more feelings of"divided loyalty". A neutral ground for children to understand relationships. 5. Give the children a voice and validation "I am important" "I am me" "I love my mom and my dad". 6. Eliminate the presence of emotional, physical, or verbal conflicts from the ohana and extended ohana. 7. Peace in the family with comfort in the child's heart. 8. Child feeling secure and engaged. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Island of Hawaii YMCA-Family Visitation Center) Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Island of Hawaii YMCA Program Name:Family Visitation Center CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50,000 50,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets 107,000 107,000 Other funding sources below): (list below Visitation Fees 24,000 24,000 Total Cash Income 181.000 181,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 181,000 181.000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Island of Hawaii YMCA Program Name:Family Visitation Center Nonprofit Other Cash In-Kind. Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 50,000 128,000 178,000 Professional Fees Operations Supplies 3,000 3,000 Equipment SUBTOTAL 50,000 131,000 181,000 TOTAL PROGRAM BUDGET 50,000 131,000 181,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Island of Hawaii YMCA Program Name: Family Visitation Center 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.gpv, 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.. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Island of Hawaii YMCA Program Name: Family Visitation Program 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 30'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, 2023 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. dehtsl ' V January 6, 2022 Signature of Authorized Person , Wendy Botelho-Cortez Date Chief Executive Officer Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Island of Hawaii YMCA Program Name: Family Visitation Program 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: No conflicts of interest. xx If no conflicts exist, check here. January 6, 2022 Signature o Authorized Person (specify title) Date Wendy Botelho-Cortez, Chief Executive Officer Island of Hawaii YMCA New Horizons Youth Program 134 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Island of Hawaii YMCA Contact Person: Wendy Botelho-Cortez Contact Email: wendy.botelho@islandofhawaiiymca.org Contact Phone: 808-935-3721 Program Information Program Name: New Horizons Youth Program Program Years in Operation:4 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Kalapana, Kapoho, Kea'au, Kurtistown, Laupahoehoe, Leilani Estates, Mountain View, Nanawale Estates, Ninole, 'O'okala,Orchidlands Estates, Pa'auilo, Pahoa, Papa'aloa, Papa'ikou, Pepe'ekeo,Wainaku Program Target Audience:School Age (6-11), Adolescence (12-17) Services/Activities Provided: Educational concerns, Culture and the arts,Youth Amount Applying For: $15000 Island of Hawaii YMCA-New Horizons Youth Program I Page 1 Program Details Organization Mission: Build strong communities, invest in youth, teach good health, community involvement&social responsibility. 4+years of operation. Staff brings combined 21 years experience & knowledge in this field of work; current w/State of HI DHS licensing & receives training for CPR/First Aid. Other trainings by Redwoods Institute: Child Sexual Abuse Prevention, School-Aged Childcare Safety, YMCA Before &After School Program Safety. NHYP services approx. 97 children during the summer months. Program Overview: NHYP provides childcare for children ages 5-13 when schools have intercession breaks. NYHP provides learning &social skills through activities of theater&arts, cultural dance &art, exercise, sports, water play, cursive writing, anger management, COVID education, peer relations,farm- to-table gardening/nutrition. Cost per child is$150/week. Average number of participants ranges 50- 110. Children who attend NHYP come from various households including working parents; single parents; adopted families;foster families. Parents &guardians can maintain their full-time employment when children are out of school and attending NHYP. Breakfast, lunch and 2 snacks are provided daily to all children and staff. NHYP participates with the Food Basket program for ingredients. Because children are fed well,they are energized &feel content.They learn creative &expressive skills, social &analytical skills through a myriad of program activities &games designed to stimulate interactions. Program Objectives & Performances Resources Needed:We need the following: 1 standalone thermometer scanner.Temperature check upon arrival for child &staff safety. Cost: $1,100 1 double-door industrial grade refrigerator. Increased cold refrigerator space will allow storage of& ability to serve fresh local produce, dairy, &fruits 4x daily,vs. shelved-processed snacks. Cost: $6,800 2 rice pot cookers/warmers. Old rice pots are broken due to continued/constant use. Current 10-cup & 20-cup rice pots are inadequate for the amounts of food prepared for children during day camp periods. Rice pots are used to cook items other than rice, such as: purple sweet potatoes, &other steamed veggies. Cost: $400 1 flat grill for new existing stoves. Flat grill allows cooking large amounts of pancakes, sweetbread French toast, etc.,for children's breakfasts. Cost: $300 Kitchen Manager, Kitchen Associate &Youth Associate—labor(salaries/wages) needed. Cost: $6,400 Major Activities to be Completed: Children will have their temperature checked at the stand alone thermometer scanner. Upgrade & add to the YMCA kitchen a refrigerator, 2 ea. 30-cup rice pots and a flat grill. Refrigerator to store local produce & dairy products. Rice pots&flat to cook rice, steam vegetables, cook meals such as pancakes, French toast, Kitchen Manager&Associate will cook&serve the food to the children using these appliances. Island of Hawaii YMCA-New Horizons Youth Program I Page 2 Kitchen manager will coordinate & manage activities in the kitchen. They will create the menu, pick-up food at the Food Basket & local markets. They will serve children & clean the kitchen according to DoH rules. Kitchen Associate will follow direction of Manager. Outputs to be Completed: Measurable Outcomes: Kitchen Manager: 1 position @ 30 hours per week @ $17/hour 9 weeks. Associate: 1 position @20 hours per week @ $14/hour 9 weeks. Produce hot meals/snacks for 150 campers= 13,500 meals/snacks. 2,700 meals &2,700 snacks for volunteers &staff. Assist on campus at children's birthday events, maintain cleanliness in kitchen, assist with fun food activities & utilize fresh herbs &vegetables from garden. 150 children will have a temperature check 6,750 times in the mornings and 6,750 times mid-day. Monitoring temperature at various times of the day is needed to protect all participants. Attachments Program Budget(Income & Expenses) Certificate of Understanding Conflict Disclosure Island of Hawaii YMCA-New Horizons Youth Program l Page 3 Program Budget Form. Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Island of Hawaii YMCA Program Name:New Horizons Youth Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 15,000 15,000 Applicant organizational budget: Individual contributions Membership fees Earned income 202,500 202,500 Current cash assets 2,213 2,213 Other funding sources(list below): Total Cash Income 217,500 2,213 219,713 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 217,500 2,213 219,713 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Island of Hawaii YMCA Program Name:New Horizons Youth Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 6,400 173,963 180,363 Professional Fees Operations Supplies 30,750 30,750 Equipment 8,600 8,600 SUBTOTAL 15,000 204,713 219,713 TOTAL PROGRAM BUDGET 15,000 204,713 219,713 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Island of Hawaii YMCA Program Name: New Horizons Youth Program 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Island of Hawaii YMCA Program Name: New Horizons Youth Program 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, 2023 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. "1/1/4 January 6, 2022 Signature of Authorized Person, Wendy Botelho-Cortez Date Chief Executive Officer Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Island of Hawaii YMCA Program Name: New Horizons Youth Programs 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 I 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: No conflicts of interest. Ixx If no conflicts exist, check here. F9/.1bJanuary 6, 2022 Signature o Authorized Person (specify title) Date Wendy Botelho-Cortez, Chief Executive Officer Kamuela Philharmonic Orchestra Society Community Concerts 140 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Kamuela Philharmonic Orchestra Society Contact Person: BRENDA L MCCONNELL Contact Email: brenda.lea.mcconnell@gmail.com Contact Phone: 8085570693 Program Information Program Name: Community Concerts Program Years in Operation: 2 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Hawi, Hilo, Holualoa, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kea'au, Mountain View, Pahoa,Volcano, Waikoloa Village, Waimea Program Target Audience: Play Age (3-5), School Age (6-11),Adolescence (12-17),Young Adulthood (18- 39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Culture and the arts, Needs of the poor,Youth, Aged Amount Applying For: $10000 Kamuela Philharmonic Orchestra Society-Community Concerts I Page 1 Program Details Organization Mission:The Kamuela Philharmonic Orchestra Society (KPOS) is a non-profit organization established in 2005 which is dedicated to bringing live, high-quality orchestral music to audiences on Hawaii Island. KPOS celebrates and promotes the timeless beauty of classical music, as well as the rich cultural and musical traditions of the Hawaiian people. Program Overview: Kamuela Philharmonic Orchestra Society (KPOS) is seeking funding to support free orchestral concerts to serve the rural communities of Hawaii Island. These concerts will be held in out- door venues easily accessible to all people and will encourage the enjoyment of live music in a health safe enjoyment. These concerts will feature musicians from the orchestra and support them financially. The music performed to the community will be varied between Hawaiian mele's, holiday appropriate music and classical pieces. The repertoire is carefully chosen to spark interest in a large cross section of people of all ages. Besides these out-door venues these groups will be performing for Seniors in senior living homes such as Life Care of Kona and Hilo and Yukio Okutsu State Veterans Home in Hilo. Program Objectives & Performances Resources Needed: Qualified Musicians to perform the concerts, Funds to pay the musicians,Volunteers to organize the program and track the success of the program,Treasurer and Bookkeeper to pay musicians, Artistic Director(AD) who prepares the repertoire for the concerts, gets music to the musicians, and runs rehearsals.This orchestra has been doing concerts for many years and the free outdoor concerts for the past 2 years and our organization chain is established and runs smoothly.The resource needed the most is the funding to continue these concerts so that more of the community has access and we can engage with the youth to encourage them to play an instrument. Because of this organizations dedicated to keeping live orchestral music alive on Hawaii Island we have 40 classically trained musicians who we financially support and rehearse to improve their skills and make music performance financially profitable. We also have dedicated volunteers and staff to support this program. Major Activities to be Completed:The major activity to be completed is to provide free community concerts to rural communities on Hawaii island. Once the funding for this program is finalized,the KPOS board will direct the AD and the program chair to schedule the concerts.The venue for concerts is selected, repertoire is chosen, musicians are contracted, and rehearsals are performed, concert is performed,Treasurer pays musicians then evaluations of the program is performed, and feedback is given to the Board to make necessary changes. Outputs to be Completed: Provide up to 20 Free Community Concerts in rural communities on Hawaii Island, supporting 40 Musicians, Supporting 3 Staff plus$5000 in donated time and venue costs. Supporting musicians is the only way to keep live music present in our communities and schools.As students watch musicians play their instruments,they are encouraged to seek out music participation at their schools.This organization goes directly into the schools to add support to music programs. The concerts are the bridge between being inspired by music and deciding to play an instrument oneself. Kamuela Philharmonic Orchestra Society-Community Concerts! Page 2 Studies show that students who include music into their school curriculum do better in other areas of acidemia and benefit socially. Y Measurable Outcomes: Engagement with the community who benefit from the Free Concerts will be measured by quantitative numbers of participates and will be qualitatively measured by carefully listening to the comments after the concert and by encouraging people to interact with the organization on social media sites. By growing our social media following we can give the community free access to information regarding other programs and provide free links to digital programs we record for public access.This gives hard to reach rural communities access to orchestral music without travel or financial concerns. We are especially interested in engaging with the youth attending these concerts so we can inform them about our educational music programs and how they can access them.These concerts financially support musicians who are striving to make a living performing music during challenging pandemic restrictions. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Kamuela Philharmonic Orchestra Society-Community Concerts I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Kamuela Philharmonic Orchestra Society Program Name:Community Concerts CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 10000.00 10000.00 Applicant organizational budget: 207000.00 207000.00 207000.00 Individual contributions 45000.00 45000.00 45000.00 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets 800.00 800.00 800.00 Other funding sources (list below): 0 0 0 Total Cash Income 10800.00 800.00 10800.00 IN-KIND CONTRIBUTION Anticipated Committed Total Volunteer Time 400.00 400.00 400.00 Total In-Kind Contributions 400.00 400.00 400.00 TOTAL PROGRAM INCOME 11200.00 1200.00 11200.00 Appendix D--Budget Sheets (Page 2 of 2) L 10 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Kamuela Philharmonic Orchestra Society Program Name: Community Concerts C ASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai 10000.00 10000.00 Grant) Applicant organizational budget: 135000.00 207000.00 207000.00 Individual contributions 45000.00 45000.00 45000.00 Membership fees 0 0 0 Earned income 0 20 20 Current cash assets 98506.70 98506.70 98506.70 Other funding sources (list below): Private Grant Funding 25000.00 34000.00 ARP Funding 15000.00 75000.00 Calabash 931.00 Community Giving Program 999.31 Private Donations 2575.00 Total Cash Income I N-KIND CONTRIBUTION Anticipated Committed Total Volunteer Time 10000.00 46000.00 46000.00 Total In-Kind Contributions 5000.00 5000.00 5000.00 T OTAL PROGRAM INCOME 10000.00 25000.00 40000.00 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal "Year 2022-2023 Organization Name: Kar uela Philharmonic Orchestra Society Program Name: Community Concerts Nonprofit (Waiting Other CashExpense Description n TOTAL Grant Source Contribution Salary Wages (1099 Contracted i8500.00 322500.00 5000.00 36000.00 Musicians and Staff) j 3 3 .. _ .. n� Professional Fees (Bookkeeper,1500.00 1000.00 0 11500.00 ? E !Personnel Manager) 1 i Operations (Liability Insurance) 1300.00 1700.00 i0 11000.00 �,._ .. .,..�..... ................._m...e........e... ,,.,, .. ....... ...»........ ....}......,_,. -....m., ......,.. ; ...,...,... ........ ..ice.......... .........�_._, .�....,.g.. ...�..�,.,.. .....o...........� Supplies (Printing and Music Fees) 200.00 1300.00 500.00 Equipment(Cartage Fees for Large 1500.00 1500.00 1000.00 Instruments) ? j 3 3 � E Ji _ 7 x ................................e...e........e....e.e.�......e..... ...e...<�..........o..e.>n..a............ ' �....................................m. - e..e.e.,....,....e...... -_ _�a.............,..�...,.- 117 � 1 . � � 1 1 1 i 33� 13# SUBTOTAL 10000.00 1125000.00 15000.00 140000.00 TOTAL PROGRAM BUDGET 40000.00 !Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Kamuela Philharmonic Orchestra Society =Program Name:Community Concerts Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 8500.00 300.00 200.00 9000.00 Professional Fees 500.00 200.00 100.00 800.00 Operations 400.00 100.00 0 500.00 Supplies 100.00 100.00. 0 200.00 Equipment 500.00 100.00 100.00 700.00 SUBTOTAL 10000.00 800.00 400.00 11200.00 TOTAL PROGRAM BUDGET 10000.00 800.00 400.00 11200.00 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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 allsupporting 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: t,,,,uti« pk,-Ikra s,s. ,,e QNetu,-i1 Som,; e-tr Program Name: Co,,,,,„;\-�- L�J„� Certification 3 f nderstanding (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, 2023 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 fundinq 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 Signature of Authorized Person Date Title/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: u,►0,f, �.;1�� ,�t e..) �;�.� 1, . soeizsky Program Name: OGANMZ TION 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 farms 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 C Staff appointed by a member of the Council • The Mayor E 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 anyy and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: ] If no conflicts exist,check here. r� 4 �.� -� % f � �--) Signature of Aut ori ed Person (specify title) Date to_ati . • Kamuela Philharmonic Orchestra Society Elementary Music Education Program 141 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Kamuela Philharmonic Orchestra Society Contact Person: Brenda L. McConnell Contact Email: Brenda.lea.mcconnell@gmail.com Contact Phone: 808-557-0693 Program Information Program Name: Elementary Music Education Program Program Years in Operation: 5 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Hawi, Hilo, Holualoa, Honaunau-Napo'opo'o, Honoka'a, Kailua-Kona, Kapa'au, Mountain View,Volcano, Waikoloa Village Program Target Audience:School Age (6-11) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor,Youth Amount Applying For: $5000 J Kamuela Philharmonic Orchestra Society-Elementary Music Education Program I Page 1 Program Details Organization Mission:The Kamuela Philharmonic Orchestra Society (KPOS) is a non-profit organization established in 2005 which is dedicated to bringing live, high-quality orchestral music to audiences on Hawaii Is. KPOS celebrates and promotes the timeless beauty of classical music, as well as the rich cultural and musical traditions of the Hawaiian people. Through our Children's Concerts and other forms of educational and community outreach, we nurture a love and understanding of orchestral music in young people. Program Overview:As part of its mission statement Kamuela Philharmonic Orchestra Society are committed to the education of the youth. Each month KPOS brings live music instruction into the Island public school. During 2020 they worked hard to get the music education programs on a digital platform that could be shared with teachers and students during the time when students worked remotely. Looking forward to the school year of 2022-23 KPOS would like to bring music education back into the classrooms of elementary schools. During these visits the musicians from the orchestra would bring their instruments to the classroom and show the students how they work and play a little song for them. There would be 5-6 musicians at each visit so the students could be introduced to instruments from each "family' of an orchestra. After this introduction of each instrument the group will play a song together so the students could see how instruments work together in a group to create music. Program Objectives & Performances Resources Needed:There are two teams of professional trained musicians plus a coordinator who teaches these programs. Each team has 5—6 musicians representing both East and West sides of the Island. Each musicians gives a little history about their instrument, gives a demonstration to show the students how they are played and then plays with the other musicians to show how that instrument fits into the whole musical experience.The coordinator is the liaison who schedules the visit with the schools and organizes the musicians' schedules After the visit the Board Treasurer arranges for payment to the musicians and coordinator. Even though much of this time is donated by the musicians,the biggest resource need is funding to pay the musicians and coordinator. Major Activities to be Completed: Our goal is to visit 7-9 elementary schools each school year. Each school visit lasts the equivalent of one class period about 45-60 minutes. Many schools allow two back- to-back sessions to serve more students. Some schools have a gym/auditorium we can use to run the sessions. Depending on the size of the school and the number of sessions they can accommodate the reach of these visits can be 30—250 students per school per day. It is the hope that during these school visits the students will be inspired to play an instrument, attend an orchestral concert with live music or seek out listing to classical music on their own. Outputs to be Completed: Bring music into the schools help to grow students' interest in music. Give them some basic understanding of what it's like to play a musical instrument to, hopefully, spark interest in further learning. Kamuela Philharmonic Orchestra Society-Elementary Music Education Program I Page 2 Introduce the instruments families. Give some basic music theory. Perform a classical piece of music that represents how an orchestra works together. Allow the students an opportunity to participate. Expose children directly to classical music in a fully rounded context. Measurable Outcomes:After each school visit the coordinator contacts the teacher/administrator and fills out an evaluation form about the program's performance.We easily track the numbers data of students served by much of the program is evaluated by the stories we get back.Students and teachers are encouraged to write letters back to us so that necessary improvements can be made to the program. We track the success of these programs by the letters we receive and what the teachers tell us.The musicians who participate in the programs get to know the students and report back about their progress.We know that when students are offered music education and their growth is supported by our organization many students do better in school and often continue to pursue music.Since the program beginning its 6th season,we can also identify students in our more advanced programs who attended one of these elementary school programs. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Kamuela Philharmonic Orchestra Society-Elementary Music Education Program I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Kamuela philharmonic Orchestra Society Program Name: Elementary Music Education Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 5000.00 5000.00 Applicant organizational budget: 207000.00 207000.00 207000.00 Individual contributions 45000.00 45000.00 45000.00 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets 300.00 300.00 300.00 Other funding sources(list below): Total Cash Income 5300.00 300.00 5300.00 IN-KIND CONTRIBUTION Anticipated Committed Total Volunteer Hours Donated 800.00 800.00 800.00 Total In-Kind Contributions 800.00 800.00 800.00 TOTAL PROGRAM INCOME 6100.00 1100.00 6100.00 Appendix D--Budget Sheets (Page 2 of 2) ;Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 organization Name: Kamuela Philharmonic Orchestra Society ;Program Name: Elementary Music Education Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 4500.00 0 500.00 5000.00 Professional Fees 200.00 0 50.00 250.00 Operations 100.00 100.00 50.00 250.00 Supplies 100.00 100.00 100.00 300.00 Equipment 100.00 100.00 100.00 300.00 SUBTOTAL 5000.00 300.00 800.00 6100.00 TOTAL PROGRAM BUDGET 5000.00 300.00 800.00 6100.00 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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. County ofHawaii Nonprofit Grant Application FY 2022-23 tc 3 , I/Y ✓rt pg Ilii ' ffi" Agent Name: '1v l V J i Program Name: i? ) ri 'ti,- f)'l 5 Ee €" ,t rpt Certification of Understanding (Page 2 of 2) If awarded a grant from the County of`Hawai'i, I(wn )understand that a current Certificate of Liability ($1,000,000 general liability,$50,000 each occurrence)mustbe provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Flawai`i is an additional insured prior to receiving any payment(s). I(we) understand that failure to submit the final report within 60days of June 30th shall result in loss of ail grant funds received:during the grant period(must be refunded to County)and exclusion from future grant participation for a mie imuni 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://w rgv.hawaiicountv.gov,fn-nor rofiit-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 30,2023 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 recoverthese funds. Awards cannot provide funds for Capital Improvements(Cost of Construetion,.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 Date Title/Position of Authorized Person County of awal`i Nonprofit Grant Application FY 2022-23 Agency Name: ',�f*,L,'o&Q - 1441 % jre-L:-„L4;-t— „See k. Program.Name: E-it v st c F � ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, oradministrator 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 asneeded 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 Fl Staff appointed by a member of the Council n The Mayor The Managing Director Fl The Director of Finance J 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 conflictsexist,check here. rte,,.. Signattire of Authorized Person (specify.title) Date Keaukaha One Youth Development RISE 21st Century After School Program 142 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Keaukaha One Youth Development Contact Person: Naomi Ahu Contact Email: naomi.koyd.rise@gmail.com Contact Phone: 808-756-5859 Program Information Program Name: RISE 21st Century After School Program Program Years in Operation: 11 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Kailua-Kona, Kalapana, Kea'au, Kurtistown, Leilani Estates, Mountain View, Nanawale Estates, Ninole, Orchidlands Estates, Pahoa, Papa'aloa, Papa`ikou, Pauka'a, Pepe'ekeo, Pohoiki,Volcano, Wainaku Program Target Audience:School Age (6-11),Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment, Youth,Aged Amount Applying For: $50000 Keaukaha One Youth Development-RISE 21st Century After School Program I Page 1 Program Details Organization Mission: KOYD enhances the development of Hawaiian leadership.As a Native Hawaiian organization, we have developed an indigenous framework that utilizes cultural practice and ocean- based activities to: (1) stress physical fitness; (2) instruct use and maintenance of ocean canoes; (3) excel in waterman competence;train youth as qualified crew for the lomakualani double-hulled sailing canoe; and (5) provide diverse out-of-school educational opportunities for lifelong learning. Program Overview:The RISE 21st Century After School Program was established in 2011 to serve as a community resource bank for underprivileged, Native Hawaiian youth ages 8-18 in Hilo.The focus is to support in the revealing of individual strengths and passions for future career and academic success. A variety of mediums are used to create an Individual Student Success Plan (ISSP)that evolves over time through experience and facilitation of: apprenticeships, Hawaiian cultural practice, internships, multimedia, performing arts, project exhibitions, student-exchange, and work-study initiatives. The RISE Program is aligned with the mission of KOYD to enhance physical and mental wellbeing, cultural identity, and Hawaiian leadership as a foundation for excellence. Program Objectives & Performances Resources Needed: 1) Funding—to maintain the following resources listed 2) Staff—Executive Director& Fiscal Adminstrative Coordinator 3)Volunteers—Board of Directors,various mentors 4) Facilities—KOYD Headquarters located at 67 Keokea Loop, Palekai (Breakwall), maintenance associated with continued use of site 5) Equipment—Equipment rentals, computers 6) Technology—Xmind software 7) Supplies—Office supplies, snacks for youth 8)Travel—air travel and accommodations to support youth exposure and professional development opportunities Major Activities to be Completed: 1) Youth participants are exposed to various subject areas (Hawaiian culture and practices,STEM, etc.)through different mediums to inspire their future career/academic endeavors. 2)Youth develop Individual Student Success Plans (ISSP) based on experience and exposure to educational opportunities. 3) 5Cs value system is introduced and implemented throughout all program activities (commitment, character, compatibility, courage, and competence). 4) Students engage in activities to promote Hawaiian Leadership and servant-leader practices. Outputs to be Completed:We project: 1)At least 50 youth supported Keaukaha One Youth Development-RISE 21st Century After School Program I Page 2 2) 10 volunteers+ approx. 2500 hours service 3) 100%of youth have begun development of an ISSP Measurable Outcomes: For the program activities we plan to implement in 2022-23, we are confident that the outcomes of these efforts will have tremendous effect in the long-term capacities of our participants in reflecting: 1) Excellence pursued in life-long learning 2) Happier, healthier communities 3) Dynamic leaders for Hawaii's future Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Keaukaha One Youth Development-RISE 21st Century After School Program I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50000.00 pending pending Applicant organizational budget: 230000.00 70000.00 70000.00 Individual contributions Membership fees Earned income Current cash assets Other funding sources(list below): HCF-Career Connected Learning 30000.00 30000.00 30000.00 HCF-CHANGE 50000.00 pending pending Kamehameha Schools 60000.00 pending pending Total Cash Income 140000.00 30000.00 30000.00 IN-KIND CONTRIBUTION Anticipated Committed Total 40000.00 40000.00 40000.00 Total In-Kind Contributions 40000.00 40000.00 40000.00 TOTAL PROGRAM INCOME 230000.00 70000.00 70000.00 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawai`i e Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Keaukaha One Youth Development ....... . .. !Program Name: RISE 21st Century After School Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 25000.00 89000.00 6000.00 120000.00 Professional Fees 5000.00 10000.00 10000.00 25000.00 Operations 5000.00 21000.00 4000.00 30000.00 Supplies 12000.00 10000.00 8000.00 30000.00 Equipment 3000.00 7000.00 10000.00 Travel 10000.00 5000.00 15000.00 SUBTOTAL 50000.00 140000.00 40000.00 230000.00 TOTAL PROGRAM BUDGET 50000.00 140000.00 40000.00 230000.00 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program Certification of Understanding (Pagel 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 atlow 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) understandthat applications will not be reviewed by County personnel receiving our County. Nonprofit Grant submittal,and that wehave full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature mustbe 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`Hawall, 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. County of Iawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Dame: RISE 21st Century After School Program Ceif cagiion of U r derstanding (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, 2023 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. i2C/2D22-- Signature of Authorized Person Date Executive.Director/President Title/Position of Authorized Person �� C J-C-C 2-, J //25// a a County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 0 GA . IZATfON 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 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: 1 2If no conflicts exist,check here. Zi( (Executive Director/President) if es/ 2,22 , Signature of Authorized Person (specify title) Date f'' (sec/am-7v ) d254022 Keaukaha One Youth Development Paahana Vaa (formerly known as Youth Paddling Program) 143 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Keaukaha One Youth Development Contact Person: Naomi Ahu Contact Email: naomi.koyd.rise@gmail.com Contact Phone: 808-756-5859 Program Information Program Name: Paahana Vaa (formerly known as Youth Paddling Program) Program Years in Operation: 16 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Kailua-Kona, Kalapana, Kea'au, Kurtistown, Leilani Estates, Mountain View, Nanawale Estates, NInole, Orchidlands Estates, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki,Volcano, Wainaku Program Target Audience:School Age (6-11),Adolescence (12-17), Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth, Aged Amount Applying For:$30000 Keaukaha One Youth Development-Paahana Vaa (formerly known as Youth Paddling Program)I Page 1 Program Details Organization Mission: KOYD enhances the development of Hawaiian leadership.As a Native Hawaiian organization, we have developed an indigenous framework that utilizes cultural practice and ocean- based activities to: (1) stress physical fitness; (2) instruct use and maintenance of ocean canoes; (3) excel in waterman competence;train youth as qualified crew for the lomakualani double-hulled sailing canoe; and (5) provide diverse out-of-school educational opportunities for lifelong learning. Program Overview:The Youth Paddling Program was first established in 2006 for youth ages 8-18. Since 2006, our organization has trained more than a thousand youth in the practice of hoe waa—canoe paddling. More recently we have re-identified the Youth Paddling Program to what we now know as Paahana Vaa —or to be busy in all things relating to the canoe culture of our kupuna. Paahana Vaa not only reconnects us to our rich voyaging tradition, but supports all ages in developing a strong foundation through hoe waa. Hoe waa is a pre-requisite to deepening participant knowledge of the ocean and the various ocean crafts we will learn to utilize to navigate those environments. Program Objectives & Performances Resources Needed: 1) Funding—to maintain the following resources listed 2) Staff—Executive Director& Fiscal Adminstrative Coordinator 3)Volunteers—Board of Directors,various mentors 4) Facilities—KOYD Headquarters located at 67 Keokea Loop, Palekai (Breakwall), maintenance associated with continued use of site 5) Equipment—Various canoe types (6-man, OC1,V1, Surf Ski, etc) 6) Supplies—Paddles, safety gear, snacks for youth 7)Travel—bus transportation, air travel and accommodations for off island State races, IVF International World Sprints Competitions Major Activities to be Completed: 1) Youth are trained in the use and maintenance of various canoe types on a weekly basis. 2)Youth are exposed to various opportunities to compete in local,state, national, and international race events when it is determined they are ready. 3) Experiences in this program are highlighted in their Individual Student Success Plans (ISSP). 4) 5Cs value system is introduced and implemented throughout program (commitment, character, compatibility, courage, and competence). Outputs to be Completed: We project: 1) At least 50 youth supported 2) 5 volunteers+ approx. 3000 hours served 3) Participation in canoe racing events in all qualified age groups and rankings identified Keaukaha One Youth Development-Paahana Vaa (formerly known as Youth Paddling Program)I Page 2 Measurable Outcomes: For the program activities we plan to implement in 2022-23, we are confident that the outcomes of these efforts will have tremendous effect in the long-term capacities of our participants in reflecting: 1) Excellence pursued in life-long learning 2) Happier, healthier communities 3) Dynamic leaders for Hawaii's future Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Keaukaha One Youth Development-Paahana Vaa (formerly known as Youth Paddling Program) Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Keaukaha One Youth Development Program Name: Paahana Vaa (formerly known as Youth Paddling Program) CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 30000.00 pending pending Applicant organizational budget: 60000.00 35000.00 35000.00 Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Hauoli Mau Loa Foundation 20000.00 20000.00 20000.00 Total Cash Income 50000.00 20000.00 20000.00 IN-KIND CONTRIBUTION Anticipated Committed Total 15000.00 15000.00 15000.00 Total In-Kind Contributions 15000.00 15000.00 15000.00 TOTAL PROGRAM INCOME 65000.00 35000.00 35000.00 Appendix D--Budget Sheets (Page 2 of 2) !Project Budget Form: Expenses `County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Keaukaha One Youth Development [Program Name: Paahana Vaa (formerly known as Youth Paddling Program) Nonprofit Expense Description (Waiwai) Other Cash In-Kind TOTAL Source Contribution Grant , Salary Wages Professional Fees 2000.00 2000.00 Operations 3000.00 3000.00 Supplies 10000.00 10000.00 20000.00 Equipment 10000.00 10000.00 20000.00 Travel 5000.00 10000.00 5000.00 20000.00 SUBTOTAL 30000.00 20000.00 15000.00 65000.00 TOTAL PROGRAM BUDGET 30000.00 20000.00 15000.00 65000.00 County of flawai‘i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: .Paahana Vaa (formerly known as Youth Paddling Program Certification of Understanding (Page 1 of 2) l (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, Flawail 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 ORIGINALSIGNED 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 Corrce Ex ress and be compliant prior to receiving payment(s). To register, go to 1=ilysiLdors.ehawali.gov,complete the easy step-by-step process,and pay the annual registration fee online using a credit card. if awarded a :rant from the Coun of Hawai‘i I we understand and will corn.1 with the re.uirement 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 Hawari grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timey, complete, and accurate year-end report using the,template provided, will impact the evaluation,of your program's or agency's future funding requests. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: Paahana Vaa (formerly known as Youth Paddling Program 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:f/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, 2023 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. ifIci2e Signature of Authorized Person Date Executive Director/President Title/Position of Authorized Person t 1 County of Hawaii. Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: Paahana Vaa (formerly known as Youth Paddling Program ORGANIZATION CONFLICTI 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 0 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:. Ric If no conflicts exist,check here. I / (Executive Director/President) (I 2472022- Signature of Authorized Person (specify title) Date lt� ia'r-chephV l2c/ J Keaukaha One Youth Development lomakualani Voyaging Canoe (formerly known as Hokualakai Restoration Project) 144 County of Flawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Keaukaha One Youth Development Contact Person: Naomi Ahu Contact Email: naomi.koyd.rise@gmail.com Contact Phone: 808-756-5859 Program Information Program Name: lomakualani Voyaging Canoe (formerly known as Hokualakai Restoration Project) Program Years in Operation: 7 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Kailua-Kona, Kalapana, Kea'au, Kurtistown, Leilani Estates, Mountain View, Nanawale Estates, NTnole, Orchidlands Estates, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo,Volcano, Wainaku Program Target Audience:School Age (6-11),Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth, Aged Amount Applying For: $50000 Keaukaha One Youth Development-lomakualani Voyaging Canoe(formerly known as Hokualakai Restoration Project)! Page 1 • Program Details Organization Mission: KOYD enhances the development of Hawaiian leadership.As a Native Hawaiian organization,we have developed an indigenous framework that utilizes cultural practice and ocean- based activities to: (1)stress physical fitness; (2) instruct use and maintenance of ocean canoes; (3) excel in waterman competence;train youth as qualified crew for the lomakualani double-hulled sailing canoe; and (5) provide diverse out-of-school educational opportunities for lifelong learning. Program Overview: In November 2015,the Hokualakai double-hulled voyaging canoe owned and built by Aha Punana Leo was donated to KOYD and the community of Keaukaha.Since then, our organization has worked hard on restoring it which required many structural and re-engineering modifications.After seven years of managing the restoration of this 56' double-hulled vessel, we are finally ready to embark on a new chapter of its future. We plan to dedicate a new double-hulled voyaging canoe with a new vision and a new identity known as lomakualani—lo The Heavenly Parent of The Heavens. • Youth as well as community leaders and educators that are involved with this program will be given the opportunity to utilize this voyaging classroom to conduct research and implement a variety of educational opportunities while becoming active/training members of the crew. lomakualani will become one of the most valuable vessels for learning in East-Hawaii. Program Objectives & Performances Resources Needed: 1) Funding-to maintain the following resources listed 2) Staff—Executive Director& Fiscal Adminstrative Coordinator 3)Volunteers—Board of Directors,various mentors 4) Facilities—KOYD Headquarters located at 67 Keokea Loop, Palekai (Breakwall), maintenance associated with continued use of site 5) Equipment—Voyaging canoe and other machinery for ongoing maintenance 6) Supplies—Maintenance supplies, safety gear, snacks for youth 7)Travel—air travel and accommodations for off island professional development and cultural-exchange opportunities Major Activities to be Completed: 1) Participants are trained in the use and maintenance of the double- hulled voyaging canoe as aligned to Paahana Vaa curriculum 2) Experiences in this program are highlighted in their Individual Student Success Plans (ISSP) 3) 5Cs value system is introduced and implemented throughout program (commitment, character, compatibility, courage, and competence). Outputs to be Completed:We project: 1)At least 50-100 youth supported 2) 10 volunteers+approx. 2500 hours served Keaukaha One Youth Development-lomakualani Voyaging Canoe(formerly known as Hokualakai Restoration Project)I Page 2 3) Participation in sailing and canoe maintenance events Measurable Outcomes: For the program activities we plan to implement in 2022-23,we are confident that the outcomes of these efforts will have tremendous effect in the long-term capacities of our participants in reflecting: 1) Excellence pursued in life-long learning 2) Happier, healthier communities 3) Dynamic leaders for Hawaii's future' Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Keaukaha One Youth Development-lomakualani Voyaging Canoe(formerly known as Hokualakai Restoration Project)1 Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Keaukaha One Youth Development Program Name: lomakualani Voyaging Canoe (formerly known at Hokualakai Restoration Project) CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50000.00 pending pending Applicant organizational budget: 150000:00 75000.00 75000.00 Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Hauoli Mau Loa Foundation 25000.00 25000.00 25000.00 Kamehameha Schools 25000.00 pending pending Total Cash Income 100000.00 25000.00 25030.00 IN-KIND CONTRIBUTION Anticipated Committed Total 50000.00 50000.00 50000.00 Total In-Kind Contributions 50000.00 50000.00 50000.00 TOTAL PROGRAM INCOME 150000.00 75000.00 75000.00 Appendix D--Budget Sheets (Page 2 of 2) ',Project Budget Form: Expenses ;County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Keaukaha One Youth Development Program Name: lomakualani Voyaging Canoe (formerly known as Hokualakai Restoration Project) Nonprofit Expense Description (Waiwai) Other Cash In-Kind TOTAL Source Contribution Grant Salary Wages Professional Fees 10000.00 40000.00 50000.00 Operations Supplies 10000.00 30000.00 10000.00 50000.00 Equipment 30000.00 20000.00 50000.00 SUBTOTAL 50000.00 50000.00 50000.00 150000.00 TOTAL PROGRAM BUDGET 50000.00 50000.00 50000.00 150000.00 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: lomakualani Voyaging Canoe (formerly known as Hokualakai estoraltion 'roj ect'. Certification of %nderstar d g (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. County of Hawai'i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: Iomakualani Vo ain , Canoe former! known as Hokualakai ''.estorat>ion Project Certificate•n 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.hawaiicauntvgov/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 30,2023 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 C (25121 22- Signature of Authorized Person Date Executive Director/President Title/Position of Authorized Person �+ ciee y) 1 (2-50.02 2-- .7(4`)\)1° County of T awai`i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: Iomakualani Voyagin.- Canoe formerly known as Hokualakai .. •:- .b.,. --_:,,:.a.r., e �.. , ..wa .., ;w rrt»rciia a rec&--' - - •:..aa•"_., ,... estoration ''rolect'.: N8 TI %N FUUCT DlSCLOSU ' E 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 (1 The Mayor ❑ The Managing Director ❑ The Director of Finance U 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: 1E If no conflicts exist,check here. (Executive Director/President) f 1'2-St 20 Z2- Signature of Authorized Person (specify title) Date J A - C 8 cri r y t(2s0,0a. - Keaukaha One Youth Development Hoola Hou - Hawaiian Warriorship Program 145 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Keaukaha One Youth Development Contact Person: Naomi Ahu Contact Email: naomi.koyd.rise@gmail.com Contact Phone: 808-756-5859 Program Information Program Name: Hoola Hou- Hawaiian Warriorship Program Program Years in Operation: 9 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Kailua-Kona, Kalapana, Kea'au, Kurtistown, • Leilani Estates, Mountain View, Nanawale Estates, Ninole, Orchidlands Estates, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki,Volcano, Wainaku Program Target Audience:School Age (6-11),Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth,Aged Amount Applying For: $20000 Keaukaha One Youth Development-Hoola Hou-Hawaiian Warriorship Program I Page 1 Program Details Organization Mission: KOYD enhances the development of Hawaiian leadership.As a Native Hawaiian organization, we have developed an indigenous framework that utilizes cultural practice and ocean- based activities to: (1) stress physical fitness; (2) instruct use and maintenance of ocean canoes; (3) excel in waterman competence;train youth as qualified crew for the lomakualani double-hulled sailing canoe; and (5) provide diverse out-of-school educational opportunities for lifelong learning. Program Overview:The Hoola Hou system was created by the late Lohe Kaaloa to promote the warrior traditions,values, and practices of a Hawaiian martial art. Hoola Hou incorporates three necessary stages of learning: 1) Hoola hou—participants learn and engage in a revitalization process of healing; 2) Ola hou—participants learn to live revitalized and in balance with the world around them; and only then can 3) Kiai—to safeguard and protect be achieved through harmony of mind, body, and spirit.The Hoola 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. Program Objectives & Performances Resources Needed: 1) Funding—to maintain the following resources listed 2) Staff—Executive Director& Fiscal Adminstrative Coordinator 3)Volunteers—Board of Directors,various mentors 4) Facilities—KOYD Headquarters located at 67 Keokea Loop, Palekai (Breakwall), maintenance associated with continued use of site 5) Equipment—Fitness equipment 6) Supplies—Fitness supplies, safety gear, snacks for youth 7)Travel—air travel and accommodations for off island professional development opportunities Major Activities to be Completed: 1) Youth are trained in art of Hoola Hou on a weekly basis. 2) Experiences in this program are highlighted in their Individual Student Success Plans (ISSP). 3) 5Cs value system is introduced.and implemented throughout program. Outputs to be Completed:We project: 1)At least 50 youth supported 2) 5 volunteers+approx. 1500 hours served 3) Participation in Hoola Hou events Measurable Outcomes: For the program activities we plan to implement in 2022-23, we are confident that the outcomes of these efforts will have tremendous effect in the long-term capacities of our participants in reflecting: 1) Excellence pursued in life-long learning Keaukaha One Youth Development-Hoola Hou-Hawaiian Warriorship Program I Page 2 2) Happier, healthier communities 3) Dynamic leaders for Hawaii's future Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Keaukaha One Youth Development-Hoola Hou-Hawaiian Warriorship Program I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Keaukaha One Youth Development Program Name: Hoola Hou - Hawaiian Warriorship Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 20000.00 pending oending Applicant organizational budget: 30000.00 ` 10000.00 10000.00 Individual contributions Membership fees Earned income Current cash assets Other funding sources(list below): Kamehameha Schools 2000.00 2000.00 2000.00 Total Cash Income 22000.00 2000.00 2000.00 IN-KIND CONTRIBUTION Anticipated Committed Total 8000.00 8000.00 8000.00 Total In-Kind Contributions 8000.00 8000.00 8000.00 TOTAL PROGRAM INCOME 30000.00 10000.00 10000.00 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Keaukaha One Youth Development ;Program Name: Hoola Hou - Hawaiian Warriorship Program Nonprofit Expense Description (Waiwai) Other Cash In-Kind TOTAL Source Contribution Grant Salary Wages Professional Fees 2000.00 3000.00 5000.00 Operations Supplies 8000.00 2000.00 10000.00 Equipment 5000.00 50. 00.00 10000.00 Travel 5000.00 5000.00 SUBTOTAL 20000.00 2000.00 8000.00 30000.00 TOTAL PROGRAM BUDGET 20000.00 2000.00 8000.00 30000.00 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: Hoola Hou - Hawaiian Warriorship Program Certification of Under-standing (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 htto://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'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 aaencv's future funding requests. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: Hoola Hou - Hawaiian Warriorship Program .�: ��:Y-.,��m a.� _ ��:. �,��-� �� „, rte; ��•.::: :,-.R:,n Certification of Understa ding (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.