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HomeMy WebLinkAboutCOM 0112.001 2014-2016�•• William P. Kenai ,c� Deanna S. Salon Mal-4 D,,,,.,Lisa K. Miura f)epuryDbecror County of Hawaii Finance Department 25 Aupunl Street, Room 2103 • Hilo, Ilawai'i 96720 (808)961-8234 • Fax(808)961-8569 February 10, 2015 ` ' - c Dint Kanuha, Council Chair and Members of the Hawaii County Council Hawaii County Council -^ 25 Aupunl Street o 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 2015-16 nonprofit grant program. The applications are submitted as received from the applicants and may contain blank or extra pages and/or be double sided. 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 "Ped Schrey at 961-8489. Deanna S. Sako Director of Finance Enc. Applications for Nonprofit Grant Funds List of Nonprofit Grant Applicants (Note: Due to the large size of the document, the attached applications are not made a part of the duplicate copies, but are available for viewing in the Office of the County Clerk, and at http://www.hawaiicounty.gov.) Comm. No 112-1 Ref. To: SS Ref. Dale 20 5 Hawaii County is an Equal Opportunity Provider and Employer NONPROFIT GRANT APPLICANTS FOR FY2015-16 Sort Cal matches separation sheet numbers (hartl copies). Note Nat the tlisqualigetl applicants retain their sort number resultlng in those numbers beingskippatl in the mein table. Nomarlpl Bort Order ONor ORGANIZATION NAME PROGRAM NAME REOUEBTEO 1 1 Ater. Independent Living Hasan Inde ntlentLlvIo Be,... 10,00.00 2 2 Amentan Na4onel Red Cross, TM1e Disaster Pre aretlness fl Res n in Hevo li Coun u ,000 50110 3 3 Am of Kona Lae Skills For Inde ndent Living 24,500.00 4 4 Aes a Sciences Center (ABC) ASC Community Education Services 55,30000 5 5 Bay Clinic Mobile Health Unit 75000.00 6 6 Big Brothers Big Sl ten (Haws'i Island) One -to -One Merrill 10,000 00 7 7 Big island Mediation dba West Newall Mediation Center West He.,i Metliation Center 25000.0 8 8 Big Island RC80 Council Hassi i Herrailrovin Food NeMork HHFN 25,00000 9 9 Big Island Substance Abuse Council Hassell HeakM1 and Wellness Center H,10 30,000.00 10 10 Big Island Substance Abuse Council Hawaii HeakM1 antl Wellness CV Kea au 0,000.00 11 11 Big lslantl Substance Abuu Coutes West Haws'i Substance Abu. P22narn 30,000 00 12 12 Big lslantl Bubstanre Abu se CounuIBISAC East Hawaii Substance Abuse Pregnant 60000.00 13 13 Big island Wellness solutions 8, Island bh pregnant 25,000.00 14 14 Boys 8 Girls Club N the Big Island H2mBkua Outaf-SUwI Fitness For Life 40,000.00 15 15 Boys B Gids Club Of the Big Island Hilo Outo4SUool Fitness For Life 60.000.00 16 16 Boys a Gila Club of We Big Island Klfs'au OutM-SCM1ooI Fitness For tib 60000.00 17 17 Boys 8 Gins Club of the Big Island Ocean Uiew Outaf-$cM1ool Fitness For its 40,000.00 18 18 Boys 8 Gila Club of Ne Big Island Parole Outof-School Fliness For Life 40,000.00 19 19 Be, 8 Girls Club of the Big Island PeM1oa Oulbt-SUool FiNeas For Life 40,000.00 20 20 Buys to Men Menbing NMwork, Inc. Bn fO Men venturing Nattiest, M HawaiS 75,000.00 21 21 Stanley Center Em omen Rehabilitation 45.00000 22 22 Bridge House, Inc. Vccalional Bkllls Builtlin Pro ram 35,00.00 23 23 Child a Family Sork— Akernabves to Violence 60,000.00 24 24 Child a Family Service CM1iltl anti Tamil CenterP 60,000 00 25 25 Child B Family Service East Hawai l Domesgc Abuse Shelter 80,000.00 26 26 Child 6 Family Service Hale KUua be a Transitional Apartment 45,000.00 27 27 Chad B Family Be,,. West Have i Combine Abuse shelter 80,000.00 28 28 Daniel0.. $ayre Mer[orial Fountla4on Makelei Ambulance Grant Pro sal 214,000.00 29 29 East Hawai Cultural Council BI lslantl SWckK EslerP yourn 18,020.00 30 30 Epilepsy Foundation M Harris i Sliimre Smart Hassel, 40,000.00 31 31 Family Suppon He. 11 Street 0i.tol-Nameless and At -Risk Youth 30,000.00 32 32 Fami, Support Hawai West Hawaii Fatherhood Initiative 30000.00 33 33 Food Basket, Inc.. The Ensurin Ca ac -East Hawaii 30,00.00 34 34 Food Basket Inc., The Ensuln Ca ata - West Haves, I 30,000 O0 35 35 FWtl Basket Inc.. The HO Oman -Ka.. "$NAP -in Bamera' 15.000.00 36 36 Friends of Big Island Drug Court Assistance tO Om Court Clients fl Pmgram 10,000.00 37 37 Friends of Children's Justice Center EH S W Needs. Enhancement Su tie, Educator and Tri 25,000.00 38 38 Friends W the Children of West Hewai Basic Needs and Enhancement Acbehes 10,000.00 39 39 Friends "a Peace Theater Celebration of Hawaiian Music series 29.800.00 40 40 Full Life Builtlin Inde record BSea-Suffiden 120,150.00 NONPROFIT GRANT APPLICANTS FOR FY2015-16 Numerical Sort ON., Ortler ORGANIZkTIOX NAME PROGRAM NAME REQUESTED 41 41 GcWwill industries of Hawaii Job Connections 30000.00 42 42 Goer -'s lntlusGes of HawaiS, Inc. Work Ex n cePr ra 65.000,00 43 43 Grassi community Development Group Hawaii Youth Business Canui 17,000.00 44 44 Green Will Gonurvanry Hui Mars o 24,00000 45 45 Habon for Humanity West Hawai i Ho Be ins At Hame 80.000.00 46 46 Hale Jri Inc Ka'i Like Pr him 10,000.00 47 47 Ham2kua Harvest Demonstration Wwi Farm and Orchard 47,300,00 46 48 H2mi Toho Foundation Hamakus Youth Center 36,500.00 49 49 Hawai County Economic Oppoduniry Council(HCEOC) Dm Out Phavention Phoe,ram 148,23500 50 50 Hawaii County Economic Opportunity Coundl (HCEOC) Trans nation ram 600,000.00 51 51 Hal I Island Adult Care, Inc. Adunoa Carecenters 30000,00 52 52 Hawaii Islantl HlV/A106 Fountldlion (HIHAF) Conduct a Com relemaina Joidurts M Me HIHAF SJSTA Pro,man 20,00000 53 53 Howds I Island HlVIAIOS Foundation(HIHAF) Ex anon Case Manaement Servicesfor HlVantl He Cin East Hwho, 20,000.00 54 54 Hawdil Island Home for Reci Inc. HIHR Su nve Housin Pr ram 49.00000 55 55 Hawaii Island Home for Rewvery, Inc. HIHR Transitional Housin Pr ram 49,000.00 56 56 Hari I Island Wormorce d Economic Development 01(HIWE00) Hal Sarni 57 57 Haxaii Meln Pm)eq Hawaii Island Men Prevention Youth Onardwa 50000.00 58 56 Hawai1 Monosson Schools Phommal Aide hern 20,000.00 59 59 Hi'ilei Aloha, LLC Susainin aHeaXh Services C.1dinatorfor KKPCASWdents 70,00000 60 60 Kid Community Players 2015-16Theatrical Season 35,000.00 61 61 Ho orrou Ka'a Nadi -Land Planes Worksho 8,050.00 62 62 HOPE Services Hawaii, Inc Disaster Relief B Recove 50,00000 63 63 HOPE Services IIIi, Inc East Hawaii Eme an Housin 50,00000 64 64 HOPE Services Hastin ii. Inc East Hawai i Homeless Outreach 25.000.00 65 65 HOPESum ioe Hawaii, lnc Frendl Place Resource Ceder 50,000.00 66 fib HOPE Services Hai i I, Inc Goin Home C -----um 20.000.00 67 67 HOPE Se"was Hawaii, Inc Inarm/Brilge Housing 25000.00 68 68 HOPE Services Hawa i, In. rural Pua Homeless Emil e enc Shelter 25,00000 69 69 HOPE Services Haw I, Inc Shelter Plus Care Pro rams so,Odo.00 70 70 HOPE Services Hawail, Inc Tenant Sdubons: Housing Sidemminst 0,000.00 71 71 HOPE Serrces Hawaii, Inc West Hawai Em e a Housin P 0,000.00 72 72 Hosgce MHilo Hawaii Paniative care ceder6 n sia 80,000.00 73 73 Hui Malama Ola NaOiwi isth Annual Laoies Ni dOut Evem 000.00 74 74 Hui Maama Old Na'Oiwl CanCefP 6,700.00 75 75 Hui Melema Ola Na'Oiwi KOkue Nall Hearth Trans ration 50,000 as 76 76 Hui Porto Hdoholona Subsidized Low Cost 6a/Name, Cuniu 77 77 Innovative PCS Foundation zs,000.60 Cance Gardens of Ancient Hawai o.00a.00 78 79 Karua Pa a Mua Palili'O Kohala 0,000.00 79 80 I(allapa Community Association Communi Resilience and Sen -Reliance ]1 000.00 80 81 1(1 rich. Market At Kaani, The 10 oaa.00 81 82 Ka '0 Rural Health Community A eiatiaq Inc. Ke p Rural Hearth A hdann 88,3]fi.00 82 83 Nwukaha One Youth Development RISE 2tst Cantu Atter ScrOol Pr re 12,000.00 NONPROFIT GRANT APPLICANTS FOR FY2016-16 Numerical sort Omer Omer ORGANIZATION NAME PROGRAM NAME REQUESTED 83 64 Keaukalm One YouN Oevelopmen[ Youth Pill Pro ram 12,000.00 84 85 Konala Animal Rebra4on end EduratiOn Service (KARES) Green.S and Neuter 30,000.00 85 86 Kohanaie One. Ervmdcmemal and CUi St.mahle Pm9nam 30,000.00 86 67 Kola Adult Day Canhq Inc Adult Da Care 15,000.00 87 88 Some Cnorel Social, KCS Youth Cnoms 51000.00 88 89 Kone Humucal Sodery Livin Hum P came 28,500.00 89 90 Ku Aloha OM Mau Hui Ho'ola O No Nahulu 0 Hal 1 36.962.00 90 91 So earl Metliation Center Communi ComIIW Resolution Services 12,000.00 91 92 LaiOpua 2020 Susteircoli From Soil to Slul 56,125.00 92 93 Legal Aid Socreh if Hawaii Le at Pul s to SenSueiuenc 40,000.00 93 94 Lotemi Treatment Center Adolescent Substance Abuse Treatment Pnegram 23,1]8.16 94 95 Malarial Waded School Put An. An. PamnVCM1iltl Deveb merit 95 96 Melamalama waltloR School 3,500.00 Puna Ana in 11ie Pall Pm ram 15.000.00 96 97 Melamalama Waldorf Sen. Puna Off The Streets Grace Aflttcare 5,500.00 97 98 Melamalama Wal So l Safe Ami Removal 2500000 98 99 Mental Health Kokue Residential Renedilitation Services 1o,oao.ag 99 100 No how, we Hcea Moku Cance Gallen -OmN 44 064,00 100 101 Nb War Iwi Ola He emend Kamod 5.000 00 101 102 NeipM1dorM100d Piece of Puna Eme one Fom Pdn[ 20,009.90 102 103 Nerghdommed Place Y Puna Famil Seem thenin 20000 00 103 104 NeignMmmd Place W Puna On om La. Relief and Assistance 104 105 Nortn KOM1ak Commrniry Rezlurce Center 30,000.00 Komi ui Coalmon 0,00000 105 106 Norm Kdnala comminih Resource Center Nddn rcohala Radio 20.000 90 106 107 OKa'u - Kekou Famil Fun Fast 8,00000 107 108 O Ka'0 Kakou Ka'0 Coffee Trail Race and OM1ane Da 15 000.00 108 109 0 Ka'0 loso. Ka'0 Sanitation Pr m 8,500.00 109 110 0her o Sol— Puri a Annual Fishing Toumament 800000 110 111 Pacific Tsunami Museum Tsunami Education Vid. Presentations 111 112 Pelekene Kai Ocean Safe LLC 2] 395.00 , Ocean Safe Education -Island Wide 20,000 00 112 113 PATCH -Ped a Atedntiem Chuldren PATCHTrarnm Trans rtatroolydtialive ].000.00 113 114 Pm ei Vision Hasil, i Hawarl Island Mobile Heapn Services 114 115 Read Aloud America 65.00000 RAP Pr rams for the Island of Hawai 2835200 115 116 Savatioo Arm -FIS. The lode endent ovm Skills - West Hawaii 35,000.00 116 117 Salvation Arm -FIS, The Positive Youth Develoment P -tons so 117 118 SaNation Arm -FIS, The 35,000.00 Subslance Abuse Preventuri -Pill. 118 119 SOue for Koni Education & Aft SKEA 35,000.00 Ad Cam for Childmr rmd Teens 15,000.00 119 120 S car m ids Hawaii S sclal0 mcs Hawaii - Ess Hawai. Area � 35,00000 120 121 Sacrala lct Hawai.-West Hawaii SOWH General Fund 121 122 TwUForAmenw Hawai 15,00000 Hanow i Island TeacherP rammn 9000.90 1 122 123 The Arc of Hllo Client Com me, -Leamin Center 123 124 Threetha Ranch 25,000,00 Eaemshi llntemshi s/Mentorin 16.00000 124 125 Three Rin Ranco Fenm Re ladement 9.000.00 NONPROFIT GRANT APPLICANTS FOR FY2015-16 Numerlcal ORler Sart Order ORGANIZATION NAME PROGRAM NAME REOUESTEO 125 126 Urian, Foram Na Moku O Haeal I. Inc. Peanut Farm Pro ed 76,97500 126 127 Mane PMaku Ne Moku O Haxari, Inc. Reforestation of Makaku a GUIGh In 1e'0 7948200 127 128 Mane Pohaku Na Make O Haeim I, Inc. Th. Open I'a Proect 76.299 00 128 129 Volunteer Leal Services Hawai I Hasan Court, Community Le,al Access PMm 30,60000 129 130 Watindon Dr, Forest Imitated Waikoloa Future Foresters 10.00 .00 130 131 Wart Hawai I Gou Band Friends Music andEuimect Fund 6.100.00 131 132 West H..I C. Band Fiends Volumed, Musicians Fund 15,000.00 132 133 West Hawani Communi Hearin Center wHCHC Must Dental for Underserved 30,00000 133 134 west Hawaii Communi Heenn center wMCMc WHCHC MedicalVan Renovation 15,000.00 134 135 Veshua Cu.. Center. Inc Veshua Outreach Center 67,500.00 135 136 MCA Hawain Island HeaIN Stan Pr ra m -Home Vlsitin 25.00 .00 136 137 YWCA Hawai l Island $.r.1 Assault $unSvcs. 60000-00 137 138 YWCA Haven I Island YWCA Develo mental Preschool 15,000.00 roof 6501,716.18 Mote: Metals, pa xanrs as norm eetone0/meadlefduase rwnena ex uafffled 78 Ka HakO Na KeikiInc. Families at Risk 10000.00 i461 10 000.00 Aloha Independent Living Hawai'i Independent Living Services 1 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Services Agency Director: Roxanne aomen Phone No.: ( 808) 497 — 2350 Contact Person: Roxanne solder Phone No.: ( 808 ) 497 — 2350 Mailing Address: Address: Po. 6.x283 Q North Hilo Q South Kohala Address: City, ST, Zip peal Cly, Hawaii 96782 Facility Address: Address: 90.909 Kau du Place H211 Address: City, ST, Zip waipahu. Hawaii 96]9] Email Address: ro6oldw@ ohaiLlr w fl,org Fax No.: ( 800) 385 — 245,1 Accountant/CPA: .anon Lim, CPA Phone No.: ( 808) 522 — 8833 Firm (if applicable): Darrell um a company, CPAs Mailing Address: Address: 815outh Hotel Street Address: Gty, ST, Zip Hondulu, Hawaii 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: tone or more can be checked) Q Puna Q Hamakua Q North Kona Q South Hilo Q North Kohala Q South Kona Q North Hilo Q South Kohala Q Ka'e Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor Q Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page l of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 Y 11 -4 Total Program Position Count:j 4 TOO -----O-001 2. Agency Mission Statement: To provide independent living programs and services to persons with disabilities living in Hawaii. 3. Program Description: The concept behind independent living is the empowerment of persons with disabilities to make choices in their lives that will enhance their dignity and self-respect and provide full integration into the community as equal citizens with all the privileges and responsibilities available to them. We have two goals which is to address their rights and responsibilities and to facilitate their accomplishments. A- Total Budget & Position Count: Total ProgramBudget: $159,570 Total Program Position Count:j 4 Total Agency Budget: $522,659 Total Agency Position Count: 13 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Services 5 Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate itle V11 Part B Inde endent Livin Services Funded by DHS under DVR itle Vll Part C Independent Living Services Funded by DOE under RSA $237,000 $377,892 TOTAL: $614,692 Attach additional pages, 6. Explain what plans your agency or program has to increase revenues to support this program: 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. To provide one-on-one independent living skills training to carry out their everyday living activities. 2. Provide information and referrals. 3. Provide training in landlord/tenant rights. 4. Provide attendant referrals to acquire personal assistance services. EXHIBIT A County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Services 8. TABLE I: 1Ae, ,..,. +" ,.,.e..aea measurable c,. .fn, ,fq nr nutcnmes that would be achieved with this funding? Attach additional pages as necessary. n TA SLE 11- V ` PROGRAM EXPENDITURES FY 14-15 FY 15-16 Actual' Total Budget PROGRAM PERFORMANCE MEASURES Applicant Projected Results ti. e.: Number of dienh served, workshops erevents held vdurthe, hours. etc. Oesrnbe, be specific) $10,000 Training in landlordttenant rights 10 How to complete ousing application 10 How to locate and maintain housing 10 Training in independent living skills 10 Training in legal fights and self-advoca 10 Provide information and referral 40 Provide attendant referrals to acquire personal assistance services 10 Attach additional pages as necessary. n TA SLE 11- V ` PROGRAM EXPENDITURES FY 14-15 FY 15-16 Actual' Total Budget FY 1546 Grant Req Salary and Wages $112,429 $137,700 $10,000 Professional Fees $4,000 $6,000 Operations $11,242 13,770 Supplies $1,687 $2,000 Equipment 100 Other: Staff Training Other: Other: Other: Other: TOTAL $129,358 $159,570 10,000 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Services to. 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. - Chair Sec foL l 9 15 �T Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Services f f. Certification of Understanding (page t of 2) 1 (we) have read and understood all of the 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 Hawari Compliance Express, and be compliant prior to final payment. To register, go to http i/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 reoort 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 roguests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Services 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http //www hawaiicountygoy/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, 2015 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 Vour agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. �Lhai r l 5atXef(l1- Signature of Authorized Person (specify title) J EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 1�a9 1i5 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Aloha Independent Living Hawaii Program Name: Independent Living Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results I Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 American National Red Cross (The) Disaster Preparedness & Response in Hawaii County 2 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County Agency Director: comlie Matayoshl Phone No.: ( 808) 739 — 8103 Contact Person: Kerrey Gomes Phone No.: ( 808 ) 739 — 6140 Mailing Address: Address: 4155 Diamond Head Road Address: City, ST, Zip Honolulu, HI 96616 Facility Address: Address: 55ulalani St. Address: City, ST, Zip Hilo, HI 96720 Email Address: KermYGomes@redcroeeor9 Fax No.: ( 808) 735 — 8626 Accountant/CPA: KPMG LLP Phone No.: ( 703) 286 — 8000 Firm (if applicable): KMPG LLP Mailing Address: Address: 1696 International or. Address: City, ST, Zip McLean, VA 22012 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua © North Kona Q South Hilo © North Kohala © South Kona © North Hilo © South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $14,750.00 $20,000.00 $12,500.00 2. Agency Mission Statement: The Red Cross mission is to prevent and alleviate human suffering in the face of emergencies by mobilizing the power of volunteers and the generosity of donors. Twenty four hours a day, seven days a week, the Red Cross assists victims of house fires, Floods, and other natural and man-made disasters. The Red Cross delivers help, hope and healing to people affected by disasters by transforming donors' generous funding into shelter, food and emotional support. 3. Program Description: The goals of the Red Cross Disaster Preparedness and Response Program are twofold: 1) to recruit, train and coordinate volunteers to be on call to provide disaster relief assistance to victims of disasters big and small, anytime on the Big Island; 2) to provide individuals, families, schools, businesses and communities with knowledge and skills to better prepare themselves and others before emergencies occur. We respond every four days to disasters in Hawaii, and our immediate and compassionate services reduce the harsh physical and emotional distress that prevents people from meeting their own basic needs following a disaster. Educating the public about being prepared will enable entire communities to bounce back from disasters of all sizes, and this program will save lives and ensure Hawaii can survive after a major disaster strikes our islands. 4. Total Budget & Position Count: Total Program Budget: $200,7501 Total Program Position Count: i Total Agency Budget: $3,269,5911 Total Agency Position Count: 17 EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 5. Proeram Fundine Sources (identify all sources of funding applied to this Programl: Revenue Source FY15-16 Estimate County of Hawaii $20,000 Hawaii Island United Way $40,000 other contributions direct mail and grants) $67,000 subsidy by Amencan Red Cross to meet deficit $73,750 TOTAL: $200,750 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program The American Red Cross is mandated by Congress to provide disaster relief assistance, yet does not receive federal funding for disaster operations. Since its founding, the Red Cross has been the nation's premier emergency response organization. The generosity of the public through individual and corporate donations and grants from private foundations enables us to fulfill our humanitarian mission. We continue to increase visibility of the tremendous work our organization does through various forms of media, which are all donated (television public service announcements and newspaper ads, as well as social media) and continually seek contributions from the public. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Disaster Preparedness and Response Program has the following objectives: 1) Recruit, train and coordinate volunteers to be on call 24/7, 365 days/year to provide disaster relief assistance to victims of disasters; 2) Reach individuals with lifesaving information through disaster preparedness presentations, including schools and participation in community fairs; 3) Work with government entities and private partners to ensure inclusive and robust mass care plans: clear evacuation routes, private and government facilities that can serve as shelters, shelter supplies in different areas of the county, and trained partners that can assist with a mass evacuation. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Ite.: Number of dlents served, workshops or even held volunteer hours, ett Describe, be spxlkd Applicant Projected Results Number of disastersresponded to 15 Number of individuals assisted after a disaster 40 Number of individuals reached with disaster preparedness information 1,000 Number of disaster training certificates issued 200 Operations 70,000.00 70,000.00 Attach additional pages as necessory. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 53,000.00 54,000.00 29,759.70 Professional Fees Operations 70,000.00 70,000.00 Supplies 700.00 1,000.00 3,000.00 Equipment 100.00 1,000.00 2,240.30 Other: disaster relief assistance(unpredictable) 30,000.00 40,000.00 15,000.00 Other: travel, postage, gas, program related expenses 35,850.00 34,750.00 Other: Other: Other: TOTAL 189,650.00 200,750.00 50,000.00 'If applicable(fx. WWO EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 20. 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: Coralie Matayoshi POSITION: Chief Executive Officer May have a conflict or potential conflict of interest, including anyfamilial 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 WI5 Signature of Authorized Person (specify title) Cnrnlin tgnra,unsh{, CEO EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 11. 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, 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 expend ing/oversight agency) full, free, and unrestricted access and authority to examine and 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 final payment. 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 veer -end report, using the template provided, will impact the evaluation of Your program's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 11. Certification of Understanding (Page z of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30t1 shall result in loss of all Grant funds received during the ¢rant 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, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in o timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. (�� 1121 tied Signature of Authorized Person (specify title) Date Coralfe Matavo=hi, CEO EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The American National Red Cross Program Name: Disaster Preparedness & Response in Hawaii County 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES ectad Resaunt Projected Results Council Proposed Projected Result Number of disasters responded to 15 Number of individuals assisted after a disaster 40 Number of individuals reached with disaster preparedness information 1,000 Number of disaster training certificates issued 200 Equipment 2,240.30 Other: disaster relief assistance (unpredictable) 15,000.00 Other: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 29,759.70 Professional Fees Operations Supplies 3,000.00 Equipment 2,240.30 Other: disaster relief assistance (unpredictable) 15,000.00 Other: Other: Other: Other: TOTAL 50,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of The American National Red Cross - Disaster Preparedness and Response in Hawaii County Additional Page for #3 Program Description The Red Cross is unlike any other organization. Working side by side local police, fire, and civil defense, we are the only nonprofit organization that responds to disasters big and small, 24/7, 365 days a year. Our services are essential, irreplaceable, and assist county, state, and federal government in their responsibility to provide for the welfare of those who reside in their jurisdictions. Red Cross assistance includes: food, clothing, shelter, mental health counseling and financial assistance to help families recover more quickly from a disaster. In a larger disaster or tragic event, crisis counseling, mass care, family reunification, emergency first aid and other support services as appropriate are also provided to victims. Response is only the tip of the spear. It takes preparation, resources, and infrastructure to be able to respond everyday throughout the year. We accomplish this with a small staff and hundreds of volunteers who work 12 -hour shifts, morning, noon, and night. Having volunteers play such a vital role in carrying out our mission makes the Red Cross unique. Whereas other organizations may pay for drug counselors or child care workers to provide services, we leverage the free services of Red Cross volunteers to fulfill our mission. lust as the County would fund contracts/salaries of drug counselors or child care workers as a program expense, the salary of our Red Cross staff person, who enables us to use volunteers to provide services, is a program expense. The fact that we don't have to pay our volunteers to do the work demonstrates that Red Cross is a very wise investment. Most funders want to donate money to buy tangible items like cots and blankets, but don't think about the cost to rent space to store the cots or how the cots and blankets will get transported to shelters when needed. County of Hawaii funding would help to support the basic infrastructure of our disaster response and preparedness program so that the Big Island Red Cross is able to respond and prepare the community beforehand to mitigate the loss of life and property. Hawaii County funding would be used to support the partial salary and benefits of our only paid staff person on the Big Island who recruits and trains volunteers, works with volunteers to secure, inventory, and preposition disaster supplies, ensures that volunteers are mobilized to help disaster victims anytime and anywhere on the Big Island, organizes volunteers to do community disaster education outreach, engages the community in disaster preparedness planning, and works with government agencies and other non-profit organizations to plan and exercise for disasters. All of these duties entail direct program (not administrative) expenses. Whether a disaster happens or not, the Red Cross must constantly recruit and train volunteers to be ready to respond and educate the community about disaster preparedness. Without support of these fixed costs, we couldn't operate and would not able to respond when needed. Our volunteers are ready to respond to disasters 24 hours a day, 7 days a week, 365 days a year. All disaster training and response are provided free of charge. Another component is community disaster education, which empowers families and individuals to prepare for and respond to disasters before they strike. The geographic remoteness of the Hawaiian Islands makes community preparedness and resiliency crucial. Following a major disaster like a tsunami, hurricane or earthquake, our logistics bridge would likely be compromised and critical resupply of items such as fuel, food and medical supplies could be The American National Red Cross - Disaster Preparedness and Response in Hawaii County Additional Page for #3 Program Description delayed. Educating families and businesses to take responsibility for their own preparedness can mitigate the loss of life and property. When people have a disaster plan and kit, the effects of a disaster are lessened and recovery is quicker. Since 1917, the people of Hawaii have depended on us to respond not only to everyday fires and floods, but also every major natural and man-made disaster that has struck our islands, including the: bombing of Pearl Harbor, Hurricanes Iniki and Iwa, Big Isle earthquake, multiple tsunami, Sacred Falls landslide, New Years and Manoa floods, Kaloko Dam burst, airplane and helicopter crashes, explosions, and hostage situations. The Red Cross is not a government agency and relies on the aloha spirit and generosity of Hawaii's people to provide critical services to the community. All disaster training, services, and financial assistance to victims is free. In Fiscal Year 2014 (July 1, 2013 - June 30, 2014), the Red Cross in the County of Hawaii responded to 22 disasters on the Big Island enabling 97 individuals to recover from their losses and begin rebuilding their lives; reached 1,865 people with disaster preparedness information through community presentations; held 10 disaster training courses, issued 171 disaster training certificates, and maintained a base of 168 active disaster volunteers in the County of Hawaii; trained 14 partner volunteers for a total of 56 partner volunteers (reserve corps of disaster partner volunteers who can be activated during large-scale disasters). During the first half of Fiscal Year 2015, the Red Cross in the County of Hawaii responded to 9 disasters on the Big Island and assisted 28 individuals; reached 3,133 people with disaster preparedness information; recruited 25 new volunteers, issued 159 training certificates, and maintained a base of 189 active disaster volunteers. In response to Tropical Storm Iselle (8/8/14), we opened 13 shelters, sheltered 1,325 people, distributed 19,496 relief items at 12 sites, served 4,119 meals and snacks, visited 29 homes and outreached to 568 people for health and mental health services. In response to Hurricane Ana (10/18/14), we opened 5 shelters and housed 29 people. According to the Census Bureau, from 2008 to 2012, 17% of the County of Hawaii's population lived below the poverty level. This poor and needy demographic is particularly vulnerable to disasters and is dependent on Red Cross services when affected by a disaster. Based on family size and income levels, our records show that in FY14, at least 52% of the disaster families we served on the Big Island were below the Poverty Guidelines set by the U.S. Department of Housing & Urban Development. Of the families, 73% owned their home, but only 18% had homeowner's insurance. The people who the Red Cross helps are truly destitute after a fire destroys everything they own or claims the life of a loved one. The Red Cross is truly a safety net for victims of every day disasters who have nowhere else to turn. Beyond the every day disasters, the Red Cross is preparing for and will respond to major disasters, which may affect the entire population of Hawaii, especially those with special needs like the elderly, frail, handicapped, and poor. No one can predict when or where the next disaster will strike. For the past 98 years, the Hawaii Red Cross has kept a simple promise—to be there to alleviate human suffering. As we continue to honor this pledge, we hope the County of Hawaii will support us in our efforts. Arc of Kona Life Skills For Independent Living 3 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Arc of Kona Program Name: Life Skills For Independent Living Agency Director: Michele Ku PreslderUCE0 Phone NO.: ( 908) 323 — 2626 Contact Person: Michele Ku, PresidahUCEO Phone No.: ( 908 ) 323 — 2626 Mailing Address: Address: PO9n.121 Address: City, ST, Zip Kealakekua, HI 96750 Facility Address: Address: 81-1065Konawaena School Road Address: City, ST, Zip Kealakekua, HI 96150 Email Address: michele@arcotkonavm Fax No.: ( 808) 323 — 9444 Accountani Ann N. Fukuham, CPA, MBA Phone No.: ( 808 ) 934 — 8589 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: PO 6o. 6691 Address: City, ST, Zip Hilo. HI 96120 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $ 24,500.00 Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑✓ Hamakua ✓❑ North Kona 0 South Hilo ❑✓ North Kohala W] South Kona Q North Hilo Q South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged © Victims of Health or Social Crises ❑ Needs of the poor © Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Arc of Kona Program Name: Life skins For independent Living 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $11,250.00 $10,000.00 $24,500.00 2. Agency Mission Statement: The Arc of Kona is committed to helping people with disabilities achieve the fullest possible independence and participation in society consistent with their wishes. 