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, 2023 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. ____71/66 — _____A t/4h®22 1 Signature of Authorized Person Date Executive Director/President Title/Position of Authorized Person . ) CFL ) f f20(04o2.2 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: }Keaukaha One Youth Development Program Name: Hoola Hou - Hawaiian Warriorship Program • RGANIZATION 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.con(lict 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 Li 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: ISI If no conflicts exist, check here. ✓ . (Executive Director/President) (1/40/2022 Signature of Authorized Person (specify title) Data A P C s— 'n ) l 120202L— Keaukaha One Youth Development VEX IQ Robotics Program 146 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Keaukaha One Youth Development Contact Person: Naomi Ahu Contact Email: naomi.koyd.rise@gmail.com Contact Phone: 808-756-5859 Program Information Program Name:VEX IQ Robotics Program Program Years in Operation: 5 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Kailua-Kona, Kalapana, Kea'au, Kurtistown, Leilani Estates, Mountain View, Nanawale Estates, Ninole, Orchidlands Estates, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo,Volcano, Wainaku Program Target Audience:School Age (6-11), Adolescence (12-17), Young Adulthood (18-39) Services/Activities Provided: Educational concerns, Culture and the arts, Public health and welfare of the people and the environment,Youth Amount Applying For: $15000 Keaukaha One Youth Development-VEX IQ Robotics Program I Page 1 Program Details Organization Mission: KOYD enhances the development of Hawaiian leadership.As a Native Hawaiian organization, we have developed an indigenous framework that utilizes cultural practice and ocean- based activities to: (1) stress physical fitness; (2) instruct use and maintenance of ocean canoes; (3) excel in waterman competence;train youth as qualified crew for the lomakualani double-hulled sailing canoe; and (5) provide diverse out-of-school educational opportunities for lifelong learning. Program Overview: 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.Since 2017 RISE/KOYD have developed a robust robotics program where participants continue to engage with UH-Hilo interns.Through this engagement these mentors help to train our participants in computer programming, 3D printing and construction of robots engineered to perform specific tasks to overcome challenges and game like gauntlets where we participate in the annual Waiakea-Hilo-Honokaa (WHH) VEX IQ League. Program Objectives & Performances Resources Needed: 1) Funding—to maintain the following resources listed 2) Staff—Executive Director& Fiscal Administrative Coordinator 3)Volunteers—Board of Directors,various mentors 4) Facilities—KOYD Headquarters located at 67 Keokea Loop, Palekai (Breakwall), maintenance associated with continued use of site 5) Equipment—Robotics equipment 6) Supplies—Robotics supplies, safety gear, snacks for youth 7)Travel—air travel and accommodations for on or off island competitions or professional development opportunities Major Activities to be Completed: 1) Youth are trained in VEX IQ Robotics on a weekly basis 2) Experiences in this program are highlighted in their Individual Student Success Plans (ISSP). 3) 5Cs value system is introduced and implemented throughout program. Outputs to be Completed:We project: 1)At least 20 youth supported 2) 2 volunteers+approx. 350 hours served 3) Participation in robotics events in all qualified age groups/categories Measurable Outcomes: For the program activities we plan to implement in 2022-23, we are confident that the outcomes of these efforts will have tremendous effect in the long-term capacities of our participants in reflecting: Keaukaha One Youth Development-VEX IQ Robotics Program I Page 2 1) Excellence pursued in life-long learning 2) Happier, healthier communities 3) Dynamic leaders for Hawaii's future Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Keaukaha One Youth Development-VEX IQ Robotics Program I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Keaukaha One Youth Development Program Name: VEX IQ Robotics Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 15000.00 pending pending Applicant organizational budget: 25000.00 8000.00 800100 Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): HCF-CHANGE 2000.00 pending pending Total Cash Income 17000.00 pending pending IN-KIND CONTRIBUTION Anticipated Committed Total 8000.00 8000.00 8000.00 Total In-Kind Contributions 8000.00 8000.00 8000.00 TOTAL PROGRAM INCOME 25000.00 8000.00 8000.00 Appendix D--Budget Sheets (Page 2 of 2) !Project Budget Form: Expenses County of Hawari • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 'Organization Name: Keaukaha One Youth Development Program Name: VEX IQ Robotics Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages Professional Fees 5000.00 5000.00 10000.00 Operations Supplies 5000.00 2000.00 3000.00 10000.00 Equipment 5000.00 5000.00 SUBTOTAL 15000.00 2000.00 8000.00 25000.00 TOTAL PROGRAM BUDGET 15000.00 2000.00 8000.00 25000.00 County of Hawai'i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth. Development Program Name: VEX IQ Robotics Program 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: VEX ICS Robotics Program Certsflcati s n 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-forrnsj 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 inthe application,except for a maximum ten percent(10%)for administrative and overhead. costs.Any funds unused by June 30,2023 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. r1 20'22 Signature of Authorized Person Date Executive Director/President Title/Position of Authorized Person County of Hawai'i Nonprofit Grant Application FY 2022®23 Agency Name: Keaukaha One Youth Development Program Name: VEX IQ Robotics Program 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 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 ❑ 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/President) /!2012022 Signature of Authorized Person (specify title) Date x `, 4 (iczt tri ) 1/24,0/- 22._ Keaukaha One Youth Development Na Anela Kai (formerly known as Junior Lifeguarding Program) 147 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Keaukaha One Youth Development Contact Person: Naomi Ahu Contact Email: naomi.koyd.rise@gmail.com Contact Phone: 8087565859 Program Information Program Name: Na Anela Kai (formerly known as Junior Lifeguarding Program) Program Years in Operation: 3 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Kailua-Kona, Kalapana, Kea'au, Kurtistown, Leilani Estates, Mountain View, Nanawale Estates, Ninole, Orchidlands Estates, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki,Volcano, Wainaku Program Target Audience:Adolescence (12-17),Young Adulthood (18-39) Services/Activities Provided: Educational concerns, Culture and the arts, Public health and welfare of the people and the environment,Youth Amount Applying For: $25000 Keaukaha One Youth Development-Na Anela Kai (formerly known as Junior Lifeguarding Program)! Page 1 Program Details Organization Mission: KOYD enhances the development of Hawaiian leadership. As a Native Hawaiian organization, we have developed an indigenous framework that utilizes cultural practice and ocean- based activities to: (1) stress physical fitness; (2) instruct use and maintenance of ocean canoes; (3) excel in waterman competence; train youth as qualified crew for the lomakualani double-hulled sailing canoe; and (5) provide diverse out-of-school educational opportunities for lifelong learning. Program Overview: Na Anela Kai was designed to train our youth ages 12-17 in lifesaving water skills and to develop awareness of beach hazards and ocean conditions. Participants will become certified with First Aid and CPR techniques, while improving their health and fitness. Participation in the program will result in development of team building and leadership, rescue techniques such as CPR/AED/First Aid, quick/efficient emergency response, and improved physical ability in swimming, running, strength training, and endurance. Students who meet all certifications and training requirements will be eligible to compete in the annual Jr. Lifeguard Championships held on Oahu. Program Objectives & Performances Resources Needed: 1) Funding-to maintain the following resources listed 2) Staff—Executive Director& Fiscal Adminstrative Coordinator 3)Volunteers—Board of Directors,various mentors 4) Facilities—KOYD Headquarters located at 67 Keokea Loop, Palekai (Breakwall), maintenance associated with continued use of site 5) Equipment—lifeguarding equipment 6) Supplies—training/safety gear, snacks for youth 7)Travel—air travel and accommodations for on or off island professional development opportunities Major Activities to be Completed: 1)Youth are trained in lifesaving skills during certification courses offered quarterly and monthly meetings. 2) Experiences in this program are highlighted in their Individual Student Success Plans (ISSP). 3) 5Cs value system is introduced and implemented throughout program (commitment, character, compatibility, courage, and competence). Outputs to be Completed: We project: 1)At least 25 youth supported 2) 2 volunteers+approx. 350 hours served 3) Participation in all training/certification events Measurable Outcomes: For the program activities we plan to implement in 2022-23,we are confident that the outcomes of these efforts will have tremendous effect in the long-term capacities of our participants in reflecting: Keaukaha One Youth Development-Na Anela Kai (formerly known as Junior Lifeguarding Program)I Page 2 1) Excellence pursued in life-long learning 2) Happier, healthier communities 3) Dynamic leaders for Hawaii's future Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Keaukaha One Youth Development-Na Anela Kai (formerly known as Junior Lifeguarding Program)I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Keaukaha One Youth Development Program Name: Na Anela Kai (formerly known as Junior Lifeguarding Program) CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 25000.00 pending pending Applicant organizational budget: 30000.00 5000.00 5000.00 Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Hauoli Maui Loa Foundation 2500.00 2500.00 2500.00 Total Cash Income 27500.00 2500.00 2500.W IN-KIND CONTRIBUTION Anticipated Committed Total 2500.00 2500.00 2500.00 Total In-Kind Contributions 2500.00 2500.00 2500.00 TOTAL PROGRAM INCOME 30000.00 5000.00 5000.00 Appendix D--Budget Sheets (Page 2 of 2) 'Project Budget Form: Expenses `County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 :Organization Name: Keaukaha One Youth Development ............... .. :Program Name: Na Anela Kai (formerly known as Junior Lifeguarding Program) Nonprofit Other Cash In-Kind. Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages Professional Fees 5000.00 2500.00 7500.00 Operations - Supplies 10000.00 2500.00 12500.00 Equipment 10000.00 10000.00 SUBTOTAL 25000.00 2500.00 2500.00 30000.00 TOTAL PROGRAM BUDGET 25000.00 2500.00 2500.00 30000.00 County of Hawai6 i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: Na Anela Kai formerl known as unior Life_uardin_ �.:. . . : ..: ��iiafac �a= of9�nde0~st��dal (Page g Program) g ( g 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 Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to htt : vendors.ehawaii. ov 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 time! corn•tete and accurate .ear-end re.•ort usin• the tem'late •rovided will impact the evaluation of your program's or agency's future funding requests. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: Na Anela Kai formerl known as unior Life.uardin Program) 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,$50,000 each occurrence) must be provided to the County of Hawaii Finance Department,which specifically and explicitly indicates that the County of Hawai`i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation for a minimum of one year or until a written report is submitted to,and accepted by,the council. (we) understand there is no provision for further notification to submit the final report Information and instructions are available at htt•; www.hawaiicount..:ov fn-non•rofit-.rant-forms on or about May 30 of the year the final report is due. As part of this application,you acknowledge that any funds awarded will be restricted for the purposes stated in the application,except for a maximum ten percent (10%)for administrative and overhead costs.Any funds unused by June 30,2023 must be returned to the County of Hawai`i with the final report. Failure to return these unds in a time/ manner will im.act the evaluation a our wenc 's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital improvements(Cost of Construction,materials, insurance or securities)on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you•have read and understood these requirements. i 7/ 22— Sign ure of Authorized Person Date Executive Director/President Title/Position of Authorized Person County of Hawai'i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: Na Anela Kai (formerly known as junior Lifeguarding ,,a..ar,'an. a .ee•*:a ,-"$,,,cx,. exssseM ... .: a. : „ as e,,,, .wsae.ra., rS -"s rogram (I r GAM MON CONFLOCT NCL :SURE FIR r , Please disclose anyconflicts orpotential conflicts of interest that anyboard member,officer, 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 M- ember or members of the Council Li Staff appointed by a member of the Council ❑ T- he Mayor ❑ The Managing Director n The Director of Finance (l 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: IV( If no conflicts exist,check here. (Executive Director/President) i/27 tc)02_2 6 r/t/t4"-------j Signature of Authorized Person (specify title) Date 004/MMAJA__/ (St ) 1/2.i( 7022- Keaukaha One Youth Development Temple Children Collaboration Project 148 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Keaukaha One Youth Development Contact Person: Naomi Ahu Contact Email: naomi.koyd.rise@gmail.com Contact Phone: 8087565859 Program Information Program Name:Temple Children Collaboration Project Program Years in Operation:4 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Kailua-Kona, Kalapana, Kea'au, Kurtistown, Leilani Estates, Mountain View, Nanawale Estates, Ninole, Orchidlands Estates, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki,Volcano, Wainaku Program Target Audience:School Age (6-11), Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts, Public health and welfare of the people and the environment,Youth,Aged Amount Applying For: $25000 Keaukaha One Youth Development-Temple Children Collaboration Project! Page 1 Program Details Organization Mission: KOYD enhances the development of Hawaiian leadership.As a Native Hawaiian organization,we have developed an indigenous framework that utilizes cultural practice and ocean- based activities to: (1) stress physical fitness; (2) instruct use and maintenance of ocean canoes; (3) excel in waterman competence;train youth as qualified crew for the lomakualani double-hulled sailing canoe; and (5) provide diverse out-of-school educational opportunities for lifelong learning. Program Overview:The Temple Children Collaboration Project was designed to provide our youth with opportunities to participate in community revitalization efforts through enriching experiences involving art, culture, food, and music. It will also engage our youth in bridging these arts and the local community as they share diverse cultural learning experiences.Temple Children's network of artists and project participants will collaborate to share understanding for place and how that contributes to inspiration in the genres of style and artistry that is created as a final product. Program Objectives & Performances Resources Needed: 1) Funding—to maintain the following resources listed 2) Staff—Executive Director& Fiscal Adminstrative Coordinator 3) Volunteers—Board of Directors,various mentors/artists 4) Facilities—KOYD Headquarters located at 67 Keokea Loop, Palekai (Breakwall), maintenance associated with continued use of site - 5) Equipment—equipment to support mural events 6) Supplies—art supplies, safety gear, snacks for youth 7) Travel—air travel and accommodations for incoming artists Major Activities to be Completed: 1) Youth participate in one mural event and continued beautification efforts at Palekai. 2) Experiences in this program are highlighted in their Individual Student Success Plans (ISSP). 3) 5Cs value system is introduced and implemented throughout all program activities (commitment, character, compatibility, courage, and competence) Outputs to be Completed:We project: 1) 20 youth supported 2) 10 volunteers+approx. 350 hours served 3) Participation in all mural/beautification events Measurable Outcomes: For the program activities we plan to implement in 2022-23,we are confident that the outcomes of these efforts will have tremendous effect in the long-term capacities of our participants in reflecting: 1) Excellence pursued in life-long learning 2) Happier, healthier communities Keaukaha One Youth Development-Temple Children Collaboration Project' Page 2 3) Dynamic leaders for Hawaii's future Attachments Program Budget(Income & Expenses) Certificate of Understanding Conflict Disclosure Keaukaha One Youth Development-Temple Children Collaboration Project! Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Keaukaha One Youth Development Program Name: Temple Children Collaboration Project CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 25000.00 pending pending Applicant organizational budget: 40000.00 15000.00 15000.00 Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Total Cash Income 25000.00 0.00 0.00 IN-KIND CONTRIBUTION Anticipated Committed Total 15 000.00 15000.00 15000.00 Total In-Kind Contributions 15000.00 15000.00 15000.00 TOTAL PROGRAM INCOME 40000.00 15000.00 15000.00 Appendix D--Budget Sheets (Page 2 of 2) ,Project Budget Form: Expenses !County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Keaukaha One Youth Development !Program Name: Temple Children Collaboration Project Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source . Contribution Grant Salary Wages Professional Fees 10000.00 5000.00 15000.00 Operations Supplies 5000.00 5000.00 10000.00 Equipment 5000.00 5000.00 10000.00 Travel 5000.00 5000.00 SUBTOTAL 25000.00 0.00 15000.00 40000.00 TOTAL PROGRAM BUDGET 25000.00 0.00 15000.00 40000.00 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: Temple Children Collaboration Project 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 goy, 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. County of flawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: Temple Children Collaboration Project Certification of Uderstandig (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 Department, which s specifically and explicitly indicates that the Countyof Hawaii is an Financep Y p Y 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, 2023 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. ft27f'Z- Signature of Authorized Person Date Executive Director/President Title/Position of Authorized Person 3 - ) rig?fq,o2,2_ County ofHawaii Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: Temple Children Collaboration Project (calS IXNIZATMN CS FUC I I SCL SU PI F R v 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): (l Member or members of the Council n Staff appointed by a member of the Council I I The Mayor 1 1 The Managing Director The Director of Finance U 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: t 1 If no conflicts exist,check here. , - / (Executive Director/President) if 2-?/U`2f — Signature of Authorized Person (specify title) Date (S ) 1 fvifo Keaukaha One Youth Development Hui Kui Hao -Welder's Hui 149 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Keaukaha One Youth Development Contact Person: Naomi Ahu Contact Email: naomi.koyd.rise@gmail.com Contact Phone: 8087565859 Program Information Program Name: Hui Kui Hao -Welder's Hui Program Years in Operation: 0 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Kailua-Kona, Kalapana, Kea'au, Kurtistown, Leilani Estates, Mountain View, Nanawale Estates, Ninole, Orchidlands Estates, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki,Volcano, Wainaku Program Target Audience:Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts, Youth Amount Applying For: $50000 Keaukaha One Youth Development-Hui Kui Hao-Welder's Hui I Page 1 Program Details Organization Mission: KOYD enhances the development of Hawaiian leadership.As a Native Hawaiian organization,we have developed an indigenous framework that utilizes cultural practice and ocean- based activities to: (1) stress physical fitness;•(2) instruct use and maintenance of ocean canoes; (3) excel in waterman competence;train youth as qualified crew for the lomakualani double-hulled sailing canoe; and (5) provide diverse out-of-school educational opportunities for lifelong learning. Program Overview: KOYD is seeking funds to add a new program as a way to diversify educational opportunities for our participants. Hui Ku'i Hao is proposed to continue a legacy of a welding master Shannon Warfield who we lost last year due to colon cancer. Shannon was a structural steel contractor who mentored multiple students of KOYD in the steel construction trade industry. Shannon shared his passion and knowledge of welding and fabrication with a loyal group of steel workers who want to give back to our program and train more youth interested in the trade. Shannon Warfield is also the older brother and mentor of KOYD Executive Director, Dr. Keahi Warfield. Program Objectives & Performances Resources Needed: 1) Funding—to maintain the following resources listed 2) Staff—Executive Director& Fiscal Adminstrative Coordinator 3)Volunteers—Board of Directors,various mentors 4) Facilities—KOYD Headquarters located at 67 Keokea Loop, Palekai (Breakwall), maintenance associated with continued use of site 5) Equipment—welding equipment and rentals, computers 6)Technology—software to build plans for welding projects 7) Supplies—other welding supplies, snacks for youth 8)Travel—air travel and accommodations to support youth exposure and professional development opportunities Major Activities to be Completed: 1) Youth participants are exposed to welding and steel fabrication and engage in activities to promote learning and application within the trade. 2) . Youth develop Individual Student Success Plans (ISSP) based on experience and exposure to educational opportunities 3) 5Cs value system is introduced and implemented throughout all program activities (commitment, character, compatibility, courage, and competence). Outputs to be Completed:We project: 1) At least 20 youth supported 2) 10 volunteers+approx. 2500 hours service 3) Participation in all welding and steel fabrication activities/events Keaukaha One Youth Development-Hui Kui Hao-Welders Hui I Page 2 Measurable Outcomes: For the program activities we plan to implement in 2022-23, we are confident that the outcomes of these efforts will have tremendous effect in the long-term capacities of our participants in reflecting: 1) Excellence pursued in life-long learning 2) Happier, healthier communities 3) Dynamic leaders for Hawaii's future Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Keaukaha One Youth Development-Hui Kui Hao-Welder's Hui l Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Keaukaha One Youth Development Program Name: Hui Kui Hao -Welders Hui CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50000.00 pending pending Applicant organizational budget: 100000.00 50000.00 50000.00 Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Total Cash Income 50000.00 0.00 0.00 IN-KIND CONTRIBUTION Anticipated Committed Total 50000.00 50000.00 50000.00 Total In-Kind Contributions 50000.00 50000.00 50000.00 TOTAL PROGRAM INCOME 100000.00 50000.00 50000.00 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Keaukaha One Youth Development Program Name: Hui Kui Hao - Welders Hui Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 15000.00 30000.00 45000.00 Professional Fees Operations Supplies 10000.00 5000.00 15000.00 Equipment 25000.00 15000.00 40000.00 SUBTOTAL 50000.00 0.00 50000.00 100000.00 TOTAL PROGRAM BUDGET 50000.00 0.00 50000.00 100000.00 County of Hawai'i Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: Hui Kui Hao - Welders Hui Certification of Undersea =ding (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 andability 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.ehawali.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. ..-_.._.._. ... County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name; Keaukaha One Youth Development Program Name; Hui Kui Hao - Welders Hui Certification if Ui de9'standin (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.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, 2023 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. (227/20 2/— Signature of Authorized Person Date Executive Director/President Title/Position of Authorized Person F` 1 1 ►I -I Cis til'I r ) I t27j'z�— County ofHawaii Nonprofit Grant Application FY 2022-23 Agency Name: Keaukaha One Youth Development Program Name: Hui Kui Hao - Welders Hui DZATO ! N C•NFUUCT DISCLOSURE F•R Please disclose any conflicts orotential conflicts of interest st that any board member,officer,icer, 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 0 Staff appointed by a member of the Council 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: If no conflicts exist,check here. A (Executive Director/President) 1(27(0,022— Signature oSignature of Authorized Person (specify title) Date I C VetiWrYilbp l/27/ 22-- Kohala Animal Relocation and Education Service (KARES) Veterinary Care and Spay/Neuter for Hawaii Island Family Pets 150 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Kohala Animal Relocation and Education Service (KARES) Contact Person: Elaine ANDERSON,Vice President Contact Email: eorenberg@gmail.com Contact Phone: 165-038-05819 Program Information Program Name:Veterinary Care and Spay/Neuter for Hawaii Island Family Pets Program Years in Operation: 12 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Captain Cook, Hawi, Hilo, Holualoa, Honoka'a, Kailua-Kona, Kapa'au, Kea'au, Kealakekua, Kuki'o, Kurtistown, Miloli'i, Mountain View, Ninole, Ocean View, Pahoa, PuakO, Waikoloa Village, Waimea Program Target Audience:Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment,Aged,Victims of Health or Social Crises Amount Applying For: $30000 Kohala Animal Relocation and Education Service(KARES)-Veterinary Care and Spay/Neuter for Hawaii Island Family Pets I Page 1 Program Details Organization Mission: KARES since 2009 has been dedicated to rescue and relocate abused, abandoned and stray domestic animals,to provide basic medical care for rescued and owned pets,to provide temporary housing for them through our foster care network and to facilitate adoptions into permanent homes. KARES focuses on assisting residents without financial resources to provide free medical care and spay/neuter surgeries for their pets, especially the elderly,veterans and economically-troubled residents. Program Overview: KARES program will provide veterinary care for companion pets focusing on helping low income residents with limited financial resources; all services will be free to pet owners.This program is one of compassion to preserve the Hawaiian family which often includes one or more pets. At least 800-1000 residents will directly benefit with improved health of their companion pets, which translates to improved general health of all island pets. KARES will respond to appeals for medical/surgical pet care and intervene to expedite emergency care for seriously ill or injured pets as we have done for the past 11 years. Basic vet services will involve wound &orthopedic repairs, lab tests, dental care, treatments for external & internal parasites, skin conditions, tumors, eye issues, vaccines, pain management and pet hospice. KARES will conduct monthly free spay/neuter(S/N) clinics in community locations for dogs &cats to control & reduce the overpopulation of pets on the island. Program Objectives & Performances Resources Needed: Funding is essential; KARES volunteers effectively do as much as possible to help Hawaii residents, depending on the availability of money. Guaranteed resources: availability of licensed veterinarians (2-3) and vet technicians (2);vet hospital services; KARES volunteers (10) experienced in rescue of ill/injured animals and compassionate handling of pet owners' concerns and assistance in clinics (5); surgical spay packs, portable surgery tables, anesthesia equipment for spay/neuter clinics; kennels and carrier cages; KARES'van for pet transport. Renewable resources needed: medical supplies and drugs; disposable clinic supplies and anesthesia gases; ID microchips;telephone and computer service; monthly rental space for hosted community S/N clinics; gasoline and van repairs for pet transport; additional volunteers recruited from community; collaboration with Hawaii island animal welfare groups to identify residents in need of assistance; secure pet foster care homes as needed. Major Activities to be Completed: KARES volunteers will publicize, organize and conduct monthly spay/neuter(S/N) surgery clinics in community centers; prepare sterilized surgery packs and anesthesia equipment, assist pre-and post-surgery and transport pets to and from clinics, as needed.Veterinarians and vet technicians are contracted by KARES for lowest cost S/N,fee-for service in clinics. ID microchips are provided for pet return in case of loss.The goal is to S/N every pet in a household. KARES phone line alerts, and the outreach coordinator will triage requests for general or emergency medical/surgical care.Volunteers and KARES Board members will be involved in pet rescue and facilitate Kohala Animal Relocation and Education Service(KARES)-Veterinary Care and Spay/Neuter for Hawaii Island Family Pets I Page 2 immediate care with 4 veterinary centers that will accept emergency patients transported by KARES or pet owner. KARES will financially assist pet owners with medical services when they are unable to pay the vet, and work with social service agencies to help pets of the homeless,veterans, the elderly and those in hospice. Outputs to be Completed:At least 850-1000 families and their pets will be supported over 12 months: "' 500 for canine and feline spay/neuter(S/N) procedures; "400 for basic medical services, and—50 for extensive emergency medical/surgical care. KARES will dedicate 10 volunteers, a minimum of 1,500- 1,800 unpaid man-hours to community outreach, implementation of program services, and transporting animals to S/N clinics and veterinary appointments, and at least 5 assisting in each monthly S/N clinic. KARES will have under agreement 2-3 veterinarians providing low-cost,fee for service (and pro bono in some cases) S/N surgeries, plus 2 vet technicians for S/N clinics. Private veterinary hospitals (Kona, Pahoa, Kapa'au, and Waimea) will support KARES with emergency pet services on an agreed lower cost basis. KARES will arrange experienced foster care providers for pet rehabilitation as needed when families are unable to do so. Measurable Outcomes: A goal is to enhance the bond between humans and animals,to educate and engage the community to promote responsible pet ownership and to facilitate the humane control of the pet population with spay& neuter(S/N) of all family pets. Pet population control will reduce damage to property, livestock, personal injury& nuisance reports caused by intact stray&feral dogs. Families will not be forced to surrender, abandon or euthanize beloved pets because they cannot cover the veterinary fees for serious illnesses, injuries or emergences. Health status of family pets will be improved by availability of free basic wellness and medical/surgical care. KARES anticipates helping at least 500 residents with S/N surgeries for dogs (and cats) owned by economically-troubled residents and elderly people living on modest or fixed incomes; many will have more than one pet. Neutering of 450 dogs will prevent the birth unplanned or unwanted litters; minimum of 1,800-2,400 pups (4-6 per litter). Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Kohala Animal Relocation and Education Service(KARES)-Veterinary Care and Spay/Neuter for Hawaii Island Family Pets I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)–Fiscal Year 2022-2023 Organization Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Veterinary Care and Spay/Neuter for Hawaii Island Family Pets CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $30,000 $30 000 Applicant organizational budget: — — Individual contributions $129,510 $129,510 Membership fees -_- Earned income --- --- -- Current cash assets --- -- —' Other funding sources(list below): Bissell Pet Foundation ---- $4,990 $4,990 Petco Love Foundation $9,000 $9,000 X Foundation(to remain anonymous) $10,000 --- $10,000 Total Cash Income IN-KIND CONTRIBUTION Anticipated Committed Total Volunteer services and supplies donations $10,000 -- $10,000 Subtotal $188,510 $4,990 $193,500 Total In-Kind Contributions TOTAL PROGRAM INCOME $193,500 Appendix 0--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Veterinary Care and Spay/Neuter for Hawaii Island Family Pets Nonprofit Other Cash In-Kind (Waiwai) Expense Description TOTAL Source Contribution Grant Salary Wages 0 0 0 0 Professional Fees $30,000 $129,000 0 $159,000* Operations 0 0 0 0 Supplies $10,000 0 $10,000** Equipment $1,300 0 $1,300*** Van expenses-gas&repairs(animal transport for vet services $12,000 0 $12,000 Facility rental fees for spay/neuter clinics, 12 clinics $1,200 0 $1,200 Volunteer services and donated supplies $10,000 $10,000 Pass through veterinary fees for spay&neuter clinics, medical or surgical services for ill/or injured pets • Disposable supplies for monthly spay/neuter clinics • Microchips tot neutered pets to assure return if lost MI= SUBTOTAL $30,000 $153,500 $10,000 $193,500 TOTAL PROGRAM BUDGET $193,500 County of��2wai`i Nonprofit Grant Application FY 2022-23 /~ ' ��^ ��1 Agency Name: / w1 / �� -�� d-^/ feli4tA-�vn �e��ez L��l� � ^ � ^ ^` ' '^~'' '~ ' '' ^ '- ' '~-'' ' vy' � -/" ?r` �m ��` 1~l'O��l'a�z� /�.��e: K�7r/ /nm/'�' � ura arm �i/"~`�vv*, /^~^ ' //r"v°"~-- ^-~'�^~° , ^`,/''" /'�Y� ' Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirementsgrant 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, gutohtt*:','vendors.ehavva||.:pv complete the easy step-by-5tep 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. County of Hawai'i Nonprofit Grant Application FY 2022-23 Agency Name: /P/1A/h kiinn//Q1/07:47irpra 'nit r,t/fee 669/ Ec) Program Name: lidioniir CAVe am( Skt AIM 1111409%I IC/Atm' b/s' Certification 4 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 fittp://www.hawaiicountv.p,oviin-non rofitant-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, 2023 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. /11/1 /2//0/2_02, Signature of Authorized Person Date Pi/IS—fife n 74; /if/?Ez\E Title/Position of Authorized Person S alea (aim Apoads) uosiad paz9otonv 10 aini.eals (jr"C2Z11 01Z/ /142e)7716/7; 1 1, T2/?,1, / x •alaq >pap lsva spw.uoD OU j.0 SPBLIOD leRualod JO Sp1111103 Aue `aoualeadde JO pej. ut `p!oAe o samseaw uoileSmw lie pue Aue Apads aseaid .Apsnpu!un o iniaua6 &Immo swfauaq o pasoddo so innomipul atpo aupLiam 5-411auaq loaqp aigninsnaui .gnsai iflA4 innmpui UD Aq ua>inl uopan Amqnqoid ingungqns 0:se paupp s!Isamu'40 pli4Uo3 lasunop uon.elothop Aindaa e JO lasuno3 uolleiodaop luelsIssv liasunop uogamdioD aqi apueuu Jo_imam DIU fl JOPeJIG 2upeuen aqi fl JoAetAi aqi ipunoD eq o Jaqwaw e Aq palwodde jlelS [1 ipuno3 aqlJO sJaquiaw JO JaqwatAi I :(Aidde lag lie)pap)Supotiol. Aue imnik`d!qsuon.eial mule}Aue Swpniow ' SeJaTU JO mom len.ualod AO 10%1103 e aneq Ae :NOWS0d :MANN •s4spra plljuo3 n JalpagiV1 /o ssaipitobai 'pubis aq snw sunoi ainsopsm 'asopsw Ann}o papaau se aleaqdnp aseaid •paplwqns aq o spaau papaqo uoRdo„ls!xa splquop oN„ eqi q4M`uonezweam aq Joj. LuJoi.auo 1.s!xa sp!ijuop ou J -papaau piguoo e to.vA uosiad lad tliiO4 auo .pasopsw aq o paau Anoiaq pals!! asoqi./quo 1,!emeH jo Aluno3 gliAA aAeq Aew uopezwealo anoA JO l.topaa!p `Japii_j.o`Jaqwaw ping Aue 1.eqsalam Jo spw.uoD iendalod JO spw.uo3 Aue asopsip aspaid 1A1S03 3ilS013SICI .13113NOD NOI1VZINVDHO hpwY-7, voi/sg_E /molly/ 1 04 wp/y/ r yvet ;./iop in# .aureN tual odd (30.?ita) 0,ays /14,74p3, yLibr u,1/ 7O1 ' /vi.wvy If/ yo/y :awEN ADua2v EZ-ZZOZ Ad uogeoriddy 1u-up WoiduoM mum-ell jo iClunop Ku'ikahi Mediation Center Community Mediation & Facilitation Services 155 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Ku'ikahi Mediation Center Contact Person:Julie Mitchell Contact Email:julie@hawaiimediation.org Contact Phone: 808-935-7844 ext. 5 Program Information Program Name: Community Mediation & Facilitation Services Program Years in Operation: 39 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Honoka'a, Kalapana, Kanaihiku Village, Kapoho, Kaueleau, Kea'au, Keokea, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Mountain View, Na'alehu, Nanawale Estates, NInole, 'O'okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Pualaa, 'Umikoa,Volcano, Wainaku, Wai'ohinu,Weloka Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment, Aged,Victims of Crimes, Victims of Health or Social Crises Amount Applying For: $15000 Ku'ikahi Mediation Center-Community Mediation & Facilitation Services I Page 1 Program Details Organization Mission: 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 Program Overview: Ku'ikahi is the sole nonprofit mediation center serving East Hawai'i. We help 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 39-year track record providing mediation, facilitation, and training to promote "Finding Solutions, Growing Peace" in the County of Hawaii. Mediation is an empowerment process that promotes self-determination in the face of life's most challenging situations: divorce, child custody, debt, eviction, and more. Mediated resolutions tend to be long lasting and help to improve relationships, promote understanding, and strengthen our community. Mediations are provided on an affordable sliding scale, with no one turned away for lack of funds. Between 50-60%of our mediation clients have annual household incomes of under$20,000 and are eligible for free services. Program Objectives & Performances Resources Needed: -Professionally trained volunteer mediators (who complete basic mediation training, apprenticeship program, continuing education) -Staff(case managers, administrative & program assistant, executive director) -Facilitators -Clients in conflict -Tried and true model for facilitative mediation -Office with 2 mediation rooms and 2 Zoom rooms -Agreement templates -Co-parenting workbooks and other useful forms -Software (DocuSign, Square, Zoom, etc.) -Partnership with the state's other mediation centers,judiciary, legal services providers, rental assistance providers, and other stakeholders -Funding Major Activities to be Completed: -Fielding inquiries -Client intakes and orientation to services -Mediation &facilitation scheduling Ku'ikahi Mediation Center-Community Mediation & Facilitation Services I Page 2 -Short mediation sessions (1 hour) held on site at the Hilo courthouse (paused during pandemic) -Regular mediation sessions (2-3 hours) held at our offices or on Zoom -Follow-up mediation sessions (if needed) -Crafting verbal and written agreements (interim, proposed, final) -Disposition letters to the appropriate court(if a court case) -Facilitations for small and large groups Outputs to be Completed:-500 mediation &facilitation cases opened -1,000 mediation &facilitation clients served (in cases closed) -275 mediation &facilitation sessions held -1,250 mediator volunteer hours donated -60%of mediated cases result in agreement mediation saved them time and/or money of clients felt / -95%of clients are satisfied with mediation Measurable Outcomes:-Short-Term: Participants seek understanding and self-determination through mediation &facilitation -Medium Term: Issues are resolved via agreement -Long Term: Agreements succeed over time CLIENT TESTIMONIALS "The mediators really helped our situation. We were able to come to an agreement which will be greatly beneficial for our communication and future." "The mediators were extremely helpful and mindful that this custody arrangement was sensitive and showed a level of professionalism that made it easy to converse our difficulties with full transparency. I would recommend...." "I was quite nervous about mediation and I have never had experienced an eviction mediation before. The mediator was completely professional, polite, and understanding to my situation... I can't thank her enough for her help." "I am very glad this resource was made available to me and I would not hesitate to recommend it to anyone in need of a safe and confidential place to resolve tenant/landlord disputes." Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Ku'ikahi Mediation Center-Community Mediation&Facilitation Services I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Ku'ikahi Mediation Center Program Name:Community Mediation & Facilitation Services CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 15,000 15,000 Applicant organizational budget: $89,000 Individual contributions $56,314 30,000 30,000 Membership fees Earned income Current cash assets Other funding sources (list below): Foundation/trust grants 84,000 $400,000 84,000 United Way contributions 5,000 5,000 Hawaii state & other county contracts 42,622 42,622 Program fees (mediation & facilitation) 31,000 31,000 Miscellaneous revenue 1,600 1,600 Special events revenue from fundraisers 40,000 40,000 Total Cash Income 219,222 30,000 249,222 IN-KIND CONTRIBUTION Anticipated Committed Total Professionally trained volunteer mediators 125,000 125,000 Total In-Kind Contributions 125,000 $0 125,000 TOTAL PROGRAM INCOME 344,4222 30,000 374,222 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses :'County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)- Fiscal Year 2022-2023 Organization Name:Ku'ikahi Mediation Center ;Program Name:Community Mediation & Facilitation Services Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 10,000 164,758 174,758 Professional Fees 0 5,000 5,000 Operations 5,000 59,964 64,964 Supplies 0 4,500 4,500 Equipment 0 167 167 Printing, Advertising, and Media 0 4,400 4,400 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 IN-KIND CONTRIBUTION Professionally trained volunteer mediators 125,000 125,000 SUBTOTAL 15,000 234,222 125,000 374,222 TOTAL PROGRAM BUDGET 15,000 234,222 125,000 374,222 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: e Program Name >" Fel c-L-A (-6 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.r ov, 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. County of fiawai`f Nonprofit Grant Application FY 2022-23 Agency Name: \Z'c'€ to 1 t. Program Name: 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:J www.hawaiicount ,,ovlfn-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, 2023 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. ! ( ll O Signature of Authorized Person Date Title/Position of Authorized Person County of Hawai`:i Nonprofit Grant Application FY 2022-23 Agency Name: V M 6. 1 i y• ?_r Program Name: (\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): Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance [l 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 on 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: KJ If no conflicts exist, check here. / • ,sy Sigrf'ture of Authorized Person (specify title) Date D :et:.0-1),-. Ku'ikahi Mediation Center Conflict Prevention & Resolution Education 156 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Ku'ikahi Mediation Center Contact Person:Julie Mitchell Contact Email:julie@hawaiimediation.org Contact Phone: 808-935-7844 ext. 5 Program Information Program Name: Conflict Prevention & Resolution Education Program Years in Operation: 39 for adult education &7 for youth education Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Honoka'a, Kalapana, Kanaihiku Village, Kapoho, Kaueleau, Kea'au, Keokea, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Mountain View, Na'alehu, Nanawale Estates, Ninole, 'O'okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Pualaa, 'Umikoa,Volcano, Wainaku, Wai`ohinu, Weloka Program Target Audience:School Age (6-11),Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Needs of the poor, Public health and welfare of the people and the environment, Youth,Victims of Health or Social Crises Amount Applying For: $15000 Ku'ikahi Mediation Center-Conflict Prevention& Resolution Education I Page 1 Program Details Organization Mission: 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 Program Overview: Ku'ikahi is the sole nonprofit mediation center serving East Hawai'i. We help 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 39-year track record providing mediation, facilitation, and training to promote "Finding Solutions, Growing Peace" in the County of Hawai'i. The Conflict Prevention & Resolution Education program serves the public, private, and non-profit sectors. Unique opportunities include: 1) "Free Brown Bag Lunch Series" of monthly talks, 2) public workshops in communication and conflict management (needs-based scholarships available), 3) private trainings for groups, organizations, businesses, etc.,4)free in-house continuing education for volunteer mediators; and 5)free peer mediation training for school students. During COVID,these programs are mostly via Zoom. Program Objectives & Performances Resources Needed:-Staff(program coordinator, administrative & program assistant, executive director) -Trainers and presenters -Adult and youth program attendees -School partners -Curriculum that promotes conflict prevention and resolution techniques and skills development -Program supplies, manuals, and other training materials -Funding Major Activities to be Completed:-Strategic programming -Community workshops/trainings -Brown bag lunch talks -Basic mediation training (graduates may elect to become apprentice mediators and go on to help numerous needy clients) -Coordinating with school personnel and providing program support -School presentations for staff/faculty -Peer mediation &conflict resolution for kids trainings YOUTH TESTIMONIAL Ku'ikahi Mediation Center-Conflict Prevention &Resolution Education I Page 2 After a Ku'ikahi training on the difference between passive, aggressive, and assertive communication, a middle school girl wrote, "What inspired me... is that we should all be more assertive people because if we don't speak up and share our ideas,we will be silenced and we won't be able to stand up for anything that is immoral and wrong. We also won't learn confidence or self-respect, because we need these things to be able to get ahead in life and to have a healthy state of mind. Besides, some of us have ideas that can change the world and if we don't share them, then who will?" Outputs to be Completed:ADULT EDUCATION p P -12 free brown bag lunch talks held -360 brown bag lunch attendees served -95%of brown bag lunch talk attendees report learning something new& useful -8 trainings &workshops held -160 training &workshop attendees served -95%of training &workshop attendees report learning something new& useful YOUTH EDUCATION -3 schools participating -6 peer mediation &conflict resolution for kids trainings held -90 youth trained in peer mediation & conflict resolution for kids -50%changed the way they handle conflict in their own life -60%of students and faculty/staff who felt peer mediation helped their school climate -75%of youth trained who know how to help peers resolve conflicts at school year-end -90%of faculty/staff who are satisfied with the program at school year-end Measurable Outcomes:ADULT EDUCATION -Short-Term: Participants learn strategies and tools to communicate, collaborate, and transform conflict -Medium Term:Techniques are practiced and utilized -Long Term: Families, workplaces, schools, other institutions, etc.function better due to applied learning YOUTH EDUCATION -Short-Term: Students learn mediation skills -Medium Term: Students become peer mediators and conduct mediations -Long Term: School cultures promote self-determination through mediation ADULT TESTIMONIAL "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!" Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Ku'ikahi Mediation Center-Conflict Prevention & Resolution Education I Page 3 Ku'ikahi Mediation Center-Conflict Prevention& Resolution Education I Page 4 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Ku'ikahi Mediation Center Program Name:Conflict Prevention & Resolution Education CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 15,000 15,000 Applicant organizational budget: $89,000 Individual contributions $56,314 10,000 10,000 Membership fees Earned income Current cash assets Other funding sources (list below): Foundation/trust grants 2,500 7,500 10,000 United Way contributions 3,000 3,000 Hawaii state &other county contracts $40,000 $40,000 Program fees (trainings & workshops - public) 10,000 10,000 Program fees (trainings &workshops - private) 10,000 10,000 Special events revenue from fundraisers 20,000 20,000 Total Cash Income 60,500 17,500 78,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME 60,500 17,500 78,000 Appendix D--Budget Sheets (Page 2 of 2) ,Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 'Organization Name:Ku'ikahi Mediation Center Program Name:Conflict Prevention & Resolution Education Nonprofit Other Cash In-Kind. Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 10,000 50,000 60,000 Professional Fees 5,000 5,000 10,000 Operations 0 7,000 7,000. Supplies 0 1,000 1,000 Equipment 0 167 167 Printing, Advertising, and Media 0 4,400 4,400 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 15,000 63,000 0 78,000 TOTAL PROGRAM BUDGET 15,000 63,000 0 78,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: 4:; �..� t..a� fF.e_ct� v � ..z ;: ` Program Name: C IS..{ �' ..�j .�w t'. �.s . 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 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. County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: ' tfee , - . c- 1 -ek.� �. : .� -1..< -� Program Name: ( A 4 C^.. tw. , ..w _ � gres-0 .,:f . , w; ` , :.-.,;,-� 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 j/www.hawaiicounty.gov/fn-nonprofit grant4orms/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, 2023 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. / ( /7 2-512-4- 2--?...._ Sighiature of Authorized Person Date Title/Position of Authorized Person County of ..awai`i. Nonprofit Grant Application FY 2022-23 Agency Name: • . 0.g .. <, .--t Program Name: ( ( i k :. &"? r .w ORGANIZATION LIQ 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. Signat re of Authorized Person (specify title) Date La'i'opua 2020 Ho'okahua--La'i'opua 2020/Palamanui Culinary Project 158 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: La'i`opua 2020 Contact Person: Kawehi Inaba, Executive Director Contact Email: kawehi.inaba@laiopua.org Contact Phone: 808-327-1221 Program Information Program Name: Ho`okahua--La'i'opua 2020/Palamanui Culinary Project Program Years in Operation: 1 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kuki'o, Kealakehe Program Target Audience:Young Adulthood (18-39), Middle Adulthood'(40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Needs of the poor, Public health and welfare of the people and the environment Amount Applying For: $20000 La`i`opua 2020-Ho'okahua--La'i'opua 2020/Palamanui Culinary Project I Page 1 Program Details Organization Mission: La'i'opua 2020 is a non-profit organization formed in 2006 by community members who wished to ensure a'warm and welcoming center for those transitioning into the surrounding DHHL Villages of La'i'opua. Its mission is"to provide social, recreational,vocational, economical, educational and cultural opportunities as well as infrastructure to the communities of the Kealakehe Ahupua'a. It is a place for pilina (building relationships) and a pu'uhonua (place of comfort, peace and safety)." Program Overview: L2020's GIA request for FY 2023 is a project of its Ho'okahua or Workforce Development Program. A collaboration between Hawai'i Community College's Palamanui campus and L2020, the project is designed as a cohort learning experience for post secondary adults who wish to explore a non-credit basic culinary skills curriculum focused on working in a commercial kitchen including food handling and safety requirements, menu creation, learning about and utilizing healthy local foods, equipment use and care, and knife skills. Cohorts will be guided in utilizing the L2020 commercial kitchen to create pre-ordered/pre-cooked family style take-out entrees for sale to area residents at a reasonable price at the end-of-course Ho'ike. Each haumana will receive a Certificate of Completion from the collaboration, will complete a CHANGE-based assessment, and will participate in a 3 month follow-up survey from L2020 to mark progress in achieving their post-project goals. Program Objectives & Performances Resources Needed: •Palamanui classroom space; •Professional culinary instructor hours; •Curriculum including food handling and safety certification, instruction in basics of commercial kitchens, equipment use and care, knife skills, menu preparation including traditional Hawaiian food, farm to table concepts, and in packaging for commercial sales; •La'i'Opua commercial kitchen use; • virtual learning devices--i.e. ipads/laptops •Covid-safe work environment; •Project/Kitchen Manager to support practice use of a L2020's commercial kitchen for meal preparation,food production and to support transition planning and implementation; 'Janitorial and event support for Wilkes; 'Supplies such as fresh foods from local sources for meal preparation,food prep supplies for haumana, take-out food containers and cutlery;virtual learning devices; •Professional marketing and social media consultant; •10%administrative indirect for bookkeeping, payroll, reports, data collection. La'i'opua 2020-Ho'okahua--La'i'opua 2020/Palamanui Culinary Project I Page 2 Major Activities to be Completed: •Cohorts attend night classes in basic and advanced kitchen instruction at HCC's Palamanui campus through a curriculum designed and taught by HCC's culinary instructor 3 nights per week for 4 weeks plus orientation week and Ho'ike week. •Cohorts receive food handling and safety training and certification. •Cohorts learn how to incorporate fresh, healthy, locally sourced foods into their menus. •Cohorts use their newly learned skills during the 5th week of the curriculum to prepare foods in the L2020 commercial kitchen for pre-ordered, pre-sold family-style entrees to be distributed as a part of their Ho'ike celebration meant to showcase the L2020/Palamanui Culinary Project and to recruit for both the next cohort and for Palamanui's academic and culinary programs. • Cohort members complete final assessments, plan, and implement individual workforce development goals. Outputs to be Completed: • 6 haumana are enrolled into 2 cohorts—one fall and one spring for a total of 12 per project year. • 12 haumana complete 30 hours of food service instruction at Palamanui campus culinary classroom for a total of 360 hours of culinary instruction. • 12 students receive 20 hours of"laboratory" in L2020 commercial kitchen usage for a total of 240 hours of Ho'ike meal preparation guidance. • 50 fresh family-style entrees for take-out purchase for are created by each cohort for a total of 100 commercially prepared and packaged meals distributed. • 12 haumana successfully complete the project goals and receive their Certificate of Completion by project's end. Measurable Outcomes: • 50% of haumana seek access to further post-secondary academic or other training opportunities as part of their follow-up plans (3 mo follow-up report). • 75%of haumana increase their earning potential (3 mo follow-up report). • 75%of haumana are in touch with other students in the program ( 3 month follow-up report). • 75%of haumana improve the health and nutrition of their family by introducing them to, using, and serving them meals made with locally sourced-foods (3 mo follow-up report). • The community is introduced to locally-sourced foods through the meals created for the project fund drive and featured at end-of-project showcases supporting local farmers, fishers and other food product producers. (record of sales) •Palamanui increases its presence in the DHHL/Kealakehe area and residents express interest in the academics or training programs offered. (end of year community survey). Attachments Program Budget(Income & Expenses) Certificate of Understanding La'i'opua 2020-Ho'okahua--La'i`opua 2020/Palamanui Culinary Project I Page 3 Conflict Disclosure La'i'opua 2020-Ho'okahua--La'i'opua 2020/Palamanui Culinary Project I Page 4 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: La'i'opua 2020 Program Name: Ho'okahua: L2020/Palamanui Culinary Project CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $ 20,000.00 $ 20,000.00 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Total Cash Income $ 20,000.00 $ 20,000.00 IN-KIND CONTRIBUTION Anticipated Committed Total Palamanui $ 2,000.00 $ 2,000.00 Total In-Kind Contributions $ 2,000.00 $ 2,000.00 TOTAL PROGRAM INCOME $ 20,000.00 S 22,000.00 Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)—Fiscal Year 2022-2023 Organization Name: La'i'Opua 2020 Program Name: Ho'okahua: L2020/Palamanui Culinary Project Nonprofit Expense Description (Waiwai) Other Cash In-Kind TOTAL Source Contribution Grant Salary Wages $ 2,580.00 $ 2,580.00 Professional Fees $ 9,400.00 $ 1,000.00 $ 10,400.00 Operations $ 700.00 $ 700.00 Supplies $ 5,320.00 $ 1,000.00 $ 6,320.00 Equipment Administrative Indirect @ 10% $ 2,000.00 $ 2,000.00 SUBTOTAL $ 20,000.00 $ 2,000.00 TOTAL PROGRAM BUDGET $ 20,000.00 $ 2,000.00 $ 22,000.00 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: La`i`opua 2020 Program Name: Ho`okahua: L2020/Palamanui Culinary Project 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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: La`i`opua 2020 Program Name: Ho`okahua: L2020/Palamanui Culinary Project 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 fromfuture 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 purposesstated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2023 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, insuranceor securities) on private properties unless otherwise authorized by law. By signing below,you are acknowledging that you have read and understood these requirements. January 24, 2021 Signature of Authorized Person Date Executive Director Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: La`i`opua 2020 Program Name: Ho`okahua: La`i`opua/Palamanui Culinary Project 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 duplicateas needed to fully disclose.All disclosure forms must be signed, regardless of whether a conflict exists.NAME: Kawehi Inaba POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship,with any of thefollowing (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 CorporationCounsel - 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 25, 2022 Signature of Authorized Person (specify title) Date Laupahoehoe Train Museum Honeybee Education Program Professional Development 159 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Laupahoehoe Train Museum Contact Person:Jenny Bach Contact Email:jennyabach@gmail.com Contact Phone: 808-640-0278 Program Information Program Name: Honeybee Education Program Professional Development Program Years in Operation: 10 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Hakalau, Hilo, Honomu, Honoka'a, Kailua-Kona, Laupahoehoe, Ninole, Pa'auilo, Pahoa,Waimea,Wainaku Program Target Audience:Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment, Youth Amount Applying For: $10000 Laupahoehoe Train Museum-Honeybee Education Program Professional Development I Page 1 Program Details Organization Mission: Laupahoehoe Train Museum opened in 1998 and celebrates the story of Hawaii's rich history of the Hamakua Coast.The purpose of LTM is to preserve, promote and protect the historical, cultural, educational, social, civic, and economic interests of North Hilo & Hamakua districts while highlighting the history of the railroads on the island.The 'Aina-based Education Program, developed by the Honeybee Education Program (HEP), offers programs to Hawaii Island's schools and island farmers. Program Overview:Our project focuses on community-based solutions to preserving honeybees, pollinators, and our food supply on Hawaii Island and is intended to benefit over 200 adults and farmers located in the County of Hawaii during the 21/22 fiscal year.This will include implementing two training/technical assistance programs that ultimately support food security and agriculture in Hawaii: two Beginning Beekeeping Workshops and seven Advanced Beekeeping Workshops/Training Courses. Honeybee Education Program provides free educational enrichment programs, training programs and professional development opportunities that addresses a community need that is not currently being met.The HEP has a strong base of support from beneficial partnerships, county and government organizations, and a large group of committed volunteers.This project directly benefits Hawaii Island communities, agriculture,food security, honey bees, local pollinators and their habitats. Program Objectives & Performances Resources Needed: Resources needed for the 2022-23 fiscal year include funding for wages and supplies for our educational outreach programs. Because we offer youth programs and adult workshops free of charge to Hawaii Island communities, we rely on grants and donations. Funding is needed to staff outreach programs. Instructors will offer programming to high school students,farmers and beekeepers, thus funding is needed for these positions. Supplies for training programs are also needed. Workshop materials and curriculum supplies will allow for outreach programs to deliver outcomes as stated in the proposal.To supplement county funds, all operation and equipment needs are funded through other cash sources and in-kind contributions. Major Activities to be Completed: Professional Development Opportunities for Hawaii's Beekeeping Program includes: 1. Beginning beekeeping program: We estimate to offer two free 30-hour workshops to train 30-40 Hawaii Island farmers (estimate). Workshops are geared to change behavior and attitudes of community and farmers. We anticipate 80%of participants will incorporate bees on their farms or homestead. 2.Advanced beekeeping program: Specialized instructors will provide training workshops needed to equip beekeepers with needed training to advance beekeeping in Hawaii. Seven 2-hour workshops to train up to 40 participants on advanced beekeeping practices.Workshops are geared to answer specific needs of local farmers and beekeepers. Laupahoehoe Train Museum-Honeybee Education Program Professional Development] Page 2 3. Youth will have access to a free beekeeping outreach program through: in-class presentations,field trips to local apiaries &secondary beekeeping elective classes. Over 200 students will benefit from this program objective. Outputs to be Completed: Our project focuses on community-based solutions to increasing food security on Hawaii Island and is intended to benefit over 200 youth, adults and farmers located in the County of Hawaii.This will include implementing an innovative education for youth and adults focused on 'Aina-Based learning,food security and agriculture in Hawaii. Our outputs include: -High School Elective Beekeeping Program (work with 2-4 schools per year),40-100 secondary students. -Beginning Beekeeping Workshops (two 4-week workshops), 30-40 Hawaii Island Farmers will benefit. -Advance Beekeeping Workshops/Professional Development for experienced beekeepers, 7 workshops to serve 40 beekeepers. Measurable Outcomes:We will measure the achievements and the effectiveness of our program by giving participants evaluations, document volunteer hours, etc. Participants and volunteers will fill out evaluations after workshops, community garden work days and youth programming. Evaluations will quantify our program's results using a numerical evaluation system. Data collection will be implemented to ultimately provide evidence that the program is reaching its goals and benefiting our underserved communities. -Evaluations (pre and post)will be given to all participants before and after workshops/event -Participation numbers documented -Volunteer hours documented -Workshop numbers and participants documented -Weight of produce/food grown and given away to community -Observation of attitudes changed or practices adopted -Increase participation or referrals Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Laupahoehoe Train Museum-Honeybee Education Program Professional Development Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Laupahoehoe Train Museum Program Name:The Honeybee Education Program: Professional Development Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $10,000 $10,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources(list below): Atherton Foundation 10,000 10,000 Kuki'o Foiundation 10,000 10,000 Total Cash Income 20,000 10,000 30,000 IN-KIND CONTRIBUTION Anticipated Committed Total Volunteer/Labor 6,000 6,000 Total In-Kind Contributions 6,000 6,000 TOTAL PROGRAM INCOME $26,000 $10,000 $36,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) Fiscal Year 2022-2023 Organization Name:Laupahoehoe Train Museum ;Program Name The Honeybee Education Program: Professional Development Program Nonprofit Other Cash In-Kind Expense Description (Waiwai.) TOTAL Source Contribution Grant Salary Wages $5,000 $9,000 $6,000 $20,000 Professional Fees Operations 5,000 5,000 Supplies 4,500 4,500 Equipment 3,000 3,000 Admin. Fees 500 3,000 3,500 SUBTOTAL 10,000 20,000 6,000 36,000 TOTAL PROGRAM BUDGET $10,000 $20,000 $6,000 $36,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: i—A ~7"4' rtzl" 414e**4.44 Prograrn Name: th.eicYt-E. c--DOr—ed-irzes4 Piet_VEss/6,../ 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. (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 Hawail, 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 dayafter 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 irn•art the evaluation o our •ro ram's or a enc 's uture unclin. re.uests. . • County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: LA-4621-14cielei-- m .s€'let"Ritei Program Name: hitwet aelF. aDocaot-to„,4 rot& zaretjapotp1/4" Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawari, I (we) understand that a current Certificate of Liability 41, ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Flawai`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 arrant funds received durin: the :rant •eriod must be refunded to Count 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 httpliwww.hawalicountv,govifn-non rant- rant-for s 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, 2023 must be returned to the County of Hewer'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 niay result ill 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 o(Authorized Person Date TiZ ENT Title/Position of Authorized Person County of I-Tawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Laupahoehoe Train Museum Program Name: Honeybee Education Program Professional Development 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 conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): fl Member or members of the Council n Staff appointed by a member of the Council The Mayor The Managing Director El The Director of Finance U 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: )L If no conflicts exist, check here. C . 1/31/22 1-7YZ Signature f Authorized Person (specify title) Date Laupahoehoe Train Museum Aina-based Education for Youth and Community 160 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Laupahoehoe Train Museum Contact Person:Jenny Bach Contact Email:jennyabach@gmail.com Contact Phone: 8086400278 Program Information Program Name:Aina-based Education for Youth and Community Program Years in Operation: 10 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Hawi, Hilo, Honomu, Honoka'a, Kailua-Kona, Laupahoehoe, Miloli'i, Ninole, `O'okala, Pa'auilo, Pahoa, Waimea Program Target Audience: Play Age (3-5), School Age (6-11),Adolescence (12-17),Young Adulthood (18- 39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth Amount Applying For: $15000 • Laupahoehoe Train Museum-Aina-based Education for Youth and Community l Page 1 Program Details Organization Mission: Laupahoehoe Train Museum opened in 1998 and celebrates the story of Hawaii's rich history of the Hamakua Coast.The purpose of LTM is to preserve, promote and protect the historical, cultural, educational, social, civic, and economic interests of North Hilo & Hamakua districts while highlighting the history of the railroads on the island.The 'Aina-based Education Program, developed by the Honeybee Education Program, offers programs to Hawaii Island's schools and island farmers. Program Overview:The Aina-Based Education, program of the Honeybee Education Program,will work with youth at the community garden sites to provide hands-on education, build community gardens and build food resiliency systems by providing agricultural training opportunities. HEP will provide free educational enrichment programs,training programs for youth in underserved communities. We will work with four community garden sites and provide programming at these sites. Youth will have access to 'Aina-Based Education and enrichment programs located at resilience hubs/community garden sites on Hawaii Island. Programs include planting traditional crops and canoe plants, nutrition education, medicine provided by plants, creating value-added products, gardening and beekeeping.This project directly benefits Hawaii Island communities and builds food security. Program Objectives & Performances Resources Needed: Resources needed for the 2022-23 fiscal year include securing funding for our educational outreach programs. Because we offer youth programs, adult workshops free of charge to Hawaii Island communities, we rely on grants and donations. Funding is needed to conduct outreach at sites. Educators/Instructors will offer programming to youth and families,thus funding is needed for these positions. Supplies for gardens and agricultural programs are also needed to maintain community gardens. Workshop materials and curriculum supplies will allow for outreach programs to deliver outcomes as stated in the proposal. Volunteers are needed in efforts to continue and grow community garden sites. Currently, each site has a committed group of volunteers that are involved. Maintaining these relationships and recruiting additional volunteers will assist program development. Major Activities to be Completed: 1.Youth will have access to 'Aina-Based Education and enrichment programs located at resilience hubs or community garden sites on Hawaii Island. Programs include planting traditional crops and canoe plants, nutrition education, medicine provided by plants, creating value-added products, gardening & beekeeping. 2. Four community gardens will be maintained and mentorship will be provided by the HEP & newly - formed 'Aina-Based Education Program.We expect over 400 families will benefit from this program. 3. Educational workshops will be delivered to 3 districts to over 320 community members. Workshops will focus on agriculture, gardening, nutrition and wellness. Workshops will be free to Hawaii residents. Laupahoehoe Train Museum-Aina-based Education for Youth and Community) Page 2 4. Promote community volunteerism at garden and youth program sites. We anticipate over 500 hours of volunteer time committed to this project. 5. Community garden sites will grow food and distribute to the community in efforts to encourage and promote self sufficiency. Outputs to be Completed: 1. 320+will attend the Community Garden/Food Security Workshops to increase food security. 2. 500 youth will have access to 'Aina-Based Education offered to community garden sites and located on Hawaii Island. Over 500 hours of free outreach activities will be delivered during project period 3. Mentor and assist Community Garden implementation-4 sites located in four districts 4. 500 hours of volunteer hours are expected to assist with community gardens and programming for youth 5. We expect over 1000 pounds of food will be grown at sites and distributed to families. The importance of agricultural programs such as this project ultimately provides long-term benefits for the Island community as we strive for food security and sustainability. Educational programming for youth is needed during after school. Adult farming and gardening workshops are needed more than ever to support families striving for sustainability, especially in rural locations. Measurable Outcomes:We will measure the achievements and the effectiveness of our program by giving participants evaluations, document volunteer hours, etc. Participants and volunteers will fill out evaluations after workshops, community garden work days and youth programming. Evaluations will quantify our program's results using a numerical evaluation system. Data collection will be implemented to ultimately provide evidence that the program is reaching its goals and benefiting our underserved communities. -Evaluations (pre and post) will be given to all participants before and after workshops/event -Participation numbers documented -Volunteer hours documented -Workshop numbers and participants documented -Weight of produce/food grown and given away to community -Observation of attitudes changed or practices adopted -Increase participation or referrals. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Laupahoehoe Train Museum-Aina-based Education for Youth and Community l Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Laupahoehoe Train Museum Program Name: Aina-Based Education Program for Youth and Community CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $15,000 $15,000 Applicant organizational budget: $89 000 Individual contributions 30,000 30,000 Membership fees Earned income Current cash assets Other funding sources (list below): Government (State) $400,000 $400,000 Foundations $300,000 $300,000 Corporate $40,000 $40,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income 45,000 $400,000 45,000 IN-KIND CONTRIBUTION Anticipated Committed Total Honeybee Eduation Program 5,000 20,500 25,500 Total In-Kind Contributions 5,000 20,500 25,500 TOTAL PROGRAM INCOME $50,000 $20,500 $70,500 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses ,`County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Laupahoehoe Train Musuem Program Name: Aina-Based Education Program for Youth and Community Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 8,000 20,000 10,000 $38,000 Professional Fees Operations 1,500 5,000 6,500 Supplies 4,000 5,000 10,000 19,000 Equipment 5,500 5,500 Admin Fees $1,500 1,500 • SUBTOTAL 15,000 30,000 25,500 70,500 TOTAL PROGRAM BUDGET $15,000 $30,000 $25,500 $70,500 County of Hawaii Nonprofit Grant Application FY 2022-23 .Agency Name: re-APPI "sla S Program Name: 14“1/444 7m7cti 61DLAC.04-rh)Ai rale. YOt4 trhs' egyttO 4, 4140;4440 0-rY 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, •Hawaiii 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 hap://vendorsehawaiLgov, 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 time! cornalete and accurate ear-end retort using the tern'late aravided will im.act the evaluation a our iro.ram's or a•enc 's uture undin. re.uests. County of Hawai'l Nonprofit Grant Application FY 2022-1) Agency Narne: J14 C.4 S cel.A 44-k • Program Name: rA14.173A- 6t)tAci4DoiNJ FoK 0 ) meogf.f Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Flawail, 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 :rant funds received durin: the :rant .eriod must be refunded to Count 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 htt www.hawaiicounty4mifo-noriprofit-Prant-forrnsj 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, 2023 must be returned to the County of Hawai'i with the final report. Failure to return these unds in a time! manner will imiact the evaluation o our a ienc '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, , 1/3//z.A., Signature of Authorized Person Date —TIZEtivsure - Title/Position of Authorized Person County of Flawai'i Nonprofit Grant Application FY 2022-23 Agency Name: Laupahoehoe Train Museum Program Name: "Aina-Based Education for Youth and Community 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 Hawan 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 0 Staff appointed by a member of the Council The Mayor ri 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. A6-7 Tie-GAssure(- 1 /31/22 Signator of Authorized Person (specify title) Date Legal Aid Society of Hawaii Civil Legal Services for Rural Residents 161 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Legal Aid Society of Hawaii Contact Person: Lisa Sparrell Contact Email: lisa.sparrell@legalaidhawaii.org Contact Phone: 8085278076 Program Information Program Name: Civil Legal Services for Rural Residents Program Years in Operation: Over 40 years on Hawaii Island Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki`o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, 'Umikoa,Volcano, Waikoloa Village,Waimea, Wainaku, Wai`ohinu,Weloka Program Target Audience: Infancy (0-3), Play Age (3-5), School Age (6-11), Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of thepoor, Public health and welfare of the people and the P P environment,Youth,Aged,Victims of Crimes,Victims of Health or Social Crises Amount Applying For:$10000 Legal Aid Society of Hawaii-Civil Legal Services for Rural Residents I Page 1 Program Details Organization Mission:The Legal Aid Society of Hawaii (LASH) is a public interest, nonprofit law firm whose mission is to address critical legal needs through high quality legal advocacy, outreach, and education in the pursuit of justice and fairness. LASH has empowered low-income, disadvantaged people throughout our state for over 70 years.The Hilo office was established in the 1950s, and the Kona office opened in 1979. Program Overview:The Civil Legal Services for Rural Residents project focuses on serving the critical civil legal needs of low-income residents throughout Hawaii County.The purpose is to provide legal services, outreach and education in the most rural parts of the county. LASH will assist clients with processes such as powers of attorney, advance directives, guardianships, adoptions, divorces, and custody matters. LASH is prepared to assist with housing-related matters, healthcare access, and public benefits. Services range from Counsel and Advice,to negotiation and in-court representation. LASH has invested in technology that allows for services to be provided remotely and has recently introduced the option for clients to use an online intake system to provide initial case information. Whether or not pandemic restrictions remain in effect over the course of this project, LASH will be able to continue to collaborate with rural organizations and serve rural residents. Program Objectives & Performances Resources Needed:The primary resources required are staff time,technology, and money for gas mileage so that staff may meet rural residents outside of hubs when necessary. LASH has experienced staff and has invested in technology that allows for remotely delivered education, outreach, and legal services.This project requests funding to pay for staff time used in direct service delivery, as well as any administrative staff whose time is required for project and fund management. LASH will contribute the time of AmeriCorps volunteers, paid through a different fund. Major Activities to be Completed: Major activities to be completed under this project include: intake/issue spotting; legal counsel and advice; assistance with obtaining identifying documents and with legal document preparation; and, activities may include directrepresentation in either mediation or legal proceedings. Major activities will also include coordination of services with other local providers, including participation in two outreach/education events over the course of each project year. Outreach and education may be performed remotely. Outputs to be Completed: Over the course of a year,this project will provide legal advice or service to 95 residents of Hawaii Island (impacting up to 115 when family members are included in the calculation), with an emphasis on rural residents (those outside of Hilo and Kona).The majority of service will be provided at the level of Counsel and Advice. Services to the 95 will involve up to 7 total staff members and AmeriCorps volunteers. Outputs also include 2 outreach/education sessions provided by 1 staff member each, lasting 1 hour and reaching up to 30 island residents each. Legal Aid Society of Hawaii-Civil Legal Services for Rural Residents I Page 2 Measurable Outcomes: Measurable outcomes (using LASH database) include:victims of DV achieve safety; clients receive their day in court; clients apply for identifying documents (the timeline for obtaining after applying is not within LASH control); clients receive public benefits; clients obtain divorce; clients receive child support orders. Each of these contributes to safer, more economically stable communities. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Legal Aid Society of Hawaii-Civil Legal Services for Rural Residents I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Legal Aid Society of Hawaii Program Name: Providing Civil Access to Rural Communities CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 10000 $40,000 Applicant organizational budget: $89,000 Individual contributions $56,314 $56,314 Membership fees Earned income Current cash assets Other funding sources (list below): Government (State) $400,000 $400,000 Foundations $300,000 $300,000 Corporate $40,000 $40,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income 10000 $400,000 $1,368,911 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME 10000 $400,000 $1,368,911 Appendix D--Budget Sheets (Page 2 of 2) iject Budget Form: Pro. Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Legal Aid Society of Hawaii Program Name: Providing Civil Access to Rural Communities Nonprofit • Expense Description (Waiwai) Other Cash In-Kind TOTAL Source Contribution Grant Salary Wages 7000 683,140 7000 Professional Fees 0 4,369 0 Operations 100 8,300 100 Supplies 0 13,116 0 Equipment 0 167 0 Fringe benefits 2900 4,400 2900 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 10000 1,328,911 0 10000 TOTAL PROGRAM BUDGET 10000 1,328,911 0 10000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Legal Aid Society of Hawai'i Program Name: Providing Civil Legal Access to Rural Communities 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Legal Aid Society of Hawai'i Program Name:Providing Civil Legal Access to Rural Communities 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, 2023 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. 1/27/2022 Signature of A ed Person Date Executive Director • Title/Position of Authorized Person County of flawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Legal Aid Society of Hawai'i Program Name: Providing Civil Legal Access to Rural Communities 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, option with the "No conflicts exist" 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: If no conflicts exist, check here. s-- Executive! 1/27/2022 Signature of A "`"ed Person (specify title) Date M. Nalani Fujimori Kaina, Executive Director Legal Aid Society of Hawaii Medical-Legal Partnership 162 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Legal Aid Society of Hawaii Contact Person: Lisa Sparrell Contact Email: lisa.sparrell@legalaidhawaii.org Contact Phone: 8085278076 Program Information Program Name: Medical-Legal Partnership Program Years in Operation: MLP 6/Organization 70+/on island 40+ Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Captain Cook, Hilo, Honalo, Honaunau-Napo'opo'o, Honomu, Kahalu'u- Keauhou, Kailua-Kona, Kalaoa, Kea'au, Kealakekua, Kuki'o, Kurtistown, Miloli'i, Mountain View, Orchidlands Estates, Papa'ikou, Pauka'a, Pepe`ekeo,Volcano, WaikOloa Village Program Target Audience: Infancy(0-3), Play Age (3-5), School Age (6-11),Adolescence (12-17), Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment, Youth,Aged, Physical/Emotional Disabilities,Victims of Crimes,Victims of Health or Social Crises Amount Applying For:$7500 Legal Aid Society of Hawaii-Medical-Legal Partnership I Page 1 Program Details Organization Mission:The Legal Aid Society of Hawaii (LASH) is a public interest, nonprofit law firm whose mission is to address critical legal needs through high quality legal advocacy, outreach, and education in the pursuit of justice and fairness. LASH has empowered low-income, disadvantaged people throughout our state for over 70 years.The Hilo office was established in the 1950s, and the Kona office opened in 1979. Program Overview: LASH is seeking support for its medical-legal partnership work with the West Hawaii Community Health Center.This was initially supported through a grant administered by the State of Hawaii, along with grants from Hawaii County and HIUW. LASH coordinates with WHCHC to serve indigent clients who may face legal barriers to improved health and economic stability.The project places a LASH staff member at the Clinic one to two times per week(pandemic restrictions permitting) in order that Clinic staff can simply direct a client to LASH for legal issue spotting, rather than having to make a referral for the client to follow up on.Addressing both medical and legal issues in one visit is not only more convenient and efficient for the individuals being served, it also increases the likelihood of follow-through. By using this coordinated approach to service, individuals and families will see health outcomes improved when their civil legal needs have been met. Program Objectives & Performances Resources Needed: Resources required are staff time and technology, supported with funds from this grant. Major Activities to be Completed: Major activities to be completed under this project include: intake/issue spotting; legal counsel and advice; assistance with obtaining identifying documents and with legal document preparation; and, activities may include direct representation in either mediation or legal proceedings. Major activities will include coordination of services with the WHCHC and other island healthcare providers. Outputs to be Completed:This project will provide legal advice or service to 45 clinic clients (up to 60 island residents,when affected family members are included in tally)with legal issues that present barriers to improved health, wellness, and income security.This will involve up to 250 hours of staff time. Measurable Outcomes: Measurable outcomes (using LASH database) include: Clinic clients who are victims of DV achieve safety; clients receive their day in court; clients apply for identifying documents (the timeline for obtaining after applying is not within LASH control); clients receive public benefits; clients obtain divorce; clients receive child support orders. Each of these contributes to safer, more economically stable communities and removal of barriers to better health. Legal Aid Society of Hawaii-Medical-Legal Partnership I Page 2 Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Legal Aid Society of Hawaii-Medical-Legal Partnership! Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Legal Aid Society of Hawaii Program Name: Medical Legal Partnerships CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 7500 0 $40,000 Applicant organizational budget: $89,000 Individual contributions $56,314 $56,314 Membership fees Earned income Current cash assets Other funding sources (list below): Government (State) $400,000 $400,000 Foundations $300,000 $300,000 Corporate $40,000 $40,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income $968,911 $400,000 $1,368,911 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME 7500 $400,000 0 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 .. ............. Organization Name:Legal Aid Society of Hawaii Program Name: Medical Legal Partnerships Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 5325 683,140 5325 Professional Fees 0 4,369 4,369 Operations 0 8,300 8,300 Supplies 0 13,116 13,116 Equipment 0 167 167 Fringe benefits 2175 4,400 2175 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 7500 1,328,911 0 7500 TOTAL PROGRAM BUDGET 7500 1,328,911 0 7500 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Legal Aid Society of Hawaii Program Name: Hawai'i Island Medical Legal Partnerships 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Legal Aid Society of Hawaii Program Name: Hawai'i Island Medical Legal Partnerships 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, 2023 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. 1/27/2022 Signature of Authorl�ez d •erson Date Executive Director Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Legal Aid Society of Hawai'i Program Name: Hawaii Island Medical Legal Partnerships 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 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. xecutir 'tor 1 /27/2022 Signature of Auth:y •erson (specify title) Date M. Nalani Fujimori Kaina, Executive Director Little Big Tots Foundation Ike Loa Program 163 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Little Big Tots Foundation Contact Person: Kristina Tolentino Contact Email: admin@littlebigtots.org Contact Phone: 808-796-1106 Program Information Program Name: Ike Loa Program Program Years in Operation: 2 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Hdnalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe`ekeo, Pohoiki, Puako, Pualaa, `Umikoa,Volcano,Waikoloa Village,Waimea, Wainaku,Wai`ohinu,Weloka Program Target Audience: Play Age (3-5),School Age (6-11),Adolescence (12-17) Services/Activities Provided: Needs of the poor,Youth Amount Applying For: $10000 Little Big Tots Foundation-Ike Loa Program I Page 1 Program Details Organization Mission: Little Big Tots Foundation provides financial assistance to youth members of the community ages three (3)to thirteen (13) years old.To increase the participation rate in youth extra- curricular activities.To allow every youth the opportunity to participate in an activity that will promote expansion of their education and knowledge.To direct the youth on the path to success with education, social and life aspects. Program Overview: Ike Loa is a financial assistance program that allows families in need to apply for assistance for an extra-curricular activity to all eligible children.The program awards eligible families a scholarship that pays for their child's activities registration or enrollment fees.An eligible family is one that meets all three of the following: 1. Child is between the ages of 3-13 years 2. Family is within the income/household threshold 3. Activity of choice is a credible organization The receipent of that award and their family are required to participate in a community giveback event hosted by Little Big Tots Foundation to instill community awareness. Ike Loa assist in the building of future youth leaders by allowing each child the opportunity to participate in an activity that will expand their knowledge and education and pave the path to their future successes. Program Objectives & Performances Resources Needed: Our program relies on three important aspects of resources to continue our efforts. Volunteers are an integral part of the operational aspect of the program.Volunteers will help our program grow and reach more youth and needy families. Another important factor is getting our program out into the community and spread the word of the Ike Loa program.The final layer of the prgram that is critical to its operation is funding. Without funding,the program will not be able to help a child get enrolled into a program that increases their values. A child's moral and ethic value is the foundation of building a successful leader and this can be done thru our program and its philosphies. Major Activities to be Completed:The progam's most important activity is the issuance of scholarships. These scholarships help pay for registration or enrollment fees for a child's extra-curricular activity of choice. Outputs to be Completed:The goal is to reach every child on the Big Island. Currently, as this is our 3rd' full year into the program,we are expanding our reach to do 25% more then we did in previous years. This fiscal year we are pushing to reach a minimum of 200 individual children and get them registered into an extra-curricular activity. Measurable Outcomes: Our measurable outcome is based on the increased rate of youth enrollment in extra-curricular activities. By keeping track of the amount of kids being awarded we will be able to build a database that will help enhance our future program. Little Big Tots Foundation-Ike Loa Program I Page 2 Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Little Big Tots Foundation-Ike Loa Program I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Little Big Tots Foundation Program Name: Ike Loa CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $10,000 $10,000 Applicant organizational budget: $23,860 $23,860 Individual contributions $1500 $1500 Membership fees Earned income Current cash assets Other funding sources (list below): Private Grant Opportunities $12,000 $400,000 $12,000 Foundations $300,000 $300,000 Corporate $40,000 $40,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income $23,500 $400,000 $23,500 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME $23,500 $400,000 $23,500 Appendix D--Budget Sheets (Page 2 of 2) 'Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Little Big Tots Foundation :Program Name: Ike Loa Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 40,000 683,140 723,140 Professional Fees 0 4,369 4,369 Operations $9,000 $11,000 $20,000 Supplies $1000 $1860 $2860 Equipment 0 $1000 $1000 Printing, Advertising, and Media 0 4,400 4,400 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL $10,000 $13,860 0 $23,860 TOTAL PROGRAM BUDGET $10,000 $13,860 0 $23,860 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Little Big Tots Foundation Program Name: Ilce Loa 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Little Big Tots Foundation Program Name: Ilse Loa 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, 2023 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. ciDo 01/07/2022 Signature of Authorized Person Date President Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Little Big Tots Foundation Program Name: Ilse Loa 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 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. CQD rtf2) 01/07/2022 Signature of Authorized Person (specify title) Date Lokahi Treatment Centers Health & Fitness Program 164 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Lokahi Treatment Centers Contact Person: Cory Causey Contact Email: ccausey@lokahitreatmentcenters.net Contact Phone: (808)969-9292 Program Information Program Name: Health & Fitness Program Program Years in Operation: 2 years Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Kalapana, Kea'au, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'okala, Orchidlands Estates, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Pualaa, `Umikoa,Volcano,Wainaku, Wai'ohinu, Weloka, Keaukaha Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Aged, Physical/Emotional Disabilities,Victims of Crimes,Victims of Health or Social Crises Amount Applying For:$15000 Lokahi Treatment Centers-Health&Fitness Program I Page 1 Program Details Organization Mission: LTC was founded in 2001 as an integrated model to address substance abuse and co-occurring mental health disorders. LTC has been accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) since 2002 to provide services for Integrated Outpatient Treatment; AOD/MH for both Adults and the Special Populations of Adolescent/Children and Criminal Justice.This accreditation process is completed every three years. Program Overview:The Health & Fitness Program has 5 steps. 1. Meet with counselor to assess readiness to initiate an exercise regime. - Exercise can actually help ease substance abuse withdrawal discomforts. 2. Assess physical needs. -Once a doctor has determined that the client can participate in exercise, it's important to assess the physical needs and goals for that client. 3. Assess psychological needs. - Exercise increases production of endorphins and other natural hormones in the body that can improve symptoms of depression and anxiety, encourage positive outlook, self-esteem, and confidence,to name a few. 4. Determine interest and motivation level for specific types of exercise. -Clients who are motivated to engage in treatment were more likely to complete treatment programs and have positive long-term results. 5. Develop an individualized and/or group exercise program. Program Objectives & Performances Resources Needed: Money,treatment curriculum for clients, professional staff,volunteers(practicum hours), indoor and outdoor facilities,technology, necessary furnishings, equipment, testing supplies and office supplies. Major Activities to be Completed: • Physical Development. • Social Development. • Emotional Development. • Mental Development. Outputs to be Completed: 75%of clients will remain in the program for the full course of recommended services. 75%of clients will increase the number of social supports at time of discharge-compared to admission. 75%of clients will attend additional therapy programs offered by LTC. 75%of clients will complete surveys to evaluate performance measures based on patient experience. Lokahi Treatment Centers-Health &Fitness Program I Page 2 Measurable Outcomes:This program is an outlet to counter the social and economic changes caused by the pandemic, along with the traditional treatment difficulties. 1. Enhanced out-patient individualized treatment plan. 2. Increased strategic partnerships with communities to include, but not limited to, social services, health care facilities, support groups, and P&R facilities for their continued health and fitness opportunities. This helps to expand the access and availability of services for out-patient treatment participants so they can pursue healthy, productive, and satisfying goals while gaining the benefits of abstinence and accountability. 3. Increased additional therapy programs not paid for through health insurance or other grants. i.e. Life Skills (Budgeting, etc.), Music Therapy, which is very different from music in the form of entertainment. It is a clinical and evidence-based therapeutic practice that utilizes music to accomplish goals within an individual's treatment program. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Lokahi Treatment Centers-Health&Fitness Program I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Lokahi Treatment Centers Program Name:Health & Fitness Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 15,000 15,000 Applicant organizational budget: $89,000 Individual contributions $56,314 $56,314 Membership fees Earned income 25,000 25,000 Current cash assets Other funding sources (list below): Government (State) $400,000 $400,000 HRSA Covid Relief 2,000 2,000 Fundraising 5,000 5,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income $968,911 $400,000 $1,368,911 IN-KIND CONTRIBUTION Anticipated Committed Total Practicums/Volunteers 3.000 3,000 Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME 50,000 $400,000 50,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant)- Fiscal Year 2022-2023 :Organization Name:Lokahi Treatment Centers Program Name:Health & Fitness Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 15,000 10,000 25,000 Professional Fees 0 4,369 4,369 Operations 0 18,000 18,000 Supplies 0 5,000 5,000 Equipment 0 2,000 2,000 Printing, Advertising, and Media 0 4,400 4,400 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 15,000 35,000 0 50,000 TOTAL PROGRAM BUDGET 15,000 35,000 0 50,000 County of Hawai'i Nonprofit Grant Application FY 2022-23 Agency Name: Lokahi Treatment Centers, Program Name: Health & Fitness Program Certification of Understanding (Page 1 of 2) l (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 toAppropriation of Fundsto NonprofitOrganizations. I(we)agree to allowthe 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 inspectanyfacility,equipment,property,or records pertinenttothegrant, 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 administerthe 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 thatwe 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. Ifawarded a grantfrom the County of Hawai'i,I(we)understand and will compfywiththe 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 agrantfromthe County ofHawai`',I(we)understand andwillcomplywiththe requirement to submita vear-end reportto the County Council within 60 days afterJune 30 ofthe contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation ofthe public benefits derived fromthe 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name:_Lokahi Treatment Centers Program Name: Health & Fitness Program Certification of Understanding (Page 2 of 2) If awarded a grantfromthe County ofHawai'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 thatthe County of Hawai'i is an additional insured prior to receiving any payment(s). (we)understand thatfailureto submitthefinal reportwithin 60 daysofJune 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 fora minimum ofoneyearor until a written report is submitted to,and accepted by, the council. I(we)understand there is no provision forfurther notification to submitthe final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-qrant-forms/ on orabout 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,exceptfora maximum ten percent(10%)foradministrative and overhead costs.Anyfunds unused byJune 30,2023 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely mannerwill 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. January 21,2022 Signature of Authorized Person Date President and CEO Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Lokahi Treatment Centers Program Name: Health and Fitness Program 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 anyfamilial relationship,with anyofthe 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 D The Corporation Counsel,the Assistant Corporation Counsel,ora 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: 1.41( If no conflicts exist, check here. Signatureof I Authorized Person(specify title) Date Lokahi Treatment Centers Domestic Violence Intervention Treatment Programs 165 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Lokahi Treatment Centers Contact Person:Cory Causey Contact Email: ccausey@lokahitreatmentcenters.net Contact Phone: 808-969-9292 Program Information Program Name: Domestic Violence Intervention Treatment Programs Program Years in Operation: 18 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: `Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa`aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, 'Umikoa,Volcano,Waikoloa Village, Waimea, Wainaku,Wai'ohinu,Weloka, Keaukaha - Lokahi Treatment Centers serves the entire County of HI Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Aged, Physical/Emotional Disabilities,Victims of Crimes,Victims of Health or Social Crises Amount Applying For:$30000 Lokahi Treatment Centers-Domestic Violence Intervention Treatment Programs I Page 1 Program Details Organization Mission: LTC was founded in 2001 as an integrated model to address substance abuse and co-occurring mental health disorders. LTC has been accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) since 2002 to provide services for Integrated Outpatient Treatment; AOD/MH for both Adults and the Special Populations of Adolescent/Children and Criminal Justice.This accreditation process is completed every three years. Program Overview: 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 five (5) office facilities operated by LTC throughout Hawaii Island.Two principles that determine and shape the intervention strategies are abuser accountability and victim safety. • We provide inclusion of a specialized approach that focuses on ending violence and placing the safety and rights of victims at highest priority. • To include individualized treatment and group intervention. • We include a broad definition of violence, both physical and nonphysical behavior, and address power and control as the motive. • We address safety planning, including time outs and control logs. Program Objectives & Performances Resources Needed: Money, treatment curriculum for clients, professional staff,volunteers(practicum hours), technology, necessary furnishings, equipment,testing supplies and office supplies. Major Activities to be Completed: • Intake/Assessment/Client Interview. • Personalized Treatment Planning. • Remove barriers to treatment. • Utilize the client's existing motivation. • Build trusting and positive relationships between counselors and clients. • Prioritize retention in treatment. • Determine and address individual treatment needs. • Provide continuous care and ongoing case management. • Provide group and individual counseling services. • Monitor abstinence—substance and alcohol testing. • Utilize community-based support services. • Incorporate medication-management, if needed. • Educate clients about substance use disorder and skills needed for recovery as it also relates to domestic violence. Lokahi Treatment Centers-Domestic Violence Intervention Treatment Programs I Page 2 • Involve family members, employers, and significant others. • Incorporate evidence-based strategies into treatment. Outputs to be Completed: • Provide 5 office locations—Puna, Hilo, Honokaa, Waikoloa and Kona - removing barriers for access to treatment. • Provide staff hours - Domestic Violence Counselors who are trained and certified by the Hawaii State Coalition Against Domestic Violence. • Provide necessary furnishings, equipment,testing supplies, office supplies and treatment curriculum for clients. Measurable Outcomes: 90% of Clients remain in treatment for full course of recommended services. 