3. Program Description: The Arc of Kona has served the ID/DD population for over 50 years and has developed a program for teaching life skills for independent living that focuses on the protective factors that impact the individuals' ability to function within their communities. All of these individuals are challenged with making good judgments due to cognitive delays and need various supports to insure their safety and help with activities of daily living. Protective factors include training in social development, appropriate sexual behavior, protection from abuse including family members, employers and strangers, proper nutrition, preparing individuals to find their own housing accommodations and live as independently as possible with or without assistance and other agency supports, and preparing for work either supported or unsupported at the work site or as an entrepreneurial start up. The program uses the "community as a classroom" approach where participants can practice these skill sets, which are identified and measured individually, and which are essential to strengthening the protective factors around this vulnerable population. When provided this integration, participants have opportunities to share their own gifts with the community and transfer new fife skills to multiple settings. 4. Total Budeet & Position Count: Total Program Budget: $2,600,474.00 Total Program Position Count: 75 Total Agency Budget: $3265,456.00 Total Agency Position Count: 113 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Arc of Kona Program Name: Life Skills For Independent Living 5. Program Funding Sources (identify all sources of funding applied to this Program) FY15-16 Revenue Source Estimate Medicaid H&CB8 $297,029,00 Hawaii Island United Way $30,000.00 County of Hawaii $24,500.00 TOTAL: $351,529.00 Attach additional pages, if needed 6. Explain what plans your agency or program has to increase revenues to support this program The Arc of Kona has two signature events each year: our annual Bazaar and Craft Fair held each November and our annual Blue Grass concert held each January. Revenue from these events support the Independent Living/Life Skills Program, Our Board of Directors made visibility one of our major goals this year to increase awareness and educate the community about our programs and needs which has given us monetary support from the West Hawaii Association of Realtors and West Hawaii based Rotary clubs. We have also upgraded our website so we can receive donations on line and continually write funding proposals to foundations that share our vision for our population to live independently. Our objectives are: 1) build a stronger donor base to raise unrestrictive funds, and 2) write meaningful proposals to supplement our existing funding for independent living and life skills. 7. Program Objectives Using County Nonprofit Grant Program Funds 1. Provide a safe, healthy and supportive environment for training both in the classroom and the community setting 365 days a year from July 1, 2015 -June 30, 2016 for 120 participants referred from the Department of Health Home and Community Based Services and with a special focus on individuals living in the rural, under -served areas of the island. 2. Provide individualized independent living through the fife skills training programs, with measurable goals and objectives that allow each participant to develop at his/her own pace. 3. Provide needed materials to assess, teach and support life skills training in the community as a learning laboratory and reinforce independent living skills throughout the year to teach and adapt those skills required to function on a daily basis. 4. Provide needed supports for interacting appropriately in the community including safety, reporting abuse, appropriate sexual behavior, hygiene, money management, household safety issues and nutrition as well as provide additional support services for seeking, attaining and maintaining employment for those individuals who desire to work in their community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Arc of Kona Program Name: Life skills For Independent Living B. TABLE 1: wnal are in mlenueu oleacul dine ou LPuu U w•w111— Ll I a. ._.._...a. PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i. e.: ,," he)d, wlunteer hours, em aesnbe, be specific) Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $2,196,577.00 $21,560.00 Professional Fees Operations $312,062.00 $2,940.00 Supplies Equipment Other: Other. Other: Other: Other TOTAL $2,508,639.00 $24,500.00 appm aoie EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Arc of Kona Program Name: Life skills For Independent Living io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 on industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑v7 If no conflicts exist, check here. �z(�� fUKS/lI(halCEl] January 14, 2015 Signature of Authorized Per ecifytle) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Arc of Kona Program Name: Life skills For Independent Living 11. Certification of Understanding (page 1 of z) I (we) have read and understood all of thee I igibility 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 final payment. To register, go to http-//vendors.ehawaii.pov. complete the 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 o timely, complete and accurate year-end reportusing the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Arc of Kona Program Name: Life Skills For Independent Living 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of HawaYi 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�t/www.hawaiicounty.gov/fn-nonprofit-grant-formsZ on or about May 30 of the year the final 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 lune 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in o timely manner will impact the evaluation of your agency's future funding reauest and may result in actions token to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Perso title EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 January 14, 2015 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Arc of Kona Program Name: Life skills For Independent Living i9asrye 12. COUNCIL AWARD WORKSHEET PROGRAM PERFORMANCE MEASURES See Attachment 1A Applicant Council Proposed Projected Results Projected Result PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $21,560.00 Professional Fees Operations $2.940.00 Supplies Equipment Other. Other. Other Other. Other TOTAL524.500.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Are of Kona Program Name: Life Skills for Independent Living ATTACHMENT IA Question 8 Table I MAXIMIZING INDEPENDENCE THROUGH LIFE SKILLS PROGRAM Performance Measures: Applicant Projected Results: Maximizing Independence All Home and Community Based Programs 1. a) Provide a safe, secure classroom 1. a) 260 days of ADH standard classroom activities with environment with sufficient staff a one staff to four participant ratio for 25-30 participants. supervision, 5 days a week, 52 weeks a year, for current 25 DD/ID participants. b) Deliver ongoing independence through b) 365 days of one on one service for approximately life skills training in the classroom and the 120 participants (number can grow larger with new rural areas as per each individual's plan referrals during the fiscal year). which is developed by the Department of Health, the family and the Arc of Kona. 2. Provide access to the community for 1. 144 ADH classroom transports into the community hands-on independent living through life per year to achieve individual goals for independent skills training experiences leading to living through life skills. independent living including budgeting for food and clothing, shopping, fire safety, 2. 3,500 individual transports to achieve individual ordering and eating in public, handling independent living through life skills plans in the money, making appointments, nutrition and community setting. exercise, and appropriate behaviors in public (including sexual behavior). 3. Provide on-going Independent Living 365 days of instruction provided with assessment, base Life Skills assessments and data collection line, and data collection for results reporting. Tools used for each individual. This includes areas are the Brigance Life Skills Assessment, and such as fine and gross motor skills, Individualized Service Plans (ISPs) developed by the receptive and expressive language, Participant, the family, and the Department of Health volunteering, recognizing and reporting Case Managers. abuse, health, hygiene, safety, This results in extensive progress reports written socialization, basic cooking skills, quarterly for the Department of Health and the family to behaviors, consumerism, basic literacy and determine success and any changes needed for the job skills training. current year to better achieve the individual goals. 80% of the total enrolled will meet at least one goal during the year. J Arts & Sciences Center (ASC) ASC Community Education Sewcies 9 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Arts & Sciences Center (ASC) Program Name: ASC Community Education Services Agency Director: Gail Clarke Phone No.: ( 808) 938 — 2933 Contact Person: Gail Clarke Phone No.: ( 808 ) 965 — 3730 Mailing Address: Address: PO Bet 2091 Address: City, ST, Zip Pahoa, H196718 Facility Address: Address: 15-1397 Homestead Rd - No USPS Address: City, ST, Zip Pared, HI 96])8 Emall Address: a scpura@gmail.com Fax No.: (808)965— 3733 Accountant/CPA: Rozanne Connell, CPA Phone No.: ( 808 ) 968 — 1002 Firm (if applicable): Caroonaro and Associates Mailing Address: address: Poaoxa3n Address: City, ST, Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $55,30000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hatirt ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns ❑✓ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Arts & Sciences Center (ASC) Program Name: ASC Community Education Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 j 0 $0.00 $8,000. 2. Agency Mission Statement: ASC formed as a 501c3 in 2003, to provide outstanding support and infrastructure for community based learning rooted in Puna. ASC envisions learning and sharing opportunities to empower participants to thrive, cooperate, innovate and serve. ASC works to provide (1) access to education (2) stewardship of diversity and cultural infusion (3) stewardship of our environments (4) partnerships for positive economic impacts. 3. Program Description: ASC will continue to provide support services for Puna community members and groups to hold meetings, provide educational seminars, classes and consultation for business development and grant proposal support. Community groups apply for use of facilities and fees are based on a sliding scale. ASC is developing a template for consultations to support project proposal development in response to multiple requests for this service. With funding, community access to indoor and outdoor learning spaces will be expanded. 4. Total Budget & Position Count: Total Program Budget: 57,300 Total Program Position Count t 25 Total Agency Budget: 157,393 Total Agency Position Count 0 12 E5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Arts & Sciences Center (ASC) Program Name:ASC Community Education Services S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FYIS-16 Estimate Fees for programs offered by ASC (workshops, lectures) 1000 Fees for use of facilites by community groups 1000 County of Hawaii Grant 55300 I TOTAL: 57,300 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Establish fair fees and advertise for the use of facilities including partnerships with agencies and groups such as HCC, HCEOC, HYBC, SBDC and community projects like Ho'oulu Lehua. Fees support security, maintenance, utilities and ASC overhead. ASC actively seeks grant funding to provide a venue to facilitate individuals, small and/or large groups to learn, envision, articulate, plan and implement entrepreneurial or service projects. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide an accessible place for community events, meetings and programs. 2. Support a network of mentors, partners and students who collaborate and produce together to strengthen our community and its economy. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Arts & Sciences Center (ASC) Program Name: ASC Community Education Services 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i. e.: Number of clients served workshops or events held,, volunteer hours, etc describe, be sbecifia,l Applicant Projected Results Host 20- 50 community meetings and activities 800-1000 participants Hast 4-6 public project consultations 12- 50 participants Host afterschool&intersession projects 20-100 participants Professional Fees 6000 4000 Operations 6800 11000 11000 Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual" FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 7200 32000 32000 Professional Fees 6000 4000 Operations 6800 11000 11000 Supplies 1800 1800 Equipment Other Security contract and system 6000 6000 Other:Consult on Facility Safety/Security 500 500 Other Other: Other. TOTAL 14000 57300 55300 'If applicable EXHI BIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Arts R Sciences Center (ASC) Program Name: ASC Community Education services io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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: Gail Clarke POSITION: President / Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Q If no conflicts exist, check here. k7 11" , P r fish r/ig�zoi5 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Arts & Sciences Center (ASC) Program Name: ASC Community Education Services ii. 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 allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and 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 Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii. I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Arts & Sciences Center (ASC) Program Name: ASC Community Education Services 11. Certification of Understanding (page 2 of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 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.goy/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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Arts & Sciences Center (ASC) Program Name: ASC Community Education Services 1z. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Host 20-50 Community meetings and activities 800-1000 pen Host 4-6 public project consultations 12-25 people Host afterschool and intersession projects 20-100 peopl Supplies 1800 Equipment Othersecurity contract and system 6000 Other: consult on safety/security 500 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages _ 32000 Professional Fees 6000 Operations 11000 Supplies 1800 Equipment Othersecurity contract and system 6000 Other: consult on safety/security 500 Other: Other: Other: TOTAL 55300 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Bay Clinic Mobile Health Unit 5 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Bay Clinic, Inc. Program Name: Mobile Health Unit Agency Director: Harold Wallace Phone No.: ( 8(18) 980 — p499 Contact Person: Yowsau sella Phone No.: (eo8) set — am8 Mailing Address: Address: 224 Haili st., Bldg. B Address: City, ST, Zip Hilo, HI 96720 Facility Address: Address: 224 Hair st, Bldg.B Address: City, ST, Zip Hilo, HI 96720 Email Address: ybers@bayclinio.org Fax No.: ( 808 ) 9e1 — 5678 Accountant/CPA: Kyle Hays, CPA Phone No.: ( 808) 242 — 50(12 Firm (if applicable): Carbonam CPAs 8 Management Group Mailing Address: Address: imsMainsueet Suite408 Address: City, ST, Zip W.iluku. H196793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna ❑ Hamakua ❑ North Kona © South Hilo ❑ North Kohala ❑ South Kona © North Hilo ❑ South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged © Victims of Health or Social Crises © Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Bay Clinic, Inc. Program Name: Mobile Health Unit 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 1415 $60,000 $0.00 $0.00 2. Agency Mission Statement: Mission: Bay Clinic is a community -directed healthcare organization that provides quality primary and preventive care services to the people of East Hawaii. Bay Clinic will ensure that patient -centered, culturally responsive, and affordable healthcare services are locally accessible in our communities. Founded in 1983, Bay Clinic, Inc. (BCI) is a 501(c)(3) non-profit federally qualified health center with nine sites serving over 21,000 patients with 86,033 annual encounters. BCI's community health centers are located in the districts of Hilo, Puna, and Ka'u. BCI provides comprehensive primary medical, dental, and behavioral health care for all regardless of income level or insurance status. Clinic fees are based on a federally approved Sliding Fee Schedule and applied to all patients depending on their income level, family size, and insurance status. 3. Program Description: BCI will establish a Mobile Health Unit, with one primary medical exam room and one dental operatory, that will: 1) Deliver non -emergent primary medical and dental care to residents of the more isolated towns in Ka'0 and Puna that do not have health care services in its vicinity, focusing on the 2,575 Volcano residents, 3,611 Ocean View residents, as well as the residents of lower Puna, if and when, the region is cut-off from upper Puna resulting from the June 27th Lava Flow; 2) Provide 'school-based clinic' services for the 5,645 students of the DOE Ka'0-Kea'au-PAhoa (KKP) District Complex schools through BCI's partnership agreement with the KKP Complex specifically for this service; and 3) in collaboration with our service region's police and fire departments, deploy the Unit to the most critical areas to provide medical relief services during times of natural disaster. 4- Total Budeet & Position Count: Total Program Budget: $855,729 Total Program Position Count: 7 Total Agency Budget: 1 $14.596,3071 Total Agency Position Count: 180 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Bay Clinic, Inc. Program Name: Mobile Health Unit S. Proeram Fundine Sources (identify, all sources of funding applied to this program): Revenue Source FY1S-16 Estimate Deparment of Health and Human Seonces $$0.000 USDA CommunM Facilities Program 350,000 Ouida & Doc Hill Fwndallon $20.000 TOTAL: Attach additional pages, if needed. 6. Explain what plans your agency or program has to Increase revenues to support this program In addition to the above secured grants for the project, we have non-binding commitments from the Harry & Jeanette Weinberg Foundation for $140,000 and two Bank of Hawai'i (BOH) managed private foundations for a total of $70,000. These preliminary commitments are contingent on securing 70% of the total Mobile Unit structure and equipment cost ($327,842) to trigger the Weinberg opportunity and 50% ($243,173) for the BOH managed foundations. These two funding potentials valued at $210,000 combined with the $120,000 already secured totals $330,000. We have also submitted a $100,000 grant funding request to The Hearst Foundations that is currently under review. We will continue to pursue other potential funding avenues until 100% of the funding requirement is secured for the Mobile Unit shell, outfitting, and equipment ($486,345). 7. Program Objectives Using County Nonprofit Grant Program Funds: Bay Clinic respectfully requests $75,000 from the County of Hawaii to be used to purchase equipment for the Mobile Health Unit's primary medical exam room and the dental operatory. The funds will procure the dental equipment, sterilization equipment, and custom medical equipment and appliances. In the short- to medium-term, the Mobile Health Unit will primarily be used to ensure timely access to comprehensive medical and dental care, including prescription dispensing services, for the residents of lower Puna in the wake of the June 27th Lava flow event that is expected to cut the region off from upper Puna. In the longer-term, in addition to serving the health care needs of lower Puna residents, the Unit will also be deployed to remote towns throughout East and South Hawaii, as well as serve as the 'School -Based Clinic' for the DOE KKP District School Complex. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3of9 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Bay Clinic, Inc. Program Name: Mobile Health unit 8. TABLE I: what are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES ti.e.: Number of clients served, umAllmps arevents held, volunteer hours, em Describe, be specft) Applicant Projected Results Expected new patients (all Nes) med & dental _ 6,090 Expected new encounters (medical & dental) 10.634 KKP Complex students (new patient encounter) 1,150 Professional Fees so $7,200 $0 Operations $0 $15,460 $0 Attach Ddditional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16FY Total Budget 15-16 Grant Req Salary and Wages $0 $306.353 $0 Professional Fees so $7,200 $0 Operations $0 $15,460 $0 Supplies $o $32,438 $0 Equipment $0 $470,725 $75,000 Other: Health Information Technology $0 $15,620 $0 Other: Fuel (10,000 miles O 6 mi./gal. x $4.76 gap $0 $7,933 so Other: Other: Other: TOTAL $0 $855,729 $75,000 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Bay Clinic, Inc. Program Name: Mobile Health Unit to. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: Bay Clinic, Inc. POSITION: n/a May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by 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: /I If no conflicts exist, check here. Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION Fir 2015-2016 -Tma('11 CDS ate Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Bay Clinic, Inc. Program Name: Mobile Health Unit ii. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov. complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report, using the template provided, will impact the evaluation of Your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Bay Clinic, Inc. Program Name: Mobile Health Unit 12. 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-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 lune 30, 2015 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 fundina request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Bay Clinic, Inc. Program Name: Mobile Health Unit 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Resant Projected Results Projected Council Proposed Projected Result Expected New Patients (all ages) medical & dental 4 NO Expected New Encounters (all ages) died & dental 10,630 KKP Complex students (new patient encounters) 1'1W Supplies $32,438 Equipment $470,725 Other: Health Information Technology $15,620 Other: Fuel (10,000 miles @ 6 mi/gal. x $4.76 gal) $7933 TARI P It - PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $306,353 Professional Fees $7200 Operations $15,460 Supplies $32,438 Equipment $470,725 Other: Health Information Technology $15,620 Other: Fuel (10,000 miles @ 6 mi/gal. x $4.76 gal) $7933 Other: Other: Other: TOTAL $855,729 Additional Council directives rezardinit award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Big Brothers Big Sisters (Hawai'i Island) One -to -One Mentoring County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Brothers Big Sisters (Hawaii Island) Program Name: one-to-one Mentoring Agency Director: Dennis Brown Phone No.: ( 508) Ess — 4570 Contact Person: Holly Brown Phone No.: ( 868) Ess — 4571 Mailing Address: Address: 418 Kuwol street Address: sultelo6 City, ST, Zip Honolulu. HI 86817 Facility Address: Address: Address: City, ST, Zip Email Address: info@bbbsneweiior9 Accountant/CPA: don Byre, Firm (if applicable): Mailing Address: Address: 418Kuwnistreel Address: Suite 106 City, ST, Zip Honolulu, HI 86817 Fax No.: Phone No.: ( 868) 695 — 4561 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Harri ❑ North Kona ✓❑ South Hilo ❑ North Kohala ❑ South Kona © North Hilo ❑ South Kohala ❑ Kati Services or Activities To Be Provided: (One or more can be checked) © Educational concerns ✓❑ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑✓ Victims of Health or Social Crises © Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Brothers Big Sisters (Hawaii Island) Program Name: one-to-one Mentoring 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $5,000.00 $20,000.00 $10,000.00 2. Agency Mission Statement: The mission of Big Brothers Big Sisters Hawaii is to provide children facing adversity with strong and enduring, professionally supported one-to-one relationships that change their lives for the better, forever. By matching at -risk youth with positive role models, we help children avoid risky behavior such as abusing drugs and alcohol, joining a gang, or becoming pregnant; achieve educational success by encouraging and motivating kids to do better and stay in school; and develop higher aspirations and hope for their futures by exposing children to a variety of new experiences and opportunities. This has a positive impact on the community at -large as the children have higher rates of staying in school, graduating, and pursuing higher education; treating their schoolmates and family members in a more caring way; and becoming more confident and productive members of the community. 3. Program Description: Our Community Based Program matches in -need youth, 6-17, with adult mentors. These matches meet 2-4 times per month, 2-4 hours per outing, enjoying activities in the community. Each participant is professionally supported by a case manager who is responsible for safety and coaching. Our School Based Program matches in -need elementary students, one-to-one, with high school mentors. They remain matched for the school year and remain in contact during the summer via special events and postcard exchange. A case manager facilitates weekly after school sessions, leading activities designed to strengthen relationships and increase positive outcomes for both the in -need elementary students and the high school mentors. These mentors have an opportunity to have a meaningful relationship with a supportive adult (case manager) while serving the needs of a hurting child. Our School Based mentors graduate from our program having earned service learning hours, self-awareness and confidence, knowing that one person can make a difference. 4. Total Budget & Position Count: Total Program Budget: 1 $65.150 Total Program Position Count: 1.75 Total Agency Budget: 1 $1,870,000 Total Agency Position Count: z� EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Brothers Big Sisters (Hawaii Island) Program Name: one-to-one Mentoring 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Na Lei Aloha 31.000 The Freeman Foundation 25.000 _ _ Kamehameha Schools 15.000 I _-- --- - — TOTAL: 71,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program The vision of the Big Brothers Big Sisters Hawaii agency is to continue to strengthen service in East Hawaii, while expanding to the West. In October 2014, our agency was awarded funding from the Office of Youth Services and the Atherton and Cooke Foundations, to begin serving in Waimea. As we serve in more communities, our ability to build community partnerships grows. Thirty Meter Telescope is the latest partner, pledging materials for use at each school program. On February 1, our second annual Hapuna Beach Prince Golf Tournament will take place. 7. Program Objectives Using County Nonprofit Grant Program Funds: Your support will help bring this impactful program to Keonepoko North and restart the program at Kea'au Elementary. Because of the special circumstances surrounding the children enrolled in Keonepoko and Kea'au, the mentors at Kea'au High will be trained in tutoring, conflict resolution, understanding loss/grief and listening skills. Currently, our agency employs one full-time case manager to oversee our existing after school programs. This funding will be used to cover approximately 25 percent of an additional 30 hour part-time case manager. Case management services include (but are not limited to): recruitment/intakes/interviews/assessments/training of potential participants, support/supervision of enrolled participants, and facilitation/planning/overseeing weekly sessions during the school year, as well as special events during the summer break. We are currently training 24 Kea'au High School mentors who will serve at the two elementary schools. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 9 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Brothers Big Sisters (Hawaii Island) Program Name: one-to-one Mentoring 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (Le-: Numbei of,,, served, warktho......... held, uplmteer hams, etc. Oesvlbe, be sp'10' Applicant Projected Results Recruitment of elementary students enroll 16-20 Recruitment of high school mentors - enroll 16-20 Provide weekly sessions from Oct - May 2016 conduct 18-20 sessions Administer Youth Outcomes Survey positive youth outcome 2.000 Operations 860 1,000 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FV 14-16 Actual' FY 15-16 Total Budget FV 15-16 Grant Req Salary and Wages 37,000 82,000 10,000 Professional Fees 850 2.000 Operations 860 1,000 Supplies 1,500 800 Equipment 0 2.000 Other: Training 110 150 Other: Program Activities 4.000 1,500 Other: Other: Other TOTAL 44,320 89450 10.000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Brothers Big Sisters (Hawaii Island) Program Name: one-to-one Mentoring io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest Is defined as. a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in factor appearance, any conflicts or potential conflicts of interest: /1 If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Brothers Big Sisters (Hawaii Island) Program Name: one-to-one Mentoring ti. 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, 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 final payment. 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 reportusing the template provided will imoact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Big Brothers Big Sisters (Hawaii Island) Program Name: one-to-one Mentoring 11. Certification of Understanding (Page z of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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.hawa[icounty 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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature'of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Brothers Big Sisters (Hawaii Island) Program Name: one-to-one Mentoring 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Resant Projected Results Projected Council Proposed Projected Result Recruitment of elementary students mon 16-20 Recruitment of high school mentors nmil 16-20 Provide weekly sessions from Oct - May 2016 18-20 sess. Administer Youth Outcomes Survey pas. outcome Equipment Other: Other: TABLE It: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $10.000 Professional Fees Operations Supplies Equipment Other: Other: Other: Other Other: TOTAL 510 000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Big Island Mediation dba West Hawai'i Mediation Center West Hawai'i Mediation Center County ofHawai`i Nonprofit Grant Application FY2015-16 Agency Name: Big Island Mediation Inc. dba Program Name: West Hawaii Mediation Center Agency Director: Richard spie9el Phone No.: ( 606) 885 — 5525 Contact Person: Melony Tavares Phone No.: ( am ) 995 — 5525 Mailing Address: Address: PO Box7020 Address: City, ST, Zip Kamuela, Hawaii 96743 Facility Address: Address: 65-1291 Kawalhae Rd suit. 202 Address: City, ST, Zip Kamuela, Hawaii 96743 Email Address: fdr®wh nediaron.ory Fax No.: ( 808) 687 — 525 Accountant/CPA: John Carbonaro Phone No.: ( 806) 247 — 5002 Firm (if applicable): Caruonam CPA Mailing Address: Address: L885Mamsne.is.a.40a Address: Oty, ST, Zip Wailuku, HI 96793 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna © Hamakua © North Kona ❑ South Hilo © North Kohala © South Kona ❑ North Hilo ❑✓ South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts © Aged Q Victims of Health or Social Crises © Needs of the poor ©Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Mediation Inc. dba Program Name: West Hawaii Mediation Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $12,240.00 $8,000.00 $15,000.00 2. Agency Mission Statement: The West Hawaii Mediation Center (WHMC), a 501(c)3 nonprofit, has delivered conflict resolution and mediation services on the island of Hawaii since 1988. Mediation is an informal and confidential way for people to resolve disputes with the help of two neutral mediators who are trained to help people discuss their differences. The mission of the WHMC is to help the residents of West Hawaii find peaceful, participatory solutions to the inevitable conflicts that individuals and communities experience. We do this in three ways: 1) providing mediation and facilitation services to community members; 2) providing conflict resolution education to public and private school children; and 3) training residents to act as volunteer mediators in their community. 