90% of Clients remain abstinent from substances. 90%of Clients remain in after-care to reduce recidivism rates. 90%of Clients increase social supports at time of discharge-compared to admission. 90%of Clients attend additional therapy programs. 90% of Clients master skills to manage triggers. 90%of Clients complete surveys to evaluate performance measures based on patient experience. 90%of Reduced delinquency/crime. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Lokahi Treatment Centers-Domestic Violence Intervention Treatment Programs I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Lokahi Treatment Centers Program Name:Domestic Violence Intervention Treatment Programs CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 30,000 30,000 Applicant organizational budget: $89,000 Individual contributions $56,314 $56,314 Membership fees Earned income 125,000 125,000 Current cash assets Other funding sources (list below): Adult Probation Services- State of Hawai'i 25,000 $400,000 25,000 HRSA Covid Relief 2,000 2,000 Fundraising 5,000 5,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income 187,000 $400,000 $1,368,911 IN-KIND CONTRIBUTION Anticipated Committed Total PracticumsNolunteers 3,000 3,000 Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME 190,000 $400,000 190,000 Appendix D--Budget Sheets (Page 2 of 2) :Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)- Fiscal Year 2022-2023 ;Organization Name:Lokahi Treatment Centers Program Name:Domestic Violence Intervention Treatment Programs Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 30,000 72,000 3,000 105,000 Professional Fees 0 10,000 10,000 Operations 0 30,000 30,000 Supplies 0 40,000 40,000 Equipment 0 5,000 5,000 Printing, Advertising, and Media 0 4,400 4,400 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 40,000 1,328,911 0 1,368,911 TOTAL PROGRAM BUDGET 30,000 157,000 3,000 190,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name:.Lokahi._Treatment Centers Program Name: Domestic Violence Intervention Treatment Programs 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'iCounty Code,relating toAppropriation of Fund sto NonprofitOrganizations. (we)agree to allowthe County(the Legislative Auditor,the Department of Finance,designated Council representative,or expending/oversight agency)full,free, and unrestricted access and authority toexamineand inspectanyfacility,equipment,property,or records pertinenttothegrant, 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 administerthe 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 thatwe 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. Ifawarded a grantfrom the CountyofHawai'i,I(we)understand and will complywith 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. Ifawardedagrantfromthe County ofHawai'i,l(we)understandandwillcomplywiththerequirement to submita year-end report to the County Council within 60 days afterJune 30 ofthe contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation ofthe public benefits derived fromthe 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name:_Lokahi Treatment Centers Program, Name: Domestic Violence Intervention Treatment Programs Certification of Understanding (Page 2 of 2) If awarded agrantfromthe County ofHawai'i,I(we)understand that a currentCertificate 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). (we)understand thatfailuretosubmitthefinal reportwithin 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 fora minimum of oneyear or until a written report is submitted to,and accepted by, the council. I(we)understand there is no provision forfurther notification to subm it the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-qrant-forms/ on orabout 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,exceptfora maximum ten percent(10%)foradministrative and overhead costs.Anyfunds unused by June 30,2023 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely mannerwill 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. ,, January 21,2022 Signature of Authorized Person Date President and CEO Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Lokahi Treatment Centers Program Name: Domestic Violence Intervention Treatment Programs 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, oneform 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 anyfamilial relationship,withanyofthe following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the n Council The Mayor ❑ The Managing E Director The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,ora 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: 14( If no conflicts exist, check here. . ,. �..__ ! - .:, .._ �S►4� 1� ✓ I X22_. Signatureof Authorized Person(specify title) Date Lokahi Treatment Centers Anger Management Treatment Programs 166 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Lokahi Treatment Centers Contact Person: Cory Causey Contact Email: ccausey@lokahitreatmentcenters.net Contact Phone: 808-969-9292 Program Information Program Name:Anger Management Treatment Programs Program Years in Operation: 21 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O`okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, `Umikoa,Volcano, Waikoloa Village,Waimea, Wainaku, Wai`ohinu,Weloka, Keaukaha -Servicing all of Hawaii County. Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment, Aged, Physical/Emotional Disabilities,Victims of Crimes,Victims of Health or Social Crises Amount Applying For: $30000 Lokahi Treatment Centers-Anger Management Treatment Programs I Page 1 Program Details Organization Mission: Lokahi Treatment Centers (LTC) was founded in 2001 as an integrated model to address substance abuse and co-occurring mental health disorders. LTC has been accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) since 2002 to provide services for Integrated Outpatient Treatment; AOD/MH for both Adults and the Special Populations of Adolescent/ Children and Criminal Justice.This accreditation process is completed every three years. Program Overview: 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. 2. Conflict and stress management skills. 3.. Recognizing signs and indicators of anger management. Program Objectives & Performances Resources Needed: Money, treatment curriculum for clients, professional staff,volunteers(practicum hours),technology, necessary furnishings, equipment,testing supplies and office supplies. Major Activities to be Completed: • Intake/Assessment/Client Interview. • Personalized Treatment Planning. • Prioritize retention in treatment. • Determine and address individual treatment needs. • Provide continuous care and ongoing case management. • Provide group and individual counseling services. • Utilize community-based support services. • Incorporate medication-management, if needed. • Involve family members, employers, and significant others. • Incorporate evidence-based strategies into treatment. • Expand curriculum to include tools for"Thought Disorders" for clients to be able to eliminate negative thoughts such as suicide; and a better way of getting rid of self-defeating thoughts. • Increase strategic partnerships with communities to include, but not limited to, social services, health care facilities and support groups,that will help to expand the access and availability of services for clients to maintain the self-control techniques and have an effective way to practice productive, healthy behaviors. Outputs to be Completed: 95%of Clients increase knowledge and improve anger management. 95%of Clients make positive behavioral changes. Lokahi Treatment Centers-Anger Management Treatment Programs I Page 2 95% of Clients increase or sustain anger control. 95%of Clients decrease family and interpersonal conflict. 95% of Clients decrease anger and violence. Measurable Outcomes: 1. Clients demonstrate skills and strategies for healthful relationships. Indicator: Improved ability to respond to one's own social-emotional needs and the social-emotional needs of others Indicator: Decreased involvement with unhealthful, abusive behaviors and/or relationships 2. Clients improve their knowledge about strategies to address aggression and violence. Indicator: Increased knowledge about the impacts of healthful and unhealthful relationships on individuals and setting Indicator: Increased knowledge about ways to foster safe and fair relationships and settings Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Lokahi Treatment Centers-Anger Management Treatment Programs I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Lokahi Treatment Centers Program Name:Anger Management Treatment Programs CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 30,000 30,000 Applicant organizational budget: $89,000 Individual contributions $56,314 $56,314 Membership fees 45,000 45,000 Earned income Current cash assets Other funding sources (list below): Self-Pay 15,000 $400,000 15,000 HRSA Covid Relief 2,000 2,000 Fundraising 5,000 5,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income 97,000 $400,000 97,000 IN-KIND CONTRIBUTION Anticipated Committed Total Practicums/Volunteers 3.000 3,000 Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME 100,000 $400,000 100,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses :County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)- Fiscal Year 2022-2023 (Organization Name:Lokahi Treatment Centers ,Program Name:Anger Management Treatment Programs Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 30,000 35,000 3,000 68,000 Professional Fees 0 7,000 7,000 Operations 0 '15,000 15,000 Supplies 0 8,000 8,000 Equipment 0 2,000 2,000 Printing, Advertising, and Media 0 4,400 4,400 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 30,000 67,000 3,000 100,000 TOTAL PROGRAM BUDGET 30,000 67,000 3,000 100,000 i County of Hawai i Nonprofit Grant Application FY 2022-23 Agency Name: Lokahi Treatment Centers. Pro.ram Name: An.er Mana•ement Treatment Projams 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 Fund sto NonprofitOrganizations. I(we)agree to allowthe 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 inspectanyfacility,equipment,property,or records pertinenttothegrant, 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 administerthe 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 thatwe 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 grantfrom the CountyofHawaii,I(we)understand and will complywith 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 agrantfromthe County ofHawai'i,I(we)understand andwill comply with the requirement to submita year-end reporttothe County Council within 60 days afterJune 30ofthe contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation ofthe public benefits derived fromthe 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. • County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name:_Lokahi Treatment Centers Program Name:Anger Management Treatment Programs Certification of Understanding (Page 2 of 2) If awarded a grantfrom the County ofHawai`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 thatthe County of Hawai'i is an additional insured prior to receiving any payment(s). I(we)understand thatfailure to su bmitthefinal reportwithin 60 days ofJune30thshall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion from future grant participation fora minimum of oneyear or until awritten report is submitted to,and accepted by, the council. I(we)understand there is no provision forfurther notification to submitthe final report. Information and instructions are available at http://www.hawaiiicounty.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,exceptfor a maximum ten percent(10%)foradmi nistrative and overhead costs.Anyfunds unused by June 30,2023 must be returned to the County of Hawaii with the final report.Failure to return these funds in a timelymannerwill impactthe evaluation of your agency's future funding request and may result in actions taken to recover these funds. Awards cannotp rovide 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 21,2022 Signature of Authorized Person Date President and CEO Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Lokahi Treatment Centers Program Name: Anger Management Treatment Programs 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 ofHawai`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 whethera conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest,including anyfamilial relationship,with anyofthe following (check all that apply): n Member or members of the Council ❑ Staff appointed by a member of the n 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:. Fr If no conflicts exist, check here. !Th ._ ; Signatureof J Authorized Person(specify title) Date Lokahi Treatment Centers Adult Substance Abuse and Mental Health Treatment Programs 167 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 'Organization Information Organization Name: Lokahi Treatment Centers Contact Person: Cory Causey Contact Email: ccausey@lokahitreatments.net Contact Phone: (808)969-9292 Program Information Program Name:Adult Substance Abuse and Mental Health Treatment Programs Program Years in Operation: 21 years Other County grants/ g a reements: No Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'Okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, PuakO, Pualaa, 'Umikoa,Volcano, Waikoloa Village, Waimea, Wainaku,Wai'ohinu, Weloka, Keaukaha -Servicing all of Hawaii County Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Aged, Physical/Emotional Disabilities,Victims of Crimes,Victims of Health or Social Crises Amount Applying For:$50000 Lokahi Treatment Centers-Adult Substance Abuse and Mental Health Treatment Programs I Page 1 Program Details Organization Mission: LTC was founded in 2001 as an integrated model to address substance abuse and co-occurring mental health disorders. LTC has been accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) since 2002 to provide services for Integrated Outpatient Treatment; AOD/MH for both Adults and the Special Populations of Adolescent/Children and Criminal Justice.This accreditation process is completed every three years. Program Overview:This program addresses co-occurring disorders. Our integrated treatment coordinates mental and substance use interventions providing individualized and personalized services to treat the physical and emotional aspects of mental and substance use disorders. Our caring clinicians have extensive experience in providing treatment for substance abuse and co- occurring mental health issues.We use a holistic, personalized approach to help our clients reach physical, mental, and spiritual health. Our comprehensive integrated treatment services 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. Program Objectives & Performances Resources Needed: Money,treatment curriculum for clients,facilities, professional staff, volunteers(practicum hours),technology, necessary furnishings, equipment,testing supplies and office supplies. Major Activities to be Completed: ACTIVITIES: (PROGRAM COMPONENTS) • Intake/Assessment/Client Interview. • Personalized Treatment Planning. • Remove barriers to treatment. • Utilize the client's existing motivation. • Build trusting and positive relationships between counselors and clients. • Prioritize retention in treatment. • Determine and address individual treatment needs. • Provide continuous care and ongoing case management. • Provide group and individual counseling services. • Monitor abstinence—substance and alcohol testing. • Utilize community-based support services. • Incorporate medication-management, if needed. • Educate clients about mental health and substance use disorder and skills needed for recovery. • Involve family members, employers, and significant others. Lokahi Treatment Centers-Adult Substance Abuse and Mental Health Treatment Programs I Page 2 • Incorporate evidence-based strategies into treatment. • Aftercare- Post treatment. Outputs to be Completed: 95%of clients remain in treatment for full course of recommended services. 95% of clients remain abstinent from substances. 95% of clients remain in after-care to reduce recidivism rates. 95% of clients increase social supports at time of discharge-compared to admission. 95%of clients attend additional therapy programs. 95%of clients master skills to manage triggers. 95% of clients complete surveys to evaluate performance measures based on patient experience. 95% of clients Reduced delinquency/crime. Measurable Outcomes: Clients receive patient centered and provider driven care. It is widely acknowledged that mental illness and substance use disorders are deeply intertwined, sharing biological roots and working synergistically to augment each other. LTC's treatment program will address both conditions at once through a dedicated dual diagnosis treatment to create true healing. LTC's multidisciplinary teams, including specialists in key areas of treatment, provide a range of services to clients. Members typically include mental health and Substance Use Disorder treatment counselors, case managers, and a psychiatric provider. • Clients remain in treatment for full course of recommended services. • Client remain abstinent from substances. • Clients remain in after-care to reduce recidivism rates. • Clients increase social supports at time of discharge-compared to admission.. • Clients master skills to manage triggers. • Reduced delinquency/crime- helping to build safe and healthy communities. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Lokahi Treatment Centers-Adult Substance Abuse and Mental Health Treatment Programs I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Lokahi Treatment Centers Program Name:Adult Substance Abuse and Mental Health Treatment Programs CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 50,000 50,000 Applicant organizational budget: $89,000 Individual contributions $56,314 $56,314 Membership fees Earned income 807,000 807,000 Current cash assets Other funding sources (list below): Government (State) $400,000 $400,000 HRSA Covid Relief 2,000 2,000 Fundraising 5,000 5,000 State of Hawaii,Third Circuit Court-Big Island Drug Court 25,000 25,000 State of Hawaii,DHS-Substance Abuse Assessment&Monitoring 25,000 25,000 Hawai'i Paroling Authority 30,000 30,000 Total Cash Income $968,911 $400,000 $1,368,911 IN-KIND CONTRIBUTION Anticipated Committed Total PracticumsNolunteers 6.000 6,000 Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME 950,000 $400,000 950,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)- Fiscal Year 2022-2023 :Organization Name:Lokahi Treatment Centers Program Name:Adult Substance Abuse and Mental Health Treatment Programs Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 50,000 650,000 6,000 706,000 Professional Fees 0 30,000 30,000 Operations 0 199,000 199,000 Supplies 0 10,000 10,000 Equipment 0 5,000 5,000 Printing,Advertising, and Media 0 4,400 4,400 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 40,000 1,328,911 0 1,368,911 TOTAL PROGRAM BUDGET 50,000 894,000 6,000 950,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Lokahi...Treatment_Centers, Program Name: Adult Substance Abuse & Mental HealthnTreatment Programs 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 Fundsto NonprofitOrganizations. I(we)agree to allowthe County(the Legislative Auditor,the Department of Finance,designated Council representative, or expending/oversight agency)full,free,and unrestricted access and the authority to examine and inspectanyfacility,equipment,property,orrecords pertmentto pertinenttothegrant, 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 administerthe 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 thatwe 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. Ifawarded a grantfrom the CountyofHewai'i,I(we)u nderstand and will complywith 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 atirantfrom the County of Hawaii,l(we)understandandwillcomplywiththerequirement to submita year-end reportto the County Council within 60 days afterJune 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation ofthe public benefits derived fromthe 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: LokahiTreatment.Centers. Program Name: Adult Substance Abuse & Mental Health Treatment Programs Certification of Understanding (Page 2 of 2) If awarded agrantfromthe County ofHawai'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 thatthe County of Hawai'i is an additional insured prior to receiving any payment(s). I(we)understand thatfailureto submitthefinal reportwithin 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 oneyear or until a written report is submitted to,and accepted by, the council. I(we)understand there is no provision forfurther 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,exceptfor a maximum ten percent(10%)foradministrative and overhead costs.Anyfunds unused by J une 30,2023 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely mannerwill 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. January 21,2022 Signature of Authorized Person Date President and CEO Title/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Lokahi Treatment Centers Program Name:Adult Substance Abuse & Mental Health Treatment Programs WININIZION 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, oneformfor 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 anyfamilial relationship,with anyofthe following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the n Council The Mayor ❑ The Managing ❑ Director The Director of Finance ❑ The Corporation Counsel.,the Assistant Corporation Counsel,ora 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. • _. ti/ 2. 2_ Signatureof / Authorized Person(specify title) Date Lokahi Treatment Centers Adolescent Substance Abuse and Mental Health Treatment Programs 168 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Lokahi Treatment Centers Contact Person: Cory Causey Contact Email: ccausey@lokahitreatments.net Contact Phone: (808)969-9292 Program Information Program Name:Adolescent Substance Abuse and Mental Health Treatment Programs Program Years in Operation: 21 years Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: `Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'Okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe`ekeo, Pohoiki, PuakO, Pualaa, 'Umikoa,Volcano,Waikoloa Village, Waimea, Wainaku, Wai'ohinu,Weloka, Keaukaha-Servicing all of Hawaii County Program Target Audience:Adolescence (12-17) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth, Physical/Emotional Disabilities,Victims of Crimes,Victims of Health or Social Crises Amount Applying For:$35000 Lokahi Treatment Centers-Adolescent Substance Abuse and Mental Health Treatment Programs I Page 1 Program Details Organization Mission: LTC was founded in 2001 as an integrated model to address substance abuse and co-occurring mental health disorders. LTC has been accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) since 2002 to provide services for Integrated Outpatient Treatment; AOD/MH for both Adults and the Special Populations of Adolescent/Children and Criminal Justice.This accreditation process is completed every three years. Program Overview: Individual and group counseling to address substance abuse, mental health (including co-occurring disorders) and case management services. LTC utilizes evidence-based methods and best practice standards that comply with the Commission on Accreditation of Rehabilitation Facilities (CARF) standards. Adolescents participate in individualized therapy, family therapy, group therapy, recreational therapy, and more.Therapy groups are designed to address both the emotional and cognitive behaviors surrounding substance use and mental health disorders. Adolescents in these programs get to participate in special topic groups that are designed around active engagement activities and unique challenges that adolescents face. Each week, we explore the themes in a new way and build on skills as each individual grows and as they advance in the program in the following areas: -Relationships -Emotion regulation -Coping skills -Building solid recovery support systems Program Objectives & Performances Resources Needed: Money,treatment curriculum for clients, facilities, professional staff, volunteers(practicum hours), technology, necessary furnishings, equipment,testing supplies and office supplies. Major Activities to be Completed: • Intake/Assessment/Client Interview. • Personalized Treatment Planning. • Remove barriers to treatment. • Utilize the client's existing motivation. • Build trusting and positive relationships between counselors/treatment team and clients. • Prioritize retention in treatment. • Determine and address individual treatment needs. • Provide continuous care and ongoing case management. • Provide group and individual counseling services. • Monitor abstinence—substance and alcohol testing. Lokahi Treatment Centers-Adolescent Substance Abuse and Mental Health Treatment Programs I Page 2 Outputs to be Completed: 100%of clients complete program intake, assessment and screening. 100%of clients complete weekly drug tests. 100%of clients are supported with case management sessions. 100%of clients attend weekly sessions. 100%of Client and their families supported. 95% of clients graduate. 95% of clients remain in aftercare. Measurable Outcomes: • Clients return to/stay in school. • Clients remain in treatment for full course of recommended services. • Clients remain abstinent from substances. • Clients remain in after-care to reduce recidivism rates. • Clients increase social supports at time of discharge-compared to admission. • Clients attend additional therapy programs. • Clients master skills to manage triggers. • Clients complete surveys to evaluate performance measures based on patient experience. • Reduced delinquency/crime. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Lokahi Treatment Centers-Adolescent Substance Abuse and Mental Health Treatment Programs Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Lokahi Treatment Centers Program Name:Adolescent Substance Abuse and Mental Health Treatment Programs CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 35,000 35,000 Applicant organizational budget: $89,000 Individual contributions $56,314 $56,314 Membership fees Earned income 135000 135,000 Current cash assets Other funding sources(list below): Government (State) $400,000 $400,000 HRSA Covid Relief 2,000 2,000 Fundraising 5,000 5,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income 177,000 $400,000 177,000 IN-KIND CONTRIBUTION Anticipated Committed Total PracticumsNolunteers 3.000 3,000 Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME 180,000 $400,000 180,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)- Fiscal Year 2022-2023 Organization Name:Lokahi Treatment Centers Program Name:Adolescent Substance Abuse and Mental Health Treatment Programs Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 35,000 77,000 3,000 115,000 Professional Fees 0 23,000 23,000 Operations 0 25,000 25,000 Supplies 0 15,000 15,000 Equipment 0 2,000 2,000 Printing, Advertising, and Media 0 4,400 4,400 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 35,000 142,000 3,000 180,000 TOTAL PROGRAM BUDGET 35,000 142,000 3,000 180,000 • County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Lokahi..Treatment Centers, Program Name: Adolescent Substance Abuse and Mental Health Treatment Programs 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 Fund sto Nonprofit Organizations. I(we)agree to allowthe 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 inspectanyfacility,equipment,property,or records pertinenttothegrant, 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 administerthe 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 grantfrom the County of Newell,I(we)understand and will complywith 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. Ifawardedagrantfromthe County ofHawai'i,I(we)understand and will comply withthe requirement to submita year-end report to the County Council within 60 days afterJune 30 ofthe contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation ofthe public benefits derived fromthe 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name:_Lokah Treatment_Centers. Program Name: Adolescent Substance Abuse and Mental Health Treatment Pro'rams Certification of Understanding (Page.2 of 2) If awarded a grantfrom the County ofHawai'i,I(we)understand that a currentCertificate 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 thatthe County of Hawaii is an additional insured prior to receiving any payment(s). I(we)understand thatfailureto submitthefinal reportwithin 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 fora minimum of one year or until a written report is submittedto,and accepted by, the council. I(we)understand there is no provision forfurther notification to subm it 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,exceptfor a maximum ten percent(10%)foradministrative and overhead costs.Anyfu nds unused by J une 30,2023 must be returned to the County of Hawai'i with the final report.Failure to return these funds in a timely mannerwill 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.• January 21,2022 Signature of Authorized Person Date President and CEO Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Lokahi Treatment Centers Program Name: Adolescent Substance Abuse and Mental Health Treatment Programs 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, oneform 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 anyfamilial relationship,with anyofthe following (check all that apply): E 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,ora 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. wedwedky I 3.022_ Signatureof Authorized Person(specify title) Date MALA°AI The Hawaii Island School Garden Network 170 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: MALA'AI Contact Person:Zoe Kosmas Contact Email:zoe@malaai.org Contact Phone: 808-747-7545 Program Information Program Name:The Hawaii Island School Garden Network Program Years in Operation: 3 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Captain Cook, Hawi, Hilo, Holualoa, Honaunau-Napo'opo'o, Honoka'a, Kailua-Kona, Kapa'au, Kea'au, Kealakekua, Laupahoehoe, Mountain View, Na'alehu, Ocean View, Pa'auilo, Pahala, Pahoa,Volcano, Waikoloa Village,Waimea Program Target Audience:School Age (6-11), Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59) Services/Activities Provided: Educational concerns, Public health and welfare of the people and the environment Amount Applying For: $25000 MALA'AI-The Hawai'i Island School Garden Network I Page 1 Program Details Organization Mission: Founded in 2005, the mission of Mala'ai is to cultivate connections between people, land, culture and food in school gardens. Mala'ai, which also operates the one-acre Culinary Garden of Waimea Middle School, leads the Hawai'i Island School Garden Network (HISGN).The network supports the integration into curricula of school learning gardens by providing teachers with professional development, advocacy, mentorship, and technical assistance. HISGN is part of the state- wide Farm to School Hui. Program Overview: HISGN supports 67 schools on Hawai'i Island (nearly all schools) and over 271 teachers, administrators, cultural practitioners and policy stakeholders. School learning gardens are experiential outdoor laboratories where K-12 students can deepen their relationship to nature, understand and apply STEAM, develop healthy eating habits, incorporate social studies and language arts, perpetuate Hawaiian cultural practices, and learn to become stewards of the land.They also provide a safe space for socio-emotional learning. Since 2012, HISGN has facilitated KO 'Aina Pa (KAP), an intensive school garden teacher training program for Hawai'i DOE PDE3 credit,training 23 educators in 2021. HISGN also conducts educator-focused workshops,facilitates the School Garden Talk Story support group (129 members), and supports teachers through individualized mentorship and technical assistance. Between June 2020-May 2021 we provided 48 hours of direct support to garden educators. Program Objectives & Performances Resources Needed: HISGN's aim is to increase the number of school garden teachers who have the expertise, capacity, and resources to carry out their work. In order to achieve this we need a full time Program Director who can coordinate and improve programs, receive technical assistance requests, participate in state-wide Farm to School activities/advocacy, and forge connections within the network to share resources and best practices.The Outreach Coordinator(8 hours/month) does site visits and maintains our listserve and school roster, and our Administrator manages funds and operations.We provide stipends for educators/facilitators of our PD, workshops, and Talk Story, and we need to bolster our data collection and execute our teacher evaluations which will require outside expertise.We also need an online marketing subscription in order to optimize email communications within our network and different audience members, and scholarship funding to offset PD training costs to teachers and schools. Major Activities to be Completed: Workshops (in-person when possible, online when necessary); professional development including PDE3 opportunities; garden-based learning curriculum development and curriculum training, one-on-one mentorship, talk story sessions, and networking events (in-person when possible, online when necessary); regular communication with the network via mailing list, social media and website about opportunities for learning, available resources, relevant events and current issues. We also support Act 175 and the Hawai'i Farm to School movement in building a more resilient and robust food system in Hawai'i through the continued implementation of the Hawai'i Farm to School Toolkit.The toolkit was developed in 2021 with support from the USDA's Food and Agriculture Service MALA'AI-The Hawai'i Island School Garden Networks Page 2 Learning Program (FASLP).The purpose of this toolkit is to improve access to experiential farm-to-school education for all of Hawai'i's students through systematic integration of farm-to-school programming into school culture. Outputs to be Completed: -Serve 60 Hawai'i Island educators through 4 collaborative workshops. -Support 10 or more teachers in attaining PDE3 professional development credits -Offer 6 School Garden Talk Story sessions throughout the year, reaching 150 teachers state-wide. -Help 270 teachers, educators, administrators, and community members connect through email, social media, and website communications about resources, learning opportunities, and events. -Provide 30 technical assistance consultations between June 2022- May 2023, about 60 hours of support. -Educate over 10,000 Hawai'i Island students across the 67 school gardens. -Develop additional trainings for the Hawai`i Farm to School Toolkit (part of the statewide Food and Agriculture Service-Learning Project). -Begin initial rollout of the School Garden Evaluation Tool with at least 20 teachers across the island to measure and demonstrate the impact of school gardens on students' education,social emotional learning, and future choices. Measurable Outcomes: HISGN's target constituents are teachers and educators, but success is reflected in the success of their students. Our goal is for 80%of teachers to agree or strongly agree that the support they received from HISGN advanced their professional goals and helped them positively impact their students.Another outcome is to eventually have a garden in every school with well-trained and appropriately compensated Garden Teacher.We feel this will lead to all Hawaii Island students producing their own food in school gardens and developing a taste for healthy,fresh, locally grown fruits,vegetables, herbs, edible flowers, and more. In turn,they and their families are learning about Hawai'i's food system, health and nutrition, how to nurture and keep island soils healthy, and in turn how that keeps our oceans and overall ecosystem healthy. Ultimately,young people are engaged and empowered to care for themselves, their families, our island communities, and our'aina for generations to come. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure MALA'AI-The Hawai'i Island School Garden Networks Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Mala'ai Program Name:Hawaii Island School Garden Network CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 25000 25000 Applicant organizational budget: Individual contributions 10000 8000 18000 Membership fees Earned income 8000 2000 10000 Current cash assets Other funding sources (list below): HIPHI Restricted Program Grants 14000 6000 20000 Unrestricted Grants 35000 15000 50000 Restricted Grants 10000 20000 30000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income 108,000 51000 159,000 IN-KIND CONTRIBUTION Anticipated Committed Total office space 5000 5000 Ag resources (soil, worms, seeds, etc 2000 2000 Total In-Kind Contributions $0 $0 7000 TOTAL PROGRAM INCOME $968,911 $400,000 160000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses ;County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ;Organization Name:Mala'ai ;Program Name:Hawaii Island School Garden Network Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages es 15000 85,000 100000 Professional Fees 8000 29,000 37000 Operations 2000 10000 5000 17000 Supplies 0 4000 2000 6000 Equipment 0 167 167 x10%admin included in operations 0 4,400 4,400 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Su 0 20,100 20,100 Corps Member and Alumni Suppc 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 25000 128000 7000 160000 TOTAL PROGRAM BUDGET 40,000 1,328,911 0 160000 C{}Dnt / �]f��/ ^`` � Tl��Y`rwf^ �� 2&22-2n ~ -- -- - Nonprofit Grant -�r ' - -- �� Agency Name: MaUa'ai Program Name: The H ''' Ym|and School Garden Network Certification of Understanding (Page 1 of 2) | hme\ have read and understood all ofthe eligibility[equire[nen\s;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. | ( ) `»«e, agreetmaUmvxthe [ountybheLegislative 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, Ha»vaYi 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.gar, 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 Hawaiel, 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 ofHaw/a]~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 pro pram's or agency's future funding requests. County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Mala`ai Program Name: The Hawaii Island School Garden Network 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 :rant •artici•ation for a minimum of one ear or until a written resort 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. ov/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, 2023 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. 01/29/2022 Signat - of Authorized Person Date Executive Director Title/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Mala`ai Program Name: The Hawai`i Island School Garden Network 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 con lict 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): fl Member or members of the Council (' 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: • I/ If no conflicts exist, check here. 9** 4 • (6)(eck-efl Ve Dfeoltor) Di/219/a09...D... Signature of Authorized Person (specify title) Date MALA`AI The Culinary Garden of Waimea Middle School 171 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: MALA'AI Contact Person:Zoe Kosmas Contact Email: zoe@malaai.org Contact Phone: 808-747-7545 Program Information Program Name:The Culinary Garden of Waimea Middle School Program Years in Operation: 17 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach:Waimea Program Target Audience:School Age (6-11),Adolescence (12-17) Services/Activities Provided: Educational concerns, Culture and the arts, Public health and welfare of the people and the environment,Youth,Victims of Health or Social Crises Amount Applying For: $25000 MALA'AI-The Culinary Garden of Waimea Middle School l Page 1 Program Details Organization Mission: Founded in 2005, the mission of Mala'ai is to cultivate connections between people, land, culture, and food in school gardens.We operate the one-acre Culinary Garden of Waimea Middle School where we grow and share nourishing food in our outdoor living classroom. Our work reaches beyond the boundaries of our garden connecting land stewardship, culture, health and pleasure with lifelong learning. Mala'ai also leads the Hawai'i Island School Garden Network (HISGN). Program Overview: Mala'ai provides hands-on,food-based education to the 207 students of Waimea Middle School (WMS), as well as to teachers, administrators and members of the Waimea community. The Culinary Garden offers a safe, outdoor learning environment that enhances classroom curricula and STEAM learning with real world examples,while helping to improve overall student performance. We utilize the garden as an outdoor living laboratory to reinforce classroom concepts using principles of nature and regenerative agriculture. In response to the pandemic, during the 2020-21 school year, Mala'ai sent home over 1,680 Kokua Kits that included lessons, crops, seeds, and recipes, and produced 7 educational videos that were sent to students via Google Classroom, as well as archived on the Mala'ai website and social media platforms. Mala'ai also enhances community food security; we grew and harvested over 800 lbs. of crops in 2020-21 that were distributed to WMS families,volunteers, and community members. Program Objectives & Performances Resources Needed: Garden Staff(1 FT, 1PT, both receive benefits) responsible for teacher coordination, attending staff meetings and scheduling classes, guest presenters, activity and lesson development, in- person student instruction,volunteer management, record keeping,video creation, garden management and care, after school instruction, quarterly newsletter, social media, special projects and community volunteer days.Volunteers: 3-8 volunteers on a consistent basis assist with classroom instruction,general maintenance of the garden etc.Admin: grant prospecting and management, fundraising. Supplies: include tools, seeds, soil, pest management products, organic amendments, new garden gloves, soap for handwashing, kitchen supplies, and culinary ingredients.The land and water are in-kind donations from Waimea Middle School. PPE and safety supplies are now also required.Technical consultants: provide help with program evaluation, as well as video editing and online/social media data analytics. Major Activities to be Completed: During the 22-23 school year, we will: - Provide garden classes to all WMS students via their Science, Social Studies, 'Ike Hawai'i, and their Basic Practical Arts and Technology classes. - Host special events in the garden for volunteers, community members, and visiting student groups (when possible) bringing in an extra 200 guests. - Produce crops and planting materials and distribute them to students,families,teachers, and the greater community. -Create additional STEAM lesson plans. MALA'AI-The Culinary Garden of Waimea Middle School' Page 2 - Further integrate with the school's'Ike Hawaii program to create culturally relevant lessons. - Bring in presenters who connect careers with STEAM learning. -Attend faculty meetings to provide relevant content and support, as well as track changing educational structures. -Create additional educational videos, post regularly to social media, and maintain the Mala'ai website. - Provide after school opportunities during 3 out of 4 quarters of the school year. Outputs to be Completed: - 100% (approx. 200 students) of our sixth, seventh, and eighth grade students will participate in garden classes via their Science, Social Studies, 'Ike Hawai'i, and their Basic Practical Arts and Technology classes. - Provide over 1,000 hours of student engagement in the garden. - Donate at least 1,500 lbs. of crops and planting material to students,families,teachers, and the greater community. -Achieve at least 400 volunteer hours with 8 regular volunteers. - Host at least 4 community work days - Maintain malaai.org website, email list, and social media to provide program updates and disseminate information to students, families, and interested constituents. Measurable Outcomes:Students spend more time outdoors, eat more vegetables, and find connections between subjects in school and concepts from the garden,therefore improving their performance in the classroom and overall engagement with the food system.At least 75%of all students will demonstrate: -Increase in cultural awareness and sense of place. -Increase in connection to 'aina. -Increase in important life skills. -Increased ability to make healthy choices. -Increase in active learning/academic engagement. In addition, at least 75%of our outgoing eighth grade students will Agree or Strongly Agree that they: - Know mo'olelo, or stories, about Waimea, Kohala, and Hawai'i Island. - Know how to grow traditional foods such as taro, 'uala, bananas, etc. - Believe that they're connected to the ecosystem and they have an impact on its future well-being. - Believe they can do something to make their community better. - Have positive feelings about self, including a sense of achievement. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure MALA'AI-The Culinary Garden of Waimea Middle School I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) - Fiscal Year 2022-2023 Organization Name:Mala`ai Program Name:The Culinary Garden of Waimea Middle School CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 25,000 25,000 Applicant organizational budget: Individual contributions 20,000 10,000 30,000 Membership fees Earned income 4,000 4,000 Current cash assets Other funding sources (list below): Unrestricted Foundation Grants 28,000 10,000 38,000 Restricted Grants 25,500 5,000 30,500 Business and Corporate Contributions 4,000 2,500 6,500 Waimea Middle School Contributions 15,000 15,000 TFA National Investment $531,597 $531,597 Total Cash Income $968,911 $400,000 $1,368,911 IN-KIND CONTRIBUTION Anticipated Committed Total water 600 600 lease and use of 1 acre on campus 10,000 10,000 small garden office space 4,000 4,000 electricity, printing, internet, mailing 400 400 Total In-Kind Contributions $0 15,000 15,000 TOTAL PROGRAM INCOME $968,911 $400,000 164,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Mala`ai Program Name The Culinary Garden of Waimea Middle School Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 20000 100000 120000 Professional Fees 8000 8000 Operations 2000 4000 15000 20000 Supplies 3000 12000 15000 Equipment 0 167 Professional Development 0 1000 1000 10%admin incl.in operations 0 44,815. 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Su 0 20,100 20,100 Corps Member and Alumni Suppc 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 25000 124000 15000 164000 TOTAL PROGRAM BUDGET 40,000 1,328,911 0 164000 County °t ^`iNonprofit Grant Application F- Y ' 022-7n Agency Name: Mala'ai Program Name: The Culinary Garden of WairneaM iddle School Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eliibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- l3S -2'142.l, Havva[| 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 Hawari, 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 time',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, usinq the template provided, will impact the evaluation of your program's oragency's future funding requests. County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Mala'ai Program Name: The Culinary Garden of Waimea Middle School Certification of Understanding (. 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 Count, 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, 2023 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. 01/29/2022 emit, r • Signa.0 re of Authorized Person Date Executive Director Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Mala`ai Program Name: The Culinary Garden of Waimea Middle School 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 con lict 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): E---1 Member or members of the Council El S- taff appointed by a member of the Council n T- he 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: ei If no conflicts exist, check here. '+1". ♦ SXecufi VP_ fedzi f 01/0.9/c),0 ).. Signature of Authorized Person (specify title) Date Malama 0 Puna Food Security Program 172 County of Fiawai`i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Malama 0 Puna Contact Person: Eileen O'Hara Contact Email: malamaopuna@yahoo.com Contact Phone: 8089652000 Program Information Program Name: Food Security Program Program Years in Operation: 2 years Other County grants/agreements:Yes Previously received County GIA: No Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Kalapana, Kapoho, Kea'au, Kurtistown, Leilani Estates, Mountain View, Nanawale Estates, Orchidlands Estates, Pahoa, Pohoiki,Volcano Program Target Audience: Infancy(0-3), Play Age (3-5), School Age (6-11), Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment,Youth, Aged Amount Applying For:$25000 Malama 0 Puna-Food Security Program I Page 1 Program Details Organization Mission: Malama 0 Puna is a Hawai'i non profit 501(C)(3) corporation and volunteer service organization that focuses on environmental health, community sustainability, and stability. Our mission is to protect critical habitat, native species, open spaces and traditional cultural landscapes for future generations through hands-on projects, environmental education, advocacy, and networking. It supports traditional food systems, building community capacity, and beautification/reforestation projects in Puna. Program Overview:With the 2018 volcanic event, Malama 0 Puna (MOP)focused on building greater resiliency in Puna.When the global pandemic hit, our Food Security Program (FSP) became more important in supporting the community with hands-on demonstration projects in Permaculture, instructive programs in planting fruit trees, establishing backyard gardens, and teaching community to maintain and prepare food plants that are part of traditional food production.The FSP is supported with funding from CRFs for a Pandemic Food program for seniors including fresh local produce and meat, providing materials (Tango/Xanthum Gum)for Little Fire Ant control working alongside BIISC, disseminating information to prevent Rat Lung Worm disease, and five field projects under Puna Strong/HIUW grants developing a permaculture urban garden, a YouTube channel with videos on preparing unusual edibles, planting a community fruit orchard, providing materials to establish backyard gardens, and teaching seed/start propagation. Program Objectives & Performances Resources Needed: MOP's Food Security Program is developed by its ED with input from its Board members, all of whom bring expertise to help design/implement the program. A program coordinator is needed to carry out the multiple projects underway and envisioned for this program. Additional assistance is required from staff and contract hire to assist in video recordings shared online, and to help implement; especially when project participants are elderly. We focus on low tech agricultural methods; ways to bring food production to communities through use of materials that are sustainable and don't generate noncompostable waste.We urge participants to reuse materials from sprayers for control of LFA to grow pots/trays to grow future seedlings and starts. We've been fortunate to receive donations of seeds and growing media from local businesses. Our primary financial need is for staffing and contract hire.The work already done on this program has enhanced community networks and resiliency. Major Activities to be Completed: MOP has launched several prototype projects under its Food Security Program including community fruit orchards, backyard gardening, a permaculture demonstration project, provision of seeds&starts, and a project to trial uncommon varieties of Ulu given local production concentrates only on 2-3 varieties while dozens exist. We would like to replicate the projects currently underway in other Puna communities and continue to increase food security, sustainability and resiliency in this district given its high population growth and proclivity towards natural disasters such as volcanic lava flows, hurricanes and flooding. Every project initiated under this program has been very popular with communities who have participated and we wish to continue to replicate which Malama 0 Puna-Food Security Program I Page 2 requires additional staffing and subcontractor support. Many grant sources support this type of program but often restrict funds to materials only, with limited access to funding for support staff. Outputs to be Completed:This program has already launched a fruit orchard of 51 trees planted in the Hawaiian Shores subdivision (1300 parcels/500 active households). The benefits of food production will likely extend beyond those households providing overflow production to the Food Pantry. We are engaged with 15 households in Nanawale providing each 35-70 cubic feet of raised beds,technical support, 3 trays of vegetable starts in 4" pots, and workshops on LFA/RLW. We have created a permaculture demonstration site on 5,000 sq.ft. of land in an urban setting and have hosted 3 one hour educational garden tours each attended by 25-30 persons.The Ulu project will trial unusual varieties and produce 200 plants grown for dissemination to the public.This has been accomplished with limited staff and volunteer energy.We'd like to replicate these projects in Puna requiring additional staff and paid contractors. Over 350 volunteer hours have been donated to MOP to achieve its current program successes. Measurable Outcomes:With a population of over 50,000 individuals in Puna, an area characterized by low to moderate income households, large substandard agricultural subdivisions with land generally classified as subpar for food production, our efforts will help households and communities: 1) create food production systems that work for our environment, 2) help off-set the costs of buying foods primarily imported into the State thus reducing our carbon footprint, 3) ensure greater food security for our population, and 4) create community food hubs and agricultural production networks that help revive food production knowledge that previously existed in our population, but has failed to be passed down to our younger generations.That is why this program has a positive impact on all age groups and will foster better community resiliency if replicated throughout the large subdivisions of Puna. MOP's goal is to replicate and expand its current program and apply to at least three additional communities in Puna. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Malama 0 Puna-Food Security Program I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Malama 0 Puna Program Name: Food Security Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 25000 25000 Applicant organizational budget: $89,000 Individual contributions $56,314 3200 3200 Membership fees 1650 1650 Earned income Current cash assets 2300 2300 Other funding sources (list below): HIUW 2500 $400,000 2500 State DOA 10000 10000 Puna Strong Grant 25000 25000 Kilauea Lava Recovery Grant 25000 25000 TFA National Investment $531,597 $531,597 Total Cash Income 87500 7150 94650 IN-KIND CONTRIBUTION Anticipated Committed Total Equipment 1500 1500 Donated Materials 2500 2500 Total In-Kind Contributions 2500 1500 $0 TOTAL PROGRAM INCOME 90000 8650 98650 Appendix D--Budget Sheets (Page 2 of 2) ,Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ;Organization Name: Malama 0 Puna. Program Name: Food Security Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 10000 6262 16250 Professional Fees 15000 4,369 15000 Operations 0 53250 53250 Supplies 0 8650 8650 Equipment 0 167 1500 1500 Printing, Advertising, and Media 0 4,400 4,400 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 25000 68150 1500 1,368,911 TOTAL PROGRAM BUDGET 40,000 1,328,911 0 94650 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: NAcd IYt C P � j � Pr®gram Name: 17:7-462A, �. 1 � Certification of Under tanding, (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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: V/Alck.„nA--) 1\3+1 Program Name: / 0 ci 6- Certification 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 hiltp:/,/www.hawalicountv.p,ovifn-noriprofit-grara-forrnsi 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, 2023 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. /-6),/2. 4t, Signature of Authorized Person Date X 6)6 6-'41) -6--4-4 Title/Position of Authorized Person County of Havvai`i Nonprofit Grant Application FY 2022-23 Agency Name: M cda 0, 0 'L' Program Name: focA c?c e,1t A.)\` C )71„ ORGANIZATION COFLICT 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 I I Staff appointed by a member of the Council . The Mayor The Managing Director I 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: If no conflicts exist, check here. g: ; - el / / i,.2 ec ,, rec / 'r Signature of Authorized Person (specify title) Date Malama 0 Puna Hawaii Tracker (HT) 173 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Malama 0 Puna Contact Person: Eileen O'Hara Contact Email: malamaopuna@yahoo.com Contact Phone: 8089652000 Program Information Program Name: Hawaii Tracker(HT) Program Years in Operation: 3 Other County grants/agreements:Yes Previously received County GIA: No Program Geographical Reach: `Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'okala, Orchidlands Estates, Pa`auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, 'Umikoa,Volcano,Waikoloa Village,Waimea, Wainaku, Wai'ohinu,Weloka, HT provides a digital product/service that is accessed globally Program Target Audience:Adolescence (12-17), Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Public health and welfare of the people and the environment Amount Applying For: $45000 Malama 0 Puna-Hawaii Tracker(HT)I Page 1 Program Details Organization Mission: Hawai'i Tracker(HT) provides reliable volcano and disaster information for Hawai'i Island in a complementary role to the US Geological Survey and Hawaii County since the 2018 Kilauea eruption, and has been publicly recognized for its work. HT's mission is to sustain a moderated digital information hub for the community,visitors, and principals from the county to share and gather information in near real-time on natural disasters,with a focus on our island's volcanic hazards. Program Overview: HT requests$45,000, under fiscal sponsor Malama 0 Puna,to fund a year-long volcano education and communication campaign for residents and other stakeholders getting information from social media: • Hawai'i Island residents in the eruptive footprints of Kilauea, Maunaloa, and Hualalai are the primary audience. More broadly,the project serves any resident seeking an understanding of volcanic hazards, possible impact zones and the scientific basis behind forthcoming evacuation plans tasked to HIEMA(2021 HI SR51), such as USGS lava inundation maps. • Thousands of travelers use HT for their visit to Hawai'i Island to get questions and concerns answered.The program improves the quality of visits and mitigates misinformation reported in media that contributed to the tourism losses estimated at$415 million island-wide following the 2018 eruption. • HT provides free technical training and consulting in digital communications and social media practices for Hawaii County grant recipients. Program Objectives & Performances Resources Needed:The main need is paid staff, but also production equipment and a suite of editing, broadcasting, and cloud service software. Hawai'i Tracker intends to leverage the past work of two primary principals for this project, Philip Ong and Dane DuPont, who have extensive experience in public information distribution, volcano and hazard messaging, digital communications, and community involvement.The 2021 Puna Strong Grant enabled a content production trial period of 5 months, during which they produced 106 articles, 46 short videos, and 33 live broadcasts, with a cumulative reach of 1,135,879 views and total of 169,016 interactions, spanning two Kilauea summit eruptions. Finally, collaboration with Hawai'i County, Civil Defense and USGS-HVO would greatly facilitate the educational campaign and increase its effectiveness.At minimum, Hawai'i Tracker depends on public postings by official agencies as primary data sources, to be complemented by in-house videography, research and production. Major Activities to be Completed:The principal staff have diverse duties towards this project, including: Volcano education campaign: • Gather information and media from USGS, County, and published research Malama 0 Puna-Hawaii Tracker(HT)I Page 2 • Develop and maintain software to assist in monitoring and production • Author and edit written articles and video scripts • Videography in-studio and on-location; video editing • Live video broadcast preparation (technical and content) and execution • Content distribution, audience engagement and moderation Community outreach: • Participation in Puna Strong Leadership Cohort supporting other grantees • Provide training and consultation in online communication • Promotion of community groups and local events on our platform • Assisting residents and visitors on a case-by-case basis Other: • Increase HT sustainability with grant and ad funding, maintenance and reporting The project remains flexible to adapt equally to sudden volcanic change from non-eruptive periods requiring greater network upkeep. Outputs to be Completed: Provide volcano education content in formats at a pace previously trialed with success as part of the Puna Strong grant, while also empowering other awarded community groups to expand their reach. 1) Produce monthly minimums of 16 written articles,4 live broadcasts, and 4 short videos that expand knowledge of volcanoes on Hawai'i Island. Written articles vary in length, and relate to volcano education, history, preparedness or recovery.Short videos are typically less than 5 minutes, live video broadcasts average 1 hour. 2) Empower Hawaii Island non-profits and community organizations to share their work and local events on HT's platform. Monthly minimum of 1 shared event related to eruption recovery, preparedness, or resilience when possible. 3) Provide individual or group technical training and consulting in digital communications and social media practices for Hawai'i County grant recipients.Yearly minimum of 6 Hawai'i Island based groups for at least 1 hour each. Measurable Outcomes: Over one year,the minimum outcome is 192 written articles,48 live broadcasts, 48 live videos, 12 sharing events, and 6 group trainings. As content is presented online on social media platforms, metrics compiled by each platform and direct feedback from participants through comments and personal messages are our main sources of performance data over the short term. The project's impact can be measured over the grant period both in content reach (views) as well as engagement with the community(likes and comments). Growth of the network can be measured by the number of subscribers across every platform, and analyzed for demographics and geographic coverage. However,there are outcomes beyond a single year intended for this work, namely improved community resilience ahead of and during the next residential-impact eruption.The engagement and response of Malama 0 Puna-Hawaii Tracker(HT)I Page 3 both physical and digital communities at that future time will also serve as a measure of progress since the 2018 eruption. Attachments Program Budget(Income & Expenses) Certificate of Understanding Conflict Disclosure Malama 0 Puna-Hawaii Tracker(HT)I Page 4 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Malama 0 Puna Program Name:Hawaii Tracker - Volcano Education Campaign CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 45,000 45,000 Applicant organizational budget: $89,000 Individual contributions 15,000 15,000 Membership fees Earned income Current cash assets Other funding sources (list below): State GIA 100,000 $400,000 100,000 County Puna Strong Program 15,000 15,000 Corporate $40,000 $40,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income 175,000 $400,000 175,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME 175,000 $400,000 175,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Malama 0 Puna :Program Name:Hawaii Tracker- Volcano Education Campaign Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 40,000 100,000 140,000 Professional Fees 0 3,500 3,500 Operations 500 5,000 5,500 Supplies 0 13,116 13,116 Equipment 0 10,000 10,000 Fiscal administration 4,500 11,500 16,000 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 40,000 1,328,911 0 1,368,911 TOTAL PROGRAM BUDGET 45,000 130,000 0 175,000 County of awai`1.Nonprofit Grant Application FY 2022-23 � Agency Name: ��1G �vic� F3 L-. Program Name: _1:` c t ;re:(_ Certification of Understanding (Page i 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 ljuAiq Agency.Name: /447a, ,/no,- Program Name: 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.havvalicounty.kgvitn-noriprofit-grant-forms1 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, 2023 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. („2/77a-IA-• Signature of Authorized Person Date Title/Position of Authorized Person County of Hawai`i.Nonprofit Grant Application FY 2022-23 Agency Name: i`lcti(61 tc CI) Pt) 1 c • Program Name: _tatoat I ?-ztc._ key 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): I I Member or members of the Council Staff appointed by a member of the Council The Mayor 1 I 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 factor appearance, any conflicts or potential conflicts of interest: If no conflicts exist, check here. e Xec40e l 2� � Signature of Authorized Person (specify title) Date Mental Health Kokua Residential Rehabilitation 176 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Mental Health Kokua Contact Person: Kristy Lungo Contact Email: gpayton@mhkhawaii.org; klungo@mhkhawaii.org Contact Phone: 808-746-5870 Program Information Program Name: Residential Rehabilitation Program Years in Operation: 21 years Other County grants/agreements: Yes Previously received County GIA:Yes Program Geographical Reach: Captain Cook, Hala'ula, Hawi, Hawaiian Acres, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honoka'a, Kailua-Kona, Kealakekua, Kurtistown, Leilani Estates, Mountain View, Village,ikol a Ocean View, Orchidlands Estates, Pahoa,Volcano,W a o g , Waimea Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment, Aged, Physical/Emotional Disabilities, Victims of Crimes,Victims of Health or Social Crises Amount Applying For: $15000 Mental Health Kokua-Residential Rehabilitation I Page 1 Program Details Organization Mission:Through specially designed services and settings, Mental Health Kokua assists people with mental health and related challenges,to achieve optimum recovery and functioning in the community. Program Overview: Mental Health Kokua's Residential Rehabilitation Program is designed to provide a "highly structured residential environment where the primary goals are the treatment of behavioral health needs and the fostering of personal growth leading to personal accountability" (CARF, 2021). MHK's housing structure includes daily classes, counseling, and individual activities. Residents are assigned responsibilities within the therapeutic living community. MHK's group homes "emphasize the integration of an individual within their community, and progress is measured within the context of that therapeutic community's expectation" (CARF, 2021). Services support the residents in their recovery, which consists of reducing symptoms, building resilience, restoring and improving functioning, and supporting the integration of residents into the local community. An individual service plan is developed with resident to include individualized measurable goals. Program Objectives & Performances Resources Needed: MHK's resources for residential services are dependent upon Residential Assistants who serve as direct care personnel, and as a positive mentor in a residential setting for adults with mental illness,who are in recovery, needing assistance with daily living skill, and to help them transition to more independent levels of care. Residential Assistants work as part of a team, maintains effective, positive interpersonal communication and basic problem-solving skills, uses effective oral written and communication skills. Residential Assistants along with senior Residential Assistants manages MHK's group living milieu providing safety, support and advocacy for residents. Residential Assistants participates with clinical supervision to meet MHK's mission to assist people with mental health and related challenges,to achieve optimum recovery and functioning in the community. Major Activities to be Completed: Major activities for Residential Assistants include serving as a caring and understanding mentor assisting residents with daily living skills to maintain tenancy in the community; e.g., paying rent; getting along with peers; basic problem solving; asking for assistance. Maintains a safe, clean, healthy, positive residential milieu,where residents are respected,welcomed, and encouraged as part of recovery,teaching activities of daily living skills, e.g., cooking, personal grooming, and interpersonal relationship communication skills.They respond to emergency situations report incident and complete incident report.They assist with on-going household operations such as shopping, chore planning, residential maintenance, and related safety, health and sanitation measures. Finally, they document in client's records including, progress notes related to service plan, and in clinical records according to MHK policy, including timely entry, and accurate portrayal of services. Outputs to be Completed: MHK's residential outputs are based on the measures of efficiency, effectiveness, access to services, and satisfaction as follows: For efficiency MHK has a statewide housing Mental Health Kokua-Residential Rehabilitation] Page 2 inventory of 258 beds with approximately 232 or 90%occupied monthly. For effectiveness 85%or more residents in MHK's statewide housing achieve their goals and scores on the Independent Living Skills Survey(ILSS). Regarding assess to services 95%of referrals by the Dept. of Health-Adult Mental Health Division (AMHD) are accepted within contract requirements. Regarding satisfaction 85% MHK's residents rate services as above average. Measurable Outcomes: Outcomes for Mental Health Kokua's (MHK) residential program include efficiency, effectiveness, access to services, and satisfaction. Efficiency outcomes include the percent of bed-day occupancy per month. Effectiveness outcomes include the percent of residents who achieve their goals of improving independent function based on goals met and Independent Living Skills Survey ratings. Access to services means the percent of time referrals get into housing after having been determined eligible by the Dept. of Health-Adult Mental Health Division (AMHD). Satisfaction means the ratings by residents scoring above average on MHK's satisfaction scale. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Mental Health Kokua-Residential Rehabilitation I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Mental Health Kokua Program Name:Residential Rehabilitation CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $15,000.00 $15,000.00 Applicant organizational budget: $89,000 Individual contributions $56,314 $56,314 Membership fees Earned income 1,300,000 1,300,000 1,300,000 Current cash assets Other funding sources(list below): Government (State) $400,000 $400,000 Foundations $300,000 $300,000 Corporate $40,000 $40,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income $968,911 $400,000 $1,368,911 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME 1,315,000 1,300,000 1,315,000 Appendix D--Budget Sheets (Page 2 of 2) 'Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 !Organization Name:Mental Health Kokua Program Name:Residential Rehabilitation Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $15,000.00 1,300,000 0 1,315,000 Professional Fees 0 0 0 0 Operations 0 0 0 0 Supplies 0 0 0 0 Equipment 0 0 0 0 Printing, Advertising, and Media 0 4,400 4,400 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings,and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 15,000 1,300,000 0 1,3158,000 TOTAL PROGRAM BUDGET 40,000 1,328,911 0 1,368,911 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: mental Health Kokua Program Name: Residential Rehabilitation amenazZiMENEWSZIESNIZIP Certification of Understanding (Page i 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 anal 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 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.i ov, 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 futuree funding requests. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation 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 berefunded 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) understandthere 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, 2023 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. Qr\-t6C Signature of Authoriz d Person Date Greg Payton,CEO Title/Position of Authorized Person County of Hawa:i`i Nonprofit Grant Application FY 2022-23 Agency Name: Mental Health Kokua Program Name: Residential Rehabiliation 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 1 j 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 tothe 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: IXI If no conflicts exist,check here. QA)./ CEOt2-4,1/14,-,;a, b Signature of Authoriz:d Person (specify title) Date Mental Health Kokua Case Management 177 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Mental Health Kokua Contact Person: Kristy Lungo Contact Email:gpayton@mhkhawaii.org; klungo@mhkhawaii.org Contact Phone: 808-746-5871 Program Information Program Name: Case Management Program Years in Operation: 21 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Captain Cook, Hala'ula, Hawi, Hawaiian Acres, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honoka'a, Kailua-Kona, Kealakekua, Kurtistown, Mountain View, Ocean View, Orchidlands Estates, Pahoa,Volcano,Waikoloa Village, Waimea Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment,Aged, Physical/Emotional Disabilities,Victims of Crimes,Victims of Health or Social Crises Amount Applying For:$15000 Mental Health Kokua-Case Management Page 1 Program Details Organization Mission:Through specially designed services and settings, Mental Health Kokua assists people with mental health and related challenges,to achieve optimum recovery and functioning in the community. Program Overview: Mental Health Kokua's Community Based Case Management Program provides goal-oriented and individualized supports focusing on improved self-sufficiency for the persons served through assessment, planning, linkage, advocacy, coordination, and monitoring activities.Successful service coordination results in community opportunities and increased independence for the consumer. Case Management is provided with person-centered planning and delivered by a team of internal employees of MHK,with the sole purpose of providing case management/services coordination. Services are designed and implemented to support the recovery, health and well-being, enhance the quality of life, reduce symptoms, build resilience, restore and improve functioning and support the integration of the consumer into the community(CARF, 2021). Case managers work with other community providers to develop and individualized support network to assist persons served to achieve optimal recovery. Program Objectives & Performances Resources Needed: MHK's case management resources are provided by case managers with a 25 to 1 staffing ratio, assisting with community-based support for adults recovering from serious mental illness. MHK's case management program offers goal-oriented and individualized supports focusing on improved self-sufficiency for clients through assessment, planning, linkage, advocacy, coordination, and monitoring activities.Successful service coordination results in community opportunities and increased independence for the persons served. MHK's case management coordination is provided as part of MHK's person-centered planning and delivery,that works with clients who are assigned.by MHK by Ohana Health Plan. Major Activities to be Completed: Major activities for Mental Health Kokua's (MHK) case managers include providing follow-up on service linkage and monitoring of case dispositions with continued client support, as necessary.Assess the need for psychiatric and medication evaluations; make appropriate referral consultations with the medical staff. Provide direct treatment services; coordinate services; make referrals; develop treatment plans; monitor and evaluate progress; provide ongoing support; provide intake and assessments; and make necessary changes to treatment plans. Provide transportation to appointments when appropriate. Assist client with budgeting resources when appropriate.Assist in accessing medical and psychiatric care, and attends MED medication management meetings as needed. Provide guidance and assistance in seeking and securing entitlements. Outputs to be Completed: MHK's case management outputs are also based on the measures of efficiency, effectiveness, access to services, and satisfaction as follows: For efficiency MHK's serves more than 879 clients monthly. For efficiency, 85%of clients are seen according to acuity monthly, and about Mental Health Kokua-Case Management I Page 2 80% of behavioral assessment and treatment plans are completed monthly as expected. For access to services, MHK received 95% of referrals per month from Ohana Health Plan according to contract. Finally, more than 85%of MHK's clients receiving case management rate services as above average satisfaction. Measurable Outcomes:Outcomes for Mental Health Kokua's (MHK) case management program also includes efficiency, effectiveness, access to services, and satisfaction. Efficiency for case management is maintaining caseloads of 25 clients to 1 case manager. Effectiveness means contact with each client served per month according to their acuity, as well as percent of timeliness of producing according to contact a behavioral health assessment, a treatment plan, 7-day follow-up post psychiatric hospitalization, and deterring psychiatric re-hospitalization with 30-days. Satisfaction means the ratings by residents scoring above average on MHK's satisfaction scale. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Mental Health Kokua-Case Management I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Mental Health Kokua Program Name:Case Management CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $15,000.00 $15,000.00 Applicant organizational budget: $89,000 Individual contributions 0 $56,314 Membership fees 0 Earned income 935,815 935,815 935,815 Current cash assets 0 Other funding sources (list below): 0 Government (State) $400,000 $400,000 Foundations $300,000 $300,000 Corporate $40,000 $40,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income $968,911 $400,000 $1,368,911 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME 950,815 935,815 950,815 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 -Organization Name:Mental Health Kokua ;Program Name:Case Management Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $15,000 935,815 0 950,815 Professional Fees 0 0 0 0 Operations 0 0 0 0 Supplies 0 0 0 0 Equipment 0 0 0 0 Printing, Advertising, and Media 0 4,400 4,400 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 - 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 • SUBTOTAL 40,000 1,328,911 0 1,368,911 TOTAL PROGRAM BUDGET 15,000 935,815 0 950,815 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Mental Health Kokua Program Name: Case management 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,hawaiicountygov/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, 2023 mustbe returned to the County of Hawai`i with the final report. Failure to return these funds in. 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. / /2 2Li Signature o Autho zed Person Date Greg Payton,CEO Title/Position of Authorized Person County of Hawai‘i Nonprofit (irant Application FY 2022-23 Agency Name: Mental Health.Kokua Program Name: Case Management Certification of Understanding (Pagel of 2) I (we) have read arid 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, Rawail county Code, relating to.. ppropriatiOn of Funds to Nonprofit Organizations. I (We)agree tO-allOwthe 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 supplied herein, inciciding‘all.supporting dOcurrieritS, iS correct and thtl (we) h.pve the authority and.abiiity to fully adminis-ter the progrom(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92.F, Revised Statutes. I (we) understand that applications will not be-:reviewed by County personnel receiving our County NonprofitGrant submittal, and that we have full-responsibility to ensure that all documents are. coMplete and atcurate-prior tO submittal. I (We) understand that all do,cum.en.tsj requiririg-a Current Sign.ature must be.the ORIGINAL;SIGNED document,.Unsigned documents Will be.disqUallfied, Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of I (We).understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payrnent(s):. To register, go to htto.://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.FtawaYi I (we) understandiand will comply with the requirement to submit a year-end report to the:County Council within 6.0: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 grantifurids,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.pro.gram'S or agency's future funding requests: County of I--Iawai'i Nonprofit Grant Application FY 2022-23 Agency Name: Mental Health Kokua Program Name: Case Management ......, _ . , . ,.. , .... . .„..,.... ....... 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 sinned, 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 I 1 Staff appointed by a member of the Council I I The Mayor [1 The Managing Director I 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: IX" If no conflicts exist, check here. __ /26 --- Signature of Autho ed Pe .on (specify title)— CEO I/:24— 0. Date Neighborhood Place of Puna FRC- Family Strengthening Program 179 County of Hawai`i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Neighborhood Place of Puna Contact Person: Paul Normann Contact Email: paul@neighborhoodplace.org Contact Phone: 808-345-3042 Program Information Program Name: FRC- Family Strengthening Program Program Years in Operation: 20 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Kapoho, Kea'au, Kurtistown, Leilani Estates, Mountain View, Nanawale Estates, Orchidlands Estates, Pahoa, Pohoiki,Volcano,Wainaku Program Target Audience: Infancy (0-3), Play Age (3-5), School Age (6-11),Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59) Services/Activities Provided: Educational concerns, Needs of the poor, Public health and welfare of the people and the environment,Youth Amount Applying For: $15000 Neighborhood Place of Puna-FRC-Family Strengthening Program l Page 1 Program Details Organization Mission: Founded in 2002, Neighborhood Place of Puna (NPP) works to ensure families have access to the supports and resources they need to thrive,to raise their children in safe,stable, nurturing, and loving homes. NPP was founded as a family centered, prevention focused response to the high rates of child maltreatment in Puna and the disproportionate removal of children identifying as Native Hawaiian. NPP continually works to expand services for families and deliver those services using best practice Program Overview: Neighborhood Place of Puna is seeking a grant to support our Family Resource Center(FRC) Family Strengthening Program. While the FRC is open to all families with children,The Family Strengthening Program focuses on services to families with younger children where there is some risk for child maltreatment.Younger children (ages 0-5) are the most developmentally vulnerable. The Family Strengthening Program provides more intensive in-home support to help stabilize families in crisis and/or assist parents with young children learning and adopt developmentally expectations, parenting approaches,techniques, and skills. Individualized service plan is developed for families,to address the needs as expressed by the family as well as address needs and develop strengths identified through evidence based screening tools and observation of family functioning. The program also connects families to a wide variety of community resources and supports to help them ' succeed as a family. Program Objectives & Performances Resources Needed: FRC- Family Strengthening Program Staff,Admin Staff support, Facilities, Technology(phones, computers, software, internet, apps), Parenting Curriculum,Screening Tools, Ongoing Staff Training, Office Supplies and Office Equipment, Mileage reimbursement, Insurance, Utilities, Office equipment, Printing, Client supplies (Diapers, Hygiene Supplies, Clothing, Baby Supplies, etc.), community partnerships, etc. Major Activities to be Completed: Case Management, In-Home parenting education,Tele-service parenting education and coaching, Parenting support, Homelessness Prevention and Housing Stabilization, Housing Navigation,Tenancy Skills, Resource Navigation/Connectivity, Family Needs and Safety/Risk Assessments, Parenting skills assessments,ASQ developmental screening, Individualized Service Plan development, DOE Connectivity, Insurance Connectivity, Expectant and New Mom supports, Budgeting,Assistance in acquiring essential documents, Providing Concrete Supports (Diapers, p Clothing, Hygiene Products, Baby Supplies, etc.), Community Education, Cross Agency Service Coordination, Coalition building, etc. Outputs to be Completed: Number of Families receiving on going Family Strengthening Case Management Services, Supports, Resource Connectivity(50), Families receiving a "needs and Safety Assessment" (50), Families Developing and Individualized Service Plan (50), Families who successfully Neighborhood Place of Puna-,FRC-Family Strengthening Program I Page 2 complete their individualized service plan (80%), Families remain free of Child Abuse and Neglect for up to 6 months after completing their service plan (80%). Ongoing Coordination of the East Hawaii Coalition to Prevent Child Abuse and Neglect. 2 Public events to bring awareness to issues around Childhood Maltreatment and Trauma. Measurable Outcomes:The long-term outcomes of the FRC- Family Strengthening Program is to see an Increase in thriving families, a Reduction in incidents of Child Maltreatment, Reduction of Children with ACEs; Increase in children with BCEs (Benevolent Childhood Experiences), Reduction of Family Homelessness, Reduction of ALICE or below families, Reduction in family violence, Reduction in family poverty, Reduction in childhood hunger, Increase in high school graduation rates, community intolerance for family homelessness, poverty, hunger, and violence. Shorter term outcomes include: Families successfully access needed resources. Families acquire basic and essential supplies. Parents apply developmentally appropriate parenting skills. Increased stability and functioning in the home. Families remain or return to being stably housed. Families are successfully connected with needed professional services, Children are connected with DOE. Families/Parents develop essential skills. Families Increase Income. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Neighborhood Place of Puna-FRC-Family Strengthening Program I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Neighborhood Place of Puna Program Name:FRC - Family Strengthening CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 15,000 15,000 Applicant organizational budget: Individual contributions 11,500 11,500 Membership fees Earned income Current cash assets Other funding sources (list below): Blueprint for Change 155,000 155,000 HIUW 5,000 5,000 Foundation Grants 72,000 72,000 Total Cash Income 258,500 258,500 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions 0 0 TOTAL PROGRAM INCOME 258,500 258,500 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Program Name: Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 15,000 207,808 222,808 Professional Fees 3,000 3,000 Operations 24,304 24,304 Supplies 5,000 5,000 Equipment 1,000 1,000 Other: Mileage 2,388 2,383 SUBTOTAL 15,000 243,500 0 258,500 TOTAL PROGRAM BUDGET 258,500 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Neighborhood Place of Puna Program Name: FRC - Family Strengthening Program 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. County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Neighborhood hborhood Place of Puna g Program Name: FRC - Family Strengthening Program 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.govJfn-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, 2023 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. 1/23/2022 Signature of Authorized Person Date Executive Director Title/Position of Authorized Person County of FIawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Neighborhood Place of Puna Program Name: FRC - Family Strengthening Program 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 1 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. fr--------- Executive Director 1/23/2022 Signature of Authorized Person (specify title) Date North Kohala Community Resource Center North Kohala Reunion 180 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: North Kohala Community Resource Center Contact Person: Leslie Nugent Contact Email: info@northkohala.org Contact Phone: 8088895523 Program Information Program Name: North Kohala Reunion Program Years in Operation: 22 years Other County grants/agreements:Yes Previously received County GIA: No Program Geographical Reach: Hala'ula, Hawi, Kapa'au, Keokea, North Kohala Program Target Audience: Infancy (0-3), Play Age (3-5), School Age (6-11),Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Culture and the arts Amount Applying For: $7500 North Kohala Community Resource Center-North Kohala Reunion I Page 1 Program Details Organization Mission: Kohala Reunion Committee has organized the Kohala Reunion every 5 years since 2000.This year, we beckon Kohala kama'aina to come home on July 2,3,4, 2022, to perpetuate our community's values, our traditional beliefs and behaviors. We include Hawaiian history, the missionary period, plantation period, post plantation to present, and the future. It's important for us to share this information with future generations to educate them of the history of North Kohala and to plan for the future. Program Overview: In July 2022,we will host a three day Kohala Community Reunion for people with ties to Kohala.The event, held at Kamehameha Park brings together current and past Kohala residents, visitors from other islands, as well as out of state and international guests. The Reunion features educational displays, tours, and holds space for family and class reunions. Participants enjoy ethnic food booths, cooking and baking competitions including poke, dried fish, and smoked meat contests. Family friendly competitions of tug-o-war, basketball, and kickball are featured. We'll have local music featuring Kohala musicians, Hula dancers, taiko drummers, bon dance, kachi kachi, etc. We partner with many community groups including Sustainable Kohala who specializes in training for zero waste events. Our website, "Kohala Kupa'a", will provide updates on the reunion and an on-line store. We are a sponsored project of North Kohala Community Resource Center. Program Objectives & Performances Resources Needed: Resources needed include our volunteer Kohala Reunion Committee made up of over twenty diverse community members. Committees include: Chairman, Logistics, Registration, Gym displays, Emcee, Food &Craft booths,T-shirts & memorabilia;Tours,Advisor and Historian,Sports, Cowboy Challenge, and more. Kohala Reunion partners with community including the Kohala Hawaiian Civic Club to conduct opening ceremony and a Hawaiian History Display. Kohala Hunters Club provides security and trash control. Entertainment by Halau, local musicians, dance bands, taiko dancers, bon dancers. Gym displays by North Kohala Community Resource Center(NKCRC), Kohala Filipino Club, Churches, and more.Tours to community sites at Kohala Institute at'lole, Kahua Pa'a Mua Farm, Kohala High School, Kohala Hospital and NKCRC. Local businesses advertise in the program book. Kohala Kupa'a website connects people near and far. Financial resources needed include grants, donations, registration fee, and sales. Major Activities to be Completed: "Kohala Kupa'a" website will be launched and will include: Kohala stories, pictures, past reunion memories, Kohala music, businesses, local products for sale, Kohala history, and Kohala reunion information.Tours of Kohala will be arranged with various community partners, including a 50 site self-guided tour. Displays set up in the gym will be hosted by educators, and entertainers will preform outside in tents.The cooking competitions will have applications turned in, North Kohala Community Resource Center-North Kohala Reunion I Page 2 and attendants will sample and vote on favorites. Competitions will be organized and scheduled with practice time included. Keiki activities will be set up each day. Family and class reunions will set up in tents. Committee staff will ensure successful event activities and conduct all data collection and evaluations. Outputs to be Completed:We anticipate 2000 people will attend the reunion over the three days.They will learn and enjoy the experience of Kohala by visiting our gym displays, talk stories,videos,tours, entertainment, dance performances, and food sampling. The event will feature: 10 local food and craft vendors, 10 entertainment groups, 12 family and class reunions, 25 educational displays in the gym, 50 sites on the self guided tour of Kohala, 6 live tours of Kohala sites, 6 food competitions where people get to sample and vote, 5 family friendly competitions. The event brings together current and past Kohala residents,visitors from other islands, as well as out of state and international guests. We will have data of locations from registration forms, and a count from a map with colored tacks for people to tag their home location. We will promote our website "Kohala Kupa'a" and track website views. In 2022,the Kohala Reunion will be completed after 2 postponements due to Covid. Measurable Outcomes:The benefits of the Kohala Reunion include a memorable event to last a lifetime with friends and family. Stories of kupuna and Kohala history captured with video interviews. Kohala's Hawaiian and Plantation day history shared with younger generations. Increased awareness of Kohala's present day activities including the diverse cultural and spiritual community. Increased knowledge of cultural and historical places in Kohala. Cultural and civic values instilled in the younger generation. Strengthened connections among families and between community members. Increased education about zero waste. Opportunity to remember and celebrate those that passed. Documented plans for Kohala's future. Strengthened local economy by bringing back visitors to support VRBO's, restaurants, businesses, and tour companies. Kohala Kupa'a website continues as an on-line hub for North Kohala community with memories, history, and important daily information. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure North Kohala Community Resource Center-North Kohala Reunion! Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) - Fiscal Year 2022-2023 Organization Name: North Kohala Community Resource Center Program Name: North Kohala Reunion CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 7,500 7,500 Applicant organizational budget: $89,000 Individual contributions 2,370 2,370 Membership fees 2,500 2,500 Earned income 2,892 2,892 Current cash assets 9,943 9,943 Other funding sources(list below): HTA CEP Grant 15,000 15,000 Tent and booth rentals 1,650 1,650 $40,000 $40,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income 26,855 15,000 41,855 IN-KIND CONTRIBUTION Anticipated Committed Total Entertainment 2,000 2,000 Oahu Gathering 300 300 Kupuna lei makers 240 240 Fist Aid Station 500 500 Stage Decorations 300 300 Commitee Board 2,000 2,000 Committee Chairpeople 1,208 1,208 Prize donations from local businesses 500 500 Total In-Kind Contributions 7,048 $0 7,048 TOTAL PROGRAM INCOME 33,903 15,000 48,903 Appendix D--Budget Sheets (Page 2 of 2) 'Project Budget Form: Expenses `County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: North Kohala Community Resource Center Program Name: North Kohala Reunion Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 683,140 723,140 Professional Fees 4,369 4,369 Operations 8,300 8,300 Supplies 0 13,116 13,116 Equipment 0 167 167 Entertainment 1300 4958 2000 8,258 Logistics 0 5029 0 5029 Hawaii Johns Lua 0 780 0 780 Fire extinguisher 0 100 0 100 Oahu Gathering 0 0 300 300 Program Book 600 769 0 1369 Prizes 0 0 500 _ 500 Kupuna lei 0 0 240 240 First Aid 0 0 500 500 Stage decorations 0 0 300 300 Advertising 0 500 0 500 T-shirts 0 2500 0 2500 Pens 0 250 0 250 Bags 0 500 0 - 500 Website 5000 5000 0 10000 Postage 0 742 0 742 Carryover 0 10000 0 10000 Insurance 0 322 322 Fiscal Sponsorship 600 1200 0 1800 Security 0 750 0 750 Committe Boards 0 0 2000 2000 Committee Chairmans 0 0 1208 1208 SUBTOTAL 7,500 33,400 7,048 47,948 TOTAL PROGRAM BUDGET 7,500 33,400 7,048 47,948 County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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. County of Ilawai‘i Nonprofit Grant Application FY 2022-23 Agency Name: ovAkik V;AiditA. Co1161v mir7 t \'''-'(-1 -cs' ' Program Name: ,jKAAA Pdt_rsits, &A/NW% Certification of Understanding (Page z 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 htto:fiwww,howaiicourity.govifn-non rofit-Qrant4orrnsi 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 30,2023 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 token 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/ ',/ 1 /9fi' g")— °:nature of Authorized'Ps ssa Dale & - D t(ecitmeic Title/Position of Authorized Person • County or Hawai'i Nonprofit. Grant Application FY 2022-23 (AN, Agency Name: kjoe-ii414'--,(1,, tx-Lc Ccv‘'Ve'2- Program Name: 44--Ar <tAiv,‘ ‘SCNA\Aryl 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 sioned, regordless 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); r Member or members of the Council 0 Staff appointed by a member of the Council The Mayor fl The Managing Director 0 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 on 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, ar 1 9—a g *ture of Authorized Pero (specify title) Date North Kohala Community Resource Center North Kohala Golf Park 181 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: North Kohala Community Resource Center Contact Person: Leslie Nugent Contact Email: Leslie@northkohala.org Contact Phone: 808-889-5523 Program Information Program Name: North Kohala Golf Park Program Years in Operation:4.5 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Kapa'au Program Target Audience:School Age (6-11), Adolescence (12-17), Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Public health and welfare of the people and the environment,Youth, Aged Amount Applying For: $5000 North Kohala Community Resource Center-North Kohala Golf Park I Page 1 Program Details Organization Mission:The mission of the North Kohala Golf Park is to provide a low-cost golf park to the community and to encourage people of all ages to "get out and play". North Kohala Golf Park is a fiscally sponsored project of the North Kohala Community Resource Center(NKCRC) 501(c)3 nonprofit serving the district of North Kohala.The mission of NKCRC is to support successful community projects that benefit North Kohala. NKCRC has been the fiscal sponsor for North Kohala Golf Park since 2017. Program Overview: North Kohala Golf Park(NKGP), located in Kapa'au behind Kamehameha Park, is a recreation area for children to learn and play golf and for people of all ages to practice their skills.The 14 acre, 9-hole course has a putting and chipping practice area, driving range and a recently installed 18- hole Disc Golf Course. In FY 22-23 we will focus on continuing to upgrade our greens, increase community play, host tournaments and community events, and strengthen educational programming. The golf park has been part of this community since the 1990's and has been enjoyed by many. The project is currently managed by volunteers Chelsea and Abe LaFrance. Chelsea is a school counselor and active community organizer and Abe, has worked and played golf since he graduated from high school and currently serves as a Superintendent for the Hapuna Golf Course.Their leadership has established and retained other volunteers from our island's golf industry to help support and maintain the course. Program Objectives & Performances Resources Needed:To carry out our program,we will rely on growing our community volunteer and partnership group. We heavily rely on volunteers to maintain and keep the gates open daily.With growing our community partners, we will build our capacity to be able to continue to provide a low-cost community area.To finish restoring our greens, we will need to complete irrigation installation, remove current greens, aerate and cover with sand, and plant paspalum grass. Machine maintenance is essential to keeping the park open.The care for our aging yet essential machinery will require parts and skilled labor. Another valuable resource is volunteer golf coaches that lead youth instruction as well as volunteers that are available to answer questions about the golf course. Our website and social media presence are the primary way we advertise and ongoing maintenance is required. Major Activities to be Completed: Currentlythe lain conditions on the course are not upto par. We p playing g have been working diligently to replace irrigation to improve the greens. In FY 22-23 we will complete the greens restoration including irrigation, aeration, and replanting. Machines that are essential to our courses functioning and ensuring the safety and accessibility for seniors include a variety of mowers, weed eaters, blowers, a ball washer and more that all require regular maintenance. The park will remain open for community play 7-days a week for 9.5hrs per day to serve residents and visitors alike with discounted rates for seniors and kamaaina. Children under 18 golf for free and we offer free classes for kids and seniors every Saturday.As allowed by Covid restrictions we will begin to offer afterschool and school break programming once again. North Kohala Community Resource Center-North Kohala Golf Park i Page 2 Outputs to be Completed:We will continue to measure outputs by expanding our sign in procedures to include more demographics for reporting reasons. Increase the number of players served to 350 golf and disc golf users each month Expose 100 students to golf education and training Maintain the parks seven main machines Complete the greens restoration for the 9-hole course Obtain four sets of kid's clubs Host quarterly family friendly golf and disc golf tournaments Measurable Outcomes:The main outcomes that will be seen by the public are: -increased exposure to golf as a healthy lifelong sport for individuals of all ages. -encourages seniors to get outside, be active and social, in a safe environment. g improved playing conditions for community players, specifically youth and seniors. -Increase opportunities for families to engage in fun and healthy activities together though participation in low-cost family friendly golf and disc golf tournaments. -increase safe, healthy, outdoor spaces for community of all ages to gather. - increase sense of pride in community by offering well cared for and maintained facilities. -introduce community to a new and fast-growing international sport of disc golf. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure North Kohala Community Resource Center-North Kohala Golf Park i Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: North Kohala Communtiy Rescource Center Program Name: North Kohala Golf Park CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $5,000 Applicant organizational budget: Individual contributions $4,000 Membership fees $2,500 Earned income $10,000 Current cash assets $1 ,900 Other funding sources(list below): Total Cash Income $23,400 IN-KIND CONTRIBUTION Anticipated Committed Total Volunteer Administrator/Program Director $10,000 Grounds maintanence $11,000 Greens Installation $1,000 Equiptment Maint. & Repair $1 ,000 Advertising $100 Total In-Kind Contributions $23,100 TOTAL PROGRAM INCOME $46,500 Appendix D--Budget Sheets (Page 2 of 2) ;Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ,Organization Name: North Kohala Community Resource Center !Program Name: North Kohala Golf Park Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $6,000 $21,000 $27,000 Professional Fees $0 Operations $0 Supplies $1,000 $500 $1,500 Equipment $1,000 $300 $1,300 Other: Admin (8%fiscal sponsorship fee) $400 $400 Greens Instalation and irrigation repair $2,000 $1,000 $1000 $4,000 Equiptment Maintenance & Repair $1,000 $1,000 $1000 $3,000 Fuel $3600 $3,600 Advertisting $100 $100 $100 $300 Youth Golf Clubs *5 sets $500 $300 $800 SUBTOTAL $5,000 $13,300 $23,600 ' $41,900 TOTAL PROGRAM BUDGET 5,000 13,000 23,600 41,900 County of flawai‘i Nonprofit Grant Application FY 2022-23 • /1(e(i) - C0f113.,TurA-t-Nt 11.P.Aaita,(- Agency Name: Program Name: Nocktet C-61 ( Certification of of Understanding (Page 3.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 sipplied 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 Havvari. 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 yia- 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 time/ cam 8lete and accurate ear-end re art usin the ter n,late .rovided will impact the evaluation of your program's or agency's future funding requests. County or Hawal alit Oitut Applik-ation FY 2022-23 dki GC:t"6.' Agency Name: Program Name: Aid(IDA YNO C—O Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawarl, 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 payrnent(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 ear or until a written re,art 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 Np://www.havvaiicounty.goviin-nonprofiuLat 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, 2023 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will hnpact the evaluation of your aqencv'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. nature of Authorized P: son Date Title/Position of Authorized Person County of liawail Nonprofit Grant Application FY 2029-23 1 Agency Name: kjorivl 14401/4 Gismivw;1-y Program Name: Mil-14 Y\ok4N1m. (7-elf padc. --- 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 he 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 signedyreqordles.s 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): Li Member or members of the Council O Staff appointed by a member of the Council El The Mayor El The Managing Director 0 The Director of Finance El The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest Is defined as:a substantial probability that action token 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: liga If no conflicts exist,check here. 1 .,, .,ttire of Authorized Per.• (specify title) 0 Date North Kohala Communtiy Resource Center. HoIola Honey Bee Relocation 182 County of Flawai`i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: North Kohala Communtiy Resource Center Contact Person: Leslie Nugent Contact Email: Leslie@northkohala.org Contact Phone: 808-889-5523 Program Information Program Name: Ho'ola Honey Bee Relocation Program Years in Operation: 5 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Hala'ula, Hawi, Honoka'a, Kailua-Kona, Kalaoa, Kapa'au, Keokea, Kuki'o, Kukuihaele, Pauka'a,_Waikoloa Village,Waimea Program Target Audience:School Age (6-11), Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Needs of the poor, Public health and welfare of the people and the environment Amount Applying For:$7500 North Kohala Communtiy Resource Center-Ho'ola Honey Bee Relocation I Page 1 Program Details Organization Mission: Ho'ola Honey Bee Relocation was organized in 2016 under the sponsorship of North Kohala Community Resource Center (NKCRC), a nonprofit supporting community projects that benefit North Kohala. Ho'ola's mission is to save honey bees and support Hawaii's natural environment and agricultural community.Through bee removal services and education, Ho'ola has relocated 150 bee colonies, decreasing the number of pollinators killed each year in Hawai`i in order to secure a sustainable, local food system. Program Overview: Ho'ola Honey Bee Relocation program provides free and prompt swarm catching services in the Kohala district, as well as humane structural removal and relocation services of established bee colonies throughout the North Hawai'i Island at sliding scale fees based on need. Depending on variables, each live bee removal incurs costs averaging$800 to cover equipment, fuel, and 20+ hours of labor. Unfortunately, many property owners are unable to afford the full costs of these services. In order to prevent detrimental extermination attempts and to mitigate potentially unsafe bee situations, currently over half of yearly bee removals are performed voluntarily by Ho'ola beekeepers, limiting the number of requests the team can accommodate.The program is seeking funding to continue offering this necessary and important service to community members as well as to create 3 educational videos that will help build value and increase support for the work and expertise required by beekeepers. Program Objectives & Performances Resources Needed: Key resources needed for bee relocation services include full time beekeepers, new protective bee suits, liability insurance, reliable transportation and fuel, maintenance of the current program website. Post relocation, Ho'ola facilitates a hive rehabilitation program to ensure relocated colonies remain healthy and disease free.The program has secured hive equipment and tools for removals from existing structures, however relies heavily on volunteer labor, community donations and grant funding. Partnerships are a key, Ho'ola maintains good rapport with pest control companies, State of Hawaii Vector Control, and island wide beekeepers who regularly send referrals. Ho'ola hopes to build on its partnerships with educators in Hawaii schools by providing educational resources to be shared with students and community members. To produce educational videos, Ho'ola will work closely with a professional videographer and editor to create and share engaging, inspiring content centered on bees. Major Activities to be Completed:Activities to be completed include: Receiving and responding to bee removal inquiries in a timely manner On-site assessments of hives and bees in undesirable area Risk assessment and strategic planning of removal process to ensure safety and success for each removal Removal of all comb and relocation of bees to desirable locations for pollination North Kohala Communtiy Resource Center-Ho'ola Honey Bee Relocation I Page 2 Sealing and filling of cavity post removal to prevent future bee infestations Proper handling of honey and brood comb following hive removal Education and dissipating unwarranted fear associated with bees Addressing public safety and health concerns related to bees and beekeeping Working with videographers to plan and produce educational videos relating to bee rescue, a pollinator pledge, and a children's video from a Hawaiian perspective on bees. Disseminate videos across a wide and diverse cross section of the community across various platforms. Track the number of views to measure effectiveness. Outputs to be Completed: 24 hives rescued 1.2 million bees relocated 4 apiary sites strategically placed Pollinating a 5 mile radius for each unique apiary location, totaling 50,000 acres for each site 3 educational videos created and shared with 15 agencies including local schools and community partners. Measurable Outcomes: Beneficial outcomes to the public include: More sustainable pollinator friendly practices Increased pollination for farmers in Kohala Increased knowledge about bees and beekeeping careers for younger generation Increased community awareness of bees as an ally not a threat Reduced poison and pesticide use Increased food security Increased pollinators Strengthened Community network and partners Protection of natural resources Increased value and appreciation for important pollinators Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure North Kohala Communtiy Resource Center-Ho'ola Honey Bee Relocation Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:€North€Kohala€Community€Resource€Center€(NKCRC) Program Name:€Hoola€Honey€Bee€Relocation CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 7500 7500 Applicant organizational budget: Individual contributions 1500 1500 Membership fees 0 Earned income 0 Current cash assets 0 Other funding sources(list below): Bee€Removal€Income€from€sliding€fE 12000 12000 Fundraising 12000 12000 HCF€West€Hawaii€Fund 5770 5770 Total Cash Income 33000 5770 38770 IN-KIND CONTRIBUTION Anticipated Committed Total Voluntary€Labor 20000 20000 In-Kind€Videography 5000 5000 Total In-Kind Contributions 25000 25000 TOTAL PROGRAM INCOME 33000 30770 63770 Appendix D--Budget Sheets (Page 2 of 2) !Project Budget Form: Expenses tCounty of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 organization Name:€North€Kohala€Community€Resource€Center€(NKCRC) Program Name:€Hoola€Honey€Bee€Relocation Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 4800€ 13800 €20000 38600 Professional Fees 600€ 500 € 1100 Operations 1900 10220 €12120 Supplies €200 €1470 1670 Equipment 0 167 0 Educational€Video€Series€ 0 5000 5000 10000 €Advertising€and€website 0 €280 €280 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Su 0 20,100 20,100 Corps Member and Alumni Suppc - 0 12,767 12,767 National Support 0 531,597 531,597 • SUBTOTAL €7500 31270 25000€ TOTAL PROGRAM BUDGET 1,328,911 0 63770 County of liawai‘i Nonprofit Grant Application FY 2022-23 Agency Name: A0(44\- Y-Attati— "FvoLAtur-- , . , Program Name: 00010,- 1--101 toc.Ava- Certification of aderstanding (Page lof 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 timelyz_complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. County ofTiawai'i Nonprofit Grant Application FY 2022-23 Novcv, Agency Name: 1\itiait ,k C6'01rA'i CI Program Name: 4Oc2 41) e<6" 1. Ci ID CA-1-10n t I Certification of Understanding (Page 2 of 2) It 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). 1 (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 httu://www.hawalicouuty.Rovifn-nonprofit-grant-for ins/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 30,2023 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will im.act the evaluation a our a enc '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. • io4 AA./ // /g-61 g )—• •.;nature of Authorized P: s a Date Title/Position of Authorized Person Comity u.nictwai .1quripro:nt Grant Application FY 2022 23 Agency Name: t\jtekti VolifvAitok (u Zvi ' 1'�'ca Program Name: Po'0 -To n Dee Re f"Cd1' 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): (l Member or members of the Council Staff appointed by a member of the Council f The Mayor The Managing Director The Director of Finance I I 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. Iure of Authorized Pero (specify title) Date Orchidland Neighbors Multi-Purpose Community Complex 184 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Orchidland Neighbors Contact Person:Virginia Aste Contact Email: info@orchidlandneighbors.org Contact Phone: 808-854-1225 Program Information Program Name: Multi-Purpose Community Complex Program Years in Operation: 6 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Orchidlands Estates Program Target Audience: Infancy (0-3), Play Age (3-5), School Age (6-11),Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment Amount Applying For: $50000 Orchidland Neighbors-Multi-Purpose Community Complex I Page 1 Program Details Organization Mission: Orchidland Neighbors (ON)was created in 2015, as a 501(c)(3) organization in order to create a multi-purpose community complex with a meeting house, kitchens, offices, emergency supply storage, a market, a food basket, and recreation areas that will enhance community resiliency. ON distributes food each month to 200 families and has distributed food and emergency supplies at a church. ON to continue to call upon experienced and licensed contractors to design the project. Program Overview: ON is seeking funds to grade and fence as much of a four-acre parcel on 36th St. off Orchidland Dr. as possible.This is the future site of a community complex to house existing and future programs and activities for residents of Orchidland and communities in the Puna District. Grading and fencing the site is necessary to allow accurate placement of buildings and utilities and to secure the site as building proceeds. ON has consolidated two two-acre lots, registered with the Bureau of Conveyances, completed a grading survey, received a grading permit and completed the archeologicalsite survey. ON has already received $10,000 toward grading. ON will select contractors with sufficient expertise. Any infrastructure in Orchidland for community use will have a ripple effect on all six areas of the CHANGE program since it will provide a venue for a variety of programs for residents of all ages.The site selected is in Lava Zone 3 having a significantly lower threat level. Program Objectives & Performances Resources Needed:The resources needed are that ON will need to secure bids from at least two contractors for grading.The contractors will provide expertise and equipment for the project. ON will need funds to pay for the selected bid for grading. ON will secure bids from at least two contractors for fencing.The contractor will provide expertise and equipment for the project. ON will need funds to pay for the selected bid for fencing. ON will invite volunteers to assist in clearing the property. ON will invite volunteers to spread gravel and create a walkway around the site. Major Activities to be Completed: ON Board of Directors will review the bids, sign contracts, oversee the performance of the selected contractors on the scope of work per the approved grading and fencing plan and pay the contractors. ON Board of Directors will supervise volunteers. Outputs to be Completed: Four acres cleared, graded and fenced with work to be done by contractors following a scope of work as determined by the ON Board of Directors. Walking path graded,gravel spread on path by volunteers. Measurable Outcomes:After grading and fencing of the four acres are completed, the public will see that the project is going forward, and the site is being prepared for construction of a multipurpose complex in Orchidland.The grading and fencing will provide the delineation of site, safety of equipment Orchidland Neighbors-Multi-Purpose Community Complexi Page 2 and materials on site.As stated before, any change or addition to infrastructure will produce a ripple effect through areas of the CHANGE lens. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Orchidland Neighbors-Multi-Purpose Community Complexi Page 3 Program Budget Form: Income County of Hawaii m Nonprofit Grant-in-Aid (Waiwai Grant)—Fiscal Year 2022-2023 Organization Name: Orchidland Neighbors Program Name: Multi-Purpose Community Complex- Budget. 'CASH Anticipated Committed Total County Nonprofit Grant-in-Aid(Waiwai Grant) 50,000.00 50,000.00 • Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources(list below): Total Cash Income 50,000.00 50,000,00 IN-KIND CONTRIBUTION Anticipated Committed Total Grading - Puna Strong Grant 10,000.00 10,000.00 Volunteers 10 @ $17 per hour x 10 1,700.00 1,700.00 Total In-Kind Contributions 1,700,00 10,000.00 11,700.00 TOTAL PROGRAM INCOME 51,700.00 10,000.00 61,700.00 Appendix D--Budget Sheets(Page 2 of 2) 1;1 'h I, !'" Project Budget Form: Expenses County of Hawaii ® Nonprofit Grant-in-Aid (Waiwai Grant)—Fiscal Year 2022-2023 Organization Name: Orchidland Neighbors Program Name: Multi-Purpose Community Complex- Budget. Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages Professional Fees Operations Supplies Equipment Grading 15,000.00 15,000.00 Fencing 35,000.00 35,000.00 Puna Strong Grant-Grading 10,000.00 10,000.00 SUBTOTAL 50,000.00 10,000.00 60,000.00 TOTAL PROGRAM BUDGET 50,000.00 10,000.00 60,000.00 County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Or ch iculct jh )ori Program Name: IA i.4 i.f-i - Pu_r Fri 5e Lc vit y earn pi —" 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. County of flawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Orchtaia.ncAP.1 bor.5 Program Name: MAI 'i PU.r 5e. dovaimLt.ri E Cory?_-. r1 X 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:f/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, 2023 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 i f Authorized Person Date ! 7 Title/Position of Authorized Person 1 , County of awai`i Nonprofit Grant Application FY 2022-23 Agency Name: c levo( . N bo(5 Program Name: M.64,tt i-aurpose ' oryirrt unityIle A 'IZATION CONFLICT CIS*SURE 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 } f 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. Signature of Authorized Person (specify title) Date PETFIX Spay and Neuter Spay and Neuter Clinics 186 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: PETFIX Spay and Neuter Contact Person: Beate Neher Contact Email: petfixbigisland@gmail.com Contact Phone: 808-989-4075 Program Information Program Name:Spay and Neuter Clinics Program Years in Operation: 2 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau- Napo'opo'o, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kea'au, Kealakekua, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O`okala, Orchidlands Estates, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pepe`ekeo, Pohoiki, Puako, Volcano, Waikoloa Village, Waimea, Wainaku, Wai'Ohinu Program Target Audience:Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided:,Public health and welfare of the people and the environment Amount Applying For:$20000 PETFIX Spay and Neuter-Spay and Neuter Clinics I Page 1 Program Details Organization Mission: PETFIX Spay and Neuter works to protect Hawaii's environment by providing safe and professional spay and neuter services on the Big Island at free clinics. We educate the public about the impact of pet overpopulation and the welfare of animals across the island. Our experienced leadership team has enabled significant success during our 2 years of operation. Each of the 5 board members has from 15 to 40 years of experience in animal welfare and/or nonprofit administration. Program Overview: PETFIX will conduct 7 spay/neuter clinics for small animals with requested project funds. Clinics will be conducted at no cost to pet owners. At least 4 of the clinics will be conducted in Ka'u, the county's largest district and one of its poorest. In-person outreach and education will be conducted at the Ocean View flea market to prioritize participation by lower-income pet owners and raise awareness of pet overpopulation issues. Additional outreach and education will be conducted online. Each clinic will sterilize approximately 50 animals. PETFIX will spay or neuter at least 350 animals during the funding period. Agency-wide, over 2,300 animals were fixed in in 2021 and over 1,500 in 2020. Program Objectives & Performances Resources Needed: • Veterinarians and vet techs • Trained volunteers • Pet owners and community volunteers • Animals • Supplies • Clinic facilities • Community donations • County non-profit grant funds Major Activities to be Completed: • Conduct free spay/neuter clinics. • Spay or neuter animals. • Maintain an active volunteer base, including pre-veterinarian students. • Conduct outreach events to raise awareness of the impacts of pet overpopulation. Outputs to be Completed: • Conduct a minimum of 7 free spay/neuter clinics during the project period. • At least 4 clinics will be conducted in the low-income Ka'u district. • Spay or neuter at least 350 animals during the project period. • Maintain an active volunteer base sufficient for 80 volunteer hours per clinic. • Distribute information to raise project awareness at 12 in-person events in Ka'u during the project year. • Create online publicity for each clinic. Measurable Outcomes: • More animals will be spayed and neutered; a minimum of 350 animals will no longer be able to reproduce and cause harm to public health or the environment. PETFIX Spay and Neuter-Spay and Neuter Clinics I Page 2 • At least 200 low-income pet owners will have their pet sterilized free of charge through 7 clinics and be free of the financial burden of caring for unwanted animals. • An estimated 3,500 unplanned, potentially feral animals will be prevented in the first year of the project. • PETFIX will sustain its mission by maintaining an active volunteer base. • Volunteers will share knowledge of animal overpopulation efforts with community members. • A greater number of community members will be educated about and act on animal overpopulation efforts • Fewer unwanted animals will be born or placed in shelters. • Fewer animals will cause harm to public health or the environment • Spay/neuter clinics will expand to additional areas of the island Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure PETFIX Spay and Neuter-Spay and Neuter Clinics I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: PETFIX Spay and Neuter Program Name: Spay and Neuter Clinics CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 20000 20000 Applicant organizational budget: $89,000 Individual contributions 1000 1000 Membership fees Earned income Current cash assets Other funding sources (list below): Government (State) $400,000 $400,000 Foundations $300,000 $300,000 Corporate $40,000 $40,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income 21000 $400,000 21000 IN-KIND CONTRIBUTION Anticipated Committed Total Volunteers @$20/hour @ 80 hours/clinic @ 7 clinics 11200 11200 Total In-Kind Contributions 11200 $0 11200 TOTAL PROGRAM INCOME 32200 $400,000 32200 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses ;County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ;Organization Name: PETFIX Spay and Neuter ;Program Name: Spay and Neuter Clinics Nonprofit Expense Description (Waiwai) Other Cash In-Kind TOTAL Source Contribution Grant Salary Wages 0 0 11200 11200 Professional Fees 17500 0 0 17500 Operations 0 0 0 0 Supplies 2500 1000 0 3500 Equipment 0 0 0 0 Printing, Advertising, and Media 0 4,400 4,400 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 20000 1000 11200 32200 TOTAL PROGRAM BUDGET 20000 1000 11200 32200 . County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: PETFIX Spay and Neuter Program Name: Spay and Neuter Clinics 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 Nonprofit Organizations. to g 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 authorityto examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, orprogram for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correctand 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 CountyNonprofit 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 requirementto 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 requirementto 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, willimpact the evaluation of your program's or agency's future funding requests. County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: PETFIX Spay and Neuter Program Name:Spay and Neuter Clinics 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 fromfuture 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. Informationand 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 purposesstated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2023 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, insuranceor securities) on private properties unless otherwise authorized by law. 0 By signing below, you are acknowledging that you have read and understood these requirements. 1/24/22 Jan 24,2022 Signature of Authorized Person Date President Title/Position of Authorized Person • County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: PETFIX Program Name:Spay and Neuter Clinics 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 duplicateas 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 CouncilThe Mayor The Managing n DirectorThe 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 potentialconflicts of interest: X If no conflicts exist, check here. 1/24/22 Beate Neher(Jan 24,2027.16:23 HST) Signature of Authorized Person (specify title) Date President Title/Position of Authorized Person Pohaha I Ka Lani Kahuli 187 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Pohaha I Ka Lani Contact Person: Kulia K.Tolentino-Potter Contact Email: pohahaikalani@gmail.com Contact Phone: 808 937 4243 Program Information Program Name: Kahuli Program Years in Operation: 20 years Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, Hakalau, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Honoka'a, Kalapana, Kapa'au, Kea'au, Kukuihaele, Kurtistown, Laupahoehoe, Mountain View, Na'alehu, Pa'auhau, Pa'auilo, Pahoa, Puako,Volcano,Waikoloa Village, Waimea Program Target Audience: Infancy(0-3), Play Age (3-5),School Age (6-11), Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth, Aged, Physical/Emotional Disabilities, Victims of Crimes,Victims of Health or Social Crises Amount Applying For: $50000 Pohaha I Ka Lani-Kahuli I Page 1 Program Details Organization Mission: Pohaha I Ka Lani's mission is to revitalize and advance indigenous Hawaiian culture. Program Overview: POhaha I Ka Lani was established in 2001 and conducts place-based land stewardship, cultural education, and community engagement at sacred places surrounding Waipi'o Valley(Hamakua District) and 'Ola'a (Puna District) on Hawaii Island. We offer the community meaningful, enriching opportunities to malama 'aina and understand the significance of the different wahi pana. Due to COVID-19, many families have been dealing with socioeconomic and personal challenges, such as loss of jobs, income, depression, anxiety, and social connections. Our programs are designed to help with nurturing, providing knowledge needed for healthy social and emotional development to empower their self-esteem, self-confidence, self-control, problem solving, self-sufficiency, focus, patience,good communication skills, and empathy.These skills play a critical role in a family's and individual's overall wellbeing. In addition, we will continue to donate food, PPE, home essential items to families in need. Program Objectives & Performances Resources Needed: For our malama 'aina section of this program, additional staff is needed to help us with preparing the site to ensure tools,tables, chairs and other items utilized by volunteers are sanitized to ensure safety for all. Staff members are also needed to assist with group hostings to allow us to comply with gathering sizes. For example, some days,we received over 80 volunteers and we need to split volunteers into smaller groups to ensure safety for all.We are currently stewarding 2100+acres and need assistance with our community gardens that we are growing food to help families. We also need funding to purchase heavy duty machines to help with preparing areas to plant. Currently we are digging large guinea grass clumps with picks and it is really difficult to do. A machine could save us the time and energy. For our assistance to families, we really need a building for our hub. We had large heavy duty tents but it got stolen and others broke due to weather conditions. Major Activities to be Completed:The project looks to further embody the translation of Pohaha I Ka Lani, which is the emergence of intelligent stewardship to perpetuate and advance Hawaiian resources.As the Waipi'o Valley rimlands are our organization's largest and newest land stewardship, at over 2,100 acres, in addition to the parcels we steward in Waipi'o Valley, a sustainable social and economic model is needed to care for them in perpetuity. The project aims to establish a sustainable, eco-conscious stewardship model that engages participants in co-stewardship and facilitates reciprocal and respectful connections that will benefit both 'aina and kanaka. We aim to provide a safe space for individuals to come and learn, and be part of a great cause Pohaha I Ka Lani-Kahuli I Page 2 while receiving the benefits of such involvement.Volunteers will also help with our gardens in which we are growing food to help feed many families.We will continue to provide food, PPE and home essential items to families in need. Outputs to be Completed:Through the Kahuli Program, • 500 individuals will participate while working with a minimum of 12 organizations. • 40 volunteers per month with an average of 3 hours served by each volunteer. • Host 12 different organizations • 1,440 hours served by volunteers • 6 farmers supported • 10,000 square feet of invasive species cleared. • 100 outplanted native plants Measurable Outcomes: Pohaha I Ka Lani proposes the continuation and expansion of cultural stewardship of the culturally, ecologically, and geographically areas under our stewardship in and above Waipi'o Valley. Pohaha I Ka Lani will serve a minimum of 500 individuals and work with a minimum of 12 organizations. We will continue to have safety protocols in place to ensure safety of all.The core of this propsal is to implement a model stewardship program that would ensure the continued, expanded and sustainable stewardship of important Waipi'o Valley overall sites while including a holistic opportunity for many to participate and benefit from. Through these efforts, individuals will be provided with a safe space to assist with establishing of a sustainable, eco-conscious stewardship model. Which will provide benefit to the 'aina and kanaka while ensuring we work towards a sustainable food system, keeping our people healthy and providing a solid foundation for our upcoming generations. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Pohaha I Ka Lani-Muni Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Pohaha I Ka Lani Program Name: Kahuli CASH Anticipated Committed Total County Nonprofit Grant-in-Aid(Waiwai Grant) $50,000 $50,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets S15,000 $15,000 Other funding sources (list below): Total Cash Income IN-KIND CONTRIBUTION Anticipated Committed Total HPA Students& Staff(Monthly Volunteer $13,450 $13,450 Hours) UHH & HCC Students & Staff(Monthly $27,000 $27,000 Volunteer Hours) Pahoa High School Students& Staff(Monthly $7,000 $7,000 Volunteer Hours) Community Members of Mahiki Donating Native Plants That They Grew To Be Planted $1,000 $1,000 in Waipi`o Valley Rimlands Ava Fujimoto-Strait, John Strait& Sam $4,000 $4,000 Houston State University Students (Visiting 1 - 2 a year,Volunteer Hours) GIVE Volunteers (Spring, Summer and Winter $25,000 $25,000 Groups averaging 15 in each group, estimated of 15+ groups) Rustic Pathways Summer Programs. Average $13,430 $13,430 120 volunteers Total In-Kind Contributions $49,430 $41,450 $90,880 TOTAL PROGRAM INCOME $99,430 S56,450 $155,880 Appendix D--Budget Sheets (Page 2 of 2) • Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: Pohaha I Ka Lani ;Program Name: Kahuli Nonprofit Expense Description (Waiwai) Other Cash In-Kind TOTAL Grant Source Contribution Salary Wages Project Assistant $22,000 $15,000 $30,000 Professional Fees Volunteer Help $89,880 $89,880 HR Fees $3,000 $3,000 Equipment Landstewardship tools,battery powered $5,000 $5,000 Operations Plants $3,000 $1,000 $4,000 Honorarium $6,000 $6,000 Supplies, Land Stewardship $4,500 $4,500 Supplies, Fuel $4,000 $4,000 Supplies, PPE $1,000 $1,000 Supplies, Misc $500 $500 Small Tools $1,000 $1,000 SUBTOTAL $50,000.00 $15,000 $90,880 $155,880 TOTAL PROGRAM BUDGET County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Pohaha I Ka Lani Program Name: Kabuli 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 toAppropriationofFunds toNonprofitOrganizations. 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 inspectanyfacility,equipment,property,orrecordspertinenttothegrant,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)pursuantto 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 responsibilityto ensure thatall 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. Ifawarded agrantfromthe CountyofHawai`i,I(we)understand and will complywith the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.qov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. Ifawarded agrantfromthe Countyof Hawaii,I(we)understand and will complywith the requirement tosubmitavear-end reporttothe CountyCouncilwithin 60daysafterJune30ofthecontractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awardi ng 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 otherfunding 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 request. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Mafia I Ka Lani Program Name: Kahuli Certification of Understanding (Page 2 of 2) Ifawarded agrantfromthe CountyofHawai'i,I(we)understand thata 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 specificallyand explicitly indicates thattheCountyofHawai'iisan additional insured prior to receiving any payment(s). I(we)understandthatfailuretosubmitthefinal reportwithin60days ofJune30thshall result in loss of all grant funds received durinothe grant period(must be refunded to County)and exclusion from future grant participation fora minimum of one year or until awritten report is submitted to,and accepted by, the council. I(we)understand there is no provision forfurthernotification tosubmitthefinal report.Information and instructions are available athttp://www.hawaiicounty.gov/fn- nonprofit-grant-forms/on orabout 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,exceptfora maximum ten percent(10%)for administrative and overhead costs.Anyfunds unused byJune 30,2023 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 ofvouragencv's future funding request and mav 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. 01/24/22 Signature of Authorized Person Date President Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Pohaha I Ka Lani g Y Program Name: Kahuli ORGANIZATION CONFLICT. DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, oradministratorofyourorganization may have with the County of Hawai`i.Onlythose 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: Ronald Jake Sykes POSITION: Legislative Assistant for Ashley Kierkiewicz May have a conflictorpotential conflictof interest,including anyfam ilial relationship,with anyofthe following (check all that apply): 14 Member or members of the Council n Staff appointed by a member of the Council n The Mayor ❑ The Managing Director n The Directorof Finance n The Corporation Counsel,the Assistant Corporation Counsel,ora 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: Ronald Jake Sykes has abstain from participation in writing this grant including email discussions, and/or providing information etc. ❑ If no conflicts exist, check here. ItLI„.4.../<02644.„ President 01/27/22 Signature of Authorized Person(specifytitle) Date 1 Project Vision Hawaii HiEHiE Homeless Outreach 188 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Project Vision Hawaii Contact Person: Darrah Kauhane-Floerke, Executive Director Contact Email: darrah@projectvisionhawaii.org Contact Phone: 808-201-3937 Program Information Program Name: HiEHiE Homeless Outreach Program Years in Operation: 3 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Hilo, Kailua-Kona, Pahoa Program Target Audience:School Age (6-11),Adolescence (12-17), Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Needs of the poor, Public health and welfare of the people and the environment Amount Applying For:$45000 Project Vision Hawaii-HiEHiE Homeless Outreach I Page 1 Program Details Organization Mission: Project Vision Hawaii works in partnership with the people of Hawaii to promote health, happiness and dignity for all. Our success in reaching vulnerable populations comes largely because of two unique components: (1)we bring health and human services directly to access- challenged communities via mobile service units; and (2) services are always 100%free of charge to participants. HiEHIE delivered 5,942 showers at 670 events statewide in 2021,which was a 62% increase in showers over 2020. Program Overview: HiEHiE mobile hygiene increases access to clean water, which is considered a basic human right by the World Health Organization. In addition to the daily difficulties of finding meals and shelter, while keeping themselves and their belongings safe, individuals who are homeless must find water for drinking and bathing.The opportunity to take a hot, private shower and access clean facilities restores dignity and emotional wellbeing for our guests. In addition to access to showers, mobile outreach increases access to preventative care and general wellness to enable a higher quality of life. The ADA-accessible hygiene trailer has three compartments with a private shower, sink, and toilet; a utility room; and outdoor covered space. Staff members, partners and volunteers follow Covid-19 guidelines for safety, cleaning, and social distancing. In 2021, HiEHiE delivered 2,323 showers at 207 events in Hilo and Kona. Program Objectives & Performances Resources Needed:The resources needed to carry out this program include program staff, administrative support,truck and hygiene trailer, fuel, supplies, insurance and registration, event facilities, and funding. Staffing includes the mobile manager, community health workers, drivers, and custodians. We are investing in technology to improve mobile data management and patient follow-up. The resources of collaboration and partnerships are essential to this work. We currently offer shower events at Hilo Salvation Army, Pahoa County Building, and Old Kona Airport.These locations provide facilities and water hook-up, enabling a regular schedule of shower events for continuity of care. Current funders support staffing and program costs including Office of Housing and Community Development, County of Hawaii; Hawaii State Legislature; Zilber Foundation; and Kaiser Permanente. Project Vision pursues a diverse revenue base of public and private sources to ensure sustainability. Major Activities to be Completed: Project Vision and partners will coordinate health and wellness events in Hilo and Kona. Hygiene services will benefit people experiencing homelessness by providing access to hot, private showers.The opportunity to shower with toiletries and a clean towel restores dignity and emotional wellbeing for our guests. Further, washing with soap is a positive health behavior that protects individuals from a range of diseases and infections. At each event, staff members greet shower guests and conduct the intake process. Guests share any immediate issues or concerns, as part of an informal triage process. Participants access on-site services or referrals for general vision screenings, Covid-19 tests and vaccinations, glucose tests, diabetes Project Vision Hawaii-HiEHiE Homeless Outreach! Page 2 retinopathy screenings, and blood pressure tests. Over months of visiting the same locations,we get to know shower users, build trust, and help them identify resources toward wellness and stability. Outputs to be Completed:This project will increase access to health care and hygiene services using the mobile service delivery approach. The outputs related to this objective are: ▪ Provide 2,000 showers to people experiencing homelessness ▪ Coordinate 200 community outreach events in Hilo and Kona I7 Offer primary health care,vision care, dental care, and mental health services through referrals and partnerships with local service providers ▪ Develop systems to support services, referrals, data management, and partner relationships Measurable Outcomes: People experiencing homelessness in Hawaii County will increase access to healthcare and hygiene support to help them achieve a higher quality of life.The organizations that assist our homeless community will increase coordination and collaboration around the many issues faced by this population. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Project Vision Hawaii-HiEHiE Homeless Outreach I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Project Vision Hawaii Program Name:HiEHiE Homeless Outreach CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 45,000 45,000 Applicant organizational budget: $89,000 Individual contributions 23,569 23,569 23,569 Membership fees Earned income 290,931 147,273 290,931 Current cash assets 2,027,003 2,027,003 Other funding sources (list below): Corporate & Foundation Contributions 1,547,255 501,000 1,547,255 Government Grants & Contracts 2,396,657 1,467,952 2,396,657 Special Event 114,935 114,935 Miscellaneous Revenue 166,887 166,887 TFA National Investment $531,597 $531,597 Total Cash Income 4,585,234 2,139,794 4,585,234 IN-KIND CONTRIBUTION Anticipated Committed Total Not applicabe Total In-Kind Contributions 0 0 0 TOTAL PROGRAM INCOME 4,585,234 2,139,794 4,585,234 Appendix D--Budget Sheets (Page 2 of 2) ;Project Budget Form: Expenses County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 'Organization Name:Project Vision Hawaii Program Name:HiEHiE Homeless Outreach Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 36,000 125,690 161,690 Professional Fees 0 4,369 4,369 Operations 0 8,300 8,300 Supplies 9,000 6,055 15,055 Equipment 0 167 167 Mileage, Parking, Fuel 0 14,400 14,400 Utilities, Laundry, Waste Disposal 0 8,400 8,400 Indirect (10% De Minimus Rate) 0 15,455 . 15,455 Telecommunications 0 3,973 3,973 Transportation, Meetings,and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 45,000 170,000 0 215,000 TOTAL PROGRAM BUDGET 45,000 170,000 0 215,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Project Vision Hawaii Program Name: HiEHiE Homeless Outreach 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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.hawaiicountu.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, 2023 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 24, 2022 Darrah Kaunane-Boerke dar:25,2072 09:00 HST) Signature of Authorized Person Date Darrah Kauhane-Floerke, Executive Director Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Project Vision Hawaii Program Name: HiEHiE Homeless Outreach 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: x❑ If no conflicts exist, check here. �I,►� January 24, 2022 7S'1'0, -STi Signature of Authorized Person (specify title) Date Darrah Kauhane-Floerke Executive Director, Project Vision Hawaii Puna Canoe Club Keiki Wa'a Camp 189 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Puna Canoe Club Contact Person:Andrea M Kaawaloa-Okita Contact Email: akaawaloa@yahoo.com Contact Phone: (808) 640-0743 Program Information Program Name: Keiki Wa'a Camp Program Years in Operation: Zero-This program will merge components from the organizations existing programs. Other County grants/agreements: No Previously received County GIA: No Program Geographical Reach: Hilo, Kalapana, Kea'au,Volcano, Keauhou Forest Program Target Audience:Adolescence (12-17) Services/Activities Provided: Culture and the arts, Public health and welfare of the people and the environment,Youth Amount Applying For:$50000 Puna Canoe Club-Keiki Wa'a Campj Page 1 Program Details Organization Mission: Puna Canoe Club, since its establishment, has completed many ventures and administered an array of funding. Overseeing members include professionals and program experts. Together, the organization has the necessary expertise to complete this program which aims to expand the club's mission of educating community members in the culture of outrigger canoe paddling in hopes that it will, not only, strengthen then members and the broader community but also ensure the perpetuation of Polynesian traditions. Program Overview: Puna CC is requesting funding to implement a Keiki Wa'a Camp which is a multifaceted educational program,to include 'ohana (family) days,that will serve 60 haumana (students); 30 haumana during Fall intersession (October 2022) and 30 during the Spring intersession (March 2023). Each session will consist of three hui (group) of 10 haumana. Hui 'ekahi (1)will be instructed in 'olelo Hawai'i (Hawaiian language). Hui 'elua and 'ekolu (2 &3) will be instructed in English but designed for different age groups; Hui 'elua -high school and Hui 'ekolu - intermediate. Age- appropriate curricula will be developed by educators to enhance haumana knowledge of the wa'a culture while fostering leadership and personal growth necessary to sustain this rich cultural heritage into the future. In addition,this project will include five 'ohana days, designed to increase positive 'ohana bonding while immersed in wa'a related activities such as native koa outplanting, safety training, and canoe paddling. Program Objectives & Performances Resources Needed: Puna CC would require the following: -Staff: * 1 Program Coordinator(Project management skills and expertise in outrigger paddling) * 1 'Olelo Hawai'i Kumu (Hawaiian language speaking teacher knowledgeable in curriculum development and wa'a traditions) * 2 Kumu (Teachers knowledgeable in curriculum development and wa'a traditions) * 3 Kumu Kako`o [Educational Assistants (EA)] * 6 Alaka'i (Haumana selected from the October camp to serve as leaders in March) * Photographer/Videographer(Assist with oral histories) * 2 'Ohana Day Kako'o (EA with in-depth padding experience) * Resource Experts (Kupuna/Kahuna) * 2 Kumu (Experts in paddle making) -Supplies & Equipment: * Wa'a * Uniforms (Each haumana will receive uniforms for identification and safety purposes) * Lunches (Each haumana & staff will receive lunch, snacks, and drinks daily) * Video Equipment (For the collection of oral histories) * Hoe Kits (40) * Graduation Item (For haumana upon completion) Puna Canoe Club-Keiki Wa'a Camp Page 2 * 2 CPR/AED supplies Major Activities to be Completed:The Kumu who has designed the camp include Haunani Keamo, `Olelo Hawai'i Kumu at Ke Kula 'o Nawahiakalani'opu'u with 16 years of teaching and culture-based STEM curriculum development skills; Alana Cabatu, English Kumu, and Principal for Ke Kula Kauwela (summer school) at Kamehameha schools with 21 years of teaching; and Andrea Kaawaloa-Okita, Retired Park Ranger with the Division of Interpretation and Education at Hawaii Volcanoes National Park.The camp will include the following major activities: - Haumana will learn: * History of the wa'a * Wahi pana (significant place-names) of the area * Na mahele wa'a (part names) of the wa'a and hoe (paddle) * Rigging techniques for affixing an ama (float)to a wa'a * Wa'a etiquette and paddling technique - Haumana will collect oral histories from kupuna (elder experts) with genealogical ties to the local wa'a culture. * Haumana and 'ohana will engage in wa'a related activities: * Planting of native koa trees * Hoe making * CPR/AED training Outputs to be Completed: By activity, haumana will complete the following: - History Output: Research illustrations of ancient wa'a. -Wahi pana Output: Review historic maps and learn the mo'olelo (significance) of 10 place names. - Na mahele wa'a Output: Learn 15 of the 24 parts of the wa'a and hoe. - Rigging technique Output: Learn how to prepare the lashing, measure the boom and affix the ama. -Wa'a etiquette and paddling technique * Output 1: Learn the significance of a wa'a and hoe and what is appropriate when in-and-around a wa'a. * Output 2: Learn how to launch a wa'a and basic paddling technique. -Oral History * Output 1: learn the importance of collecting oral histories, interview design and techniques. * Output 2: Interview 12 kupuna/kahua - Paddle making Output: High school haumana will make a paddle -CPR/AED Output: 20 haumana will be trained in CPR/AED - 'Ohana will: * Output 1: Engage in paddling * Output 2: Plant native koa * Output 3: Learn water safety techniques Measurable Outcomes:This Wa'a Keiki Camp will enroll 60 youth and engage countless 'ohana in a uniquely designed program that will provide its participants with a broad understanding of the historical Puna Canoe Club-Keiki Wa'a Camp I Page 3 significance of the wa'a along with the many traditions associated with this ancient Hawaiian practice. Likewise,the camp will promote leadership by providing a forum where haumana can interact with kupuna to capture — and in-turn share — the rich history and traditions of the wa'a culture as practiced on Hawai'i Island. Puna CC believes that this camp will not only unite multiple generations and foster leadership but also provide an educational platform where learning and collaboration will be conducted in both English and 'Olelo Hawaii. Considering a native language encapsulates generations of traditional knowledge, customs, and traditions,the organization felt it vital to incorporate a 'Olelo Hawai'i hui into the camp design. Both English and Hawaiian speaking haumana will benefit from the interaction. Attachments Program Budget(Income & Expenses) Certificate of Understanding Conflict Disclosure Puna Canoe Club-Keiki Wa'a Camp j Page 4 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Puna Canoe Club Program Name: Keiki Wa•a Camp (and •Ohana Days) CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $49,892.25 $49,892.25 Applicant organizational budget: Individual contributions 8,500.00 8,500.00 Membership fees $15,928.00 $1,046.00 $16,974.00 Earned income $1,800.00 $1,800.00 Current cash assets $24,513.00 $42,549.56 $67,062.29 Other funding sources(list below): GRANT: Cooke Foundation TBD TBD GRANT: Office of Hawaiian Affairs TBD TBD Total Cash Income $ IN-KIND CONTRIBUTION Anticipated Committed Total All In-Kind contributions to the project r 0.00 0.00 0.00 been included on the Project Budget R Total In-Kind Contributions $0.00 TOTAL PROGRAM INCOME $144,228.54 Appendix D--Budget Sheets (Page 2 of 2) !Project Budget Form: Expenses `County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ,Organization Name: Puna Canoe Club . .......... Program Name: Keiki Wa•a Camp (and •Ghana Days) Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 0.00 0.00 0.00 0.00 Professional Fees $5,350.00 0.00 $900.00 $6,250.00 Operations $3,197.25 0.00 $910.00 $4,107.25 Supplies $18,515.00 0.00 $9,400.00 $27,915.00 Equipment $5,500.00 0.00 $5,000.00 $10,500.00 Stipend - in lieu of salary $17,330.00 0.00 $13,050.00 $30,380.00 for support of the following: 44,815 44,815 Coordinator, Kumu, Kumu Kako'o 0 2,167 2,167 and Alaka•i 0 3,973 3,973 Transportation, Meetings,and Subsistence 0 20,100 20,100 Note: Professional Fees will supp 0 12,767 12,767 Professional PhotographerNidea 0 531,597 531,597 and Resource Experts (kupuna & Note: Puna Canoe Club has recei grants to support other projects. Although those requests were scoped and approved for other ix they will likely include expenses tl will serve as additional in-kind contributions to this project. SUBTOTAL 49,892.25 0.00 29,260.00 79,152.25 TOTAL PROGRAM BUDGET 40,000 1,328,911 0 79,152.25 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Pu1(1& Ca-inoea G v b Program Name: 1?e1 ,J l3afa_ C.c ry p 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 programfor 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 abilityto•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 wehave full responsibility to ensure that all documents are complete andaccurate prior to submittal. I (we)understand that ail documents requiring a current signature must be the ORIGINAL,SIGNED document. Unsigned documents will be disqualified. Faxed`or:copied documentswill 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-endreport to the County Council within 60 days after June 30 of the contractual year for which thegrant: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. County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Puhdi-.) Coe Club Program Name: ttei K o u_VaL,Camp 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 inloss 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.eov/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 30,2023 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 aaencv's future funding reauest and may result in actions takento 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. VA 7/ P' 19- Signature of Authorized Person • Date rs ( CC Title/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Puna.) Cc de> G vb Program Name: lei :ai ua'ct, Ca-i-'' - 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. / 9/ Signature of Authorized Person (specify titl r Date Salvation Army, a California corporation: DBA; The Salvation Army-Family Intervention Services, The Independent Living Skills Program — East Hawaii 191 County of Hawai i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:The Salvation Army, a California corporation: DBA;The Salvation Army-Family Intervention Services Contact Person: Roxanne Costa Contact Email: roxanne.e.costa@usw.salvationarmy.org Contact Phone:808-959-5855 Program Information Program Name: Independent Living Skills Program—East Hawaii Program Years in Operation: 22 years Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Eden Roc, Fern Acres, Fern Forest, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Honoka'a, Kalapana, Kea'au, Kurtistown, Laupahoehoe, Leilani Estates, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'okala, Orchidlands Estates, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa`ikou, Pauka'a, Pepe'ekeo, Pohoiki,Volcano, Wai'Ohinu Program Target Audience:Adolescence (12-17),Young Adulthood (18-39) Services/Activities Provided: Educational concerns, Needs of the poor,Youth Amount Applying For:$10000 The Salvation Army, a California corporation: DBA;The Salvation Army-Family Intervention Services-Independent Living Skills Program-East Hawaii I Page 1 Program Details Organization Mission: For nearly five decades The Salvation Army Family Intervention Services (TSA-FIS) has successfully provided services to youth throughout Hawaii Island, fulfilling its mission 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 to succeed,youth must feel a sense of belonging to their community, culture, peers and within their families. Program Overview:The Independent Living Skills Program (ILSP) is part of Independent Living Skills— Higher Education-Imua Kakou (IHI) Programs that serve current and former foster youth-and young adults who have exited the Children Welfare system.The ILSP targets youth and young adults ages 12- 26, helping them develop and acquire essential skills to transition into adulthood.We assist youth and young adults in areas of education, employment readiness,transportation and personal/social skill building, increasing support networks so they are empowered to achieve self-sufficiency. A strength-based model is utilized to assess and address needs of youth and young adults while working with the Department of Education, alternative learning centers, University of Hawaii, workforce/housing programs, Family Court Judiciary Guardian Ad Litems and other service providers.These partnerships are critical in our efforts to achieve positive outcomes for young people who have experienced foster care. Program Objectives & Performances Resources Needed:To successfully carry out this program, we will need staff,transportation, technology, money, additional resources for young adults exiting the program and training opportunities for a staff resiliency hub as needed. Major Activities to be Completed:TSA-FIS staff provide ILSP services that include: Presentation of Life Skills curriculum and positive alternative activities for young ages 12-17 Extensive case management for youth ages 18-21 for the Imua Kakou Program Case management for young adults ages 18-26 for Higher Education program to support post-secondary education Outputs to be Completed: • 3 full-time staff recruited • 1 additional full-time employee or volunteer incorporated into program • 245 current and former foster youth served annually The Salvation Army,a California corporation: DBA;The Salvation Army-Family Intervention Services-Independent Living Skills Program—East Hawaii! Page 2 Measurable Outcomes: A comprehensive program for current youth in care and young adults(former and foster youth) Access to services and support that address education, employment,finances, health care, safety and wellness, housing and social capital Preparation for transitioning out of care and progressively navigating through adulthood to become successful and self-sufficient contributing members of society Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure The Salvation Army, a California corporation: DBA;The Salvation Army-Family Intervention Services-Independent Living Skills Program—East Hawaii l Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:The Salvation Army-Family Intervention Services ....... ......... Program Name: Independent Living Skills Program - East Hawaii CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 10000 10000 Applicant organizational budget: $89,000 Individual contributions $56,314 $56,314 Membership fees Earned income Current cash assets Other funding sources (list below): Department of Human Services 91038 $400,000 91038 Foundations $300,000 $300,000 Corporate $40,000 $40,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income 101038 $400,000 101038 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME 101038 $400,000 101038 Appendix D--Budget Sheets (Page 2 of 2) ;Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ianiz Or g ' ation Name.The-Salvation Army-Family Intervention Services 1Program Name: Independent Living Skills Program - East Hawaii ' Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 40,000 75000 75000 Professional Fees 1200 2000 3200 Operations 4600 10838 15438 Supplies 2400 2000 4400 Equipment 0 167 167 Program Activities 1800 1200 3000 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings,and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 10000 91038 0 101038 TOTAL PROGRAM BUDGET 10000 91038 0 101038 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: The Salvation Army-Family Intervention Services Program Name: Independent Living Skills Program- East Hawaii 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 htto://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. County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: The Salvation Army-Family Intervention Services Program Name: Independent Living Skills Program- East Hawaii 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, 2023 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. 