3. Program Description: Mediation offers a safe, neutral setting where participants can create and feel empowered by having some control of the outcome. A resolution that they;the involved parties created. Mediation addresses many issues including child custody, divorce,landlord/tenant disputes, foreclosures, and Special Education issues. WHMC has partnered with the Hawaii State Department of Education as well the State Judiciary, United Way, Hawaii Police Department,and S.K District Court. The WHMC services 3000 children in response to the growing instances of violence and bullying among youth, WHMC designed and implemented Working it Out! our elementary school peer mediation program as well as a highly -successful conflict resolution and peer mediation training program for middle and high schools. On average we have 45 trained volunteer mediators that are skilled in all different levels of mediations. Our center offers mediation services to an estimated 85,000 residents in our service area. WHMC is the only non profit mediation service in West Hawaii 4. Total Budget & Position Count: Total Program Budget: $332,567.001 Total Program Pos tlon Count: a.o Total Agency Budget: $332,567.00 Total Agency Position Count: 4.5 EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Mediation Inc. dba Program Name: West Hawaii Mediation Center S. Program Funding Sources (identify all sources of funding applied to this Programl: FY1S-16 Revenue Source Estimate SEE ATTACHED TOTAL: Attach additional 0ove5, if needed 6. Explain what plans your agency or program has to increase revenues to support this program West Hawaii Mediation is reaching out to resources that may be available for our youth programming. We have secured funding for two years, not just one from three separate sources. The center is seeking new partnerships such as the Charity Walk that is promoted by the visitor industry. We have added a highly skilled staff member who is social media savvy and has been tasked to do community outreach with an action plan to present the WHMC at a social media level that is new to our program. WHMC expects to see an increase in funding and interest in our organization through our peer mediation program. Peer mediation budget has expanded and monies in this area are increasing. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide mediation service in an affordable and accessible manner for disputes arising both in and out of the oourttlegal system for a wide array of dispute issues including:divorce, custody, foreclosure, landlord/tenant, domestic, small claims, civil rights, etc. 2. Continue to educate our youth in peaceful conflict resolution skills and peer mediation. Through peer mediation and conflict resolution students learn to work effectively with their schoolmates to facilitate positive outcomes and reduce the amount of unresolved conflict in their schools. Students in conflict can request mediation or be referred by staff or other students. Mediators help disputants reach and document agreements that are fair, mutually acceptable, and workable. 3.Provide continuing training for our skilled volunteer mediators and train community members to increase their volunteer skills to help provide high quality community service. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of County ofHawai`i Nonprofit Grant Application FY2015-16 Agency Name: Big Island Mediation Inc. dba Program Name: West Hawaii Mediation Center 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES fi.e.:N=m fofcl nns d, wodshops or evenn helb volunteerhoun, en. eeur@, 6e specX) Applicant Projected Results Case Management Fours 4500 Mediation Cases Served 625 Mediated Sessions Conducted 500 reements Reached in Mediation 78% Affordable or free service to low income 50% Peer Mediation Training for Youth 15 Schools Volunteer Training B Skills Enhancement Train 12 Attach additional pages as necessary. 9. TABLE 11: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $199654.00 219,000.00 $5,000.00 Professional Fees 29600.00 28100.00 Operations 31200.00 31955.00 $10000.00 Supplies 4400.00 4126.00 Equipment 7200.00 3200.00 Other: Foreclosure Program 27327.00 23000.00 Other: Training Programs 27121.00 27000.00 $10000.00 Other: Travel (Programs g General) GOG5.00 4500.00 Other: Other: TOTAL $332587m $340881.00 $25000.00 "R applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Mediation Inc. dba Program Name: West Hawaii Mediation Center io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 if no conflicts exist, check here. fz� -7 F5? vU r uc a �� ezraQ 2 Signature of Au razed Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Mediation Inc. dba Program Name: west Hawaii Mediation Center 11. Certification of Understanding (rage 1 of 2) 1(we) have read and understood all of the 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 final payment. To register, go to htto://vendors.ehawaILgov, complete the 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 o timely, complete and accurate Year-end report using the template provided will impact the evaluation of Your Program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Mediation Inc. dba Program Name: West Hawaii Mediation Center 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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 300 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 lune 30, 2015 must be returned to the County of Hawai'i with the final report. Follure to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. K6 i rIGLGUr(1/eS' 'D�rop Signature of Aut ri ed Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 12�1, 141— Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Mediation Inc. dha Program Name: west Hawaii Mediation Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council proposed Projected Result Case Management Hours 4500 Mediation Sessions Conducted 500 Mediation Cases Served 625 Agreements Reached in Mediation 78% Affordable or Free Service to low income 50% Peer Mediation Training for Youth 15 schads Volunteer Training & Skills Enhancement 12 TABLE If: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 51000.00 Professional Fees Operations 1000000 Supplies Equipment Other: Trainings t0000.00 Other: Other: Other: Other: TOTAL 25,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Big Island RC&D Council Hawai'i Homegrown Food Network (HHFN) County of Hawai4i Nonprofit Grant Application FY2015-16 Agency Name: Big Island RC&D Council Program Name: Hawai'i Homegrown Food Network (HHFN) Agency Director: Larry Komata Phone No.: ( ) 935 — 8426 Contact Person: Carol Sampaia Phone No.: ( ) 935 — 8426 Mailing Address: Address: 200 Kanoelehua Ave, PIAa 285 Address: City, ST, Zip Hilo, HI 96720 Facility Address: Address: 2028 Chong St (this is a home office) Address: City, ST, Zip Hilo, HI 96720 Email Address: hrcd@hawar.m.com Fax No.: ( ) 935 — 8426 Accountant/CPA: Max J. smith Phone No.: (an) 257 — 6484 Firm (if applicable): Mailing Address: Address: 1403 Frank street Address: City, ST, Zip Honolulu, HI 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $20,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ H5ri © North Kona ❑ South Hilo © North Kohala © South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises © Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island RC&D Council Program Name: Hawai'i Homegrown Food Network (HHFN) 1. Prior Year Award of County Nonprofit Grant Program funds: FY 12-13 FY 13-14 FY 14.15 0 $0.00 4,000 2. Agency Mission Statement: BIRCD: "To assist people in achieving sustainable development while caring for and appreciating their natural environments; to ensure broadened economic opportunities, enriched communities and better lives" HHFN: Our vision is of an abundant and self-sufficient community-based food system for Hawai'i that promotes health and well-being and is grounded in indigenous wisdom, socio-economic justice, and sustainable agricultural practices. Our mission is to build and support a new food paradigm based on a thriving community network of sustainable food system stakeholders through education, research, information, partnership and training. 3. Program Description: One of Hawaii Homegrown Food Network's primary projects is the Ho'oulu ka'Ulu project. The Ho'oulu ka'Ulu is a project to revitalize'ulu (breadfruit) as an attractive, delicious, nutritious, abundant, affordable, and culturally appropriate food which addresses HawaiTs food security issues. County Council funds would be used to support two initiatives: Breadfruit vs. Potato and Breadfruit Harvest for Hunger. Breadfruit vs. Potato is a public education campaign to enhance the competitiveness of breadfruit, a Hawaiian staple, as opposed to potato, an imported food. Breadfruit Harvest for Hunger harvests excess breadfruit through established relationships with landowners and donates it to social service agencies (such as Kealakehe Meet & Eat and Hawai'i Island Food Bank). The project uses and existing and underutilized food source to feed the food insecure. 4. Total Budget & Position Count: Total Program Budget: 50,000 Total Program Position Count: 1.5 Total Agency Budget: 33,000.00l Total Agency Position Count: .5 EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big island RC&o council Program Name: Hawaii Homegrown Food Network (HHFN) S. Program Funding Sources (identify all sources of funding applied to this programl: FY15-16 Revenue Source Estimate HOOA specialty Crops Grant (secured) 25,000 County Council (applied for) 25,000 TOTAL: 50,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hawaii Homegrown Food Network funds its programs primarily through grant sources. Plans for 2015-16 include pursuing federal, state and private foundation grants. HHFN also makes a limited amount of sales revenue from sales of cookbooks and a Breadfruit Production Guide. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Harvest excess breadfruit and re -distribute to food insecure population through social service agencies. 2. Increase public awareness about the value of a locally grown vs. imported staple (Breadfruit vs. Potato) through a media campaign that includes print, social media, info -graphics, articles, handouts, posters and store signage focusing on health/nutrition, recipes, varieties, harvesting and overall use of breadfruit. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island RC&D Council Program Name: Hawai'i Homegrown Food Network (HHFN) S. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e,: Numb roJcflen6 carved, w rrahops orevcnn )*rd, wluntrerhours, eW,, oesmbe, be speafrc.f Applicant Projected Results Breadfruit Harvested g Distributed 500 pounds Gross impressions in the media 30,000 people reached Professional Fees 8,000 15,000 Operations ZDDO 10,0D0 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual• FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages Professional Fees 8,000 15,000 Operations ZDDO 10,0D0 Supplies Equipment Other: Other: Other. Other: Other: TOTAL 10,000 25,000 "If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island RC&D Council Program Name: Hawai'i Homegrown Food Network (HHFN) io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑J If no conflicts exist, check here. REsf Signature of Author zed Pers�tle) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island RC&D Council Program Name: Hawaii Homegrown Food Network (HHFN) 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, 1 (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. 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 timeiv, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big island RC&D council Program Name: Hawaii Homegrown Food Network (HHFN) 11. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of 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 30v' 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://�Nww.hawaiicounty.zov/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, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in o timely manner will impact the evaluation of your agency's future fundina request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. fadeldd,_YagI r5� Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island RC&D Council Program Name: Hawaii Homegrown Food Network (HHFN) 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Breadfruit Harvested 8 Distributed 500 pounds Gross impressions in the media 30,000people Operations 10,000 Supplies Equipment Other: Other: TABLE It: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees 15Op0 Operations 10,000 Supplies Equipment Other: Other: Other: Other: Other: TOTAL 25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8of8 Big Island Substance Abuse Council Hawai'i Health and Wellness Center - Hilo E County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Center - Hilo Agency Director: Dr Hannan Praston-Pita Phone No.: ( 808) 969 — 9994 Contact Person: or. Hannah Preaton-Plta Phone No.: ( 808) 654 — 2837 Mailing Address: Address: t6-279Melekahlwa Street Address: City, ST, Zip Kea au, Hawaii 96749 F a cility Address: Address: 297 waianuanue Avenue (Bldg 2) Address: City, ST, Zip Hilo, Hawaii, 96720 Email Address: dr.hannah@blaaccom Fax No.: ( 608) 969 — 7570 Accountant/CPA: camonaro CPAs Phone ND.: ( 805) 968 — 2002 Firm (if applicable): camonaro CPAs Mailing Address: Address: P.o.6ox73n Address: City, ST, Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna © Harri ❑ North Kona © South Hilo ❑ North Kohala ❑ South Kona Q North Hila ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns ❑✓ youth © Victims of Crimes ❑ Culture and the arts © Aged © Victims of Health or Social Crises © Needs of the poor © Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Center - Hilo 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 0 $0.00 0 2. Agency Mission Statement: Agency Mission Statement: Inspiring individuals to reclaim and enrich their lives by utilizing innovative resources and harnessing the strengths within each person. Program's Goal is to enhance well-being and create meaningful changes in the community that we serve. Policies and procedures comply with all State and Federal laws prohibiting discrimination against all individuals regardless of their race, color, national origin, religion, creed, gender, sexual orientation, age or disability. The agency strives to instill dignity, respect, hope and compassion to all our clients and families. 3. Program Description: The Hawaii Island Health and Wellness Center (HIHWC) is a subsidiary of the Big Island Substance Abuse Council. Established in 2011, HIHWC has treated over 250 individuals on the island of Hawaii. HIHWC provides individual, group, couple's and family treatment to adults, children, and adolescents. Licensed therapists use evidenced -based therapies focusing on mental health issues such as depression, anxiety, relationships, parenting, adjustment, smoking cessation, weight management, sleep difficulties, etc. Other components of the program is to assist with closing gaps in service for rural under -served areas and providing training opportunities to Licensure Candidates to gain licensure and provide well needed services. In the wake of recent storms and the lava flow issue, HIHWC has provided workshops to train first responders with: suicide awareness, trauma, basic counseling issues, and compassion fatigue. Current plans are to expand services to assist outside agencies with providing training to their employees. HIHWC is currently looking at ways to provide mobile mental health services to address the growing needs for services in under -served, rural areas. 4. Total Budget & Position Count: r ITotal Program Budget: I $265,e71 I Total Program Position Count: 3.9 Total Agency Budget: $4,195,227 Total Agency Position Count: 75 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of6 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Center - Hilo S. Program Funding Sources (identify all sources of funding applied to this Program): Revenue Source FY15-16 Estimate Third Party Insurance $237,881 Hawaii Island United Way $10.000 County of Hawaii $30,000 TOTAL: $277,881'. Attach additional pages, if needed. 6. Explain what plans your agency or program has to Increase revenues to support this program BISAC continues efforts to diversify funding sources, expand services, increase efficiency, and align with the Health Care Reform. BISAC's electronic medical records system increased efficiency in both clinical and billing areas. Its capacity to do electronic billing has helped because of quick turn around time and baseline cash flow. Implementation of new programs and policies increased revenue and expanded BISAC's capacity to treat clients. This was made evident by the 9% increase in mental health clients. Additional revenue streams will be focused on possible mobile services to close gap in services in rural areas as well as provide trainings for outside agencies and their employees. Recent developments in this area was providing training to over 100 first responders to assist with the recent lava flow issues and tropical storm Iselle. This brought in an additional $20K to the department. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide immediate access to psychological evaluations and treatment services to any adults requiring mental health services. 2. Increase the availability of psychological services (e.g. individual and groups) to adults who may have no funding for treatment services. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Center - Hilo 8. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.: Numh /rots Served, workshops or eventr held volunteer hours, etc 0e"'be, he sp ifc) Mental Health Treatment Units _ 250 pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-I6 Total Budget FY 1546 Grant Req Salary and Wages 165,170 213.028 16,124 Professional Fees 3,500 6,230 0 Operations 29,923 33,363 10,226 Supplies 5,323 8,250 3650 Equipment 4,518 5.000 0' Other. Other Other Other. Other. TOTAL 208,434 265,870 30,000' 'It applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Center - Hilo io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action 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: ✓❑ If no conflicts exist, check here. D. C;r� C(-,tD Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 01120)15 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Center - Hilo 11. 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, relatingto Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to htto,//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 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 Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit o timely, complete and accurate year-end report using the template provided will impact the evaluation of vourprowam's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Center - Hilo 11. Certification of Understanding (Page 2 of g) 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 lune 301h 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!y.goy/fn-nonprofit-P.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 lune 30, 2015 must be returned to the County of Hawai'i with the final report. failure to return these funds in o timely manner will impact the evaluation of your agency's future funding request and may result in actions token to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. ('5A -e' cuo Signature of Authorized Person (specify title) 01/20/15 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Center - Hilo 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Mental Health Treatment Units 1 250 1 1 TABLE It: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 16,124 Professional Fees Operations 10,226 Supplies 3,650 Equipment Other: Other Other: Other Other. TOTAL 30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Big Island Substance Abuse Council Hawai'i Health and Wellness Ctr Kea'au 10 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Ctr Keaau Agency Director: or Hannah Past. Pita Phone Ni (8W) 969 - 9994 Contact Person: or. Hannah Preston -Pita Phone No.: ( 808) 935 - 0077 Mailing Address: Address: 16.179 Meiekah-iwa street Address', City, ST, Zip Keaa, Hawaii 96149 Facility Address: Address: 16-199 Melekahiwa Street Address: City, ST, Zip Keaau. Hawaii. 96749 Email Address: dr.hannah@lAo ncom Accountant/CPA: callonam CPAs Firm (if applicable): ce,ree, CPAs Mailing Address: Address: Bo.Box1312 Address City, ST, Zip Hllo. Hawaii 96120 Fax No.: ( aoe ) 969 - 1570 Phone No.: (floe) 968 — 1002 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna ❑ Hamakua ❑ North Kona © South Hilo ❑ North Kohala ❑ South Kona © North Hilo ❑ South Kohala ✓❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns ©Youth © Victims of Crimes ❑ Culture and the arts © Aged✓❑ Victims of Health or Social Crises © Needs of the poor © Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness CAT Keaau 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $0.00 $0.00 $0.00 2. Agency Mission Statement: Agency Mission Statement: Inspiring individuals to reclaim and enrich their lives by utilizing innovative resources and harnessing the strengths within each person. Program's goal is to enhance well-being and create meaningful changes in the community that we serve. 3. Program Description: The Hawaii Island Health and Wellness Center (HIHWC) is a subsidiary of the Big Island Substance Abuse Council. Established in 2011, HIHWC has treated over 250 individuals on the island of Hawaii. HIHWC provides individual, group, couple's and family treatment to adults, children, and adolescents. Licensed therapists use evidenced -based therapies focusing on mental health issues such as depression, anxiety, relationships, parenting, adjustment, smoking cessation, weight management, sleep difficulties, etc. Other components of the program is to assist with closing gaps in service for rural under -served areas and providing training opportunities for Licensure Candidates to gain licensure and provide well needed services. In the wake of recent storms and the lava flow issue, HIHWC has provided workshops to train first responders with: suicide awareness, trauma, basic counseling issues, and compassion fatigue. Current plans are to expand services to assist outside agencies with providing training to their employees. HIHWC is currently looking at ways to provide mobile mental health services to address the growing needs for services in under -served, rural areas. Site specialization in treating adults, adolescents, children, couples, and families. 4. Total Budget & Position Count: Total Program Budget: 158,1229 Total Program Position Count: a Total Agency Budget: 4,195,2271 Total Agency Position Count: I 75 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Ctr Keaau 5. Program Funding Sources (identify all sources of funding applied to this Program): Revenue Source FY1S-16 Estimate Third Party Insurance Training Revenue (COH 1st Responders, CSAC, other) $103,200 $35,000 County of Hawaii $30,000' TOTAL: $1ss,zoo Attach additional pages, iif needed. 6. Explain what plans your agency or program has to increase revenues to support this program BISAC continues efforts to diversify funding sources, expand services, increase efficiency, and align with the Health Care Reform. BISAC's electronic medical records system increased efficiency in both clinical and billing areas. Its capacity to do electronic billing has helped because of quick turn around time and baseline cash flow. Implementation of new programs and policies increased revenue and expanded BISAC's capacity to treat clients. This was made evident by the 9% increase in mental health clients. Other revenue opportunities will be focused on possible mobile services to close gap in services in rural areas as well as provide trainings for outside agencies and their employees. Recent developments in this area was providing training to over 100 first responders to assist with the recent lava flow issues and tropical storm Iselle. This brought in an additional $20K to the department. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide immediate access to psychological evaluations and treatment services to any individuals requiring mental health services. 2. Increase the availability of psychological services (e.g. individual and groups) to any individuals who may have no funding for treatment services. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Ctr Keaau 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES ( Applicant Projected Results Numberpfthenaserved,.,4haps orm,aheld, volunteer hours, etc Oesrribe, be speci)rc.J tal Health Service Units 1250 as nece55ON 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual` FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 40,600 119.196 19,081 Professional Fees 3.820 li Operations 5,150 24,613 8,326 Supplies 1,250 5,500 2,593 Equipment 5,000 5,000 Other. Other. Other: Other: Other. — - _- - � -_- TOTAL 58,000 158,12930,000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Ctr Keaau io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. 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: 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 probobility 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: 0 If no conflicts exist, check here. � cEo - Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 01120115 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Ctr Keaau tt. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 final payment. 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 Hawai i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit o 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. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Ctr Keaau 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 301^ 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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. ?� -t�'0 cmc- CEJ Signature of Authorized Person (specify title) 01/20/15 Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: Hawaii Health and Wellness Ctr Keaau TABLE 1: 1z. COUNCIL AWARD WORKSHEET PROGRAM PERFORMANCE MEASURES Applicant council Proposed Projected Results I Projected Result I Mental Health Service Units 1 250 TABLE 11: PROGRAM EXPENDITURES FY 15-I6 Grant Request Council,,,. Award Salary and Wages 19,081 Professional Fees Operations 8,326 Supplies 2,593 Equipment Other: Other. Other: Other Other: TOTAL 30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 Big Island Substance Abuse Council West Hawai'i Substance Abuse Program 11 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Substance Abuse Program Agency Director: or. Hannah Preston -Pita Phone No.: ( 609) 969 — 9994 Contact Person: or. Hannah PrestonPt.Phone No.: ( 609) 969 — 9994 Mailing Address: Address: 16-179 Melckahiwa Street Address: Gty, ST, Zip Kea au, Hawaii, 96749 Facility Address: Address: 61-947 Haleldi street Address: City, ST, Zip Kealakekuam Hawaii 96750 Email Address: drhannah@bisaocom Fax No.: ( 808) 969 — 7570 Accountant/CPA: Carbonaro CPAs Phone No.: ( 699) 968 — 1002 Firm (if applicable): Mailing Address: Address: eo. S,,4372 Address: City, ST, Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO NEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) Puna Q Hamakua Q North Kona South Hilo © North Kohala Q South Kona ❑ North Hilo Q South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns QYouth Q Victims of Crimes Culture and the arts✓Q Aged✓❑ Victims of Heatth or Social Crises Q Needs of the poor Q Physical/Emotional Disabilities Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Substance Abuse Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $0.00 $0.00 $0.00 2. Agency Mission Statement: Inspiring individuals to reclaim and enrich their lives by utilizing innovative resources and harnessing the strengths within each person. Policies and procedures comply with all Stale and Federal laws prohibiting discrimination against all individuals regardless of their race, color, national origin, religion, creed, gender, sexual orientation, age or disability. The agency strives to instill dignity, respect, hope and compassion to all our clients and families. 3. Program Description: BISAC's WH programs provide comprehensive substance abuse treatment services for adults and adolescents through evidenced -based methods and best -practices designed for the area's target population. BISAC's continuum of care includes: Intensive Outpatient, Outpatient, and Continuing Care. BISAC recognizes the significant impact of substance abuse on individuals, families, children, and communities and has designed programs to intervene in the addiction process and build on an individual's and/or family's strengths to abstain from the use of substances, increase protective factors, and relapse prevention skills to maintain their sobriety. 4. Total Budget & Position Count: Total Program Budget: $466,659 Total Program Position Count: 7.70 Total Agency Budget: $4 195,2271 Total Agency Position Count: 75 EXHIBIT A NONPROFITGRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Substance Abuse Program 5. Program Funding Sources (identify all sources of funding applied to this Program): Revenue Source FY15-16 Estimate SOH, DOH Alcohol and Drug Abuse Division $139,188 SOH, Judiciary (Big Island Drug Ccun) $54.667 SOH, Dept. of Public Safety, Hawaii Paroling Authority _ $9,000 Third Party Insurance $270,000 Client Fees $3,000 County of Hawaii $30,000' TOTAL: $505,855 Attach additional pages, iif needed. 6. Explain what plans your agency or program has to increase revenues to support this program BISAC continues efforts to diversify funding sources, expand services, increase efficiency, and align with the Health Care Reform. BISAC's electronic medical records system increased efficiency in both clinical and billing areas. Its capacity to do electronic billing has helped because of quick turn around time and baseline cash flow. Implementation of new programs and policies increased revenue and expanded BISAC's capacity to treat clients. This was made evident by the 9% increase in mental health clients and by the 15% increase in third party billing which accounts for 6% of the budget. BISAC's sound fiscal policies are incorporated into decisions related to program expansion or to enter market niches that would expand the behavioral health continuum. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Provide immediate access to assessment and treatment services to any individuals who are assessed and diagnosed with any substance related disorders. 2. Increase the availability of extended outpatient treatment services to addicted adults and adolescents who may need treatment services. 3. Identify social support networks and community linkages which support continuity of treatment. EXHIBIT A NON PROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Substance Abuse Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results /i.e.: Number.fth.n served, worFSM1ops o/ evenb held, voluntee/ hours, etc. 0e11ibe, be spenfic) necessory. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 1 Actual' FY 15-16 Total Budget FY I5 -I6 '.. Grant Req Salary and Wages 79,113 312,463 11,586 Professional Fees 10,050 Operations 66,123 119,896 15,0301 Supplies Equipment._— _. 