1/27/2022 Signature of Authorized Person Date Divisional Commander Title/Position of Authorized Person •ti County of Hawa> Nonprofit Grant Application FY 2022-23 Agency Name: The Salvation Army-Family Intervention Services Program Name: Independent Living Skills Program - East Hawaii 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 If no conflicts exist,one form for a conflict is needed. need to be disclosed.One form per person with li 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 ❑ 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: 1 1 2 If no conflicts exist, check here. i]ivisional Commander 1/27/2022 Signature of Authorized Person (specify title) Date Salvation Army, a California corporation: DBA; The Salvation Army-Family Intervention Services, The Project TLP Hilo 192 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:The Salvation Army, a California corporation: DBA;The Salvation Army-Family Intervention Services Contact Person: Roxanne Costa Contact Email: roxanne.e.costa@usw.salvationarmy.org Contact Phone: 808-959-5855 Program Information Program Name: Project TLP Hilo Program Years in Operation: 5 years Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honoka'a, Kea'au, Kurtistown, Laupahoehoe, Leilani Estates, Mountain View, Nanawale Estates, Orchidlands"Estates, Pahoa, Papa'ikou,Volcano Program Target Audience:Young Adulthood (18-39) Services/Activities Provided: Educational concerns, Needs of the poor,Youth Amount Applying For: $10000 The Salvation Army,a California corporation: DBA;The Salvation Army-Family Intervention Services-Project TLP Hilo l Page 1 Program Details Organization Mission: For nearly five decades The Salvation Army Family Intervention Services (TSA-FIS) has successfully provided services to youth throughout Hawaii Island, fulfilling its mission 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 to succeed,youth must feel a sense of belonging to their community, culture, peers and within their families. Program Overview: Research demonstrates that vulnerable young adults,youth transitioning from foster care and those living in unstable situations comprise one of the fastest growing groups of homeless individuals.TSA-FIS is committed to helping young adults overcome barriers to independent living and self-sufficiency by providing stability, housing and education. With support and collaboration of our local programs, we help young adults get a fresh start in their lives. For example, we subsidize the rental fee for those who are eligible for a 6-month period, with possible extension as needed.With our support,young adults 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 essential as they transition to independence. Our programs ultimately help these young adults achieve both short and long-term goals for sustainable housing. Program Objectives & Performances Resources Needed:To successfully carry out this program,we will need additional staff, money (emergency housing funds),technology, increased network of property managers/landlords who offer affordable housing for former foster youth aging out of care and additional financial literacy programs in the community. Major Activities to be Completed:Staff provide 6 months of rental assistance for at-risk young adults Staff help youth develop skills and resources to acquire and maintain safe and affordable housing: (compiling housing and building rental history; monthly budgeting; establishing savings for rent and other housing expenses after program completion; home management skills, including general cleaning, cooking, etc. Outputs to be Completed: • 1 full-time staff recruited • 1 part-time employee or volunteer engaged at 60 hours per month/720 hours per year • 8-10 transitioning former foster youth served Measurable Outcomes:A supportive house program for young adults aging out of Child Welfare Services The Salvation Army, a California corporation: DBA;The Salvation Army-Family Intervention Services-Project TLP Hilo I Page 2 Access to subsidized housing for 6 months that focuses on: decreasing homelessness among one of the most at-risk groups for becoming homeless Young adults equipped to become self-sufficient and successfully maintain safe and adequate housing on their own. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure The Salvation Army,a California corporation: DBA;The Salvation Army-Family Intervention Services-Project TLP Hilo I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:The Salvation Army-Family Intervention Services Program Name: Project TLP Hilo CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 10000 10000 Applicant organizational budget: $89,000 Individual contributions $56,314 $56,314 Membership fees Earned income Current cash assets Other funding sources(list below): Hawaii Community Foundation GEIST 75000 $400,000 75000 Foundations $300,000 $300,000 Corporate $40,000 $40,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income 85000 $400,000 85000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME 85000 $400,000 85000 Appendix D--Budget Sheets (Page 2 of 2) !Project Budget Form: Expenses ;County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 ;Organization Name:The Salvation Army-Family Intervention Services ;Program Name: Project TLP Hilo Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 40,000 25000 25000 Professional Fees 1200 1000 2200 Operations 4800 11800 16600 Supplies 2000 1200 3200 Equipment 1000 167 1000 Program Activities 1000 36000 37000 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 10000 75000 0 85000 TOTAL PROGRAM BUDGET 10000 75000 0 85000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: The Salvation Army-Family Intervention Services Program Name: Project TLP Hilo 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.sov,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. �. County of Hawai > Nonprofit Grant Application FY 2022-23 Agency Name: The Salvation Army-Family Intervention Services Program Name: Project TLP Hilo 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 30,2023 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. � --� 1/27/2022 Signature of Authorized Person Date Divisional Commander Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 202223 Agency Name: 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 Nawai'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. Divisional Commander 1/27/2022 Signature of Authorized Person (specify title) Date Salvation Army, a California corporation: DBA; The Salvation Army-Family Intervention Services, The Puna Prevention and Outreach Programs 193 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:The Salvation Army, a California corporation: DBA;The Salvation Army-Family Intervention Services Contact Person: Roxanne Costa Contact Email: roxanne.e.costa@usw.salvationarmy.org Contact Phone: 808-959-5855 Program Information Program Name: Puna Prevention and Outreach Programs Program Years in Operation: 22 years Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Eden Roc, Fern Acres, Fern Forest, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Kapoho, Kea'au, Kurtistown, Laupahoehoe, Leilani Estates, Mountain View, Nanawale Estates, Orchidlands Estates, Pahoa,Volcano Program Target Audience:School Age (6-11),Adolescence (12-17),Young Adulthood (18-39) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth,Aged, Physical/Emotional Disabilities, Victims of Crimes,Victims of Health or Social Crises Amount Applying For:$20000 The Salvation Army,a California corporation: DBA;The Salvation Army-Family Intervention Services-Puna Prevention and Outreach Programs Page 1 Program Details Organization Mission: For nearly five decades The Salvation Army Family Intervention Services (TSA-FIS) has successfully provided services to youth throughout Hawaii Island,fulfilling its mission 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 to succeed,youth must feel a sense of belonging to their community, culture, peers and within their families. Program Overview:The Puna Prevention and Outreach Programming provides a safe and nurturing environment along with access to opportunities, experiences, and services to support positive youth development, along with prevention of substance use and other risky behaviors. Using a prevention approach, services are offered to youth ages 10-21 and their families residing in Puna communities. 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. Program Objectives & Performances Resources Needed:To successfully carry out this program,we will need staff,transportation, technology, money, training opportunities for staff, additional resilience hubs in the community, continued evaluator services for ADAD contract, curriculum materials, parenting support, resources for emergency needs for families and incentives. Major Activities to be Completed:Staff deliver combination of prevention and outreach services that address substance use prevention, school non-attendance/truancy prevention, community-based outreaching to youth/families and positive youth development. Major activities include.: Implementation of evidence-based Botvin LifeSkills Training (LST) curriculum to school aged through Young Adults Implementation of the Stanford Toolkit Electronic Smoking Device (ESD) Prevention curriculum to upper Elementary to high school students Delivery of parent education and family strengthening workshops and activities Delivery of Positive Alternative Activities Implementation of Case Management Referrals to resources Community collaboration Outputs to be Completed: 3 full-time staff recruited 1 additional full-time staff engaged 315 youth served The Salvation Army,a California corporation: DBA;The Salvation Army-Family Intervention Services-Puna Prevention and Outreach Programs I Page 2 At least 60%of 189 families of youth participants'families served Measurable Outcomes: Prevention services that promote positive youth development, prevention of substance use, family strengthening and school community connectedness. Increased school attendance and decreased truancy in Puna schools Decreasing high numbers of underage drinking and ESD among youth and young adults through education for youth and parents Engaged families in community resources and supports Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure The Salvation Army, a California corporation: DBA;The Salvation Army-Family Intervention Services-Puna Prevention and Outreach Programs I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:The Salvation Army-Family Intervention Services Program Name: Puna Prevention and Outreach Programs CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 20000 20000 Applicant organizational budget: $89,000 Individual contributions $56,314 $56,314 Membership fees Earned income Current cash assets Other funding sources (list below): DOH ADAD Substance Abuse Prevention 115000 $400,000 115000 Foundations $300,000 $300,000 Corporate $40,000 $40,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income 135000 $400,000 135000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions $0 $0 $0 TOTAL PROGRAM INCOME 135000 $400,000 135000 Appendix D--Budget Sheets (Page 2 of 2) ,Project Budget Form: Expenses `County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 `Organization Name The Salvation Army-Family Intervention Services ;Program Name: Puna Prevention and Outreach Programs Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 40,000 82435 82435 Professional Fees 1800 8815 10615 Operations 6200 19390 25590 Supplies 5000 1200 6200 Equipment 1000 2160 3160 Program Activities 6000 1000 7000 Rent, Utilities, and Occupancy 0 44,815 44,815 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 20000 115000 0 135000 TOTAL PROGRAM BUDGET 20000 115000 0 135000 County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: The Salvation Army-Family Intervention Services Program Name: Puna Prevention and Outreach Programs 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: The Salvation Army-Family Intervention Services Program Name: Puna Prevention and Outreach Programs AMIN 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, 2023 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. 1/27/2022 Signature of Authorized Person Date Divisional Commander Title/Position of Authorized Person County of I Hawai`i Nonprofit Grant Application FY 202223 Agency Name: The Salvation Army-Family intervention Services Program Name: Puna Prevention and Outreach Programs 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 on 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 conflicts of interest: ® If no conflicts exist, check here. Divisional Commander 1/27/2022 Signature of Authorized Person(specify title) Date Society for Kona's Education & Art Art Camps for Children and Teens 196 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Society for Kona's Education &Art Contact Person: Susan B. Rice Contact Email: susanrice@hawaii.rr.com Contact Phone: 80808-328-9392 (office) or 808-896-5858 (cell) Program Information Program Name:Art Camps for Children and Teens Program Years in Operation: 30+ Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Honaunau-Napo'opo'o Program Target Audience:School Age (6-11),Adolescence (12-17) Services/Activities Provided: Culture and the arts,Youth Amount Applying For: $5000 Society for Kona's Education&Art-Art Camps-for Children and Teens' Page 1 Program Details Organization Mission:With a focus on South Kona,the Society for Kona's Education &Art serves the people of Hawai'i Island by providing arts &educational opportunities through programs, projects, & events that contribute to a vibrant community. We are a 501c3 community organization founded in 1981 by a group of young families who wished to provide education in the arts for their own &others' children. Our site includes 2 historic buildings w. space for an office, pottery studios, &2 large rooms for classes. Program Overview:SKEA will offer day camps in the arts during the fall, winter,spring, &summer school breaks. Dates are Oct.3-7 & Dec.19-20, 2022; Mar.13-17, &June 5-23, 2023,from 8:30am -1:45 pm,for a total of 27 days of camp. Camps provide a fun learning experience in the arts for children ages 6-11,taught by experienced teaching artists. Curriculum includes a variety of activities: painting&drawing, collage, mixed media, pottery, dance, creative movement, music,theatre arts, magic, &yard games. December camp will focus on making things to give as gifts. H.S. students are hired &trained to act as counselors&teaching assistants, &the onsite supervisor is a DOE teacher.The quality of instruction is high &students are able to produce an excellent body of work that is on display at the end-of-camp performance (maybe). The County Holomua grant allowed us to purchase a large sturdy tent for outdoor classes& lunch. We have 2 large, airy rooms w.fans, &will follow all health guidelines. Program Objectives & Performances Resources Needed: SKEA has been offering art camps for 30+years, and we have a format, physical space, and personnel in place so that we can carry out a successful program. County funding will.be used for professional fees for teaching artists and program director, hourly wages for teen counselors, marketing, administration of the program, and art supplies. Program personnel:We will need 4 teaching artists per day(they will teach more than one day, usually, for multi-day projects), a program director, and an on-site supervisor(may be the same person).-we have a roster of 12+teaching artists that we can call on to teach in the art camps,and 4 people who have experience as the program director and on-site supervisor. We will hire 5 high school students to act as camp counselors.The SKEA administrative assistant will handle registrations and marketing. b. art supplies: pottery clay, implements, paint, brushes, paper, canvas, and other good quality art materials. Major Activities to be Completed: Up to 25 students (when allowed) will attend each week.The program director hires the personnel and works with the artists in designing the curriculum.The Society for Kona's Education&Art-Art Camps for Children and Teens! Page 2 students will have 4 hours of instruction each day in the arts; pottery, dance, creative movement, drama, music and mixed media projects in the visual arts have been offered in the past. Students also really enjoy time in the yard for recess and outside games with the counselors . Marketing of the art camps is done through press releases to the newspapers; social media; website calendars, our roadside sign, email updates, and word-of-mouth and bulletin boards in our small community. Program registrations are completed on our website and over the phone and in person. At the end of each camp,we will have a performance and gallery show of student work for family and friends (if covid protocols allow.) Outputs to be Completed: 25 students will attend each camp; many will be returning students, so up to 100 individual student will have the opportunity to attend. Of those students, some are siblings, so up to 75 families will benefit. Economically, 12-15 local artists will have teaching jobs and 10-15 teens will gain job experience. Measurable Outcomes:The hands-on nature of our regular in-person art camps is an excellent vehicle for building self esteem andconfidence,through creating something tangible and expressive. Learning in the arts engages children,who are naturally and freely artistic, and enhances their learning in other areas of the curriculum and life.Working with quality artistic materials produces good results and gives students confidence in their creative abilities, as does instruction by professional artists who can connect with students. The end of camp performance and gallery show is a time of socialinteraction with other families and friends in the community.Art camps engage the artistic community of South Kona, as some of them go on to offer workshops at our site or teach in our school program. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Society for Kona's Education&Art-Art Camps for Children and Teens i Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Society for Kona's Education & Art (SKEA) Program Name:Art Camps for Children and Teens CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 5,000 5,000 Applicant organizational budget: Individual contributions 2,000 2,000 Membership fees 700 700 Earned income 6,550 6,550 Current cash assets Other funding sources (list below): Kukio Community Fund 6,000 $400,000 6,000 State Foundation On Culture &the Arts 3,000 3,000 Kona Mauka Rotary Foundation 1,000 1,000 Healy Foundation 8,000 8,000 TFA National Investment $531,597 $531,597 Total Cash Income $32,250 $400,000 $32,250 IN-KIND CONTRIBUTION Anticipated Committed Total SKEA facility 6,750 6,750 art supplies 500 500 Total In-Kind Contributions $7,250 $0 $7,250 TOTAL PROGRAM INCOME $39,500 $400,000 $39,500 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses !County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant)- Fiscal Year 2022-2023 ;Organization Name:Society for Kona's Education & Art (SKEA) !Program Name:Art Camps for Children & Teens Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 40,000 683,140 723,140 Professional Fees 2,000 15,500 $17,500 Operations 0 8,300 6,750 6,750 Supplies 1,000 1,500 500 3,000 Equipment 0 167 167 teen counselors 1,000 8,000 9,000 registrations, administration 500 1,600 2,100 marketing 500 650 1, 150 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 5,000 27,250 7,250 39,500 TOTAL PROGRAM BUDGET 40,000 1,328,911 0 $39,500 County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Society for Kona's Education & Art Program Name: Art Camps for Children and Teens 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. (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 tohttn://yendors.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 Hawari, 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 expilanation of the public benefits derived from the awarding of the grant(focusing on specific, nleasurable 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, f utiare to submit o time, coma tete and acctirate ear-end re art u'ins the tem slate A rovided will firjpact the evaluatign yaiir program's Qr agency's futurefandind requests.. 7 ; '°' Application FY ��7_7� /~ounty °f��l l �� 1lK��Q� z��uuu�oom �°�~ �� Name: Society for Kona's Education & Art Program" ~ Name: Art Camps6°r Children and Teens Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hav*ai~L | (we) understand that a current Certificate of Liability /$l'0JD,ODOgeneral Uabi|bmust` Finance Department, which specifically and explicitly indicates that the County ofHavvai'iisan 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 .artici tation for a minimum of one ear or until a written retort is submitted to and accepted by,the council. \ (uve\ understand there isnoprovision for further notification tosubrnitthe final report. |nfnrnoation ` ' and instructions are available athttpl/vvwvw/.hauvaiicaumty-gowfi n mgnpro[it-grant'formns/onorabout 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, 2023 must be returned to the County of Hawai'l 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. u��, ~�� N� � , ' . ~� �� n�� r . � ~___�' Signature of Authorized Person January 28, 2022 i~?{ ° EmecWive Director County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: ct '.. k 5�� v� / Program Name: tirr .. a r- vl-t. ire v> Cr dt� 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): Ej Member or members of the Council I Staff appointed by a member of the Council The Mayor The Managing Director E The,Director of Finance ri 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 o crt.iirty to the individual as apposed 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 January 8, 2022 rs.at rt:t,fAuthorized Person Ispeci Date Er Society for Kona's Education & Art South Kona Events &Workshops - 197 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:Society for KOna's Education &Art Contact Person:Susan B. Rice, ex.Dir., or Emma Gay,Adm.Asst. Contact Email:susanrice@hawaii.rr.com Contact Phone: 808-328-9392 (office) or 808-896-5858 (cell) Program Information Program Name:South Kona Events &Workshops Program Years in Operation: 30+ Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Honaunau-Napo'opo'o Program Target Audience:School Age (6-11),Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Culture and the arts,Youth,Aged Amount Applying For: $5000 Society for KOna's Education&Art-South Kona Events&Workshops' Page 1 Program Details Organization Mission: Mission: With a focus on South Kona,the Society for Kona's Education &Art serves the people of Hawai'i Island by providing arts &educational opportunities through programs, projects, & events that contribute to a vibrant community. We are a 501c3 community organization in South Kona, founded in 1981. Our site includes 2 historic buildings w. space for office, pottery studios, & 2 large rooms for classes; we also have a large yard & sturdy tents for outdoor classes& events. Program Overview:SKEA offers a variety of workshops appealing to a broad range of interests.A full teaching studio for pottery, w. wheels, will be used for adult &youth workshops&ongoing community use. We will offer 80 hours of instruction,taught by talented practitioners in each field: pottery, floral design,figure drawing, painting, Hawaiian quilting, wreaths, leis making, wauke/tapa, coconut& lauhala weaving, handmade books, &gyotaku (fish prints), Tuition is reasonable; we feel this is a crucial element of success in this rural community. Free or low-cost events may be attended by residents &visitors. Artists, performers, & musicians donate their time, &volunteers help w.the activities. Quilt Show- Locally made quilts in a variety of styles. SOKO South Kona Studio Tour-SKEA will host 4 artists. Mauka Talent Show Variety show of local performers. Bring It! South-Open musical performance monthly Annual Membership Meeting &Art Show- Live local music, hula, kanikapila, & local art. Program Objectives & Performances Resources Needed: We need 8-10 artists who have expertise in their medium or area of study, people who are excited about passing on their knowledge & have the skills to communicate their passion &engage their students.Art supplies:clay,glazes, good quality brushes paints & papers will be needed,. For events, we have tents,tables, chairs, &sound &video equipment; parking, &a large yard. We need an army of volunteers to: set up &take down tents; man greeting tables, & clean up afterwards.Then we need performers, an event coordinator, artists to show their work(we partner with the South Kona Artists Cooperative &the Aloha Quilters), &a shuttle driver(our parking lots are not big enough for large events of over 75 people.) Marketing: Staff time for marketing-we use press releases to newspapers, bulletin board flyers, hand flyers,social media, website calendars,SKEA website, roadside sign, email updates to our 1,000+ subscribers, & personal emails & invitations to participate. Major Activities to be Completed:We will offer 80 hours of instruction in the visual arts, Hawaiian cultural arts, and pottery. Society for KOna's Education&Art-South Kona Events&Workshops! Page 2 Teaching artists will design the curriculum and prepare the supplies and setup (with assistance from program coordinator). Pottery firings will be done in partnership with the Kona Potters Guild. It is uncertain if we will be able to have events (we hope so).The South Kona Studio Tour will take place this year(Feb. 2022) and there will be a person at the door to regulate the number of people in each room. Quilt Show was cancelled for Feb. 2022, but we hope to re-schedule later in 2022. For events, SKEA has a dedicated event coordinator who will work with the volunteers in coordinating each event. Marketing will be done jointly with the volunteer groups. Outputs to be Completed: 8-10 local artists will be hired to teach workshops, for a total of 80 hours of instruction. IF Covid protocols allow, 5 cultural events will be presented by a total of 50 volunteers. Assuming a return to normal gathering, we anticipate 800+audience participants and 60 exhibiting artists and performers. Measurable Outcomes: *Engagement in the arts close to home helps to create a vibrant community. *Community members of all ages and ethnicities, including island visitors, will enjoy seeing old friends and meeting new people in a friendly atmosphere. *Workshop participants will learn a new skill that may lead to a serious hobby or professional work. *The events and workshops will help strengthen and grow the arts economy in South Kona, and contribute to the diversification of the economy in our rural community. *Visitors from around the island will visit South Kona and enjoy its scenic beauty, restaurants, and other cultural sites. * Local artists will be supported and recognized. *The SKEA organization will make new friends and supporters in the community and connect with old ones. Attachments Program Budget(Income & Expenses) Certificate of Understanding Conflict Disclosure Society for Kona s Education &Art-South Kona Events&Workshops! Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) - Fiscal Year 2022-2023 Organization Name:Society for Kona's Education & Art Program Name:South Kona Events and Workshops CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 5,000 $5,000 Applicant organizational budget: Individual contributions $56,314 $56,314 Membership fees 500 500 Earned income $6,000 $6,000 Current cash assets Other funding sources (list below): Hawaii State Foundation on Culture and the Arts 2,000 $400,000 $2,000 Foundations $300,000 $300,000 Corporate $40,000 $40,000 Events $1,000 $1,000 TFA National Investment $531,597 $531,597 Total Cash Income $13,500 $400,000 $13,500 IN-KIND CONTRIBUTION Anticipated Committed Total Operations 1,000 $1,000 Marketing 1,000 1,000 Program Coordination 1,500 1,500 Total In-Kind Contributions $3,500 $0 3,500 TOTAL PROGRAM INCOME $17,000 $400,000 $17,000 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) - Fiscal Year 2022-2023 Organization Name:Society for Kona's Education & Art Program Name:South Kona Events and Workshops Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 40,000 683,140 723,140 Professional Fees 1,000 3,800 4,800 Operations 0 8,300 1,000 1,000 Supplies 1,000 1,200 2,200 Equipment 0 167 0 Printing, Advertising, and Media 0 4,400 4,400 Marketing 1,500 2,000 1,000 4,500 program coordination 1,500 1,500 1,500 4,500 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL $5,000 $8,500 $3,500 $17,000 TOTAL PROGRAM BUDGET 40,000 1,328,911 0 $17,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Society for Kona's Education & Art Program Name: South Kona Events & Workshops Certification of Understanding (Page J. 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 fitto://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 tu submit a time! corns/etc and accurate ear-end resort usins the tem slate •rovided will inpuct the evaluation o ow srosram's or asenc 's uture undins resuests. ' County � �'�'^' �� licati0n |P�/ 2027-23 of' ~~'` ^ ^ Nonprofit Grant ^ ^ Agency Name: Society for Kona's Education & Art Program Name: South Kona Events & Worksho Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawail, 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 Hawari Finance Department, which specifically and explicitly indicates that the County of Hawari 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 h8p://www.havvaiixounty.gnv/fn'nonpzfit-g7ant-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, 2023 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/ ^�� y �L=��' Signature of Authorized Person January 28, 2022 �~ �� S t �� Executive Director �y \ 'Ire i` County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Narne: '` i�tc - 5 Ed„u�.- -- r Program Name: t..Yt--tr\ FtlP 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): L Member or members of the Council Staff appointed by a member of the Council [� The Mayor The Managing Director L 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 henefrts 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: If no conflicts exist,check here. 47,11 a`4r -`. . # t v _ . K_ January 8, 2022 f ert 3ir nt u'thorii d Person(.,perify title) Date fi Special Olympics Hawaii Special Olympics West Hawaii -General Fund 198 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:Special Olympics Hawaii Contact Person: Denise Lindsey Contact Email:sowhdenise@gmail.com Contact Phone: (808) 345-0433 Program Information Program Name:Special Olympics West Hawaii-General Fund Program Years in Operation: 50 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Captain Cook, Hawi, Holualoa, Honalo, Honaunau-Napo'opo`o, Honoka'a; Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kealakekua, Kuki'o, Miloli'i, Ocean View, Puako,WaikOloa Village, Waimea Program Target Audience: Play Age (3-5),School Age (6-11),Adolescence (12-17),Young Adulthood (18- 39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Public health and welfare of the people and the environment,Youth, Aged, Physical/Emotional Disabilities,Victims of Health or Social Crises Amount Applying For: $15000 Special Olympics Hawaii-Special Olympics West Hawaii-General Fund I Page 1 Program Details Organization Mission: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. Program Overview: Special Olympics is founded on the belief that people with intellectual disabilities can, with proper instruction and encouragement, learn, enjoy and benefit from participation in individual and team sports, adapted as necessary to meet the needs of those with special mental and physical limitations. Special Olympics believes that consistent training is essential to the development of sport skills. In addition, competition among those of equal abilities is the most appropriate means of testing these skills, measuring progress and providing incentives for personal growth. Special Olympics believes that through sports training and competition, people with intellectual disabilities benefit physically, mentally, socially, and spiritually. Families are also strengthened; and the community at large, can participate in and observe an environment of equality, respect and acceptance. Program Objectives & Performances Resources Needed: Coaches,volunteers, PPE supplies, sport equipment for 9 sports, office equipment/supplies, advertising, event locations for training/competition and fundraising, money, food/hydration,transportation on ground and by airplane, storage facility, awards for athletes and unified partners, mahalo awards for volunteers, lei's,tents, lua's,tables, chairs, coolers,water jugs, paper and utensil goods, medical supplies,volunteer and medical logo T-shirts, uniforms for 9 sports. Major Activities to be Completed:Area Director coordinates all activities, Coaches fly to Oahu for sports certification, Athletes, Coaches, Unified Partners and VolunteersTravel to Oahu for 3 State competitions, we host 9 Regional sport competitions in; Swimming,Softball-coach pitch, Unified and Individual sports, Powerlifting,Soccer, Bocce Ball and Bowling, Fundraising and community event for Law Enforcement Torch Run,volunteers provide help passing out hydration and snacks at local community fundraising events like Lavaman Triathlon, Honu Triathlon, Kona Marathon, Volunteers assist at Cop on Top, Bus Pull, Underpants Run, Parker Ranch Halloween candy give away, Bowling fundraiser, Hilton Crafts Fair by donating their time with set up, breakdown, meals, registration, information and fundraising. Outputs to be Completed: 75 Athletes supported for the year in 9 different sport, 15 certified coaches= 3 Powerlifting, 2 swimming, 2 track, 3 soccer, 3 bocce ball 2 basketball, 525 volunteers for 15 events locally and 3 events on Oahu,4800 hours of volunteer time, 75 families supported with our program, 525 volunteers supported with our program. 30 Athletes competing at 3 State Games on Oahu. Special Olympics Hawaii-Special Olympics West Hawaii-General Fund! Page 2 Measurable Outcomes: Special Olympics is the only comprehensive sports program in West Hawai'i for children and adults with intellectual disabilities. Nowhere else can they go to find a program that offers certified coaches, minimum of 10 weeks of training in 9 different sports, and competition at the area, statewide, and international levels. Without Special Olympics, quality sports opportunities for our athletes would be virtually non-existent. Volunteers come back year after year because they believe in the Mission of Special Olympics,they witness the athletes demonstrating courage and participating the joy and friendship, plus our fundraising events are accommodating to us because they witness their employees interacting with our athletes and it encompasses the employees to strive and do better at there work and home. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Special Olympics Hawaii-Special Olympics West Hawaii-General Fund I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:Special Olympics Hawaii Program Name: Special Olympics West Hawaii - General Fund CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 15000 15000 Applicant organizational budget: $89,000 Individual contributions 3500 3500 Membership fees 0 0 Earned income 0 0 Current cash assets 0 0 Other funding sources(list below): Kona Commons Bus Pull Fundraiser 4000 $400,000 4000 Walmart Foundation 2000 2000 Visitor Industry Charity Walk 2000 2000 Cop on Top fudraiser 15000 15000 Hilton Christmas Craft Fair 7000 7000 Golf Fundraiser 9500 9500 Bowling Fundraiser 5000 5000 Kona Marathon & Lavaman Aid Stations 3000 3000 Underpants Run Fundriser 5000 5000 Total Cash Income 71000 $400,000 71000 IN-KIND CONTRIBUTION Anticipated Committed Total Local Talent M/C for 3 major events 3000 3000 3000 SR Rentals (equipment) 2000 2000 Roberts Hawaii Bus 800 800 Kona Lua 700 700 Volunteer Hours 7000 7000 7000 Donated meals for Cop on Top 800 800 Golf fundraiser donations 700 700 Total In-Kind Contributions 15000 10000 15000 TOTAL PROGRAM INCOME $968,911 $400,000 86000 Appendix D--Budget Sheets (Page 2 of 2) ;Project Budget Form: Expenses !County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:Special Olympics Hawaii Program Name: Special Olympics West Hawaii - General Fund Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 0 15825 15825 Professional Fees 0 2000 2000 Operations 1500 1500 3000 Supplies 1000 2500 3500 Equipment 500 2500 3000 Area Competitions(Softball, Bocce&Soccer) 6000 4500 10500 Airfare for Athletes to Oahu (State Games) 6000 27175 33175 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings,and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 SUBTOTAL 15000 56000 0 71000 TOTAL PROGRAM BUDGET 40,000 1,328,911 0 71000 County of Fl , `=i`^ Nonprofit Grant Application FY 2022-23 Agency Name: ProgramName: 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—Z'142.l, Havva[iCountyCode, re|at|nQtoApprppriationufFundstoNVnproftOrganizatiwns. 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 Halve', 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 provided,for which the grant was awarded.The report, using the template mh�(� in�mdemn 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 Hawaig grant funds, and a flsting 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. ` � Count��0n�t�/ ~^^ Nonprofit �� Application FY ~y��'�� y of^ ".,.�� ^ Grant z.v^�^~ `._/ Agency Name: Program Name: Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'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 Hawari 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 oneyear 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 h;p://mvvvv.havvaiicnunty.govfin'nonpro0C'Qrant'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, 2023 must be returned to the County of Hawaiti with the final report. Failure to return these funds in a timely manner will impact the evaluation of your oqencVs uture undin. re uest and ma 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 sinin86e|ow\youa,eacknovv|edg|n0tha1ynuhavereadandunderstoodthesenaquire,nents. \ t /w- \ 2~ 2— , Signat re of Authorized Pen Date (1 63 Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: 5"e-e c• 'A-k 0 il virte.i'c'S ‘),Le S*t iActi,Aiez-) i Program Name: -e_A.(•t-a_k Fu Vk 0 0?6NIZATI•N 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 Hawari. 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 ofyhether 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 O Staff appointed by a member of the Council O The Mayor 0 The Managing Director O 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: lig If no conflicts exist,check here. Pii 4 4 ,4 if a i; , ) 7;•-if ir CE 0 I 1'2, 6 1 1, 2- g n atu re of Aut %Tired Person (specify title) Date Special Olympics Hawaii Special Olympics East Hawaii 199 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name: Special Olympics Hawaii Contact Person: Heather Dansdill Contact Email: easthawaiiad@sohawaii.org Contact Phone: 808-430-4952 Program Information Program Name:Special Olympics East Hawaii Program Years in Operation: 51 years Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, Hakalau, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Honomu, Honoka'a, Kea'au, Kurtistown, Laupahoehoe, Leilani Estates, Mountain View, Na'alehu, Nanawale Estates, Ninole, 'O'okala, Pa'auilo, Pahoa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Volcano, Wainaku Program Target Audience:School Age (6-11),Adolescence (12-17), Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Public health and welfare of the people and the environment, Youth, Physical/Emotional Disabilities,Victims of Health or Social Crises Amount Applying For: $20000 Special Olympics Hawaii-Special Olympics East Hawaii I Page 1 Program Details Organization Mission: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. Program Overview:Special Olympics Hawaii -Our East Hawaii Area Program is open to everyone with intellectual disabilities in Hawaii, regardless of the extent of their disability or their age. 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. 2022 continues to highlight the value of social interaction and relationships. Now more than ever our Special Olympic athletes, our most vulnerable population, need the social connection that comes from these Special Olympic activities. Program Objectives & Performances Resources Needed: In order for our program to be successful, we estimate utilizing 700 volunteers, 30 are consistent Coaches for 8 Delegations, 150 of these volunteers are Unified Partners who practice and compete with our Athletes. Materials needed are: Personal Protection Equipment to safeguard against COVID, sports equipment for 8 different sports,volunteer shirts, uniforms for 250 Athletes. Operational resources needed are 2 storage units, office space &supplies, 2 part-time employees,venues for practice and competitions. For our competitions we need money to purchase food and hydration, awards, ground transportation and airfare.We also need money to purchase fundraising items. Major Activities to be Completed:The Area Director coordinates all activities.A year in Special Olympics includes year-round athletic practices for 3 different Seasons. East Hawaii hosts 5 Area competitions: Track and Field, Swimming, Bocce ball, Basketball and Golf. We compete in two competitions hosted by West Hawaii: Soccer and Softball. Our programs are 90% managed by volunteers.At each of these competitions,volunteers are utilized in the planning, set-up and take down, on-site coordination and officiating. Our teams also compete in two State competitions in Oahu. EHI has a variety of fundraising activities that engage our Athletes and provide an opportunity to interact with the community.These fundraisers include: Cop on Top,Tip a Cop,Torch Run, Charity Walk, Hilton Craft Fair just to name a few. We are fortunate to have a great working relationship with the Hawaii Police Department, our families and service organizations at both the school and community level that assist us with all of these activities. Outputs to be Completed: 250 Athletes will participate for the year in 8 different sports, 3 different Sports Seasons, and compete in 2 State Games on Oahu Special Olympics Hawaii-Special Olympics East Hawaii I Page 2 32 certified coaches will Coach our Teams: 2 swimming, 14 Track and Field, 1 soccer, 7 Bocce ball, 7 Basketball, 1 Golf. 700 volunteers are utilized for 17 events locally totaling approximately 15,000 hours of volunteer time, 185 families are supported by our program and 150 Unified Partners work directly with our Athletes. Measurable Outcomes:Special Olympics is the ONLY program in the State which provides both fitness and health services to individuals with intellectual disabilities. People who are isolated from life experiences by a disability have little chance for the developmental growth and acquisitions of important skills necessary to gain employment, maintain relationships, and function within the community.The consequences of not serving these individuals is possibly an increase in obesity, heart disease as well as other preventable health conditions. We have also found that those individuals who do not participate in our program, yet are eligible, experience depression more often, have an increased chance of engaging in unlawful activities and the chance of unwanted pregnancy increases substantially. The value our Program has on the community is profound. Hundreds of people volunteer every year at our events because it makes such a deep impact in their lives and the lives of our athletes. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure Special Olympics Hawaii-Special Olympics East Hawaii I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: Special Olympics Hawaii Program Name: Special Olympics East Hawaii CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $20,000 $20,000 Applicant organizational budget: $89,000 $89,000 Individual contributions $4500 $4500 Membership fees $0 Earned income $0 Current cash assets $0 Other funding sources(list below): Fundraiser (Cop on Top) $20,000 $400,000 $20,000 Fundraiser(Tip a Cop) $5000 $5000 Fundraiser (Steak tckts) $10,000 $10,000 Fundraiser(Candy) $10,000 $10,000 Fundraiser(Calendar sales) $10,000 $10,000 Fundraiser (Torch Run Shirts) $7000 $7000 Walmart Grant $2000 $2000 SOHI Airfare fund $500 $500 Total Cash Income $89,000 $400,000 $89,000 IN-KIND CONTRIBUTION Anticipated Committed Total Use of Facilities $300 $300 $300 Polynesian Bus & Driver $3000 $3000 Volunteer Hours $10,000 $7,000 $10,000 Moving Truck (3 times per year) $500 $500 Meal donations (Cop on Top) $1200 $1200 Golf Tournament donations $5000 $5000 Total In-Kind Contributions $20,000 $7,300 $20,000 TOTAL PROGRAM INCOME $968,911 $400,000 $109,000 Appendix D--Budget Sheets (Page 2 of 2) 'Project Budget Form: Expenses =County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 (Organization Name:Special Olympics [Program Name:Special Olympics East Hawaii Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $0 $13,008 $13,008 Professional Fees $0 $2000 $2000 Operations $3600 $3600 $7200 Supplies $1,500 $2200 $3700 Equipment $1000 $2092 $3092 Area Competitions(Track, Bocce&Basketball) $6500 $4500 $11,000 Airfare for Athlete to Oahu(State Games) $7400 $41,600 $49,000 Subscriptions and Dues 0 2,167 2,167 Telecommunications 0 3,973 3,973 Transportation, Meetings, and Subsistence 0 20,100 20,100 Corps Member and Alumni Support 0 12,767 12,767 National Support 0 531,597 531,597 • SUBTOTAL $20,000 $69,000 0 $89,000 TOTAL PROGRAM BUDGET 40,000 1,328,911, 0 $89,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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. County of ^^~ Nonprofit ��rm�� Application FY ��'�~�� ~. ~~. � ^^`"..