11,152 19,250 3,384 4,500 5,000 _ Other: Other: Other Other. Other: TOTAL 160,888 7fi6,659 30,000 -If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Substance Abuse Program io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in factor appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 01120115 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Substance Abuse Program ii. Certification of Understanding (Paget of z) I (we) have read and understood all of the 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 expend i ng/ove rsight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. 1 (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability 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 final payment. 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 (wel 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 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 Providedwill impact the evaluation of yourproarom's or agency's future funding reauests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: west Hawaii Substance Abuse Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 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.goy/fn-nonprofit-grant-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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. AP '- s6ty o' ce-0 Signature of Authorized Person (specify title) 01120/15 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council Program Name: West Hawaii Substance Abuse Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results I Projected Result Substance Abuse Treatment Service Units 1 250 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 11,5116 Professional Fees Operations 15,030 Supplies 3,384 Equipment Other: Other: Other: Other: Other: TOTAL 30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Big Island Substance Abuse Council BISAC East Hawai'i Substance Abuse Program 12 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council BISAC Program Name: East Hawaii Substance Abuse Program Agency Director: Dr.. Hannah Preston -Pita Phone No.: ( 508) 969 — 9994 Contact Person: Dr. Hannah Preslon-Pita Phone NO.: ) BOB ) 969 — 9994 Mailing Address: Address: 16-179 Melekahiwa Street Address: City, ST, Zip Kea'au, Hawaii, 96749 Facility Address: Address: 297 Waianuenue Avenue Address: City, ST, Zip Hilo, Hawaii96720 Email Address: dr.hannah@lheii Fax No.: ( 808) 969 — 7570 Accountant/CPA: Carboni GPA Phone No.: ( 808 ) 96B — 1002 Firm (if applicable): Mailing Address: Address. P.O. ena4372 Address. City, ST, Zip Hilo. Hawaii, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna✓❑ Hamakua © North Kona W] South Hilo © North Kohala © South Kona ❑✓ North Hilo © South Kohala✓❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns ❑ Youth © Victims of Crimes ❑ Culture and the arts © Aged d❑ Victims of Health or Social Crises © Needs of the poor © Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council BISAC Program Name: East Hawaii Substance Abuse Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 0.00 $0.00 .00 2. Agency Mission Statement: Inspiring individuals to reclaim and enrich their lives by utilizing innovative resources and harnessing the strengths within each person. Policies and procedures comply with all Stale and Federal laws prohibiting discrimination against all individuals regardless of their race, color, national origin, religion, creed, gender, sexual orientation, age or disability. The agency strives to instill dignity, respect, hope and compassion to all our clients and families. 3. Program Description: BISAC's EH programs provide comprehensive substance abuse treatment services for adults and adolescents through evidenced -based methods and best -practices designed for the area's target population. BISAC's continuum of care includes: Intensive Outpatient, Outpatient, Continuing Care, Therapeutic Living, and Clean Sober Living, and Prevention Programs. BISAC recognizes the significant impact of substance abuse on individuals, families, children, and communities and has designed programs to intervene in the addiction process and build on an individual's and/or family's strengths to abstain from the use of substances, increase protective factors, and relapse prevention skills to maintain their sobriety. To improve recidivism additional programs were added to address risk factors (e.g. unemployment, mental illness, trauma, etc.). These programs include: 1) Po'okela Program which provides vocational training and application (e.g. resume building, interviewing, time management, etc.). Upon completion several trades within the organization have been established for on the job training (e.g. food truck, maintenance, clerical, etc.). 2) The Hawaii Island Health and Wellness Center is a mental health department with Licensed Providers who provide specialized MH treatment. 4. Total Budget & Position Count: Total Program Budget: 1,683,832 Total Program Position Count: 15.6 Total Agency Budget: 4,195,2211 Total Agency Position Count: 75 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County ofHawai`i Nonprofit Grant Application FY2O15-16 Agency Name: Big Island Substance Abuse Council BISAC Program Name: East Hawaii Substance Abuse Program 5. Program Fundine Sources (identify all sources of funding applied to this programj: Revenue Source FY15-16 Estimate SOH, DOH Alcohol and Drug Abuse Division $937,000.00 SOH, Judiciary (Big Island Drug Court) $201,355.00 SOH, Department of Public Safety. Hawaii Paroling _ $29,700.00 Third Party Insurance $456,000,00 Client Fees $73,875.00 County of Hawaii $60,000.00 TOTAL r $1757,930,00 Attach additional Poge5, iif needed. 6. Explain what plans your agency or program has to increase revenues to support this program BISAC continues efforts to diversify funding sources, expand services, increase efficiency, and align with the Health Care Reform. BISAC's electronic medical records system increased efficiency in both clinical and billing areas. It's capacity to do electronic billing has helped because of quick turn around time and baseline cash flow. Implementation of new programs and policies increased revenue and expanded BISAC's capacity to treat clients. This was made evident by the 9% increase in mental health clients and by the 15% increase in third party billing which accounts for 6% of the budget. BISAC's sound fiscal policies are incorporated into decisions related to program expansion or to enter market niches that would expand the behavioral health continuum. Current plans to implement a social entrepreneurship program will provide additional revenue to support the agency. These additional revenue streams are an effort to support capacity building, sustainability efforts, and reduce reliance on State and County funds. 7. Program Objectives Using County Nonprofit Grant Program Funds 1. Provide immediate access to assessment and treatment services to any individuals who are assessed and diagnosed with any substance related disorders. 2. Increase the availability of extended outpatient and therapeutic living program treatment services for uninsured or under -insured individuals who have no funding available for treatment services. 3. Identify social support networks and community linkages which support continuity of treatment. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse council BISAC Program Name: East Hawaii Substance Abuse Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i. e.: NumbN of [Ilen4 served, worksbo05 or evenh held, volunteer hoes, R[. Describe, be specifil Substance Abuss Treatment Unils 500 m necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 1,167,289.00 1,351,157.00 34,682.00. Professional Fees 30,000.00 31,150.00 Operations 153,921.00 219,025.00 18,24300, Supplies Equipment 45,461.00 47,500.00 6,875.00, 15,000.00 35,500.00 Other: Other Other _ Other Other TOTAL 1,411,671.00 1,683,832.00 60000.00�i 'If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council BISAC Program Name: East Hawaii Substance Abuse Program lo. 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: 1279181UL`9 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: o 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: 0 If no conflicts exist, check here. ovzons Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council BISAC Program Name: East Hawaii Substance Abuse Program 11. 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 allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and 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 final payment. To register, go to http://vendors.ehawaii.aov, complete the 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 o tmely, comoiete and accurate year-end reportusing the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council BISAC Program Name: East Hawaii Substance Abuse Program ii. Certification of Understanding (Page 2 o 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 reportwithin 60 days of June 301h shall result in loss of all grant funds received during the grant period (must be refunded to Countyl 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 htti)'//­www.hawalicounty.gov/fn-nonprofit-grant-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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. ek%j P40 C,5k- Mo Signature of Authorized Person (specify title) 1/20/15 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Substance Abuse Council BISAC Program Name: East Hawaii Substance Abuse Program 12. COUNCIL AWARD WORKSHEET TART P I• Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result Substance Abuse Treatment Units 1 500 TABLE It: PROGRAM EXPENDITURES FY SS -16 Grant Request Council Award Wages 34,882.00 l Fees tEquipment 18,243.00 6,675.00 Other: Other. Other: Other Other: TOTALI 60,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFITGRANT APPLICATION FY 2014-2015 Page8 o1`8 Big Island Wellness Solutions Big Island Wellness Solutions - Community Outreach Program 13 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Big Island Wellness Solutions Program Name: "Big Island Wellness Solutions - Community Outreach Program" Agency Director: Audrey WE. Phone No.: ( 808) 985 — 7191 Contact Person: Jessica Takayama Phone No.: ( 808) 959 — 4711 Mailing Address: Address: P.O. Bm 355 Address: City, ST, Zip Volcano, HI 96785 Facility Address: Address: 615 Haihei St. Address: City, ST, ZIP Hilo, H196720 Email Address: jwius a@J9maitcom Fax No.: Accountant/CPA: NIA Phone No.: ( ) — Firm (if applicable): NIA Mailing Address: Address: NIA Address: NIA City, ST, Zip NIA YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds Geographical Areas To Be Served: (One or more can be checked) 0 Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑✓ North Hilo Q South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑ Victims of Crimes ❑✓ Culture and the arts ❑ Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Wellness Solutions Program Name: 'Big Island Wellness Solutions - Community Outreach Program" 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 2. Agency Mission Statement: The mission of Big Island Wellness Solutions (BIWS) is to improve the quality of life in our Hawaii communities through innovative, means -appropriate, culturally -sensitive health and nutrition education by empowering the individual with life saving knowledge, and the tools, facility and environment to implement this knowledge in the present and for future generations. 3. Program Description: The "Big Island Wellness Solutions - Community Outreach Program" includes three ongoing projects: the "Hawaii Healthy Me" Children's Workbook Distribution Project - created in collaboration with the South Hilo Rotary, and distributed to 1,400 fourth graders island wide in 2014, Hawaii Island Community Small Business Resource - assisting small and startup culinary based businesses by providing information and resources for free or low user cost, and Vocational Training and Assistance Project- aiding individuals in economic need by offering free culinary career education/training, support resources/mentoring, and paid internship with a certified kitchen and catering company. Our home base of operations is our certified kitchen facility in Hilo, where we specialize in nutrition education, culinary entrepreneurship, and vocational training. Our mobile certified food truck is used as another excellent opportunity for hands on vocational training. Our collaborative project partners include Rotary Club of South Hilo (Hawaii Healthy Me), Hilo District Department of Health (Small Business Resource), and Big Island Substance Abuse Council (Vocational Training). 4. Total Budget & Position Count: Total Program Budget: $35,740.00 Total Program Position Count: fc Total Agency Budget: $297,450.03 Total Agency Position Count: fe EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Wellness Solutions Program Name: "Big Island Wellness Solutions - Community Outreach Program' S. Program Funding Sources (identify all sources of funding applied to this program): FYIS-16 Revenue Source Estimate Pnvate Donations $1000.00 TOTAL: $1000.00 Attach additional pages, if needed 6. Explain what plans your agency or program has to increase revenues to support this program: Big Island Wellness Solutions is currently seeking grants from multiple sources, including this Hawaii County grant, State of Hawaii, Hawaii Island United Way, United States Department of Agriculture, Hawaii Community Fund, as well as other public and private grantors. Additionally, Big Island Wellness Solutions has started a letter writing campaign to seek funds from interested parties and individuals to partner in this program and it's projects through funding, in-kind donations, and collaboration toward our program goal: "Wellness: Physical - Mental - Economic - Community". 7. Program Objectives Using County Nonprofit Grant Program Funds: Big Island Wellness Solutions will use funds obtained to achieve the following objectives in 1) Print, and distribute 1,400 "Hawaii Healthy Me" workbooks to 4th graders at 30+ Hawaii Island schools in the 2014-2015 school year, partnering with the South Hilo Rotary. 2) Provide access to certified kitchen facility and equipment for a low rental fee, and free information resources to the Hawaii Island community, partnering with the Hilo District Department of Health. 3) Assist individuals who are in economic need by offering free education and vocational training in a mobile food truck business, partnering with the Big Island Substance Abuse Council. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Wellness Solutions Program Name: "Big Island Wellness Solutions - Community Outreach Program' 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES p.e.� e„mber p7nienn seree, wwx.nap: m ewer:nein, valunfeerlrours, eK. Describe, be specific) Applicant Projected Results 1,400 "Hawaii Healthy Me" workbooks printed and distributed to Hawaii Island 4th graders. 1,400 4th graders We healthier lives. Small Business Resource assists 6 clientstweek with free information for culinary start-up. 312 clients a year receive free education. 5 clients a month start a new business, with an educated plan and low overhead costs. 60 clients a year start new businesses. Certified kitchen facility gains at least 2 new clients each month. Certified Kitchen gains 24 clients/year. Vocational Training classes held 4 days/."k, hands on education for 8 indwidualshnonth. 208 classes held for 96 individualslyear. Vocational Training project graduates 4 students a month. Economic opportunity for 48 indiv./year. 35 man hours a week are volunteered towards Community Outreach Program. 2,700 man hours help 1,800 indv.lyear. Attach additional pages as necessary. 9. TABLE Il: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $192,840.00 $192,840.00 $5,900.00 Professional Fees $3,900.00 $3,900.00 $3,900.00 Operations $28,702.47 $28,702.47 $0 Supplies $2,600.00 $2,600.00 $2,600.00 Equipment $0 $0 $0 Other: Children's Workbook Printing $7,000 $7,000 $7,000 Other: Children's Workbook Distribution Tmvel $3,000 $3,000 $3,000 Other: Educational Workspace Rental $2,600.00 $2,600.00 $2,600.00 Other: Other: TOTAL $228,042.47 $228,042.47 $25.000.00 `If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Wellness Solutions Program Name: "Big Island Wellness Solutions - Community Outreach Program" to. 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 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 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Wellness Solutions Program Name: "Big Island Wellness Solutions - Community Outreach Program' 11. Certification of Understanding (Page loft) I (we) have read and understood all of the 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 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 that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. 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 Expressand be compliant prior to final payment. To register, go to htti)://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 Hawal'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 veor-end report using the template Providedwill impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Big Island Wellness Solutions Program Name: "Big Island Wellness Solutions - Community Outreach Program' 11. Certification of Understanding (Page 2of2) 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 lune 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-farmsZ on or about May 30 of the year the final 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized P rson (specify title) 01/27/2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Big Island Wellness Solutions Program Name: "Big Island Wellness Solutions - Community Outreach Program" 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result 1,400 "Hawaii Healthy Me" workbooks printed and distributed to Hawaii Island 4th graders. t poo Workbooks Small Business Resource assists 6 clientstweek with free information for culinary start-up. 312 dientsyear 5 clients a month start a new business, with an educated plan and low overhead costs. 60 clientsyear Certified kitchen facility gains at least 2 new clients each month. 24 dienW,.., Vocational Training classes held 4 days/week, hands on education for 8 individuals/month 208 dasseslyear Vocational Training project graduates 4 students a month. 48 studentslyear 35 man hours a week are volunteered towards Community Outreach Program. 1,800 indvlyear. TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $5,900.00 Professional Fees $3,900.00 Operations $0 Supplies $2,600.00 Equipment $0 Other: Children's Workbook Printing $7,000 Other: Children's Workbook Distribution Travel $3,000 Other: Educalional Workspace Rental $2,600.00 Other: Other: TOTAL $25,000.00 Additional Council directives re¢ardina award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8of8 Boys & Girls Club of the Big Island Hamakua Out -of -School Fitness For Life 14 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua out -of -School Fitness For Life Agency Director: Zavi Brees-Saunders Phone No.: ( 808) 961 — 5536 Contact Person: Kekal I.in Phone No.: ( 808) 961 — 5534 Mailing Address: Address: 100 Kamakahonu St. Address: City, ST, Zip Hilo, HI 96720 Facility Address: Address: 43-1477 Haucla Road Address: City, ST, Zip Paauilo, HI 96776 Email Address: kekai@becbi.oM Fax No.: ( 808) 961 — 5534 Accountant/CPA: Ann Fukuham, CPA, MBA Phone No.: ( 808 ) 961 — 5532 Firm (if applicable): Mailing Address: Address: 45 Pohaku Street Address: City, ST, Zip Hilo, H196720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna © Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑� Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua out-of-school Fitness For Life 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $10,000.00 $25,000.00 $25,000.00 2. Agency Mission Statement: "To inspire and enable Big Island Youth to be productive and responsible citizens, through quality programs, in a safe and caring environment." This mission has been implemented since 1952 through out-of-school programs for Big Island youth by the Boys & Girls Club of the Big Island (BGCBI) for over 60 years with more than 50,000 youth. BGCBI currently serves approximately 300 members per day. BGCBI's Hamakua Club has filled a critical gap in youth development services since 2007, providing quality out-of-school programs to promote academic success, healthy lifestyles, and good character & citizenship for approximately 30 youth per day delivered by a skilled and caring staff at a Club facility located in the Pa'auilo Hongwanji. 3. Program Description: Hamakua Out -of -School Fitness For Life is a healthy lifestyles initiative. The project will instill physical activity habits early in life to prevent obesity and the many associated chronic diseases. The resources of the SPARK After School Physical Activity Program will be used to increase the daily moderate to vigorous physical activity (DMVPA) of youth participants. Identified by the Center for Disease Control as a model obesity prevention program, SPARK is an extensively evidence -based intervention that has the explicit goal of fostering participant adoption of DMVPA patterns beyond program activities as part of an active lifestyle. Randomized controlled trials of SPARK have demonstrated success with the following variables: significantly increased DMVPA of participants, improved academic achievement, and participant enjoyment leading to the formation of healthy habits. The program has demonstrated success with youth of all backgrounds, not just those who are talented at sports and naturally drawn to fitness activities, thus removing an important barrier to participation for those who need it most. Requested funds will be used to provide the curriculum, training, staffing and supplies necessary to implement the SPARK program with fidelity. 4. Total Budget & Position Count: Total Program Budget: $65,000.00 Total Program Position Count: 4 Total Agency Budget: $i,z2i,2ia Total Agency Position Count: 26 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua Out -of -School Fitness For Life S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Office of Hawaiian Affairs 25,000. County of Hawaii Community Grants 40,000. TOTAL: 1 65,000. Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program BGCBI views the "Hamakua Out -of -School Fitness For Life" program as highly relevant and timely for Big Island youth. Enhanced fitness programming of the type proposed through this capacity building initiative is "strongly recommended" by the U.S. Centers for Disease Control and Prevention's Guide to Community Preventive Services. As such, the evidence -based project will play an important role in addressing the obesity epidemic in the communities to be served. This type of project has important health, economic and societal ramifications for the future wellness of populations in Hawaii and throughout the U.S. Thus, it represents a funding priority at the local, state, and national levels. BGCBI has already forged many community partnerships to leverage resources, is seeking additional grant funds and community contributions, and anticipates further funding streams as project success is documented. 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase daily moderate to vigorous physical activity (DMVPA) from pre to post by 10 minutes. Increase healthy attitudes towards regular physical activity for 90% of project participants. Improve knowledge of the health benefits of DMVPA among 90% of program participants. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua out-of-school Fitness For Life 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES fi.e.: rvumber o)dienes served, workshops or events held, volunteer hours, etc Describe, be specific Applicant Projected Results Average daily physical activity increase of FY 15-I6 Grant Req 10 minutes for participating youth. 300 minutes - 30 youth 90% of youth participants improve in 21,090 healthy attitudes towards physical activity. 90% of 30 youth 90% of youth participants improve in 590 knowledge of the health benefits of DMVPA 90% of 30 youth 12,000 8,000 Attach additional pages cs necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual" FY 15-16 Total Budget FY 15-I6 Grant Req Salary and Wages 36,000 21,090 Professional Fees 1,000 590 Operations 12,000 8,000 Supplies 6,000 4,000 Equipment 1,000 Other: Liability Insurance 2,000 1,000 Other: Administrative Support 1,000 5,500 Other Other Other: TOTAL 65,000 40,000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua out-of-school Fitness For Life io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Bonnie J. Geiger POSITION: Chief Volunteer Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ 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: none ❑✓ If no conflicts exist, check here. 7uh ) af.e 0DO Signature of Athorie erson(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua out -of -School Fitness For Life 11. Certification of Understanding (Pagel of z) I (we) have read and understood all of the 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 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 Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.guv, complete the 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 Mel understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Hamakua Out -of -School Fitness For Life 11. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30r^ 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:// vww.hawaiicounty.gov/fn-ronprofit-grant-formsZon or about May 30 of the year the final 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. is�_ � A 44-1(11)0 Signature of thorize erson (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Harn kua Out -of -School Fitness For Life 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Resant Projected Results Projected Council Proposed Projected Result (1) Average daily physical activity increase of 10 (1) 300 mi, minutes for participating youth. for 30 youth (2) 90% of youth participants improve in (2) 90% of healthy altitudes towards physical activity. 30 youth (3) 90% of youth participants improve in (3) 90% of knowledge of the health benefits of DMVPA. 30 youth Other: Administrative Support 5,500 TABLE II: PROGRAM EXPENDITURES FY 15-16Council Grant Request Award Salary and Wages 21,000 Professional Fees 500 Operations 8,000 Supplies 4,000 Equipment Other: Liability Insurance 1,000 Other: Administrative Support 5,500 Other: Other: Other: TOTAL 40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Boys & Girls Club of the Big Island Hilo Out -of -School Fitness For Life 15 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo Out -of -School Fitness For Life Agency Director: Zad Brees-Saunders Phone No.: ( 806) 961 — 5536 Contact Person: Kekai Imm Phone No.: ( 608 ) 961 — 5534 Mailing Address: Address: 100 Kamakahonu sl. Address: City, ST, Zip Hilo. HI 96720 Facility Address: Address: 100 Kamakahono Sl. Address: Hilo, HI 96720 City, ST, Zip Email Address: kekaiQob9rbi.org Fax No.: ( 808) 961 — 5534 Accountant/CPA: Ann Fukuham, CPA, MBA Phone No.: ( 808) 961 — 5532 Firm (if applicable): Mailing Address: Address. 45 Pohako Street Address: City, ST, Zip Hilo,H196720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona © South Hilo ❑ North Kohala ❑ South Kona © North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo Out -of -School Fitness For Life 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $10,000.00 $15,000.00 $13,000.00 2. Agency Mission Statement: "To inspire and enable Big Island Youth to be productive and responsible citizens, through quality programs, in a safe and caring environment." This mission has been implemented with Big Island youth by the Boys & Girls Club of the Big Island (BGCBI) for over 60 years with more than 50,000 youth. BGCBI currently serves approximately 300 members per day. 3. Program Description: Hilo Out -of -School Fitness For Life is a healthy lifestyles initiative. The project will instill physical activity habits early in life to prevent obesity and the many associated chronic diseases. The resources of the SPARK After School Physical Activity Program will be used to increase the daily moderate to vigorous physical activity (DMVPA) of youth participants. Identified by the Center for Disease Control as a model obesity prevention program, SPARK is an extensively evidence -based intervention that has the explicit goal of fostering participant adoption of DMVPA patterns beyond program activities as part of an active lifestyle. Randomized controlled trials of SPARK have demonstrated success with the following variables: significantly increased DMVPA of participants, improved academic achievement, and participant enjoyment leading to the formation of healthy habits. The program has demonstrated success with youth of all backgrounds, not just those who are talented at sports and naturally drawn to fitness activities, thus removing an important barrier to participation for those who need it most. Requested funds will be used to provide the curriculum, training, staffing and supplies necessary to implement the SPARK program with fidelity. 4. Total Budget & Position Count: Total Program Budget: $117,500.00 1 Total Program Position Count: 7 Total Agency Budget: $1.221,2141 Total Agency Position Count: 26 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8, County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo Out -of -School Fitness For Life S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY1S-16 Estimate Office of Hawaiian Affairs 30,000 South Hilo Rotary 10,000 Healy Foundation 12,500 Boys 8 Girls Club of America 5,000 County of Hawaii Community Grants 60,000 TOTAL: 117,500 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program BGCBI views the "Hilo Out -of -School Fitness For Life' program as highly relevant and timely for Big Island youth. Enhanced fitness programming of the type proposed through this capacity building initiative is "strongly recommended" by the U.S. Centers for Disease Control and Prevention's Guide to Community Preventive Services. As such, the evidence -based project will play an important role in addressing the obesity epidemic in the communities to be served. This type of project has important health, economic and societal ramifications for the future wellness of populations in Hawaii and throughout the U.S. Thus, it represents a funding priority at the local, state, and national levels. BGCBI has already forged many community partnerships to leverage resources, is seeking additional grant funds and community contributions, and anticipates further funding streams as project success is documented. 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase daily moderate to vigorous physical activity (DMVPA) from pre to post by 10 minutes. Increase healthy attitudes towards regular physical activity for 90% of project participants. Improve knowledge of the health benefits of DMVPA among 90% of program participants. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo Out -of -School Fitness For Life 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Number o/dients served, workshops o eventsheld, volunteer hours, etc Describe, bespecific.) Applicant Projected Results Average daily physical activity increase of FY 15-16 Grant Req 10 minutes for participating youth. 600 minutes - 60 youth 90% of youth participants improve in 33,000 healthy attitudes towards physical activity. 90% of 60 youth 90% of youth participants improve in 1,000 lZnowledge of the health benefits of DMVPA 90% of 60 youth 20,000 10,000 Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 68,500 33,000 Professional Fees 3.000 1,000 Operations 20,000 10,000 Supplies 10,000 6,000 Equipment 1 2,000 1.000 Other: Liability Insurance 4,000 2,000 Other: Administrative Support Moot) 7,000 Other: Other: Other. TOTAL 117,500 60,000 'If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo Out -of -School Fitness For Life io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: Bonnie J. Geiger POSITION: Chief Volunteer Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ 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: none ❑✓ If no conflicts exist, check here. j " P66) Signature of A orize P on (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls club of the Big Island Program Name: Hilo out -of -School Fitness For Life 11. Certification of Understanding (Page 1 of z) I (we) have read and understood all of the 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 Cade, 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 final payment. To register, go to http;//vendars.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 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 Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo out-of-school Fitness For Life 11. Certification of Understanding (Page 2 o 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 lune 30t1 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.goy/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 lune 30, 2015 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 ogenc✓s future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. l!/�Gf/JO ignature of Au ori- P son (specify title) EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 / 020 �2deS Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Hilo Out -of -School Fitness For Life 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result (1) Average daily physical activity increase of 10 (1) 600 min, minutes for participating youth. for 60 youth (2) 90% of youth participants improve in (2) 90% of healthy attitudes towards physical activity. 60 youth (3) 90% of youth participants improve in (3) 90% of knowledge of the health benefits of DMVPA. 60 youth Other: Administrative Support 7,000 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 33,000 Professional Fees 1,000 Operations 10,000 Supplies 6,000 Equipment 1,000 Other: Liability Insurance 2,000 Other: Administrative Support 7,000 Other: Other: Other: TOTAL 60,000 Additional Council directives regarding award: EXHIBIT B NON PROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 Boys & Girls Club of the Big Island Kea'au Out -of -School Fitness For Life 16 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Kea'au Out -of -School Fitness For Life Agency Director: Zavi Brees-Saunders Phone No.: ( 808) 961 — 5536 Contact Person: Kekai Irwin Phone No.: ( BOB ) 961 — 5534 Mailing Address: Address: loo Kamakahonu St Address: City, ST, Zip Hilo. Hl 96720 Facility Address: Address: 16- 565 Keaau P2hoa Road Address: City, ST, Zip Kea'au, HI 96749 Email Address: kekai@b9ebi org Fax No.: ( 808) 962 — 5534 Accountant/CPA: Ann Fukuhara. CPA, MBA Phone No.: (808)962 — 5532 Firm (if applicable): Mailing Address: Address: 45 P8haku sl. Address: City, ST, Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns F/ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Kea'au Out -of -School Fitness For Life 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $10,000.00 $15,000.00 $15,000.00 2. Agency Mission Statement: "To inspire and enable Big Island Youth to be productive and responsible citizens, through quality programs, in a safe and caring environment." This mission has been implemented with Big Island youth by the Boys & Girls Club of the Big Island (BGCBI) for over 60 years with more than 50,000 youth. BGCBI currently serves approximately 300 members per day. 3. Program Description: Kea'au Out -of -School Fitness For Life is a healthy lifestyles initiative. The project will instill physical activity habits early in life to prevent obesity and the many associated chronic diseases. The resources of the SPARK After School Physical Activity Program will be used to increase the daily moderate to vigorous physical activity (DMVPA) of youth participants. Identified by the Center for Disease Control as a model obesity prevention program, SPARK is an extensively evidence -based intervention that has the explicit goal of fostering participant adoption of DMVPA patterns beyond program activities as part of an active lifestyle. Randomized controlled trials of SPARK have demonstrated success with the following variables: significantly increased DMVPA of participants, improved academic achievement, and participant enjoyment leading to the formation of healthy habits. The program has demonstrated success with youth of all backgrounds, not just those who are talented at sports and naturally drawn to fitness activities, thus removing an important barrier to participation for those who need it most. Requested funds will be used to provide the curriculum, training, staffing and supplies necessary to implement the SPARK program with fidelity. 4. Total Budget & Position Count: Total Program Budget: $1o5,000.00 I Total Program Position Count: 7 Total Agency Budget: $1,221,2141 Total Agency Position Count: 26 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Kea'au Out -of -School Fitness For Life 5. Program Funding Sources (identify all sources of funding applied to this Program): FY15-16 Revenue Source Estimate Office of Hawaiian Affairs 45,000 County of Hawaii Community Grants W000 TOTAL: 105,000 Attach additional pages, iJneeded. 6. Explain what plans your agency or program has to increase revenues to support this program: BGCBI views the "Kea'au Out -of -School Fitness For Life' program as highly relevant and timely for Big Island youth. Enhanced fitness programming of the type proposed through this capacity building initiative is "strongly recommended" by the U.S. Centers for Disease Control and Prevention's Guide to Community Preventive Services. As such, the evidence -based project will play an important role in addressing the obesity epidemic in the communities to be served. This type of project has important health, economic and societal ramifications for the future wellness of populations in Hawai'i and throughout the U.S. Thus, it represents a funding priority at the local, state, and national levels. BGCBI has already forged many community partnerships to leverage resources, is seeking additional grant funds and community contributions, and anticipates further funding streams as project success is documented. 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase daily moderate to vigorous physical activity (DMVPA) from pre to post by 10 minutes. Increase healthy attitudes towards regular physical activity for 90% of project participants. Improve knowledge of the health benefits of DMVPA among 90% of program participants. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls club of the Big Island Program Name: Kea'au out -of -School Fitness For Life S. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (re.: Number of climb served, workshops or events held, volunteer hours, etc. Describe, be ipeaiJic) Applicant Projected Results Average daily physical activity increase of FY 15-16 Grant Reg 10 minutes for participating youth. 600 minutes - 90 youth 90% of youth participants improve in 30,000 healthy attitudes towards physical activity. 90% of 90 youth 90% of youth participants improve in 2,500 knowledge of the health benefits of DMVPA 90% of 90 youth 18,000 12,000 Attach additional pages as necessary. 9. TABLE 11: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget FY 15-16 Grant Reg Salary and Wages 60,000 30,000 Professional Fees 4,000 2,500 Operations 18,000 12,000 Supplies 8,000 6,000 Equipment 2000, 1,000 Other. Liability Insurance 4,000 2,500 Other Administrative Support 9,000 6,000 Other. Other: Other. TOTAL 105,000 60,000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Kea'au out -of -School Fitness For Life io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: Bonnie J. Geiger POSITION: Chief Volunteer Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council The Mayor 0 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 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: none Q If no conflicts exist, check here. awrn_ atu re of XtAqo%iferson (specify title) EXHIBIT A NON PROFIT GRANT APPLICATION FY 2015-2016 ?0 oma Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Kea'au Out -of -School Fitness For Life 11. 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 allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and 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 final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i. I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of Your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Kea'au Out -of -School Fitness For Life 21. 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 lune 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-fornis/on or about May 30 of the year the final 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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. > ) A4je-dO Signature o Auth rize erson (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 /.4 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Kea'au out -of -School Fitness For Life 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result (1) Average daily physical activity increase of 10 (1) 600 min, minutes for participating youth. for 60 youth (2) 90% of youth participants improve in (2) 90% of healthy attitudes towards physical activity. 60 youth (3) 90% of youth participants improve in (3) 90% of knowledge of the health benefits of DMVPA. 60 youth Other: Administrative Support 7,000 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 31,000 Professional Fees 1,000 Operations 12,000 Supplies 6,000 Equipment 1,000 Other: Liability Insurance 2,000 Other: Administrative Support 7,000 Other: Other. Other: TOTAL 60,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT G RANT APPLICATION FY 2014-2015 Page 8 of Boys & Girls Club of the Big Island Ocean View Out -of -School Fitness For Life 17 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls club of the Big Island Program Name: Ocean View Out -of -School Fitness Agency Director: Zavi areasSaundersPhone No.: ( 808) 961 — 5536 Contact Person: Kekai Irvin Phone No.: ( 808) 961 — 5534 Mailing Address: Address'. 100 Kamakahonu St. Address: City, ST, Zip Hilo, HI96720 Facility Address: Address: N.'alehu Community Center Address: 95-5635 Mamalema Highway City, ST, Zip Na alehu, HI 96772 Email Address: kekai@becbi.org Fax No.: ( 808) 961 — 5534 Accountant/CPA: Ann Fukuhara, CPA, MBA Phone No.: ( 808) 961 — 5532 Firm (if applicable): Mailing Address: Address: 45 Pbhaku street Address: City, ST, Zip Hilo, HI96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala © Ka'6 Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Ocean View out-of-school Fitness 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $10,000.00 $15,000.00 $15,000.00 2. Agency Mission Statement: "To inspire and enable Big Island Youth to be productive and responsible citizens, through quality programs, in a safe and caring environment." This mission has been implemented with Big Island youth by the Boys & Girls Club of the Big Island (BGCBI) for over 60 years with more than 50,000 youth. BGCBI currently serves approximately 300 members per day. 3. Program Description: Ocean View Out -of -School Fitness is a healthy lifestyles initiative. The project will instill physical activity habits early in life to prevent obesity and the many associated chronic diseases. The resources of the SPARK After School Physical Activity Program will be used to increase the daily moderate to vigorous physical activity (DMVPA) of youth participants. Identified by the Center for Disease Control as a model obesity prevention program, SPARK is an extensively evidence -based intervention that has the explicit goal of fostering participant adoption of DMVPA patterns beyond program activities as part of an active lifestyle. Randomized controlled trials of SPARK have demonstrated success with the following variables: significantly increased DMVPA of participants, improved academic achievement, and participant enjoyment leading to the formation of healthy habits. The program has demonstrated success with youth of all backgrounds, not just those who are talented at sports and naturally drawn to fitness activities, thus removing an important barrier to participation for those who need it most. Requested funds will be used to provide the curriculum, training, staffing and supplies necessary to implement the SPARK program with fidelity. 4. Total Budget & Position Count: Total Program Budget: $40,000.00 Total Program Position Count: 4 Total Agency Budget: $1,221,214 Total Agency Position Count: zs EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Ocean View Out -of -School Fitness 5. Program Funding Sources pdemay au sources or runamg appuea to cros oroxramp FY15-16 Revenue Source Estimate IG]/a14 if needed 6. Explain what plans your agency or program has to increase revenues to support this program BGCBI views the "Ocean View Out -of -School Fitness' program as highly relevant and timely for Big Island youth. Enhanced fitness programming of the type proposed through this capacity building initiative is "strongly recommended" by the U.S. Centers for Disease Control and Prevention's Guide to Community Preventive Services. As such, the evidence -based project will play an important role in addressing the obesity epidemic in the communities to be served. This type of project has important health, economic and societal ramifications for the future wellness of populations in Hawai'i and throughout the U.S. Thus, it represents a funding priority at the local, state, and national levels. BGCBI has already forged many community partnerships to leverage resources, is seeking additional grant funds and community contributions, and anticipates further funding streams as project success is documented. 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase daily moderate to vigorous physical activity (DMVPA) from pre to post by 10 minutes. Increase healthy attitudes towards regular physical activity for 90% of project participants. Improve knowledge of the health benefits of DMVPA among 90% of program participants. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Ocean View out-of-school Fitness 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.: Number ojdients served, workshops .,,t, held, volunteer hours, eto. Describe, he specific.) Applicant Projected Results Average daily physical activity increase of FY 15-16 Grant Req 10 minutes for participating youth. 250 minutes- 25 youth 90% of youth participants improve in 18,000 healthy attitudes towards physical activity. 90% of 25 youth 90% of youth participants improve in 1,500 knowledge of the health benefits of DMVPA 90% of 25 youth 8,000 8,000 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual• FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 18,000 18,000 Professional Fees 1,500 1,500 Operations 8,000 8,000 Supplies 5,000 5,000 Equipment 500 500 Other: Liability Insurance 2,000 2,000 Other: Administrative Support 5,000 5,000 Other: Other: Other: TOTAL 40,000 40,000 It applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Ocean View out -of -School Fitness io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: Bonnie J. Geiger POSITION: Chief Volunteer Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council Q 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 an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: none ❑✓ If no conflicts exist, check here. Signatur z Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls club of the Big Island Program Name: Ocean View Out -of -School Fitness 22. 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 allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and 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 final payment. 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 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 Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NON PROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls club of the Big Island Program Name: Ocean View Out -of -School Fitness 11. Certification of Understanding (rage 2 of 21 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 3011 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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. 1El %a-rc�r�rI2X6s/.f._i tt-✓ C' !�U Signature of Auth�zed Pers®n (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 ao.cs- Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: ocean view out-of-school Fitness 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result (1) Average daily physical activity increase of 10 (1) 250 min, minutes for participating youth. for 25 youth (2) 90% of youth participants improve in (2) 9D% of healthy attitudes towards physical activity. 25 youth (3) 90% of youth participants improve in (3) 90% of knowledge of the health benefits of DIAL 25 youth Other. Administrative Support 5,000 TABLE It: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 18,000 Professional Fees 1,500 Operations 8,000 Supplies 5,000 Equipment 500 Other: Liability Insurance 2,000 Other. Administrative Support 5,000 Other: Other. Other: TOTAL 40,000 Additional Council directives regardinit award: EXHIBIT B NON PROFIT G RANT APPLICATION FY 2014-2015 Page 8 of Boys & Girls Club of the Big Island Pahala Out -of -School Fitness For Life County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahala Out -of -School Fitness For Life Agency Director: Zara Brees-Saunders Phone No.: ( 808) 961 — 5536 Contact Person: Kekai Irwin Phone No.: ( 606 ) 961 — 5534 Mailing Address: Address: 100 Kamakahonu St Address: City, ST, Zip Hilo, 11I96720 Facility Address: Address: 96-1149 Kamani St. Address: City, ST, Zip Pahala, HI 96777 Email Address: kekai@b9cbi.org Accountant/CPA: Ann Fukuhara, CPA, MBA Firm (if applicable): Mailing Address: Address: 45 PLhsku Streat Address: City, ST, Zip Hilo, HI 96720 Fax No.: ( 808) 961 Phone No.: ( 606 ) 961 — 5534 5532 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahala out -of -School Fitness For Life 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $10,000.00 $25,000.00 $15,000.00 2. Agency Mission Statement: "To inspire and enable Big Island Youth to be productive and responsible citizens, through quality programs, in a safe and caring environment." This mission has been implemented since 1952 through out-of-school programs for Big Island youth by the Boys & Girls Club of the Big Island (BGCBI) for over 60 years with more than 50,000 youth. BGCBI currently serves approximately 300 members per day. BGCBI's Pahala Club has filled a critical gap in youth development services for vulnerable youth since 2007, providing quality out-of-school programs to promote academic success, healthy lifestyles, and good character & citizenship. The skilled and caring Club staff currently serves approximately 35 youth per day at the Pahala Community Center. 3. Program Description: Pahala Out -of -School Fitness For Life is a healthy lifestyles initiative. The project will instill physical activity habits early in life to prevent obesity and the many associated chronic diseases. The resources of the SPARK After School Physical Activity Program will be used to increase the daily moderate to vigorous physical activity (DMVPA) of youth participants. Identified by the Center for Disease Control as a model obesity prevention program, SPARK is an extensively evidence -based intervention that has the explicit goal of fostering participant adoption of DMVPA patterns beyond program activities as part of an active lifestyle. Randomized controlled trials of SPARK have demonstrated success with the following variables: significantly increased DMVPA of participants, improved academic achievement, and participant enjoyment leading to the formation of healthy habits. The program has demonstrated success with youth of all backgrounds, not just those who are talented at sports and naturally drawn to fitness activities, thus removing an important barrier to participation for those who need it most. Requested funds will be used to provide the curriculum, training, staffing and supplies necessary to implement the SPARK program with fidelity. 4. Total Budget & Position Count: Total Program Budget: $65,000.00 Total Program Position Count: 4 Total Agency Budget: $1,221,2141 Total Agency Position Count: 26 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahala out-of-school Fitness For Life 5. Program Funding Sources (identify all sources of funding applied to this programl: FY15-16 Revenue Source Estimate Office of Hawaiian Affairs 25,000 County of Hawaii Community Grants 40,000 TOTAL: 65,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: BGCBI views the "Pahala Out -of -School Fitness For Life' program as highly relevant and timely for Big Island youth. Enhanced fitness programming of the type proposed through this capacity building initiative is "strongly recommended" by the U.S. Centers for Disease Control and Prevention's Guide to Community Preventive Services. As such, the evidence -based project will play an important role in addressing the obesity epidemic in the communities to be served. This type of project has important health, economic and societal ramifications for the future wellness of populations in Hawai'i and throughout the U.S. Thus, it represents a funding priority at the local, state, and national levels. BGCBI has already forged many community partnerships to leverage resources, is seeking additional grant funds and community contributions, and anticipates further funding streams as project success is documented. 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase daily moderate to vigorous physical activity (DMVPA) from pre to post by 10 minutes. Increase healthy attitudes towards regular physical activity for 90% of project participants. Improve knowledge of the health benefits of DMVPA among 90% of program participants. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys8, Girls Club of the Big Island Program Name: Pahala out -of -School Fitness For Life 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES h e.: Number of clients served, workshops or events held, volunteer hours, etc DPSC me, be specific) Applicant Projected Results Average daily physical activity increase of FY I5-16 Grant Req 10 minutes for participating youth. 300 minutes - 30 youth 90% of youth participants improve in 20,000 healthy attitudes towards physical activity. 90% of 30 youth 90% of youth participants improve in 1,000 knowledge of the health benefits of DMVPA 90% of 30 youth 12,000 8,000 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-I6 Total Budget FY I5-16 Grant Req Salary and Wages 36,000 20,000 Professional Fees 1,000 1,000 Operations 12,000 8,000 Supplies 6,000 4,000 Equipment 1,000 500 Other: Liability Insurance 2,000 1,000 Other: Administrative Support 7,000 5,500 Other: Other: Other: TOTAL 65,000 40,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahala Out -of -School Fitness For Life io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether o conflict exists. NAME: Bonnie J. Geiger POSITION: Chief Volunteer Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council 7 Staff appointed by a member of the Council The Mayor D The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: as ubstantiol 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: none Q If no conflicts exist, check here. Signature of Auth riz Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls club of the Big Island Program Name: Pahala Out -of -School Fitness For Life ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 — 2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to hup://vendorsehawaii.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 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. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Malls Out -of -School Fitness For Life it. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30'h 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.howaiicaunty.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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. >��"&I�b ignature of Authoriz Pe on (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 o, Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahala Out -of -School Fitness For Life 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Resant Projected Results Projected Council Proposed Projected Result (1) Average daily physical activity increase of 10 (1) 300 min. minutes for participating youth. for 30 youth (2) 90% of youth participants improve in (2) 90% of healthy attitudes towards physical activity. 30 youth (3) 90% of youth participants improve in (3) 90% of knowledge of the health benefits of DMVPA. 30 youth Other: Administrative Support 5,500 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 20,000 Professional Fees 1,000 Operations 8,000 Supplies 4,000 Equipment 500 Other. Liability Insurance 1,000 Other: Administrative Support 5,500 Other: Other: Other: TOTAL 40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 Boys & Girls Club of the Big Island Pahoa Out -of -School Fitness For Life 19 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls club of the Big Island Program Name: Pahoa Out -of -School Fitness For Life Agency Director: zavi Brees-saundars Phone No.: ( 808) 961 — 5536 Contact Person: Kekai Irvin Phone No.: ( 808) 961 — 5534 Mailing Address: Address: 100 Kamakahonu St. Address: City, ST, Zip Hilo, H196720 Facility Address: Address: 15-3003 Kauhale sl. Address: City, ST, Zip Pahoa, HI 96]]8 Email Address: kekal@bgebi.or9 Fax No.: ( 808) 961 — 5534 Accountant/CPA: Ann wkuhara, CPA, MBA Phone No.: ( 808) 961 — 5532 Firm (if applicable): Mailing Address: Address. 45 Pohaku street Address: City, ST, Zip Hilo, HI96120 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahoa out -of -School Fitness For Life 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $10,000.00 $25,000.00 $25,000.00 2. Agency Mission Statement: "To inspire and enable Big Island Youth to be productive and responsible citizens, through quality programs, in a safe and caring environment." This mission has been implemented since 1952 through out-of-school programs for Big Island youth by the Boys & Girls Club of the Big Island (BGCBI) for over 60 years with more than 50,000 youth. BGCBI currently serves approximately 300 members per day. BGCBI's Pahoa Club has filled a critical gap in youth development services since 2003, providing quality out-of-school programs for approximately 50 youth per day. Despite the uncertainty presented by the advancing Puna lava flow, a skilled and caring staff maintains normalcy for youth through fun and engaging programs. 3. Program Description: Pahoa Out -of -School Fitness For Life is a healthy lifestyles initiative. The project will instill physical activity habits early in life to prevent obesity and the many associated chronic diseases. The resources of the SPARK After School Physical Activity Program will be used to increase the daily moderate to vigorous physical activity (DMVPA) of youth participants. Identified by the Center for Disease Control as a model obesity prevention program, SPARK is an extensively evidence -based intervention that has the explicit goal of fostering participant adoption of DMVPA patterns beyond program activities as part of an active lifestyle. Randomized controlled trials of SPARK have demonstrated success with the following variables: significantly increased DMVPA of participants, improved academic achievement, and participant enjoyment leading to the formation of healthy habits. The program has demonstrated success with youth of all backgrounds, not just those who are talented at sports and naturally drawn to fitness activities, thus removing an important barrier to participation for those who need it most. Requested funds will be used to provide the curriculum, training, staffing and supplies necessary to implement the SPARK program with fidelity. 4. Total Budget & Position Count: Total Program Budget: $85,000.00 Total Program Position Count: 6 Total Agency Budget: $1,221,214 Total Agency Position Count: 26 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahoa Out -of -School Fitness For Life 5. Program Funding Sources (identify all sources of funding applied to this program): FY15-16 Revenue Source Estimate Office of Hawaiian Affairs 45,000 County of Hawaii Community Grants 40,000 TOTAL: 85,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program BGCBI views the "Pahoa Out -of -School Fitness For Life' program as highly relevant and timely for Big Island youth. Enhanced fitness programming of the type proposed through this capacity building initiative is "strongly recommended" by the U.S. Centers for Disease Control and Prevention's Guide to Community Preventive Services. As such, the evidence -based project will play an important role in addressing the obesity epidemic in the communities to be served. This type of project has important health, economic and societal ramifications for the future wellness of populations in Hawai'i and throughout the U.S. Thus, it represents a funding priority at the local, state, and national levels. BGCBI has already forged many community partnerships to leverage resources, is seeking additional grant funds and community contributions, and anticipates further funding streams as project success is documented. 7. Program Objectives Using County Nonprofit Grant Program Funds: Increase daily moderate to vigorous physical activity (DMVPA) from pre to post by 10 minutes. Increase healthy attitudes towards regular physical activity for 90% of project participants. Improve knowledge of the health benefits of DMVPA among 90% of program participants. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahoa Out -of -School Fitness For Life 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES he Number ofclienn served, workshops or events held, volunteer hours, etc. Describe, be specific) Applicant Projected Results Average daily physical activity increase of FY 1546 Grant Req 10 minutes for participating youth. 400 minutes - 40 youth 90% of youth participants improve in 26,000 healthy attitudes towards physical activity. 90% of 40 youth 90% of youth participants improve in knowledge of the health benefits of DMVPA 90% of 40 youth 14,500 5,000 Attach additional pages as necessary. 9. TABLE It: - PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 1546 Grant Req Salary and Wages 50,000 26,000 Professional Fees 2,000 Operations 14,500 5,000 Supplies 6,000 2,500 Equipment 1,500 Other: Liability Insurance 3,000 1,000 Other: Administrative Support 8,000 5,500 Other: Other: Other. TOTAL 85,000 40,000 'if applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahoa Out -of -School Fitness For Life 1o. 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: Bonnie J. Geiger POSITION: Chief Volunteer Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council The Mayor 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 any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: none ❑✓ If no conflicts exist, check here. 4g -d2/ l k4./ l!" % O "Signature of/Authofiz Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Boys & Girls Club of the Big Island Program Name: PAhoa Out -of -School Fitness For Life ii. 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, 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 final payment. 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 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. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahoa Out -of -School Fitness For Life ii. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized lVerson (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys & Girls Club of the Big Island Program Name: Pahoa Out -of -School Fitness For Life 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result (1) Average daily physical activity increase of 10 (1) 400 min. minutes for participating youth. for 40 youth (2) 90% of youth participants improve in (2) 90% of healthy attitudes towards physical activity. 40 youth (3) 90% of youth participants improve in (3) 90% of knowledge of the health benefits of DMVPA. 