�� ^ ��..... .�w^.^. `.-' Agency Name: ProgramName: Certification of Understanding (Page 2 of 2) |fawerdedagrantfromtheCountyofHawm|l | (me) understandthatacunentCertiOcateofUabi|ity ($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://u/vvm/.hawaiicounty.Aov/fn'nonpro0t'Arant'ho/ms/un 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, 2023 must be returned to the County of Hawail with the final report. Failure to return these funds in a timely manner will impoct 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 siningbe|ow\ yuuaoeacknuvv|edQin�thatyouhavereadandundeotnodtheseroqu�ementy. ., D^~_, \ r� =" ��` - \\ �� Signatc1F "of Authorized Person Date '.� � /J-s Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: Program Name: 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: ci4If no conflicts exist,check here. pAA / n L40 I z6 ) 1 'gnature of Aute�'#rized Person (specify title) Date The Children's Law Project of Hawai'i Victim Options for Child Empowerment and Safety 201 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:The Children's Law Project of Hawai'i Contact Person:Valerie J. Grab Contact Email:Valerie.grab@clphi.org Contact Phone: 808-959-2574 x1 Program Information Program Name:Victim Options for Child Empowerment and Safety Program Years in Operation: 3 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, HOnaunau-Napo'opo`o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki`o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli`i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O`okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa`ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, `Umikoa,Volcano,Waikoloa Village,Waimea, Wainaku, Wai'ohinu,Weloka Program Target Audience: Infancy(0-3), Play Age (3-5), School Age (6-11), Adolescence (12-17) Services/Activities Provided: Public health and welfare of the people and the environment,Youth, Victims of Crimes,Victims of Health or Social Crises Amount Applying For: $15000 The Children's Law Project of Hawai'i-Victim Options for Child Empowerment and Safety' Page 1 Program Details Organization Mission:The Children's Law Project of Hawai'i provides holistic advocacy services for court-involved children and those at-risk of child protective service involvement.Since 2017, our attorneys have served as court-appointed Guardians ad litem for children in foster custody,juvenile law violation, Persons in Need of Supervision and contested custody proceedings. We also advocate for children's best interests through permanecy options such as powers of attorney,guardianships and adoptions. Program Overview:Victim Options for Investigation, Child Empowerment and Safety("VOICES") was established in 2019 to provide Guardian ad Litem ("GAL") adovacy for victims of crime, specifically children exposed to domestic violence whose parents are involved in contested custody disputes. Children may be the primary victims of the crime of domestic violence or secondary victims,traumatized by witnessing abuse.Through our program, GALs intervene in these toxic environments and help the Family Court determine when a child had been victimized and by who. We recommend specific court orders and litigate when necessary to ensure that our clients are safe. We have recently expanded our program to include a multidisciplinary approach including (1) a formal Domestic Violence Screening tool (the SAFeR Protocol developed by the Battered Women's Justice Project); (2) parenting assessments and counseling through P.A.R.E.N.T.S. Inc;, and (3) expert consultation and testimony from Matapuna Levenson, MSW. Program Objectives & Performances Resources Needed:The resources needed to implement our VOICES program include: o Attorney and staff time to conduct screenings, investigations, home visits, communicative efforts to parties involved,follow-up with professional referrals, and attend court hearings as necessary. o Training on Domestic Violence GAL legal advocacy and best practices. o Professional services including parenting evaluations, parenting counseling, and Domestic Violence experts. o Program overhead (rent, utilities,telecommunications, office supplies.) o Attorney and staff time to continue to build community collaborative efforts to address the trauma children and youth experience when they are the primary victims of or exposed to domestic violence. Major Activities to be Completed:The major activities to be completed through VOICES include: o Identify appropriate GAL appointments in contested custody cases with allegations of domestic abuse. o Conduct intial investigations, making referrals to domestic violence programs, family strengthening services and visit supervisors, as necessary. o Interview parties involved,visit clients in home settings, request client records and make judicial recommendations. The Children's Law Project of Hawai`i-Victim Options for Child Empowerment and Safety I Page 2 o Follow-up with case management monitoring services and compliance, if necessary. o Mediate with parties to create a reasonable and safe resolution if appropriate. o Update court orally or in writing as to case direction and final proposals. Outputs to be Completed:The specific outputs to be completed by VOICES include: o GAL appointments for four sibling groups from family court cases involving allegations of abuse. o Conduct four thorough GAL family investigations and when needed sibling groups to receive case management efforts. o Meet semi-annually with judges, court clerks and community providers to review program outcomes, identify service gaps and strengthen community collaborative efforts. o Collaborate with expert witnesses, parent coordinators, family and child services, as outlined in our program initiatives. Measurable Outcomes:The outcomes to the public and program participants: o Protection and healthy environments for children and youth. o Increased trust in community advocacy that highlights safety, security and stability. o Independent,third-parties to review cases and influence judicial decision-making. o Collaborative community efforts in supporting families. o Greater systemic understanding of the dynamics of domestic violence. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure The Children's Law Project of Hawai'i-Victim Options for Child Empowerment and Safety I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:The Children's Law Project of Hawai'i Program Name:Victim Options for Investigation, Empowerment and Safety CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 15,000 15,000 Applicant organizational budget: Individual contributions 0 0 0 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets 0 0 0 Other funding sources (list below): Victims of Crime Act Grant 0 26,000 26,000 Hawaii Justice Foundation 0 5,000 5,000 Total Cash Income 15,000 31 ,000 46,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions 0 0 0 TOTAL PROGRAM INCOME 15,000 31 ,000 46,000 Appendix D--Budget Sheets (Page 2 of 2) Apr oject Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:The Children's Law Project of Hawai'i Program Name:Victim Options for Investigation, Empowerment and Safety Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 15,000 14,630 . 0 29,630 Professional Fees 0 4,940 0 4,940 Operations 0 11,200 ` 0 11,200 Supplies 0 230 0 230 Equipment 0 0 0 0 SUBTOTAL 15,000 31,000 0 46,000 TOTAL PROGRAM BUDGET 15,000 31,000 0 46,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: The Children's Law Project of Hawaii Program Name: Victim Options for Investigation, Empowerment and Safety 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 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: The Children's Law Project of Hawaii Program Name: Victim Options for Investigation, Empowerment and Safety 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, 2023 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. • 1/31/2022 Signature of Authorized Person Date Valerie J. Grab, Executive Director Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: The Children's Law Project of Hawaii Program Name: Victim Options for Investigation, Empowerment and Safety 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 ri Staff appointed by a member of the Council 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 conflicts exist, check here. Valerie J. Grab,'Executive Director 1/31/2022 Signature of Authorized Person (specify title) Date The Children's Law Project of Hawai'i Project Permanence: Guardianships and Adoptions for At-Risk Kids 202 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:The Children's Law Project of Hawaii Contact Person:Valerie J. Grab Contact Email:Valerie.grab@clphi.org Contact Phone: 808-959-2574x1 Program Information Program Name: Project Permanence: Guardianships and Adoptions for At-Risk Kids Program Years in Operation:4 Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, 'Umikoa,Volcano,Waikoloa Village,Waimea, Wainaku, Wai'ohinu,Weloka Program Target Audience: Infancy(0-3), Play Age (3-5), School Age (6-11),Adolescence (12-17) Services/Activities Provided: Public health and welfare of the people and the environment,Youth, Victims of Health or Social Crises Amount Applying For: $10000 The Children's Law Project of Hawai'i-Project Permanence:Guardianships and Adoptions for At-Risk Kids I Page 1 Program Details Organization Mission:The Children's Law Project of Hawai`i provides holistic advocacy services for court-involved children and those at-risk of child protective service involvement. Since 2017, our attorneys have served as court-appointed Guardians ad litem for children in foster custody,juvenile law violation, Persons in Need of Supervision and contested custody proceedings.We also advocate for children's best interests through permanecy options such as powers of attorney,guardianships and adoptions. Program Overview: Project Permanence was organized in 2018 to establish legal relationships between children whose parents cannot safely care for them and the adults who are committed to their protection and care.This fundamental goal is achieved by securing uncontested guardianships and adoptions for the families. Children's Law Project intervenes in these situations to represent both relative and non-relative caretakers to legalize and solidify their relationships to the children.The goal of this ongoing project is for children and youth to first avoid child welfare intervention and foster care all together, and next to expedite children's exit from the child welfare foster system. Our staff guide petitioners through the necessary steps to secure the guardianship or adoption. It usually takes 2-3 months to make contact, file the appropriate documents and present the case to the court. Program Objectives & Performances Resources Needed:The resources needed to implement Project Permanence include: o Attorney and staff time to complete legal documents and establish guardianships and adoptions. o Filing Fees. o Publication Expenses. o Process server fees. o Program overhead (rent, utilities,telecommunications, office supplies). o Expenses to cover outreach events, such as 'Ohana Day/National Adoption Day. Major Activities to be Completed:The major activities to be completed through Project Permanence: o Identify safe, appropriate and compassionate relative and non-relative caretakers for children and youth in need of permanent placements. o Assist in drafting legal paperwork on behalf of proposed guardians and adoptive parents petitioning the court. o Prioritize guardianship and/or adoption cases in which children and youth may avoid Child Welfare Services involvement. o Expedite guardianships and adoptions for children and youth in foster care for them to quickly exit the Child Welfare system. The Children's Law Project of Hawaii-Project Permanence:Guardianships and Adoptions for At-Risk Kids I Page 2 Outputs to be Completed:The specific outputs to be completed by Project Permanence include: o Assist 10 sibling groups in receiving permanancy through legal guardianships or adoptions. o Provide legal counsel to 15 proposed guardians or adoptive parents. o Administer a community 'Ohana Day, coordinating with the Judiciary and Child Welfare Services, to schedule hearings on a particular day at least once per year. o Provide petitioners the appropriate resource referrals to organizations that provide post- permanancy services and cultural identity programs. Measurable Outcomes:The outcomes to the public and program participants: o Safe and stable home settings for children in need of permanent ("forever home") placements. o Fewer children in foster custody. o Improved phyiscal, emotional and social outcomes for children and youth whose parents cannot safely care for them. o Collaborative community efforts in supporting clients (petitioners) and children and youth exiting foster care. o Free legal counsel for those seeking permanency outcomes for children and youth in their care. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure The Children's Law Project of Hawaii-Project Permanence: Guardianships and Adoptions for At-Risk Kids I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:The Children's Law Project of Hawaii i Program Name:Project Permanence Guardianships and Adoptions for At Risk Kids CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 10,000 10,000 Applicant organizational budget: Individual contributions 0 0 0 Membership fees 0 0 0 Earned income 10,000 0 10,000 Current cash assets 0 0 0 Other funding sources (list below): Hawai'i Women's Law Foundation 3750 3750 7,500 Total Cash Income 23,750 3,750 27,500 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions 0 0 0 TOTAL PROGRAM INCOME 23,750 3,750 27,500 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 :Organization Name:The Children's Law Project of Hawaii ,Program Name:PrOjeCt Permanence: Guardianships and Adoptions for At-Risk Kids Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 10,000 11,000 0 21,000 Professional Fees 0 400 0 400 Operations 0 6,000 0 6,000 Supplies 0 100 0 100 Equipment 0 0 0 0 SUBTOTAL 10,000 17,500 0 27,500 TOTAL PROGRAM BUDGET 10,000 17,500 0 27,500 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: The Children's Law Project of Hawaii Program Name: Project Permanence: Guardianships and Adoptions for At-Risk Kids 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.Rov, 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: The Children's Law Project of Hawaii Program Name: Project Permanence: Guardianships and Adoptions for At-Risk Kids 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, 2023 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. Juui'& b 1/31/2022 . U Signature of Authorized Person Date Valerie J. Grab, Executive Director Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: The Children's Law Project of Hawaii Program Name: Project Permanence: Guardianships and Adoptions for At-Risk Kids 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 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. Aicattitit 401) Valerie J. Grab, Executive Director 1/31/2022 Signature of Authorized Person (specify title) Date The Salvation Army, a California corporation; DBA The Salvation Army-Family Intervention Services Cultural Based Program 205 County of Hawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:The Salvation Army, a California corporation; DBA The Salvation Army-Family Intervention Services Contact Person: Roxanne Costa Contact Email: roxanne.e.costa@usw.salvationarmy.org Contact Phone: 808-959-5855 Program Information Program Name: Cultural Based Program Program Years in Operation:4 years Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: Captain Cook, Hala'ula, Hawi, Hilo, Honaunau-Napo'opo'o, Honoka'a, Kailua-Kona, Kalapana, Kea'au, Keokea, Laupahoehoe, Miloli'i, Mountain View, Na'alehu, Pa'auilo, Pahala, Pahoa, Pohoiki,Volcano, Waimea, Wai'ohinu Program Target Audience:School Age (6-11),Adolescence (12-17),Young Adulthood (18-39) Services/Activities Provided: Culture and the arts,Youth Amount Applying For: $10000 The Salvation Army,a California corporation; DBA The Salvation Army-Family Intervention Services-Cultural Based Program I Page 1 Program Details Organization Mission: For nearly five decades The Salvation Army Family Intervention Services (TSA-FIS) has successfully provided services to youth throughout Hawaii Island,fulfilling its mission 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 to succeed, youth must feel a sense of belonging to their community, culture, peers and within their families. Program Overview: Our Cultural-Based Program provides a safe and nurturing environment for youth ages 10-21 in East Hawaii, along with access to opportunities, experiences, and services to support cultural identity, positive youth development and prevention of risky behaviors. Program services include 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 held by our ancestors. Youth also participate in community service-learning projects and engage in skill building opportunities, such as basic water safety, First Aid and CPR, environmental conservation, native plant identification, hiking, canoe paddling, life guarding and education on the fundamentals of safety and preparedness. Program Objectives & Performances Resources Needed:To successfully carry out this program, we will need staff,transportation, technology, money for supplies,training certifications and materials. Major Activities to be Completed:TSA-FIS staff provide hands-on cultural based program activities that promote natural resources, community connectedness and cultural identity Community excursions offered Ocean and mountain safety offered Service-learning projects offered Skill building session delivered: Life Guarding; First Aid and CPR Outputs to be Completed: • 1 full-time staff recruited • 1 volunteer engaged • 60-80 youth served • 30-50 families served annually island wide Measurable Outcomes: • Delivery of innovative and hands-on cultural-based program • Increased community connectedness • Enhanced cultural identity The Salvation Army, a California corporation; DBA The Salvation Army-Family Intervention Services-Cultural Based Program Page 2 • Youth understand proper use of natural resources • Increased safety/lifesaving skills among youth • Stewardship of island community promoted • Career pathways in public safety(life guarding, medical field, etc.) opened • Increased acceptance and respect of diverse community Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure • The Salvation Army,a California corporation; DBA The Salvation Army-Family Intervention Services-Cultural Based Program I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name:The Salvation Army-Family Intervention Services Program Name: Cultural Based Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 10000 10000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Department of Human Services OYS 108000 108000 Total Cash Income 118000 118000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 118000 118000 Appendix D--Budget Sheets (Page 2 of 2) ;Project Budget Form: Expenses :County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 lOrganization Name:The Salvation Army-Family Intervention Services ;Program Name: Cultural Based Program Nonprofit Expense Description (Waiwai) Other Cash In-Kind TOTAL Source Contribution Grant Salary Wages 74473 74473 Professional Fees 2000 2400 4400 Operations 3000 21407 24407 Supplies 3800 3000 6800 Equipment 3120 3120 Program Activities 1200 3600 4800 SUBTOTAL 10000 108000 118000 TOTAL PROGRAM BUDGET 10000 108000 118000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: The Salvation Army-Family Intervention Services Program Name: Cultural Based Program 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. l(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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: The Salvation Army-Family Intervention Services Program Name: Cultural Based Program 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 30,2023 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. 1/27/2022 Signature of Authorized Person Date Divisional Commander - Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: The Salvation Army-Family Intervention Services Program Name: Cultural Based Program 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 D. 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. Divisional Commander 1/27/2022 Signature of Authorized Person (specify-title) Date West Hawaii Community Health Center Inc. Outreach to Vulnerable Populations Program 206 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:West Hawaii Community Health Center Inc. Contact Person: Natasha Ala Contact Email: nala@westhawaiichc.org Contact Phone: 808-938-1699 Program Information Program Name: Outreach to Vulnerable Populations Program Program Years in Operation: 8 Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: Captain Cook, Holualoa, Kahalu'u-Keauhou, Kailua-Kona, Kealakekua, Ocean View,Waikoloa Village Program Target Audience: Infancy (0-3), Play Age (3-5), School Age (6-11), Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided: Educational concerns, Needs of the poor, Public health and welfare of the people and the environment,Youth,Aged, Physical/Emotional Disabilities,Victims of Health or Social Crises Amount Applying For: $45000 West Hawaii Community Health Center Inc.-Outreach to Vulnerable Populations Program I Page 1 Program Details Organization Mission:The mission of West Hawaii Community Health Center is to offer quality, comprehensive and integrated health services accessible to all who pass through our doors, regardless of their ability to pay. We promote improved health and well-being through ho'ola kino - healing on individuals,families and communities. Our vision is to live in a health community, woven like lauhala, nurtured by strong, productive individuals and families. Ua mau - unending continuation. Program Overview:The Community Outreach Program supports under-served and vulnerable populations, and disadvantaged youth groups by connecting these populations with resources and opportunities that will result in strengthening their community ties and promote community wellness. By addressing upstream issues and working to improve social determinants of health (SDOH) facing the most under-served populations in West Hawaii, WHCHC improves community well-being and decrease health disparities among low income and under-served populations. Outreach to Vulnerable Populations Program provides the following services to the community: 1. WHCHC staff members participate regularly at community health screenings and health education opportunities to promote and inform the public about personal health and disease prevention. 2. WHCHC staff provide health education and training classes in community. 3. WHCHC staff assist patients in identifying greatest needs through filling out the PREPARE tool. Program Objectives & Performances Resources Needed: Resources received from this award will be used to fund .5FTE Health Educator position and to purchase supplies that will assist this program in connecting with communities, building relationships, reducing cultural and language barriers, addressing health equity, education equity and workforce development activities. Major Activities to be Completed: WHCHC will conduct outreach/health education/SDOH health screening activities in remote and rural locations across the West Hawaii service area (South Kohala to Ocean View). Outreach to focus on COFA, Migrant&Seasonal Farm Workers, Native Hawaiian and individuals/families living in public housing. Outputs to be Completed: Outreach to occur via skills training/workforce development planning, workshops, and online classes and meetings. 2,800 people will be reached. 250+ people will receive SDOH screening. Measurable Outcomes: High-risk populations receive support and special clinics to improve their access to receiving primary care and support resources.Vulnerable populations are strengthened through improved access to receiving vital resources such as health care, housing,food and safety. West Hawaii Community Health Center Inc.-Outreach to Vulnerable Populations Program! Page 2 Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure • West Hawaii Community Health Center Inc.-Outreach to Vulnerable Populations Program I Page 3 Program Budget Form: Income $45,000 County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: West Hawaii Community Health Center Program Name:Outreach to Vulnerable Populations CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $45,000 " "="""- "" $45,000 Applicant organizational budget: Individual contributions Membership fees Earned income Current cash assets Other funding sources (list below): Total Cash Income $45,000 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME $45,000 Appendix D--Budget Sheets (Page 2 of 2) f...,._..._W.W. ..:...,d... .......... ........_...�,...._...,. .................._ .,..,..,_..,..w._: .._._„_,.,. ..._..._,,,,_.r.,.,,,.._........,... .... .......:.. ._. :....._.......,....> .,._...... ..,....>...._ ...__......, .. ,,.,,,...,.w.....,...� Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) Fiscal Year 2022-2023 ;organization Name: West Hawaii Community Health Center Inc. Program Name Outreach to Vulnerable Populations Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $30,000 $30,000 Professional Fees Operations Supplies $15,000 $15,000 Equipment SUBTOTAL TOTAL PROGRAM BUDGET $45,000 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: w00A1c1jii C0w,v4(01; ,. j{ .c 4 h3 r Tnc • Program Name: Ocuty-tack.. +0 Vulrti .rQblo aptAla'fia-- 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. ov 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. County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name: W es'r }latraaki ,Co wt w, ,,,:, 'rk 4 C'ev►-k v IAC Program Name: Oct4r c #d ?a .t1�±, ( tea �t wig 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:/lwww.hawaiicounty.gov//,fn-non rofit rant-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 administrative and overhead costs. Any funds unused by June 30, 2023 must be returned to the County of Hawai'i with the final report. Failure to return these unds in a time! 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. i i fSignature of Authorized Pers Date Title/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: weg+- wci+, Cov+awtuvn;' -tett Co v vrc Program Name: 00-d'-ec,1‘ Vo,1 &rc&tot� ® P kkr-t-1,►a-y�5 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 U 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. ' /(2-512.-0 Signature of Authorized Per n (specify title) Date YWCA Hawaii Island YWCA Developmental Presch000l 207 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:YWCA Hawaii Island Contact Person: Michelle Flemming Contact Email: mflemming@ywcahawaiiisland.org Contact Phone: 808-930-5767 Program Information Program Name:YWCA Developmental Presch000l Program Years in Operation:We have been in operation for over 80 years. Other County grants/agreements: No Previously received County GIA:Yes Program Geographical Reach: 'Ainaloa, Hakalau, Hawaiian Paradise Park, Hilo, Honomu, Kahalu'u- Keauhou, Kea'au, Kurtistown, Mountain View, Ocean View, Orchidlands Estates, Pahoa, Papa'aloa, Papa'ikou, Wainaku Program Target Audience: Infancy(0-3), Play Age (3-5) Services/Activities Provided: Educational concerns, Culture and the arts, Needs of the poor, Public health and welfare of the people and the environment,Youth Amount Applying For:$25000 YWCA Hawaii Island-YWCA Developmental Presch000l I Page 1 Program Details Organization Mission:The YWCA is dedicated to eliminating racism, empowering women and promoting peace,justice,freedom and dignity for all. Program Overview:The rising cost of food has become exorbitant.With the reduction of students and keeping the same amount of staff, meals for students are a major cost of our program. One hundred percent of our students in our preschool receive a nutritious breakfast, lunch and afternoon snack at no additional cost to the tuition.We order an average of 60 lunches a day. On average, we spend an additional $4.80 a day on breakfast Lunch and afternoon snack per child. This is about a 55% increase from 2019-2020 school year. We believe that when children's physical needs are met, they're able to learn better. Nutrition is one of the most important factors when it comes to children's development. Proper nutrition is essential for children to succeed in school. By feeding children a proper diet,we are helping them to be able to function properly in school in addition to fostering their growing minds and bodies. Program Objectives & Performances Resources Needed:Teachers and Teacher's Aides will carry out the curriculum and are responsible for making sure our students are provided with their meals. Money is needed to ensure we are able to purchase the necessary ingredients and food items for the meals. Computers/Laptops are needed to keep data, menu and points of services up to date. Lunch Vendors are essential as they are the ones who provided our students with lunches. Kitchen Supplies are important as we need to make sure we have enough supplies in the kitchen. Major Activities to be Completed:Staff prepare breakfast, lunch and afternoon snack for each student that is in attendance for the day. Staff coordinate responsibilities; prepping, plating, dishes., Each staff will fulfill their daily responsibilities to ensure that the food program runs smoothly. Staff complete inventory, and purchase what is needed for following week. Outputs to be Completed: 12 Teachers/Preschool Aides+3,335 hours food preparation, 100%of Keiki to be fed nutritious meals while in school. Measurable Outcomes: • All students will be provided with a nutritional breakfast, lunch and afternoon snack when in school. • Students are provided adequate time to eat: (20) minutes sit down time for breakfast;thirty (30) minutes sit down time for lunch; (20) minutes sit down time for afternoon snack. • A qualified nutritional professional reviews the school meals program. • When in school students receive proper nutrition, and will receive quality education YWCA Hawaii Island-YWCA Developmental Presch000l I Page 2 • Raising awareness to parents in proper nutrition. • Foods available at out Preschool will meet Child and Adult Care Food Program (CACFP) guidelines. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure • YWCA Hawaii Island-YWCA Developmental Presch000l I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: YWCA Hawaii Island Program Name:Developmental Preschool CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) $25,000.00 $25,000.00 Applicant organizational budget: Individual contributions $0.00 Membership fees $0.00 Earned income $0.00 Current cash assets $0.00 Other funding sources (list below): Hawaii Island United Way $15,000.00 $15,000.00 Program Service Fees $988,250.00 $988,250.00 USDA $60,000.00 $60,000.00 Total Cash Income $1,088,250.00 $1,088,250.00 IN-KIND CONTRIBUTION Anticipated Committed Total Total In-Kind Contributions TOTAL PROGRAM INCOME 1,088,250.00 $1,088,250.00 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name:YWCA Hawaii Island !Program Name:Developmental Preschool Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages $679,194.00 $679,194.00 Professional Fees $25,713.00 $25,713.00 Operations $255,601.00 $255,601.00 Supplies $17,000.00 $17,000.00 Equipment Meals $25,000.00 $71,002.00 $96,002.00 SUBTOTAL TOTAL PROGRAM BUDGET $25,000.00 $978,218.00 $1,003,218.00 County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: \MCS C1' C\V1 \sm Program Name: ootumen'co1 Preakioui Certification of Understanding (Page lof2) 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:/'/vendor .ehav,laii,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. County of:Hawai'i Nonprofit Grant Application FY 2022-23 Agency Name:\M9\ kACMO t \Md Program am Name DeAcko °( ut P1 cC) DDt _....x,.;,-::�r�,.,.>....:.�.,:Lc« ��ss>muwrs_ .._.. am.«..,,,.Lai.^�.,..^za,.x.�_..............w::,.w. „....:^..�.v.ZEi �..r .._.-saii. r.,,._ ....:.._iami<.;aa-:.N..w.,..rZie,.. ..^rs5- aiW^T-_a....a::Mm 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 httu:,t/ww ..h waiicotint gov fn nonorofiit er: nt-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, 2023 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. K7)..)2.77/1/' 7 , . f� '`� / 7 s '/ .%7/1/� //n.26 fes.. Signat.re of Auto orized Person Date Title/Position of Authorized Person County of Havvai`i (Nonprofit Grant Application FY 2022-23 Agency Name: a 1WCI\ NC:It 1S\MC1 1 Program Name: Qe.,,\f ` p i 1 CC\ ps chOO\ 1.. W..,,tea.,—.- r,,.,. ";,2.,..'3.k.„,,,,._1 . _ ........... .w•e..., Pov ua.,r.w.a....�...b.« ..�u:L' ':'�4s."""5,.....�hLL"F`e'- x3.S..�w.�3,""SSw'....«aui:�4�la�'.52-��.&'�?.Y94.ffi1Z8fawTy w.—},:L'-u',Y.u`£xl�l 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: 1 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 j Staff appointed by a member of the Council The Mayor The Managing Director Li 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 on 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: q 1 If no conflicts exist, check here. r 041,2,2. Signa re of Aura orized Person (specify title) Date 1 YWCA of Hawaii Island Sex Assault Nurse Examiner Program (SANE) 208 County of Flawai'i Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:YWCA of Hawaii Island - Contact Person: Lorraine Davis, Chief Operating Officer Contact Email: Idavis@ywcahawaiiisland.org Contact Phone: (808) 854-5856 Program Information Program Name:Sex Assault Nurse Examiner Program (SANE) Program Years in Operation: 10 years Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: 'Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kuki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli'i, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'Okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, `Umikoa,Volcano,Waikoloa Village, Waimea, Wainaku, Wai`ohinu,Weloka,This program serves the entire island. Program Target Audience: Infancy(0-3), Play Age (3-5), School Age (6-11),Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided:Victims of Crimes Amount Applying For:$30000 YWCA of Hawaii Island-Sex Assault Nurse Examiner Program (SANE)l Page 1 Program Details Organization Mission:The YWCA of Hawaii Island (YWCA)is dedicated to eliminating racism, empowering women, and promoting peace,justice, freedom and dignity for all. Established in 1919 and receiving 501(c)3 status in 1965,the organization has been offering programs to benefit women, children and their families. Current programs include a child abuse and neglect prevention program, a nationally accredited preschool,sexual assault support services program, and sexual assault nurse examiner services. Program Overview:The Sexual Assault Nurse Examiner(SANE) program has been with the YWCA since 2012 as a subcontract to the Hawaii Police Department.The program provides the forensic examination (SAFE) and evidence collection from a victim of sexual assault/violence and/or strangulation within a 120-hour window. The victims receive a medical assessment, head to toe examination, collection of evidence and advocacy services for entry into a support program. Evidence is given to the Hawaii Police Department for DNA testing, other forensic testing, and a report to support prosecution. The nurse will provide referrals to their primary care physician, sex assault support services and other partner agencies to support the victim through their trauma. Current services provided by the SANEs are at no cost to the victim. The program is seeking$30,000 to support an on-island training for incoming nurses. Program Objectives & Performances Resources Needed: Personnel needed: Accredited instructors for 5 days x 2 courses. Supervising SAN Es for Mock SAFEs: 4 SAN Es for 8 hours x 4 days. Volunteers for mock SAFEs Students. Community partner agencies to discuss the Mulit-Disciplinary Approach by the County. Event Coordinator. SDFI personnel for training on specialized camera system. Other needs: Space to perform mock SAFEs. Printed materials and County forms for Mock SAFEs. Sex Assault Kits for mock SAFEs. Funding to support the paid personnel, either program and contractors. Funding for per diem and mileage reimbursement of personnel and SANEs. Major Activities to be Completed:Secure instructors for courses (5 days x 2 courses). YWCA of Hawaii Island-Sex Assault Nurse Examiner Program (SANE)! Page 2 Recruit for nurses in West Hawaii (simultaneous with obtaining instructors and setting dates for training.) Secure SDFI trainers. Secure supervising SANEs for training and mock training. Secure rooms and dates for mock SAFEs. Set timelines for all days. Set timelines for all mock SAFEs. Have 5 day Adult/Adolescent training. Have 1 day for SDFI training. Superivising nurse provides feedback and recommendations. Have 2 days of mock SAFEs. Have 5 day Pediatric training. Have 2 days of mock SAFEs. Supervising nurse provides feedback and recommendations. Nurses are contracted to perform SAFEs in West Hawaii. Outputs to be Completed: 10 nurses will begin training to become a SANE. 6 nurses will complete the training. 4 nurses will be on the clock to perform SAFEs in West Hawaii. 100%of sex assault victims will be able to access services on Hawaii Island. 40 victims in West Hawaii will be able to access services. 40 victims in West Hawaii will be offered additional services to support their trauma. 40 victims in West Hawaii will have a better chance of moving forward with prosecution. Measurable Outcomes:With addition of SANE nurses in West Hawaii,victims of sexual assault and strangulation will be able to have a medical assessment and forensic exam that will allow for the victim to access additional services for their truama. The services,for most part are at no cost to the victim and the estimated lifetime costs of untreated trauma will be reduced. Hawaii Police Department will be able to get evidence and provide kit testing that will strengthen the possibility of prosecution of the offender and ultimately getting the offender off the streets. Getting the offender off the streets will result in a decrease in the offender committing another crime in the community. The victim and family can feel safer; and the community is safer. Attachments Program Budget (Income & Expenses) Certificate of Understanding Conflict Disclosure YWCA of Hawaii Island-Sex Assault Nurse Examiner Program(SANE)I Page 3 Program Budget Form: Income County of Hawai`i • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: YWCA of Hawaii Island Program Name:SANE Program CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 30,000 30,000 Applicant organizational budget: Individual contributions 0 250 250 Membership fees 0 0 0 Earned income 0 0 0 Current cash assets 0 0 0 Other funding sources(list below): VAWA Grant Pass Through HPD 54,995 54,995 Total Cash Income 30,000 55,245 85,245 IN-KIND CONTRIBUTION Anticipated Committed Total Exam Room Use ($45/hour x 8 hours x 4 days) 1,440 1,440 SDFI Specialized Training (already purchased) 6,000 6,000 Mock SAFE Volunteers($100/day x 6 volunteers x 4 days) 2,400 2,400 Total In-Kind Contributions 3,840 6,000 9,840 TOTAL PROGRAM INCOME 3,840 61,245 95,085 Appendix D--Budget Sheets (Page 2 of 2) ;Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: YWCA of Hawaii Island Program Name: SANE Program Nonprofit Other Cash In-Kind Expense Description (Waiwai) TOTAL Source Contribution Grant Salary Wages 8,502 8,502 Professional Fees 16,114 86 16,200 Operations 3,000 8,840 11,840 Supplies 0 0 Equipment 0 0 Travel/Per Diem Reimbursement 2,384 596 2,980 SUBTOTAL 30,000 682 8,840 39,522 TOTAL PROGRAM BUDGET 30,000 682 8,840 39,522 County of Hawai'i'i Nonprofit Grant ApplteatIon FY 2022-23 Agency Name: � 8 Hn `R\\ waQ` Program Name: \\\\ACSt ��Oyy\\Y\e,c.G Certification of Understanding (Page 1uf2) | (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.I, Hovvai'i County[ode, 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 expenrsight 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 andthat|(vve) havetheauthorityandabi|itytofu}|yadnministertheprnQra/n(s) pursuantto |aw. I (we) understand that information supplied herein shall be made public accordingto Chapter 92F, Hawa[i Revised Statutes. I (we) understand that applications will not be reviewed byCounty personnel receiving our County 0onprofitGrantsubnnitta|, andthatwehavefu|| responsibi||tytoensWrethataUdocunnentsare complete and accurate prior to submittal. I (we) understand that all documents requirinB 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. |favvardeda8rantfronntheCountyofHaxvai'i, | /xve\ udeotandandvv|||cornp|yxv|ththerequirecnent to enroll with Haxnail Compliance Express and be compliant prior to receiving payment(s). To register, go to -ehacomplete the easy step-by-step process,and pay the annual registration fee online using.a credit card. |faxva/dedagrantfromtheCoun1yofHavvai'i| (we) understandandvvi||cnnn0|ywiththerequirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year forvxhichtheArantvvasavxarded.Thereport,usin0tbeterpp|ateprovided, sha|| imdudean 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, LISi17(1 the template provided, will imacttheevaluation(yourrorani fs or'a enc . County Of^ -' -^‘- Nonprofit Grant Applirmf^ ' FY 2022-23 \ �\ 0�� AgencyyJ�%Dl�� N�� \‘ %�\-" .~` [�� z`r/�� t' \[�f��S Program0@D]8 w`��\ ��U0 `� ��`, ' ' '^~' .� • ~~� Certification of Understanding (Page 2pf2) If awarded a grant from the County of Hawail, 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 Hawai9 Finance Department,which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving anypayhlentb\. 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 athttWl/vvu@w,haxyaiounty.govifm-numnrofit-grant- 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 30,2023 must be returned to the County of Hawari with the final report. Failure to return these funds funds in a time/v manner will impact the evaluation of your aqency's future/mndiog/request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements <Cost of Construction, materials, insurance orsecurities)on private properties unless otherwise authori2ed by law. By signing below, you are acknowledging that you have read and understood these requirements. , °L. 06/2,,6iQnatdreofAutNohzedPerson Date Title/Position of Authorized Person County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name:" \10 Otk Is\Q Program Name: StA P8s, omAk INAuds 1 "C, S 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 I 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: rX1 If no conflicts exist, check here. r .7".„,/ 4, .../7---' //2,67-2,2- Signatl re of A thorized Person (specify title) Date YWCA of Hawaii Island Sexual Assault Support Services (SASS) 209 County of Hawaii Nonprofit Grants-in-Aid Program FY 22-23 Organization Information Organization Name:YWCA of Hawaii Island Contact Person: Lorraine Davis, Chief Operating Officer Contact Email: Idavis@ywcahawaiiisland.org Contact Phone: 808-854-5856 Program Information Program Name:Sexual Assault Support Services (SASS) Program Years in Operation:40+ Other County grants/agreements:Yes Previously received County GIA:Yes Program Geographical Reach: `Ahualoa, 'Ainaloa, Captain Cook, Eden Roc, Fern Acres, Fern Forest, Discovery Harbor, Hakalau, Hala'ula, Hawi, Hawaiian Acres, Hawaiian Beaches, Hawaiian Paradise Park, Hilo, Holualoa, Honalo, Honaunau-Napo'opo'o, Honomu, Honoka'a, Kahalu'u-Keauhou, Kailua-Kona, Kalaoa, Kalapana, Kanaihiku Village, Kapa'au, Kapoho, Kaueleau, Kea'au, Kealakekua, Keokea, Kaki'o, Kukuihaele, Kurtistown, Laupahoehoe, Leilani Estates, Miloli1, Mountain View, Na'alehu, Nanawale Estates, Ninole, Ocean View, 'O'okala, Orchidlands Estates, Pa'auhau, Pa'auilo, Pahala, Pahoa, Papa'aloa, Papa'ikou, Pauka'a, Pepe'ekeo, Pohoiki, Puako, Pualaa, 'Umikoa,Volcano,Waikoloa Village,Waimea, Wainaku, Wai'ohinu,Weloka Program Target Audience: Infancy(0-3), Play Age (3-5),School Age (6-11), Adolescence (12-17),Young Adulthood (18-39), Middle Adulthood (40-59), Kupuna (60+) Services/Activities Provided:Victims of Crimes Amount Applying For: $30000 YWCA of Hawaii Island-Sexual Assault Support Services(SASS)I Page 1 Program Details Organization Mission:The YWCA of Hawaii Island (YWCA) is dedicated to eliminating racism, empowering women, and promoting peace,justice,freedeom and dignity for all. Established in 1919 and receiving 501(c)3 status in 1965,the organization has been offering programs to benefit women, children, and their families. Current programs include a child abuse and neglect prevention program, a nationally accredited preschool, sexual assault support services program, and sex assult nurse examiner services. Program Overview:The Sexual Assault Support Services (SASS) program has been with the YWCA for over 40 years.The program operates a 24/7 crisis line, provides face-to-face crisis stabilization and intervention services, as well as therapeutic services for victims of sexual violence and their families.The SASS program has two offices, one in Hilo and one in Kona where services are offered.The program also now offers telehealth services when meeting face-to-face is a challenge for the victim. The SASS program works very closely with the Sex Assault Nurse Examiner(SANE) program to provide emotional support and advocacy during a forensic exam. Recently, our other program, SANEs began offering medical/forensic exams for victims who were strangled, with no sex assault. The program is seeking$30,000 to: 1. Improve 24/7 access to a crisis line via text and chat, and 2. Provide advocacy and referral services to victims of strangulation that are not related to a sexual assault. Program Objectives & Performances Resources Needed: 1. For Text/Chat Capabilities Funding for labor to monitor telephone/computer texts/chats. Resource Connect licensing fees. Community awareness funds to advertise the services and website. 2. For Advocate Providing Services for Non Sex Assault Strangulation Exams Funding for direct labor services. Mileage reimbursements. Upgrade SASS software to include Non Sex Assault Strangulation documentation and data collection. Referral Resources. Major Activities to be Completed: 1. For Text/Chat Capabilities All Advocates will be trained to use the text/chat system. All Advocates will have a unique login. Hours for monitoring will be determined and advocates assigned to those hours. Hours of availability will increase as demand increases. 2. For Advocate Providing Services for Non Sex Assault Strangulation Exams Advocates will be trained and given resources for strangulation cases. Advocates will respond to non sex assault cases as they would with sex assault cases. Advocates will provide follow-up outreach to victims and connect them with the appropriate services. YWCA of Hawaii Island-Sexual Assault Support Services(SASS)I Page 2 The software developer of the SASS database will make a module that will support non sex assault strangulation cases documentation and data collection. Outputs to be Completed: 1. For Text/Chat Capabilities Text and Chat capabilities will be made available to the public. The number of reports by 18-24 age group will increase from 3%to 6%during the course of the grant. 100%of the chats/texts will be addressed and victims will be able to access the appropriate services. 2. For Advocate Providing Services for Non Sex Assault Strangulation Exams 100%of non sex assault strangulation victims will receive advocacy services. 100%of the victims will be offered additional services and/or referred out to the appropriate partner agency. The SASS database will have a module to support non sex assault strangulation cases. 100%of the cases will be documented and the appropriate data collected for reporting. Measurable Outcomes:With two additional avenues of connecting to services,there is potential for more victims to access services. Having advocates at the ready will allow the victim to access additional services for their trauma,whether it is sex assault or strangulation. The services,for most part, are at no cost to the victim and the estimated lifespan costs for the trauma has the potential to be reduced, both for the victim and the community. Advocacy services encourage victims to work with the Hawaii Police Department to strengthen the possibility of prosecution to get the offender off the streets and decreasing the possibility of repeated offenses to either the victim or others in the community. The victim and family can feel supported and begin a healing process; and the community can feel safer. Attachments Program Budget(Income & Expenses) Certificate of Understanding Conflict Disclosure YWCA of Hawaii Island-Sexual Assault Support Services(SASS)I Page 3 Program Budget Form: Income County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant) — Fiscal Year 2022-2023 Organization Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services CASH Anticipated Committed Total County Nonprofit Grant-in-Aid (Waiwai Grant) 30,000 30,000 Applicant organizational budget: Individual contributions 7,000 7,000 Membership fees 0 0 Earned income 0 0 Current cash assets 0 0 Other funding sources (list below): VOCA pass through HI CO OPA 10,000 10,000 Sex Abuse Treatment Center 451,789 451,789 Fundraising 8,000 8,000 Total Cash Income 506,789 506,789 IN-KIND CONTRIBUTION Anticipated Committed Total HCASA(training on Resource Connect) 500 500 Total In-Kind Contributions 500 500 TOTAL PROGRAM INCOME 507,289 507,289 Appendix D--Budget Sheets (Page 2 of 2) Project Budget Form: Expenses County of Hawaii • Nonprofit Grant-in-Aid (Waiwai Grant)— Fiscal Year 2022-2023 Organization Name: YWCA of Hawaii Island !Program Name: Sexual Assault Support Services (SASS) Nonprofit Expense Description (Waiwai) Other Cash In-Kind TOTAL Source Contribution Grant Salary Wages 13,591 500 14,091 Professional Fees 8,240 8,240 Operations 3,829 3,829 Supplies 500 500 Equipment 0 0 Travel/Per Diem Reimbursement 840 840 Administrative Fees(10%) 3,000 3,000 SUBTOTAL 30,000 500 30,500 TOTAL PROGRAM BUDGET 30,000 500 30,500 County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name:`01\LCA \--\VAOM 1S\CM Program Name: 5t Q\ PSSOU1'i 5 PCA a°4 kC '-C >,a, 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 htt;://vendors_ehawaii,go'v, 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. County of Hawai'i Nonprofit Grant Application FY 2022-23 Agency Name:`MCP\ \Q\NQti \S\Q\r'1a Program. Name: Cud. \-1C\ i\a0 IVC \S ??Ori aN\i‘ ,e5 ,..,..,..,. ..,..Ws„ ..rte aasn'�.+:...,.x....<�..,:«�.rz�,.,.<,:«�.,«i:=.,w�.�.s �.�z��.�,--_x.�.�+r�:x e....._..,.�ew-s.��a-..s_.�..,x wet:^,_»s:aa�u.,o<sxsc�sa; x�,a�<sus.as.,�a�x�zu.«a ..,:• csa 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 30'r'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 9,rtp://w v,dw hr:waiicsa=.into. cvr'trr-nortrare fit-fir int-fornisf 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, 2023 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. /,;22 Signa ure of Acrthorized Person Date Title/Position of Authorized Person County of Hawai`i Nonprofit Grant Application FY 2022-23 Agency Name:' tlaWWa '1i \S\and Program Name: SSXugl ASS au\I. SUPPofA" Services ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potentialconflicts 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 token 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: 1 If no conflicts exist, check here. _--- /A46/.2...2 Signature f Auth rized Person (specify title) Date