40 youth Other: Administrative Support 5,500 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 26,000 Professional Fees Operations 5,000 Supplies 2,500 Equipment Other: Liability Insurance 1,000 Other: Administrative Support 5,500 Other: Other: Other: TOTAL 40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Boys to Men Mentoring Network, Inc. Boys to Men Mentoring Network of Hawai'i 20 County of Hawai4i Nonprofit Grant Application FY2015-16 Agency Name: Boys to Men Mentoring Network, Inc. Program Name: Boys To Men Mentoring Network of Hawaii Agency Director: coag Nolaias Phone No.: ( 619) 469 — 9599 ContactPerson: Michaei aoneren Phone No.: (eoe) 937 — 9554 Mailing Address: Address: 9WTmpko Di Address: City, ST, ZIP le Mese, CA 91941 Facility Address: Address: 59-114Hoewe'ei=iece Address: Clty, ST, ZIP Kamuele. H196]43 Email Address: hx,haI,Kt axIaiacc.can Fax No.: ( 1 0 — e Accountant/CPA: Pon Horror, F.A. Phone No.: ( 691) 291 — Ins Firm (if applicable): Mailing Address: Address: 3991 Ohio Shael Address: City, ST, ZIP San Diego. CA 92154 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: s 75,000.50 Geographical Areas To Be Served: (One or more an be checked) © Puna H5m5kua © North Kona © South Hilo © North Kohala © South Kona m North Hilo - © South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns © youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged Victims of Health or Social Crises Needs of the poor © Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys to Men Mentoring Network, Inc. Program Name: Boys To Men Mentoring Network of Hawaii 1. Prior Year Award of County Nonprofit Gram Program Funds: FY 12.13 FY 13-14 FY 14-15 0.00 $0.00 0.00 2. Agency Mission Statement: The mission of Boys To Men is to recruit, train and support men from the local community who guide boys to become the empowered compassionate partners, fathers and leaders needed in our communities. Boys to Men Mentoring changes the way a boy sees his life, relationships and potential so he can leave behind destructive patterns and become the man he wants to be. Our mentors strive to be authentic role models who lead by example. We support boys as they adopt a positive values oriented lifestyle of their own choosing. Boys to Men partners with educational and juvenile justice organizations to deliver school-based group mentoring programs throughout the County of Hawaii. The key values we promote are acceptance, connection, integrity, respect and leadership. 3. Program Description: Boys to Men Mentoring Network of Hawaii (B2M) provides community based mentoring for adolescent boys 12 to 17 years of age. Every week dedicated B2M mentors show up at middle schools, high schools, community centers, & foster care facilities to give teenage boys a community of mentors who listen, encourage & believe in them. The weekly meetings give boys, from the most challenged environments, access to a variety of male role models. These mentors show up consistently, tell the truth about their trials in life, ask the boys to look at their future, praise them for their unique gifts, support them through their struggles, & encourage them to become the good men they want to be. 132M enrolls productive, successful men from the local community & trains them to mentor in a facilitated group setting. The boys are invited to feel safe & to feel accepted. They learn to speak honestly whenever they choose. Mentors listen without judgment, teach by example, & honor & support the boys as they begin to adopt a new set of values & behaviors. Over time, the young men grow into "Journeymen", senior level mentees, who team to guide & support the new boys who enter the program. CONT. APPENDIX ONE 4. Total Budget & Position Count: Total Program Budget: t48,5oo.00 Total Program Position Count: I i Frn PT Total Agency Budget: 295.000.00 I Total Agency Position Count: I 4Fn4IT EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys to Men Mentoring Network, Inc. Program Name: Boys To Men Mentoring Network of Hawaii S. Program Funding Sources (identify all sources of funding applied to this Programl: Revenue Source FY15-16 Estimate Individualtnbulions 8,700.00 Co rate Corudbutons 18,000.00 Prognur, Fees 2,000.00 Grants 75,000.00 Special Evenis Fundraiser 45,000.00 End of Year Appeal 10,000.00 TOTAL: 158,700.00 Attach additiana/ pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program Boys To Men engages in ongoing fundraising and has to date accrued over 40% of the Individual and Corporate goal. The remainder of the corporate contribution will be sourced from local and state wide businesses. Many substantial businesses have expressed an interest in supporting the development of such a local resource. We are today receiving contributions from Tommy Bahamas, Kohala Creative Construction, Pueos and Monsters Restaurants and the Mauna Lani, Mauna Kea and Haulalai Resorts. Teams of Boys To Men volunteers actively solicit targeted businesses. Two major fund raising drives are already under development. The special event fund raiser, "Tee It Up With Tom Watson" is nearly sold out. Projected revenue of $45,000. The end of year appeal will be focused on individuals from all economic levels in the state; will engage local celebrities from a variety of ethnicities and cultural backgrounds such as Uncle Willie K., Danny Akaka and Keali'i Reichel. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Using the Boys To Men community mentoring model, build a self sustaining and sell replicating young mens mentoring organization in Hawaii County and prepare to duplicate it across the state in cooperation with the Hawaii County Council, the Mayors office, the Hawaii Prosecutors Office, and the State Department of Youth Services. 2. Initiate ongoing mentoring relationships with minimum 120 at risk or otherwise disadvantaged boys, as defined in accordance with HB2489 and HB2490, in total of 8 weekly JI -Groups in direct supervised contact with 50 trained, cleared and insured adult mentors by December 15, 2015. 3. In partnership with the Hawaii Office of Youth Services, the Hawaii Department of Justice and the Hawaii County Prosecutors Office develop systems for enrollment, referral monitoring and measuring program effectiveness to enable Boys To Men Hawaii to serve at risk, ex -offender and substance abusing youth. Obtain sign off by Hawaii County Counsel and State DOJ by September, 2015. SEE APPENDIX ONE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys to Men Mentoring Network, Inc. Program Name: Boys To Men Mentoring Network of Hawaii 8. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (%e.:Numberofdlenn' xd, enhslwps orewntshel4 wlunreerfiours, etc oesoibe, hes flc) Applicant Projected Results Grow active memor count to 72 man by 12.15 100 mentors by 12/31 Hold 6 recruitment events in County by 12.15 100% See Appendix 1 Hold 4 mentor trainin s by 12.31 100% See A ndtx 1 Locate and activate 6 new J -Group sites 100% See ApPenda 1 Develop enrollmam, monftDdng and metrics 100% See Appendix 1 Boys in J -Groups to 120 in County 100% See Appendix 1 Qualiffy one Mentor Facilitator per J-Group8 Qualified Mentors Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Totat Budget FY 15-16 Gram Req Salary and Wages 50,000.00 Professional Fees 10,000.00 10,000.00 Operations 21,000.00 21,000.00 Supplies 10,000.00 6,000.00 Equipment 11,500.00 5,500.00 Other: Insurance I 4,500.00 4,250.00 Other: National Background Checks(01251nentor) 6,250.00 6,250.00 Other: Computerized Mentor Tracking/Retengon System 2,800.00 Other: Mentor Trainings x 4@ 1500.00 each 6.000.00 6,000.00 Other: Mentor Facilitatior Stipends (1 par JGroup) 16,000.00 16,000.00 TOTAL 148,05000 75,000.00 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys to Men Mentoring Network, Inc. Program Name: Boys To Men Mentoring Network of Hawaii lo. 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, regordless 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): ❑ 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 naruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. I I V.IPI WIh A L Signatu f Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys to Men Mentoring Network, Inc. Program Name: Boys To Men Mentoring Network of Hawaii it. Certification of Understanding (page 1 of z) 1 (we) have read and understood all of the 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 final payment. To register, go to httn://vendors.ehawai 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 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 wmplete 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 o timely, complete and accurate yeor-end report using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NON PROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys to Men Mentoring Network, Inc. Program Name: Boys To Men Mentoring Network of Hawaii 11. Certification of Understanding (Pa9e2m2) If awarded a grant from the County of Hawaii, 1(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 301h shall result in loss Of all grant funds received during the grant period Imust be refunded to CouMI and exclusion from future grant RIEticipation foul minimum of one ygiir or until a written report is submitted to,and accepted bm 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 ha wa 2ounty iv non oft rms/ on or about May 30 of the year the final 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, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in o timetv manner will im pct the evaluation o our a en 's future funding request and may It in actions to k en to recover hese funds. By signing below, you are acknowledging that you have read and understood these requirements. _(Iq.4 k462&" 1.25.2015 Signatd& of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Boys to Men Mentoring Network, Inc. Program Name: Boys To Men Mentoring Network of Hawaii 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Coundi Proposed Projected Results I Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives reeardin¢ award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 APPENDIX ONE Item 3, cont. B2M utilizes a proven curriculum that has been developed over the past 18 years. The meetings combine learning, fun, leadership opportunities, peer mentoring & self-esteem building exercises. The safety of the boys is our first priority. Each potential mentor is interviewed & screened by B2M leadership & must pass a School District approved background check prior to his acceptance into the program. All Mentor Leaders must attend a specially designed 24 hour experiential Mentor Training. 132M Facilitators must undergo additional leadership & mentor trainings. These trained facilitators lead mentor trainings, the Adventure Weekend, & all weekly mentoring sessions. The group mentoring aspect further adds to our program's safety by allowing us to monitor & evaluate the mentor's interactions with boys. Item 7. cont. 4. Highlight these grass roots volunteer mentoring programs in print, television and electronic new media across the county and within the state. Identify prospective part- time public relations staff TBH in 2016. 5. Develop, organize and begin execution of fund raising projects to fund FY 2016-17, with volunteer staffing, targeted at Hawaii county businesses, state grant funding entities, private charitable and religious organizations by July, 2015. Deliver $50,000.00 in FY2016 operating funds dedicated exclusively to supporting mentoring opportunities across Hawaii county and the state by December 31, 2015. 6. Within six months from start of funding attain an enrolled mentor and boy roster of 50 adult mentors and capacity to serve minimum 120 boys 12 to 15 attending weekly J -Group meetings. Page 1 of 2 Item 8, cont. County districts will be addressed in descending order of need. Puna district schools, particularly Palma and Keaau Intermediate, are in distinct need due to increased volcanic activity. Families are being uprooted, causing havoc on the lives of young men in the target age group. Class A and Class B violation rates are unusually high in these two schools. Consequently, Pahoa and Kapaa Intermediate will be immediate targets for B2M activity. The target populations will be the initial focus for Boys To Men mentor recruiting and mentoring activity. Active Mentor Count is a headcount total from the Boys To Men maintained Mentor Roster. Optimal headcount is derived as follows: Optimal I -Group size = 12-15 boys aged 12-14 or 15-17 Optimal Mentor attendance per J -Group 4-5 mentors Rotating Mentor'Bench' = 9 trained and cleared men per J -Group Mentor Facilitator = Mentor given advance training to support Mentors in each J -Group Thus, 8 J -Groups in County = 96 -120 boys, 72 -trained and cleared men in county. Recruitment Events refers to targeted invitational events directed at men of the local community to educate and enroll them as Mentor Candidates. Mentor Trainings refers to private sponsored training events (known as Reignite Your Teenaged Fire) which reconnect mentor candidates with the experiences of their youth and provides the insight and experience to function as supervised Mentors at weekly B2M J -Group meeting with the boys. J -Groups refers to the weekly of bi weekly meetings between the boys available more the program, as determined by Boys To Men in partnership with Juvenile justice and educational officials in the County and local school administrators. Development of Metrics will be done in partnership with juvenile justice officials, the State Board of Education and local educators to facilitate integration with existing standards on the justice and educational community. Page 2 of 2 T m o 0 � d d a N ON tOi LL � pp A OO O O o a 0 O 0 0 � W O O m CO O < tD N O Z 0 00 0 0 0 O O O 0 0 0 0 0 0 O O O N 0 0 0 0 0 0 O O O OO O N N N O O O F O tG L V tD 16 16 N l) 0 0 0 0 0 0 0 0 0 0 0 O 0 0 0 0 0 0 0 0 0 0 O 0 0 0 0 0 0 0 0 p O O 0 0 0 O O O O V1 O00 O O O N X 0 0 0 0 tt1 N N m 0 0 0 O moo .ti o .--i v t6 ri � b o ro Vl e4 N e4 N rl rl R � ~ O. r' c 0 c v °J N W C s o � o v c Z w � c c c i0 o — c F w o � w n z v E a c a m E m na c a y a c ^ m O 6 d d N C L N r m N W a d] o V V C C W n 0 t'n w � m H ti O Brantley Center Employment Rehabilitation 21 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Brantley Center, Inc. Program Name: Employment Rehabilitation Agency Director: Cy Cabreros Phone No.: ( e0e) ns — 7246 Contact Person: cy Cabreros Phone No.: ( soa) ns — 0211 Mailing Address: Address: Address: P.O. Box 1407 City, ST, Zip Honaka's, Hi 96721 Facility Address: Address: 45-370 Oheio Rd Address: City, ST, Zip Honoks'a, Hi W721 Email Address: b.nteQ@haw lisMei.net Accountant/CPA: MOE Bcokeepirq Services Firm (if applicable): Mailing Address: Address: Rc.aox246 Address: City, ST, Zip laupahoehoe, Hi 96764 Fax No.: ( 906) 116 — 1445 Phone No.: ( aoe ) 962 — 6524 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna Hamakua ❑ North Kona ❑ South Hilo North Kohala ❑ South Kona North Hilo © South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) Educational concerns ❑ youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1Of9 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Brantley center, Inc. Program Name: Employment Rehabilitation 1 _ Prior Year Award of County Nonprofit Grant Program Funds: FY 12.13 1 FY 13-14 FY 14-15 13,500.001 $40,000.00 0 2. Agency Mission Statement: Our mission is to provide quality rehabilitation services that empower people with disabilities to participate independently in their community. 3. Program Description: The Employment Rehabilitation Program provides participants with a variety of services that develop and support the accomplishment of goals leading to meaningful employment. These services include; job -readiness classes, competitive employment placement services, and on-the-job follow-up services. Participants receive quality vocational training and at the same time are paid for the work performed. Program staff work closely with community to provide community-based vocational training, and at the same time provide the public with an additional workforce. Also included in this program are the work transition services for high school students with disabilities. Total Program Budget: 276,te2.00 Total Program Position Count: 4 Total Agency Budget: 450 0001 Total Agenry Position Count: :o EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Brantley Center, Inc. Program Name: Employment Rehabilitation cundlne Snuraec (identifv all sources of funding applied to this programl: Attach additional page; if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Brantley Center, Inc. has made a concerted effort to expand its fund development capabilities. With fresh ideas from new Board Members and Staff, the center is currently working on plans for additional fundraising. The Center also has been able to yield more crops on the hydroponic lettuce and will be exploring new vegetables to market. The goal for this program is to become self-sustaining , but the current reality of the economic climate makes that impossible. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Provide vocational evaluations to 35 clients 2) Provide individualized employment planning services to 25 clients. 3) Provide work adjustment training to 25 clients 4) Provide occupational skills to 25 clients 5) Provide job - readiness classes to 20 clients 6) Provide competitive job placement and follow-up services to 15 clients 7) Provide work transition services to 15 high school students with disabilities EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of FY1S-16 Revenue Source Estimate State of Hawaii Division of Vocational Rehab 30,000 County of Hawaii . Mase Transit 21,000 Hawaii Island United Way 10,000 County of Hawaii 40,000 Program Sales & Services 140,000 10,000 Fundraising TOTAL: 251,000 Attach additional page; if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Brantley Center, Inc. has made a concerted effort to expand its fund development capabilities. With fresh ideas from new Board Members and Staff, the center is currently working on plans for additional fundraising. The Center also has been able to yield more crops on the hydroponic lettuce and will be exploring new vegetables to market. The goal for this program is to become self-sustaining , but the current reality of the economic climate makes that impossible. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Provide vocational evaluations to 35 clients 2) Provide individualized employment planning services to 25 clients. 3) Provide work adjustment training to 25 clients 4) Provide occupational skills to 25 clients 5) Provide job - readiness classes to 20 clients 6) Provide competitive job placement and follow-up services to 15 clients 7) Provide work transition services to 15 high school students with disabilities EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Brantley Center, Inc. Program Name: Employment Rehabilitation 8. TABLE 1: _. ___ _ IM. ._..J...lrae—t- itcnr— itrnmec that would be achieved with this funding? ROGRAM PERFORMANCE MEASURES lie,:mberofclienasb v d, worksdops orevenes held, volunreerbours, etc. Describe, be specijcl Applicant Projected Results f Giants who received emplo merit rehab services 25 f consumers with im coved scores on Ne voretbnal Eval T2ining Report 10 f consumers with im rovedroductivi10 Eb 20,500.00 f consumers who suo>3ssfutly completed the job-reetliness class 5 f consumers placed in comDetilive emplo ment for a minimum of 90 days 10 f students who received work transition services 8 were laced in comDebtive 5 ment. 15,500.00 Attach additional pages as necessary. PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 153,077.84. 166,192.00 20,500.00 Professional Fees 976.00 1,000.00 2,000.00 Operations 92,005.00 100,000.00 15,500.00 Supplies 3,730.95 4,000.00 2,000.00 Equipment 5,000.00 5,00000 5,000.00 Other: Other: Other: Other: Other: TOTAL 254,789.791 276,192.00 45,00000! eyyuwu�c EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Brantley Center, Inc. Program Name: Employment Rehabilitation io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 pmbabiliry that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to bene lts 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: ❑vr If no conflicts exist, check here. Q�&l/� i/P-49 - Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Brantley Center, Inc. Program Name: Employment Rehabilitation 11. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 programs) 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 he accepted as original documents. If awarded a grant from the County of Hawaii, 1 (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. 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 ¢rant from the County of Hawai'i I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after lune 30 of the 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 reportusing the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Brantley Center, Inc. Program Name: Employment Rehabilitation 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 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 accented 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--ww.hawaiicounty.gov/fn-noni2rofit-grant-formsZ on or about May 30 of the year the final 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 lune 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will imaact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Alt.Pj, Af��a l� Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Brantley Center, Inc. Program Name: Employment Rehabilitation 12. COUNCIL AWARD WORKSHEET rXOLL r: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of clients who received employment rehab services 25 Number of consumers with improved scores on the vocerional Eval Training Report 10 Number of consumers with improved productivity percentages 10 Number of consumers who successfully completed the job -readiness claw 5 Number of consumers placed in competitive employment for a minimum of 90 days 10 Numer of students who received work transition services and were place in competitive 5 employment ROLL Ir: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 20,500.00 Professional Fees 2,000.00 Operations 15,500.00 Supplies 2,000.00 Equipment 5,000.00 Other: Other: Other: Other: Other: TOTAL a5,00o.00 Additional council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 20142015 Page 8 of 8 Bridge House, Inc. Vocational Skills Building Program 22 County of Hawaii Nonprofit Grant Application FY2015-16 exlf o� Agency Naive: Bridge House, Inc. Program Name: "Vocational skills Building Program' Agency Director: Mark Sdw Phone No.: (ane) 322 — 5305 Contact Person: Mark schueler Phone No.: (8W) 3n — 3305 Mailing Address_ Address: P.O. Boz 2488 Address: CRY. ST, ZIP KaNua.Kara, HI W45 Facility Address: Addrens. 79'sas743 Ua.. 1OaH". Address: City, ST, LP Hokoft HI 96725 6nag Address: mmk_bridpdKs aMtdink.�+ Fax No.: (sae) M — ew ACCountant/CPA: 9reaCe Sm Phone No.: (806)OW — 6"1 Firm (if applicable): �saknkma Mailing Address: Address: P.O. Bw 1254 Address: CRY, ST, IW Ka ffl Kone. W 86746 YOU ARE RESPONSBLE TO KEEP THEABOVE iNFORNNATMIN CURRENT ANATO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of iteguesf for County Nonprofit Grant Program Funds: M,6*66 Gaegrapkkal Aran To Be Sem6dt (Oft of tW* rah bi Cbftk*) [� Puna ® NamSkua ® North Kona m South Hilo © North Kobala © South Kona ® North Hilo 0 South Kohala @ Ka'd Services or Activities To Be Provided: (One or more can be checked) Educational concerns Youth Q Victims of Crimes ID Culture and the arts ® Aged Vkilms of Health or Social Cries ® Needs of the Poor ® Physical/Emotional Disabilities ® Public Health and Welfare of the People and the Environment EXHIBIT A County of Hawaii Nonprofit Grant application FY201-16 Agency Name: Bridge House, Inc. Pro ram Name: "vocational skills Building Program- _ 1. Prior Year Award of County Nonprofit Grant Program Funds: fY 12-13 FY 13-14 FY 14-15 t _0_ 1 $25,000.00 $25,000.00 2. Agency Mission Stetemertt: The Bridge House mission is to assist adults who are in recovery from drug/alcohol addiction, to develop successful living skills through residential and vocational experiences in our safe, structured and supportive environment. 3. Program DesulPtiali Research indicates that employment is one of the strongest rzrirelates with successful recovery from addiction and re -connection with family and community. As a result of their substance abuse, approximately 90% of our admits are unemployed/unemployable upon arrival at Bridge House. Ag new admits are required to complete a vocational history questionnaire, Results of this evaluation, along with personal observation by staff, then helps identify skills, attitudes and behaviors that require refneiliation. The program also provides on-site job training, evaluates performance of job assignments, assists with resume preparation, engages residents in mock job interviews, provides instruction in the use of basic office equipment and development of basic computer skills, facilitates linkages to other community resources and offers guidance to jobs appropriate to ability. Transportation necessary to obtain job applications, attend interviews and arrive at their work site is provided, as well. A. ToW Budget Z Pbaftlee Counts Total Program Budget: $W.350.00 Total Program Position Count: 1.25 Total Agency Budget I M.6916.041 Total Agency position County 4 EXHIBIT A �,nubi�nPm FBum •Sri, ,I�TnM rv1MF 4m,f n " p County of Hawaii Nonprofit Grant Application FY2015-16 Agenfy Name: Bridge House, Inc. Program Name:yocationat skills Building Program - 5 sew M cunkans s uurrea fidentity all sources of funding applied to this programs: Revenue Source FY1546 Estimate -- mawas 535.000.(14 NewelI•iaM United W 436.000.00 -Fee $6.40(1.00 CaAwbuv&d 4x50.00 Slab AWMADyg Abuse OMMM 54,600.44 TOTAL_ 580,360A0 AtxMb wWfrW0a1 paD", if needed. 6. Explain what prate Your agency or program has to Increase revenues to support this program: As a result of our on-site agricultural development (organically grown vegatablesRlerbs), are have increased our sales to a heat, established distributor. We are continuing expansion of our growing grounds as a way to increase further sales/revenue. Additionatly, our approximately 2 acres of lychee production remains in great demand and is sold locally during the season. Although those agricultural pursuits yield some income, they remain significantly insufficient to support the program, thus we also continue to apply for grants through other foundations as they become available. 7. Program objectives Using County Nonprofit Grant Program Fundii The VSB program's primary objective Is to prepare our residents to enter/retum to the workforce. As a result of their addiction, most individuals have disengaged from mainstream society (e.g. abandoning family, losing employment, turning to criminal activity). The addict often no longer shares many of the healthy bellefsixieals that are found within our community. Employment has clearly been identified as are of the primary, components that facilitates successful recovery, as a result of contributing to one's self-esteem, enhancement of responsible behaviors and the ability and willingness to'give back' to the community. EXHIBIT A County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Bridge House, Inc. Program Name: "Vocational Skits Building Program" B. TABLE is �...-.,C!eti mee!....I, o —Irma% er outromes that would he achieved with this funding? Attach addWonot pages os necessary. 1. TABLE R: PROGRAM EXPENDITURES FY 14-15 FY 15-16 Alt"' Total Budget PROGRAM PERFORMANCE MEASURES Appiicant Projected Results ryr::bmoere)cAmrarmcA waRshoys arererm ANA wRmkerArmb es. prfce£84 Dr raw7#J 17,660.00 ApproArnowly 45 adLft mebliemeb wig 6616 of raduates va pwadpete in hie Program. be ornoloved or LmOm 1,400M saffixIng a trairift supplies brobrarn A16 am of Wall MW M new aneem and be employed or eaab Mees banctiawk e hod w 7,615 7,400.00 Attach addWonot pages os necessary. 1. TABLE R: PROGRAM EXPENDITURES FY 14-15 FY 15-16 Alt"' Total Budget FY 15-16 Grant Rap Salary and Wages _ 52.960.60 40.060.60 17,660.00 Professional Fees 5.500.00 6.400.00 2,500.00 Operations LmOm 1,400M B00m supplies 2,400.00 3.000-0 1.300.00 Equipment 2,000.00 200.00 1,450.60 Other: Payroll Ta>me6Fmge Benefit 7,615 7,400.00 3,200.00 Other: Omgnrwr 16,500.00 16,950.00 7,400.00 Other: MSAmce 1A00.00 2,400.OD 1.050.06 Other. Other: TOTAL 69.516,60 80,360.00 35.o0R00 •aepptkebk EXHIBIT A unt,M1nn�n �nu{T .nn{.A�Aa, �i'\nwP Snit n •_fn County of Hawaii Nonprofit Grant Application FY204 5-16 Agency Name: Bridge House, Inc. PCoE2m Name: "Vocational Skills Building Program- ar to. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose my conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of HawaM. Only those listed below need to be disclosed. One form per person with a conflict is needed. if no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. AN disclosure farms must be sioned reaartfkm of whether a conflict exists. NAME: POSITION: May have a Conflict Or potential conflict Of interest, Including any familial relatl6nship, 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 tgttllEt of keeis defined as: a substantial prababi t Hurt action taken by an individual will result In measurable direct benelks accruing to the individualm opposed to beneRts accruimg in general to on industry. Please specify any and all mRigation measures to avold, In fact or appearance, any conflicts or potential conflicts of interest: ❑✓ if no conflicts exist check here. Signature of AuthttNted Parson (specify title) EXHIBIT A IMM15 Date County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Bridge Hasse, Inc. Program Name: "Vocational Sldlis Building Program" 11. Certification of understanding (page 1 of z) 1(we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated In Article 2S, Sections 2- 135 — 2-142.1, Hawal'1 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 expend ngloversight agency) full, free, and unrestricted access and authority to examine and 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. 1 (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawal'1 Revised Statutes. I (we) understand that applications will not be reviewed by County 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 Hawalh, I (we) understand and will comply with the requirement to enroll with Haw^i'i Qmni ante ExoM j and be compliant prior to final payment. To register, go to h tto //vers Inrc ehawail, ktjv, cmplete the easy step-by-step process, and pay the annual registration fee online using a credit card. if awarded a grant from the County of HawaiviI (we) understand and will comoly with the requirement to submit a year-end report to the County Council within 60 days after lune 30 of the contractual year for whkh the grant was awarded. The report, using the template provided, she# tndUde an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hewell grant funds, and a listing of other funding sources and amounts obtained dud" the award period. Failure to submit a timely. complete. and accurate year-end report, using the template providedwin impact the evatugSon of your program's or agency's future funding requests. EXHIBIT A u/{uA�[r\f1T /`n{l,T l6TS V11TIM1v N4R{f'iRV 0...-I �iq County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Bridge House, Inc. ProPram Name: "Vocational skills Building Program" 11. Certification of understanding basezofz) 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 specifitaly 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 lune 300 shall restdt Inpf baa r grant funds reeeh d &oft the tram aetort from be refunded to C&Aity) and Owhisleii from future usnt oaruGtaati:tt for a rnlr'.mein of ane year or until a written report Is submitted to,and accented by, the council. f (wel understand there 13 do provfsfon forftnther ooHHtaHon to attbitlH Hie fhtat report, InfcrnMien and Instructions are available at on or about May 30 of the year the final report Is due: As part of this application, you atknowledge that any funds awarded will be testritted for the purootet stated In the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30; I015 must be returned to the County of Hawaii with the final report: Folium to return these funds in a timely manner M11 Impact the evaluation of Your aoency's future fulino reac st and may mutt in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. signature of Authorized Person (specify title) 1126/2015 Date EXH(B(T A 11,i�iRXRtrt I'RIiM ,. ReillftiiflGli ry Sn�r SF�f �+ -i _tn County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Bridge House, Inc. Program Name: "vocational skills Building Program" _ u. COUNCIL AWARD WORKSHEET 1 AYLC 1. PROGRAM PERFORMANCE MEASURES A Projmw RewRs UcR t proladed RawR I AppmtMaatety 45 edeas VA penidpet0 in the BOYO mobyed p f d in actmd Operations 500.00 Ata—," poatdiedfettte,UreCutlle°eiBfepdi eD%b no nerd arrests, and be effWWed or in aamd or a attain v%ft job heroine popram. bwmhm ". othen oomwenoy 7AW 00 TAJ R: PROGRAM EXPENDITURES FV 15-16 Gram Request Council Award Salary and Wages tT.5m,00 Professional Fees 2.500.00 Operations 500.00 Supplies 1,300.00 Equipment 1,450.00 Other: Payroll taxewwkve banetas 3.206.00 othen oomwenoy 7AW 00 other: 1.050.00 Other. Other: TOTAL 35,0mm •'. 11 •l c. .t. 1' itlC. _ �.0 L' EXHIBIT B a�<:5�,r Child & Family Service Alternatives to Violence 23 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: Alternatives to Violence Agency Director: Howard Gznal Phone No.: ( 808) 681 — 3500 Contact Person: Karen Tan Phone No.: ( BOB 1681 — 3500 Mailing Address: Address: 91-1841 Fon Weavor Road Address'. City, ST, Zip Ewa Beach, H196813 Facility Address: Address: 1945AK11a1ca Ave. Address'. City, ST, Zlp Hilo, H196720 Email Address: kan&fis-hawallom Fax No.: ( 808) 681 — 5280 Accountant/CPA: H&K CPA c, Inc. Phone No.: 808 524 — 2255 Firm (if applicable): H & K CPAs, Inc. Mailing Address: Address: 1001 Blshopstrcct Address'. Sudap1709 City, 5T, Zip Honolulu, 11196813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: s 5o,0oo oo Geographical Areas To Be Served: (One or more can be checked) © Puna Q Hamakua Q North Kona Q South Hilo Q North Kohala Q South Kona Q North Hilo Q South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns Q youth Q Victims of Crimes ❑ Culture and the arts Q Aged Q Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page l of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: Alternatives to Violence 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY14-15 $22,500.00 $40,000.00.00 $4,613,004 2. Agency Mission Statement: "Strengthening families and fostering the healthy development of children". Continued on attachment. 3. Program Description: Funds are requested to support the operation of the Alternatives to Violence (ATV) Program in the County of Hawaii, more specifically the victim support component of our program. Continued on attachment. 4. Total Budget & Position Count: Total Program Budget: $694,877 Total Program Position Count: 1e.875 Total Agency Budget: $4,613,004 Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: Alternatives to Violence Funding Sources lidentif r all sources of funding applied to this program): Revenue Source Fy1S-16 Estimate Judiciary $535,499 County of Hawaii $60,000 HIUW $10,000 VOCA $15,000 Program Fees $35,500 TOTAL: $ssssss Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: CFS is always searching for possible funding sources. As the leader of Domestic Violence services, CFS was recently awarded the contract from the Department of Human Services to provide domestic violence services for families in the child welfare system impacted by domestic violence. These services are provided to victims, child witnesses and offenders. The contract runs from July 1, 2014 to June 30, 2015 and we will be pursuing a one year extension to this contract. Continued on attachment. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Hawaii Island Alternatives to Violence Program's objective is to reduce the impact that domestic violence has on families and the community to break the intergenerational cycle of violence. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: Alternatives to Violence 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES h e.: Number o)dients served, workshops or events held volunteer hours, etaae1110e, be speer)' Applicant Projected Results 'Unduplicated individuals served. 2.180 'Individuals sewed through TRO assistance. 1.285 'Family Court TRO hearings -Court Advocacy provided to petitioners. 1,800 -Group sessions held for victims of domestic violence. 175 'Individuals that completed Pattern Changing group. 50 'Number of men who completed the Domestic Violence Intervention Program. 110 'Number of women who completed the Domestic Violence Intervention Program. 30 Attach additional pages as necessary. 'Projected results are based on historical data. 9. TABLE It: PROGRAM EXPENDITURES For 14-15 Actual' FV 15-16 Total Budget FV 15-16 Grant Req Salary and Wages $466,029 $488,959 $44,170 Professional Fees $375 $400 Operations $195,018 $198,918 $15,610 Supplies $6,574 $6,600 $220 Equipment Other: Other Other Other. Other. TOTAL $667,996 $694,877 $60,000 applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: child & Family Service Program Name: Alternatives to Violence ro. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potentiaIcon flicts 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. q4 k� Executive VP & COO Signature of Authorized Person (specify title) EXHIBIT A NON PROFIT GRANT APPLICATION FY 2015-2016 1/30115 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: child & Family service Program Name: Alternatives to violence 11. Certification of Understanding (Paget of 21 I (we) have read and understood all of the 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 Ex2ress_and be compliant prior to final payment. 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 ¢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 o timely, complete and accurate year-end reportusing the template provided, will impact the evaluation of your program's or poency s future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FV 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: Alternatives to Violence 11. Certification of Understanding (Page 2of z) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of 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 301h shall result in loss of all grant funds received during 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 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Executive VP & COO Signature of Authorized Person (specify title) 1/30/15 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: Alternatives to Violence 12. COUNCIL AWARD WORKSHEET Teal P P PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result 'Unduplicated individuals served 2,180 'Individuals served through TRO assistance 1265 -Family Court TRO hearings -Court Advocacy provided to petitioners 1,800 'Group sessions held for victims of domestic violence 175 'Individuals that completed Pattern Changing group 50 'Number of men who completed the Domestic Violence Intervention Program 110 'Number of women who completed the Domestic Violence Intervention Program 30 TABLE II: PROGRAM EXPENDITURES FV 15-16 Grant Request Council Award Salary and Wages $44,170 Professional Fees Operations $15,610 Supplies $220 Equipment Other: Other Other. Other. Other. TOTAL 860.000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8 of Attachment Applicant: Child & Family Service Program: Hawaii Island Alternatives to Violence 2. Mission Statement: continued Since 1899, Child & Family Service (CFS) has dedicated its efforts to its mission of "Strengthening families and fostering the healthy development of children." CFS has 38 programs statewide that offer an array of effective and culturally relevant services to Hawaii's residents in need. The broad spectrum of services provided by CFS include: domestic violence intervention, case management, residential group homes, alternative education for alienated youth, prevention and treatment of child abuse, and family, school, and community-based counseling services for children and their families. Infants, children, adolescents, young adults, older adults, individuals, and families in need benefit from these services. In Fiscal Year 2014, CFS directly served 9,509 individuals ranging from infants to elder adults. In addition the organization has "touched" the lives of over 40,000 individuals through hot-line calls, educational presentations, and providing food and clothing to those in need. CFS's programs are responsive, flexible, and focused on positive outcomes. Services are provided in homes, schools and in the community as well as in CFS's offices throughout the State. CFS provides services at 36 sites throughout the State, on the islands of Oahu, Hawaii, Kauai, Maui, Molokai, and Lanai. CFS's strengths lie not only in its size and ability to share expertise and resources statewide, but also in its ability to adapt services so that they are unique and appropriate to the island and communities it serves. CFS has years of experience working with a wide range of target populations and partnering with funding sources to implement new models of service delivery. In recent years, social policy change has presented challenges to human service providers, requiring the development of new skill sets and service delivery models with little time for preparation. CFS has the skills, knowledge and abilities to meet these challenges and remains strong, flexible and prepared to meet future challenges. CFS demonstrates its commitment to service excellence and quality care through the provision of services that are responsive, effective and efficient. CFS establishes goals to achieve service excellence through its strategic planning process. This process involves all levels of the organization, including clients, community stakeholders, direct service staff, management and the Board of Directors. CFS's strategic vision is to become a family -centered, full-service organization. The organization has established four focus areas to reach this vision. They include: Welcome Families (Develop Family - friendly Points of Entry); Walk With Families (Develop Integrated Family and Community Partnerships); Meet Families Where They Are (Provide Adaptive and Culturally Appropriate Practices); and Prove Effectiveness (Demonstrate Impact and Sustain Gains). The administrative management and service delivery systems of CFS emphasize service excellence. 3. Program Description: continued Domestic Violence is traumatic!! It impacts every family member. Victims have a diluted sense of worth and their confidence is sapped. Children are left confused and traumatized. Offenders have often grown up in a family where domestic violence was present and are mimicking the behaviors they observed. CFS offers services to victims, children and adolescents, and offenders. We provide services to all affected by domestic violence. The Alternatives to Violence (ATV) program provides the following services: Page 1 of 3 Attachment Applicant: Child & Family Service Program: Hawaii Island Alternatives to Violence The victim support component of the ATV program consists of assisting clients seeking assistance with an application to the Family Court for a Temporary Restraining Order (TRO), providing court advocacy for the client during TRO hearings in the Family Court, and providing case management and facilitation for the survivors of domestic abuse through the Support and Pattern Changing groups. The Domestic Violence Specialist (DVS) works with the survivors of domestic violence with the goal of ensuring future safety for every member of the family. A Safety Plan is developed with each survivor at intake that is tailored to his/her unique situation. The ATV program provides an array of Domestic Violence Intervention (DVI) services to men, women and youth. All sites use the Stop Abuse for Everyone (SAFE) curriculum for the men's DVI program. This is a curriculum that incorporates evidence -based components including motivational interviewing, cognitive behavior therapy and change theory into our work with offenders. The services to male and female batterers include psycho -educational groups and case management. This proposal seeks funding to support services for all family members by funding two part-time DVS positions, one part-time for East Hawaii and one part-time for West Hawaii. Our approach to our work has four key components. We refer to the acronym R.I.C.H.. "R," is for respect. Meeting clients where they are without judgment. T' is for information, which may include individual or group services as well as community resources. "C", is for connection. By assisting clients, they are able to access services and resources that can help to build a more secure foundation. Finally, "H" is for hope. By walking with clients through the process of learning to manage the trauma they have experienced, sharing skills and tools, and working with resources to live a life of self-sustainment. The goal for our clients is to recognize that domestic violence in intimate relationships generates disrespect and harm that is inconsistent with the values, beliefs and conduct of every culture. Our goal is to end domestic violence through providing services, partnering with community resources, and participating in community education about domestic violence, thereby creating a tipping point in our community awareness that we must not tolerate domestic violence. 6. Explain what plans your agency or program has to increase revenues to support this program: continued Since 2009, CFS has continued to seek funding opportunities to cover the cost of services in the ATV program since the Judiciary decreased the funding by 40%. CFS has received funding from the Hawaii Island United Way for over 19 years for our Youth Services program. We are in the process of re -applying for this grant for the next 2 fiscal years. For over 5 years we have received funding and actively participated in the yearly Visitor Industry Charity Walk and will be doing the same and applying for additional funding for this year. CFS is always engaged in seeking national funding sources, especially those from the federal Victims of Crime Act, where we have received funding over the last 5 years. CFS does collect a group fee for our Domestic Violence Intervention program for men and women of $18 per group session. (This fee can be waived and replaced with work exchange for indigent clients or unemployed clients). In fiscal year 14 we advocated for additional funding from the Third Circuit Court and did receive additional funding in the amount of $65,000 to support victim services. Despite the financial challenges, CFS has continued our commitment to quality services. All staff are trained in Trauma -Informed Care through our 24hr/3-day Risking Connection® Training. We are Page 2 of 3 Attachment Applicant: Child & Family Service Program: Hawaii Island Alternatives to Violence implementing Results Based Accountability (RBA) across all of the programs in the organization. RBA will provide grantors and State and Federal agencies a clearer picture of how our programs and services have positively impacted the individuals we serve. CFS is committed to remaining a leader in the domestic violence field by staying focused on implementing evidence -based programs and outcomes that will attract additional funding resources. Page 3 of 3 Child & Family Service Child and Family Center Program 24 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: Child and Family Center Program Agency Director: Howard Garval Phone No.: ( 808) 681 — 3500 Contact Person: Karen Tan Phone No.: ( 808) 681 — 3500 Mailing Address: Address: 91-1641 Fort Weaver Road Address: City, ST, Zip Ewa Beach, H196706 Facility Address: Address: 1045A Kilauea Ave. Address- City, ST, Zip Hilo, HI 96720 Email Address: etan5_cls-hawali.ar9 Fax No.: ( 908) 681 — 5280 Accountant/CPA: N & K CPA's, Inc. Phone No.: ( 908 ) 524 — 2255 Firm (if applicable): N & K CPA's, Inc. Mailing Address: Address: 1001 Blshap Sheet Address: Suitep900 r City, ST, Zip Honolulu. HI96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL MANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua ❑ North Kona © South Hilo ❑ North Kohala ❑ South Kona © North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth © Victims of Crimes Culture and the arts © Aged © Victims of Health or Social Crises ❑� Needs of the poor✓❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page Iof8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: Child and Family Center Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FV 12-13 FY 13-14 FV 14-15 $30,000 2. Agency Mission Statement: Since 1899, Child & Family Service (CFS) has dedicated its efforts to its mission of "Strengthening families and fostering the healthy development of children" CFS has 38 programs statewide that offer an array of effective and culturally relevant services to Hawaii's residents in need. The broad spectrum of services provided by CFS include: domestic violence intervention, case management, residential group homes, alternative education for alienated youth, prevention and treatment of child abuse, and family, school, and community-based counseling services for children and their families. Infants, children, adolescents, young adults, older adults, individuals, and families in need benefit from these services. Continued on attachment 3. Program Description: To enhance and expand community outreach provided by the CFS Child and Family Center. Continued on attachment. 4. Total Budget & Position Count: Total Program Budget: $60,OD0 Total Program Position Count: i Total Agency Budget: ga,6l a,00a Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: Child and Family Center Program S. Program Funding Sources (identify all sources of funding applied to this program): FY15-16 Revenue source Estimate TOTAL: Attach additional pages, 6. Explain what plans your agency or program has to increase revenues to support this program: Future and additional funding is being pursed through private and public donations and grants. The Child and Family Center has enabled CFS to enhance community collaborations and partnerships, building potential for future funding opportunities. 7. Program Objectives Using County Nonprofit Grant Program Funds: - Increase awareness and knowledge of community resources that promote health, safety, well-being, self-sufficiency and individual /family potential. - Expand and enhance education and outreach programs to the community -at -large. - Increase knowledge of nurturing parenting approaches. - Increase knowledge of positive coping and problem solving skills for children and adolescents. - Increase awareness and knowledge about self-care for individuals of all ages. - Foster collaborations and partnerships with other community organizations to expand East Hawaii's capacity to promote healthy individuals and families. Continued on attachment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: Child and Family Center Program B. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i. e.' Number of chenh served, workshops or events held, volunleer hours, eta Describe, be specific) Applicant Projected Results Total Contacts 30,000 Adult Groups 8 Etlucation Sessions 72 per year, 500 unduplicated individuals Child/Adolescent Groups & Education Sessions 72 per year, 500 unduplicated individuals Community Outreach Events (Booths, Meetings) 3 per month = 36 per year WHYTRY Education Sessions 30 per year, 30 unduplicated individuals Nurturing Father Parenting Sessions 26 per year, 24 unduplicated individuals Continued on Attachment $1,787 Attoch odditional orioles as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $15,013 $42,071 $42,071 Professional Fees $4,800 $4,800 $4,800 Operations $2,895 $1,787 $1,787 Supplies $1,327 $1,200 $1,200 Equipment $265 $120 $120 Other Client Assistance $1200 $1,022 $1,022 Other Administrative Support $4,500 $9,000 $9,000 Other. Other Other TOTAL $30,000 $60,000 $60,000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: child & Family Service Program Name: Child and Family Center Program 1o. 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: 1291111[111PP 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: o 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. !f'i1'fd/ x Executive VP 8 COO Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 1/30/15 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family service Program Name: Child and Family Center Program ii. Certification of Understanding (Paget 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 final payment. 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 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 reportusing the template provided, will impact the evaluation of your programs or agency s future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: Child and Family Center Program 11. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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 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. 1 (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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements Executive VP & COO 1/30/15 Signature of Authorized Person (specify title) Date EXHIBIT A NON PROFIT GRANT APPLICATION FV 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: Child and Family Center Program 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Projected Resant PrpjeRed Results Council Proposed Projected Result Total Contacts 30,000 Adult Groups & Education Sessions 72 per year, 500 Indio. Child/Adolescent Groups & Education Sessions 12 per year, 500 null Community Outreach Events (Booths, Meetings) ! 3 per manlh, 36 per yr. WHYTRY Education Sessions 30 per year, 30 lndiv. Nurturing Father Parenting Sessions _ 26 per year, 24 Ire iv. Continued on Attachment $9,000 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $42,071 Professional Fees $4,800 Operations $1 797 Supplies $1,200 Equipment $120 Other: Client Assistance $1,022 Other: Administrative Support $9,000 Other: Other: Other: TOTAL $60,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Attachment Applicant: Child & Family Service Program: Child and Family Center Program 2. Agency Mission Statement Since 1899, Child & Family Service (CFS) has dedicated its efforts to its mission of "Strengthening families and fostering the healthy development of children." CFS has 38 programs statewide that offer an array of effective and culturally relevant services to Hawaii's residents in need. The broad spectrum of services provided by CFS include: domestic violence intervention, case management, residential group homes, alternative education for alienated youth, prevention and treatment of child abuse, and family, school, and community-based counseling services for children and their families. Infants, children, adolescents, young adults, older adults, individuals, and families in need benefit from these services. In Fiscal Year 2014, CFS directly served 9,509 individuals ranging from infants to elder adults. In addition the organization has "touched" the lives of over 40,000 individuals through hot-line calls, educational presentations, and providing food and clothing to those in need. CFS's programs are responsive, flexible, and focused on positive outcomes. Services are provided in homes, schools and in the community as well as in CFS's offices throughout the State. CFS provides services at 36 sites throughout the State, on the islands of Oahu, Hawaii, Kauai, Maui, Molokai, and Lanai. CFS's strengths lie not only in its size and ability to share expertise and resources statewide, but also in its ability to adapt services so that they are unique and appropriate to the island and communities it serves. CFS has years of experience working with a wide range of target populations and partnering with funding sources to implement new models of service delivery. In recent years, social policy change has presented challenges to human service providers, requiring the development of new skill sets and service delivery models with little time for preparation. CFS has the skills, knowledge and abilities to meet these challenges and remains strong, flexible and prepared to meet future challenges. CFS demonstrates its commitment to service excellence and quality care through the provision of services that are responsive, effective and efficient. CFS establishes goals to achieve service excellence through its strategic planning process. This process involves all levels of the organization, including clients, community stakeholders, direct service staff, management and the Board of Directors. CFS's strategic vision is to become a family -centered, full-service organization. The organization has established four focus areas to reach this vision. They include: Welcome Families (Develop Family - friendly Points of Entry); Walk With Families (Develop Integrated Family and Community Partnerships); Meet Families Where They Are (Provide Adaptive and Culturally Appropriate Practices); and Prove Effectiveness (Demonstrate Impact and Sustain Gains). The administrative management and service delivery systems of CFS emphasize service excellence. CFS has experience with Family Centers on Kauai (now called Neighborhood Places), The Neighborhood Place of Wailuku on Maui and most recently on Hawaii Island. At the time of the writing of this proposal, the Child and Family Center, located at the Hilo CFS office, has been in operation for six months. The concept of combining service offices with the Family Center framework derives from the CFS Strategic Planning process and supports CFS's strategic goal to develop "welcoming, informative, and supportive environments' at all CFS sites. Despite decreases in funding for some critical programs, CFS has successfully continued to provide high quality services on the island of Hawaii by consolidating operations and optimizing resources. The implementation of the Child and Family Center, at the CFS Hilo office, Page 1 of 6 Attachment Applicant: Child & Family Service Program: Child and Family Center Program has been essential to these efforts by bringing together critical information and resources under one roof and facilitating vital connections to other community resources, with the aim of minimizing the burden on families who must navigate a complex social service system. 3. Program Description: In 2014, with funding and support from the County of Hawaii Nonprofit Grant, CFS was able to launch the Child and Family Center in Hilo. The center is based on a Family Resource Center model as a prevention strategy to address the many challenges that individuals and families face in Hilo and East Hawaii. To improve outcomes for both families and communities, the Child and Family Center brings together services and activities that educate, develop skills and promote healthy families and healthy communities. The Child and Family Center promotes the health and well-being of CFS program participants and the community at -large. One of the primary goals is to build strong relationships with other community resources and services to strengthen capacity and sustainability. The Child and Family Center relies on the key principles of: • Family support, • East Hawaii resident involvement, • Public/private partnership within the County of Hawaii and State, and • Community building and shared accountability for the health of the community. Since its inception, the Child and Family Center has provided the following services and resources to the community: 1. Parent Education and support 2. Child and Teen Education (classes, support groups, peer-to-peer) 3. Child Development Activities (play time) 4. Resource and Referral (links to community resources and services) 5. Drop-in Availability (a comfortable place for confidential conversations, neighbor -to -neighbor meetings, Coffee Hour) 6. Peer -to -Peer Supports (such as support groups, mentoring) * Life Skills Advocacy (such as Pattern Changing, Domestic Violence Intervention, Anger Management classes, self-care and assistance with applying for college) * Community Outreach and Information booths 9. Health Screening through a collaboration with Project Vision 10. Meeting space for community partners The Child and Family Center has been instrumental in linking individuals and families to other community resources. A rolling resource library was developed for use by other program staff and the community -at - large. Essential resource information is provided such as housing information, food assistance and educational opportunities. CFS program staff utilize the Child and Family Center as a resource for their clients and report the following client outcomes due to participation in center activities: improved self- esteem and confidence, positive interactions among family members and peers, family bonding, and increased verbal expression. The environment of the Child and Family Center was designed with the vision of to E Komo mai, Nou Ka Hale - "Come Inside, the House is Yours". An emphasis was placed on creating a welcoming family - Page 2 of 6 Attachment Applicant: Child & Family Service Program: Child and Family Center Program centered, trauma -informed atmosphere that is community- based. With Support from the County of Hawaii, CFS has been able to obtain furnishings, decor, and activity supplies to provide a safe place for play, confidential conversations, learning and connecting. The location is close to State and County agencies, the schools and other partners in the community, and is ideal for accessibility and collaboration. The Child and Family Center is open Monday thru Friday, from 8:OOam to 4:30pm except for state holidays. In addition, activities and educational groups are scheduled during evening and Saturday hours. A variety of classes, groups and activities are provided to individuals of all ages. Activities are not referral based and are open to the community -at -large. The hope is that individuals and families in the East Hawaii community will see the Child and Family Center as a gathering place or one-stop shop for information, meaningful activities and social support. Goals for FY 2015-2016 Building upon last year's accomplishments, CFS would like to enhance and expand the Child and Family Center's services and reach. Outreach to the community -at -large is a top priority for the Child and Family Center. The goal of outreach efforts is to alleviate and/or prevent family strain and breakdown, with the aim of mitigating and preventing family violence. Specifically, this entails increasing education and activities for children and adults; incorporating culturally tailored, values and strengths -based education curriculums. Some of the curriculums to be utilized are as follows: • Kamalama Parenting Education Program: This program was created through a partnership with Venus Rosete-Hill and the staff of the Neighborhood Place of Wailuku on Maui with the support of the Consuelo Foundation. The curriculum presented in a Metaphoric -Values based model, which utilizes Hawaiian language and metaphors to present universal parenting values. The Kamalama Parenting Education program is comprised of 13 2 -hour sessions, with one session being held per week. • Nurturing Fathers Program: The Nurturing Fathers Program (NFP) is an evidence -based, 13 - week training course designed to teach parenting and nurturing skills to men. Each 2 12 hour class provides proven, effective skills for healthy family relationships and child development. NFP has been successfully implemented by Schools, Head Start, Churches, State Department of Human Services, Prisons, Halfway Houses, Prevent Child Abuse, Parenting and Counseling Centers, Military, Community Action Agencies and many others. • WHYTRY: The W HYTRY program is a strengths -based approach to helping children and adolescents overcome their challenges and improve outcomes. It is evidence -based and is used for Bullying Prevention, Drop -Out Prevention, Changing Behavior, Improving Academics, Drug and Alcohol Prevention, Improving Decision -Making, and Truancy Reduction. The program leaches ten visual analogies to help children and adolescents deal with life's daily pressures and challenges, and expanding community outreach and education to foster collaboration and partnerships, with the aim of building capacity to promote healthy families and healthy communities in East Hawaii. The education programs and activities will be provided at the Child and Family Center and at various locations throughout the community. Page 3 of 6 Attachment Applicant: Child & Family Service Program: Child and Family Center Program To support this plan, the county funds will be used to invest in community education and training; outreach materials: presentation board and display materials; developing a volunteer program to expand activities and outreach; professional fees to bring in speakers and instructors to enhance activity programming; activity supplies to host open houses for welcoming community members; tablets that provide educational and informational software products; printing supplies for brochures and fliers; education and training opportunities for professionals and other community service providers; and activities and community events to promote healthy families, arts, culture and history of Hawaii. To support the activities, facilitators and supplies will be secured through contracting with a culturally diverse faculty that represents the community and the clients CFS serves in East Hawaii. The Director of Hawaii Island Programs oversees the coordination of this project with the assistance of the Child and Family Center Coordinator. The Child and Family Center Coordinator will schedule the activities, organize support groups, oversee the resource center, coordinate with the community and handle other logistics of the project. The Child and Family Center Coordinator will also be responsible for organizing community outreach events and with representing the Child and Family Center during community events and fairs. Additionally, CFS will utilize a Life Skills Specialist to provide the W HYTRY program at various schools on Hawaii Island. Project coordination, communication and knowledge of the community are vital to the success of the program. Although the Director of Hawaii Island Programs will oversee the Child and Family Center Program, a CFS Big Island Leadership Team will monitor the progress as a Guiding Coalition. The members of the Guiding Coalition represent all Hilo CFS programs, professional and cultural backgrounds. 5. Program Funding Sources (identsi sources of funding applied to this ptggLdi Continued Although there are not currently any additional funding sources, the Child and Family Center is now embedded in all CFS programs and is supported by all program staff across the continuum. CFS is capitalizing on all resources to maximize the reach of the Child and Family Center. 7. Program Objectives Using County Nonprofit Grant Funds: Continued - Provide a drop-in center that is accessible to the community -al -large and is a one-stop shop for information regarding community resources, meaningful activities and social support. - Provide a welcoming atmosphere at the CFS office in Hilo that emphasizes meeting the needs of individuals, of all ages, that have experienced trauma and are in need of a supportive and trauma -informed environment. - Develop a volunteer program to expand the number of activities and programs provided as well as the reach of the Child and Family Center. Page 4 of 6 Attachment Applicant: Child & Family Service Program: Child and Family Center Program 8. Table 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? Program Performance Measures (i.e. Number of clients served workshops or events Applicant Projected Results held, volunteer hours, etc. Describe, be speck.) Result Total # of Kamalama Parenting Sessions; # of 26 sessions - 52 hours; undu licated artici ants 24 unduplicated participants Total # of Volunteers Recruited 5 Increased Knowledge of Community Resources. 90% of individuals who access the Child and individuals who access the Child and Family Center for Family Center for Community Resource Community Resource Information will report that their Information will report that their knowledge knowledge was increased was increased _80% of individuals who participate m Learned Something New adulUchild/teen classes and groups will report Increased Knowledge of Community Resources: that they learned something new Increased Knowledge of Self -Care: Self -Care= personal 80% of individuals (Adults or Teens) who hygiene, skin care, make-up application, grooming participate in Self -Care classes will report that for Community Resource Information will report that their knowledge of self-care was increased Increased Knowledge of Parenting Skills / Techniques 80% of individuals who participate in Resource Information will Parenting classes will report that their knowledge of Parenting Skills/Techniques was increased ,-Increased Knowledge of Positive Coping Skills 80% of individuals (Adults or Teens) who Learned Something New participate in Adult/ Teen groups or classes will report that their knowledge of positive participate in adult/child/teen coping skills was increased 12 r...,ncii Award Worksheet Tahle I Continued Program Performance Measures Council Proposed (i.e. Number of clients served workshops orProjected Applicant Projected Results Result events held, volunteer hours, etc. Describe, be specific. Total # of Kamalama Parenting Sessions; # of 26 sessions; unduplicated participants 52 hours; 24 unduplicated articipants Total # of Volunteers Recruited 5 Increased Knowledge of Community Resources: 90% of individuals who individuals who access the Child and Family Center access the Child and Family for Community Resource Information will report that Center for Community their knowledge was increased Resource Information will report that their knowledge was increased Learned Something New 80% of individuals who participate in adult/child/teen classes and groups will report that they learned something new Page 5 of 6 Attachment Applicant: Child & Family Service Program: Child and Family Center Program Program Performance Measures council Proposed (i.e. Number of clients served workshops or Applicant Projected Results Projected Result events held, volunteer hours, etc. Describe, be specific.) Increased Knowledge of Self -Care: Self -Care= 80% of individuals (Adults or personal hygiene, skin care, make-up application, Teens) who participate in grooming Self -Care classes will report that their knowledge of self- care was increased Increased Knowledge of Parenting Skills / 80% of individuals who Techniques participate in Parenting classes will report that their knowledge of Parenting Skills/Techniques was increased _ Increased Knowledge of Positive Coping Skills 80% of individuals (Adults or Teens) who participate in Adult/ Teen groups or classes will report that their knowledge of positive coping skills was increased Page 6 of 6 Child & Family Service East Hawai'i Domestic Abuse Shelter 25 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: child & Family Service (One or more can be checked) © Puna © Hamakua ❑ North Kona Program Name: East Hawaii Domestic Abuse Shelter ❑ South Kona © North Hilo ❑ South Kohala ❑ Ka'u Agency Director: Rootlet Garval Phone No.: ( 808) 681 — 3500 Contact Person: Karen Tao Phone No.: ( 808 ) 681 — 3500 Mailing Address: Address: 91.1841 Fort Weaver Road Address: City, ST, Zip Ewa Beach, H 19670 Facility Address: Address: 1045A Kilauea Ave. Address: City, ST, Zip Hilo, HI96720 Email Address: ktao@.1a-hawaii dig Fax No.: (808)681 — 5280 Accountant/CPA: N R K CPA's, Inc Phone No.: ( 806 ) 524 — 2255 Firm (if applicable): N a K CPAa, Ino. Ma ilung Address: Address: 1001 Bishop Street Address: Suite 41900 City, ST, Zip Honolulu, HI96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua ❑ North Kona © South Hilo ❑ North Kohala ❑ South Kona © North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth © Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $8,750 $40,000.00 $40,000 2. Agency Mission Statement: "Strengthening families and fostering the healthy development of children." To be continued in attachment. 3. Program Description: Child & Family Service has been providing emergency shelter for domestic violence victims on the Big Island community for 26 years. The West Hawaii Domestic Abuse Sheller opened in 1988 followed by the East Hawaii Domestic Abuse Shelter in 1995. To be continued in attachment. 4. Total Budget & Position Count: Total Program Budget: $491,535 Total Program Position Count: a.50 Total Agency Budget: $4 613,004 Total Agency Position Caunt: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter Funding Sources lidentif t all sources of funding applied to this program): Revenue Source FY15-16 Estimate Department of Human Services $340,000 County of Hawaii $80,000 DHS - BESSD - HPO Emergency Shelter Grant S14,000 Private Foundation $2,000 TOTAL: $436000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program We continue to apply for alternative funding sources for our programs. The Domestic Abuse Shelters are primarily funded by the Department of Human Services in the Slate of Hawaii. Since fiscal year 2009, the DHS has funding decreased from $393,936 to $340,000. Traditionally, the County of Hawaii, HIUW and Emergency Shelter Grants have supported the Domestic Abuse Shelters in the County of Hawaii. For FY 2013 and 2014, CFS secured private funding from the Mclnerny Foundation and the Mary Kay Foundation to fill gaps in funding. We received VAWA funding for an innovative project that addressed the needs of the population served. These funds were time-limited and helped to support staffing needs as well as a pilot project to better serve high-risk clients. Continued on attachment. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. 70°% of survivors with no incidents of violence. Violence = physical, emotional, psychological, financial, verbal, sexual, stalking, threats a. Measurements occur weekly with DAS Safety Questionnaire. 2. 70% of survivors who left the shelter for a secure and safe place. a. Measurement occurs during anticipated discharge with DAS Safety Questionnaire. 3. 70% of survivors will enhance their resiliency. a. Measurement: resiliency pre- and post- test. 4. 80% of children/youth (older than 2 years old) who leave the program know their safety plan. a. Measurement: Child's/youth's narrative as documented in progress notes. 5. 70% of children/youth will not witness further family violence in the next quarter after they leave the program. a. Measurement: Follow-up documentation. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES b e.' Number of ample served, workshops or events held, ✓munreer hours, etc Descibe be spec/(c) Applicant Projected Results Number of hotline calls. 550 Number of single women/men served. 120 Number of women/men w/chiltlren served. 80 Number of chiltlren served. 150 Number of meals served. 18,000 Number of bed days provided, 6,000 " Estimates are based on historical data. "'Continue to attachement. $17,358 Attach additional pages as necessary. Q . TABLE It - PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $301,107 $327,615 $62,492 Professional Fees $150 $160 Operations $158487 $161,620 $17,358 Supplies $2,250 $2,500 $150 Equipment Other. Other. Other: Other: Other TOTAL $461,994 $491,535 $80,000 appncame EXHIBIT A NON PROFIT G RANT APPLICATION FV 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 o 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. V//pttG" Executive VP & COO Signature of Authorized Person (specify title) Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 1/30115 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: child & Family Service Program Name: East Hawaii Domestic Abuse Shelter it. Certification of Understanding (Paget of z) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 2S, 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 final payment. To register, go to http,//vendors ehawai" 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 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 reportusing the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 11. Certification of Understanding (Page 2of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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 3011 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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Pak Executive VP & COO Signature of Authorized Person (specify title) 1/30/15 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: child & Family Service Program Name: East Hawaii Domestic Abuse Shelter 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of hotline calls 550 Number of single women/men served 120 Number of women/men w/children served 80 Number of children served 150 Number of meals served 18,000 Number of bed days provided 6,000 'Continue to attachment TABLE II: PROGRAM EXPENDITURES FV 15-16 Grant Request Council Award Salary and Wages S62,492 Professional Fees Operations $17,358 Supplies $150 Equipment Other Other Other: Other: Other TOTAL $80,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8 of Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter 2. Agency Mission Statement Since 1899, Child 8 Family Service (CFS) has dedicated its efforts to its mission of "Strengthening families and fostering the healthy development of children." CFS has 38 programs statewide that offer an array of effective and culturally relevant services to Hawaii's residents in need. The broad spectrum of services provided by CFS include: domestic violence intervention, case management, residential group homes, alternative education for alienated youth, prevention and treatment of child abuse, and family, school, and community-based counseling services for children and their families. Infants, children, adolescents, young adults, older adults, individuals, and families in need benefit from these services. In Fiscal Year 2014, CFS directly served 9,509 individuals ranging from infants to elder adults. In addition the organization has "touched" the lives of over 40,000 individuals through hot-line calls, educational presentations, and providing food and clothing to those in need. CFS's programs are responsive, flexible, and focused on positive outcomes. Services are provided in homes, schools and in the community as well as in CFS's offices throughout the State. CFS provides services at 36 sites throughout the State, on the islands of Oahu, Hawaii, Kauai, Maui, Molokai, and Lanai. CFS's strengths lie not only in its size and ability to share expertise and resources statewide, but also in its ability to adapt services so that they are unique and appropriate to the island and communities it serves. CFS has years of experience working with a wide range of target populations and partnering with funding sources to implement new models of service delivery. In recent years, social policy change has presented challenges to human service providers, requiring the development of new skill sets and service delivery models with little time for preparation. CFS has the skills, knowledge and abilities to meet these challenges and remains strong, flexible and prepared to meet future challenges. CFS demonstrates its commitment to service excellence and quality care through the provision of services that are responsive, effective and efficient. CFS establishes goals to achieve service excellence through its strategic planning process. This process involves all levels of the organization, including clients, community stakeholders, direct service staff, management and the Board of Directors. CFS's strategic vision is to become a family -centered, full-service organization. The organization has established four focus areas to reach this vision. They include. Welcome Families (Develop Family - friendly Points of Entry); Walk With Families (Develop Integrated Family and Community Partnerships); Meet Families Where They Are (Provide Adaptive and Culturally Appropriate Practices); and Prove Effectiveness (Demonstrate Impact and Sustain Gains). The administrative management and service delivery systems of CFS emphasize service excellence. 3. Program Description: CFS's East Hawaii Domestic Abuse Shelter (EHDASIHale'Ohana) and West Hawaii Domestic Abuse Shelter (W HDAS) are the only shelters on the Big Island to serve the immediate needs of residents. seeking safety due to domestic violence. Page 1 of 3 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter Funds are requested to provide partial funding for a Domestic Violence Specialist II (DVS II) and Client Advocate at the EHDAS that provides support, advocacy, counseling and referrals to residents. The Client Advocate provides case management, support groups and transportation for most clients, and the DVS II provides intensive case management for high-risk clients who present with mental health and substance abuse issues besides domestic violence. In addition, the DVS II and Client Advocate provide children and youth groups. As resources allow, the DVSII or Client Advocate transports and accompanies the residents to provide assistance in obtaining needed services and achieving their service plan goals. Within the first few days of entering the shelter, the domestic violence victim (resident) meets with the DVSII/Client Advocate who assesses the resident's needs and assists him/her in developing service plan goals. Safety issues are discussed further and a personalized safety plan is developed to address the resident's and, if applicable, his/her children's safety while at the Shelter as well as in the community. Weekly meetings are held to review the progress the resident is making in meeting his/her service plan, whether goals need to be adjusted and/or whether additional steps have to be taken to reach the identified goals. Throughout the resident's stay at the shelter, the DVSII/Client Advocate discusses how to transition the resident safely back into the community and in addition, develops an aftercare plan to ensure that needed services are in place. Hale'Ohana provides emergency shelter to single women/men and women/men with children who are victims of domestic violence (for a maximum of 120 days). The victims flee from the geographic areas from Volcano to Puna, from Puna to Hilo, and from Hilo to Hamakua. Victims from West Hawaii often access Hale'Ohana in East Hawaii for safety reasons. There are no restrictions to enter the shelter as long as the circumstances of need are identified within 48 hours as a domestic violence issue. Hale'Ohana operates 24 hours a day/365 days a year including holidays. Staff members monitor and oversee the safety and needs of the residents. The victims are from all walks of life and all socioeconomic backgrounds. The main goal of the program is to provide a safe environment. Experienced staff including the DVSII and Client Advocate help families identify their needs, their barriers and develop plans to overcome these barriers and meet these needs. The EHDAS program offers education on the dynamics of domestic violence, safe residence, emergencyfood, transportation, referrals as needed, case management, individual counseling, advocacy, outreach services, safety planning, Temporary Restraining Order assistance, support groups, and personal planning to all residents. The DVSII also works with the mothers/fathers and children to build healthy relationships and to strengthen their role as effective parents without using physical and/or verbal violence towards their children. We are committed to raising the consciousness of our society by: educating our families on a violence free lifestyle, promoting family coping and stability; and, providing a place of refuge. In addition, EHDAS operates a 24-hour domestic violence hotline which provides crisis intervention, information, and referral services. During the last 4 years, the hotline utilization by victims of domestic violence has increased due to the added economic stressors in the communities of the Big Island. The staff provides a safety assessment, makes recommendations and provides referral and resource information for the callers. It is expected that the hotline will continue to see a high volume of calls due to the violence resulting from increased poverty and homelessness. Page 2 of 3 Attachment Applicant: Child & Family Service Program: East Hawaii Domestic Abuse Shelter The EHDAS is located in a two-story home on approximately three acres in an agricultural/residential area of East Hawaii and is set off from the roadway. It has three full bathrooms, four bedrooms and has a 20 -person capacity. The downstairs of the Shelter facility has a laundry room that is accessed through the covered double car garage entrance. A comfortable -sized living room with an adjoining bathroom is accessible via the laundry room and a short walkway connects into the spacious kitchen area. There is an adjoining dining room and pantry which is also accessible via an entrance off the side of the kitchen that exits into the side yard of the property. The Shelter facility is ADA compliant: it has an ADA ramp which leads to the lower floor where an ADA bedroom is located. 6. Explain what plans your agency or program has to increase revenues to support this program: As of January 1, 2015, CFS received the new DHS contract with a gap in funding of $53,936 compared to fiscal year 2009. CFS will continue to advocate with the State for increased funding and continue to pursue alternative funding sources. 8. Table 1: Continued What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected (i.e. Number of clients served workshops or events held, volunteer Results hours, etc. Describe, be specific) Projected Result Number of additional hours of case management and advocacy hours 1,000 per week. and advocacy hours per week. Number of additional hours of parent/children activities per week. 1,000 Number of additional 10 hours of transportation/warm contacts with 500 partner agencies per week activities per week. " Estimates are based on historical data. 12. COUNCIL AWARD WORKSHEET: Continued Table I Continued PROGRAM PERFORMANCE MEASURES Applicant Projected GOuncil Proposed Results Projected Result Number of additional hours of case management 1,000 and advocacy hours per week. Number of additional hours of parent/children 1,000 activities per week. Number of additional 10 hours of transportation/warm contacts with partner agencies 500 per week Page 3 of 3 Child & Family Service Hale Kahua Pa'a Transitional Apartment 26 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child and Family Service Program Name: Hale Kahua Pa'a Transitional Apartment Agency Director: Howard Garval Phone No.: ( 808) 681 — 350D Contact Person: Karen Tan Phone No.: ( 608) 681 — 3500 Mailing Address: Address: 91-1841 Hort Weaver Road Address: City, ST, Zip Ewa Beach, HI 96706 Facility Address: Address: 1045 Kilauea Ave. Address: SuiteA City, ST, Zip Hit., HI 96720 Email Address: klan@cls-hawail.or9 Fax No.: ( 608) 681 — 5260 Accountant/CPA: m a K CPAs no Phone No.. ( 806 ) 524 — 2255 Firm (if applicable): H a K CPA's Inc. Mailing Address: Address: 1001 Bishop Street Address: S1itepl➢0o City, ST, Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $45,000.00 Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua © North Kona © South Hilo ❑✓ North Kohala © South Kona ❑✓ North Hilo © South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ youth © Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child and Family Service Program Name: Hale Kahua Pa'a Transitional Apartment 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $13,750.00 $10,000.00 $30,000.00 2. Agency Mission Statement: "Strengthening families and fostering the healthy development of children" Continued on attachment 3. Program Description: The Hale Kahua Pa'a Transitional Apartment Program is a 24 month program that assists victims of domestic violence and their children to rebuild their lives. The program goal is to assist victims and their children to gain stability and independence while transitioning into a violence -free lifestyle. Continued on attachment 4. Total Budget & Position Count: Total Program Budget: $153,369 Total Program Position Count: 1.15 Total Agency Budget: $4,613.004 Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child and Family Service Program Name: Hale Kahua Pa'a Transitional Apartment S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate U.S. Department of Justice $98,971 County of Hawaii $45,000 Program Fees $4,250 TOTAL: $148,221; Attach additional pages, iifneeded. 6. Explain what plans your agency or program has to increase revenues to support this program: The Hale Kahua Pa'a Transitional Apartment Program has been primarily funded by the Department of Justice, Office of Violence Against Women (OVW). Additional funding options have been explored including charging program fees and State of Hawaii Grant -In -AID (GIA) funding. Continued on attachment 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Increase the knowledge of community resources, including housing, employment and finances, among 80% of participants in program. 2. Maintain a safe and violence free lifestyle during participation in the program among 80% of clients in the program. 3. Support safety by having 90% of the clients maintain a Safety Plan for themselves and their children at intake and for the duration of their participation in program. 4. Secure independent housing after 24 months of safe transitional housing among 80% of the clients seeking permanent safe living quarters. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: child and Family service Program Name: Hale Kahua Pa'a Transitional Apartment 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (I. r_' Nvmber o)clients served, uror13ba0s arevents bell, volunteer hours, etc Describe, be s,e,,ftl Applicant Projected Results Number of families provided housing 8 Number of service plans developed 8 Number of provided case management 8 Number of safety plans developed 8 Number provided with aftercare services 6 Number with secured income 4 Continued on attachment Equipment Attach additional pages as necessary 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 FY 15-16 Total Budget Grant Req Salary and Wages $49,465 $55,582 $27,240 Professional Fees Operations $65,458 $96652 $17,460 Supplies $1,305 $1,135 $300 Equipment Other: Other. Other Other Other TOTAL $136,228 $153,369 $45,000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child and Family Service Program Name: Hale Kahua Pa'a Transitional Apartment lo. 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: o substantial probability that action taken by an individual will result in measurable direct benefits accruing 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: Q If no conflicts exist, check here. Pte, 1 y ,M Executive VP & COO Signature of Authorized Person (specify title) EXHIBITA NONPROFIT GRANT APPLICATION FV 2015-2016 1/30/15 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Child and Family Service Program Name: Hale Kahua Pa'a Transitional Apartment 11. 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 Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. 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 (wel 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 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 progfom s or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child and Family Service Program Name: Hale Kahua Pa'a Transitional Apartment 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 3011 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 lune 30, 2015 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 fundino request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements ca Executive VP & COO 1/30/15 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child and Family service Program Name: Hale Kahua Pa'a Transitional Apartment 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of families provided housing a Number of service plans developed e Number of provided case management e Number of safety plans developed e Number provided with aftercare services 5 Number with secured income 4 Continued on attachment TABLE It: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $27,240 Professional Fees Operations $17,460 Supplies $300 Equipment Other. Other. Other Other. Other. TOTAL $45,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Attachment Applicant: Child & Family Service Program: The Hale Kahua Pa'a Transitional Apartment Program 2. Agency Mission Statement Since 1899, Child & Family Service (CFS) has dedicated its efforts to its mission of "Strengthening families and fostering the healthy development of children." CFS has 38 programs statewide that offer an array of effective and culturally relevant services to Hawaii's residents in need. The broad spectrum of services provided by CFS include: domestic violence intervention, case management, residential group homes, alternative education for alienated youth, prevention and treatment of child abuse, and family, school, and community-based counseling services for children and their families. Infants, children, adolescents, young adults, older adults, individuals, and families in need benefit from these services. In Fiscal Year 2014, CFS directly served 9,509 individuals ranging from infants to elder adults. In addition the organization has "touched" the lives of over 40,000 individuals through hot-line calls, educational presentations, and providing food and clothing to those in need. CFS's programs are responsive, flexible, and focused on positive outcomes. Services are provided in homes, schools and in the community as well as in CFS's offices throughout the State. CFS provides services at 36 sites throughout the State, on the islands of Oahu, Hawaii, Kauai, Maui, Molokai, and Lanai. CFS's strengths lie not only in its size and ability to share expertise and resources statewide, but also in its ability to adapt services so that they are unique and appropriate to the island and communities it serves. CFS has years of experience working with a wide range of target populations and partnering with funding sources to implement new models of service delivery. In recent years, social policy change has presented challenges to human service providers, requiring the development of new skill sets and service delivery models with little time for preparation. CFS has the skills, knowledge and abilities to meet these challenges and remains strong, flexible and prepared to meet future challenges. CFS demonstrates its commitment to service excellence and quality care through the provision of services that are responsive, effective and efficient. CFS establishes goals to achieve service excellence through its strategic planning process. This process involves all levels of the organization, including clients, community stakeholders, direct service staff, management and the Board of Directors. CFS's strategic vision is to become a family -centered, full-service organization. The organization has established four focus areas to reach this vision. They include: Welcome Families (Develop Family - friendly Points of Entry); Walk With Families (Develop Integrated Family and Community Partnerships); Meet Families Where They Are (Provide Adaptive and Culturally Appropriate Practices); and Prove Effectiveness (Demonstrate Impact and Sustain Gains). The administrative management and service delivery systems of CFS emphasize service excellence 3. Program Description: Victims of Domestic Violence are faced with many challenges when making the courageous decision to finally leave their batterers. Both women and men are provided services in our Domestic Abuse programs, but it is mostly women who are confronted with financial challenges. When leaving the batterer, the victim embarks upon a path that is as fearful for her and her children as it is to stay with an abusive partner. Many of these women leave with just the clothes that they are wearing, seeking shelter, Page 1 of 3 Attachment Applicant: Child & Family Service Program: The Hale Kahua Pa'a Transitional Apartment Program safety and, most of all, assurances that they made the right choice. Many lack the skills, tools and resources needed to sustain themselves and their children away from their batterer. Many women are faced with the reality of no financial resources, and inability to access resources due to marital assets retained by the abusers which disqualifies them from eligibility for public assistance or subsidized housing. Many victims turn to the East or West Hawaii Domestic Abuse Shelters initially where they can recover and start planning a new life. The Domestic Abuse Shelters provide safety, basic needs, counseling and support for up to 120 days. Securing a safe home for themselves and their children is one of the serious challenges that the victims are facing in the County of Hawaii due to an expensive rental market and the current economic situation. Al the end of the 120 days in a Domestic Abuse Shelter, the victim must make a decision not only for herself but for her children as well. Unfortunately that decision is often to return to the abuser she sought refuge from or to become homeless since resources of financial and housing support are limited. The Hale Kahua Pa'a Transitional Apartment Program is a 24 month program that assists victims of domestic violence and their children to rebuild their lives. The program goal is to assist victims and their children to gain stability and independence while transitioning into a violence -free lifestyle. Referrals are received from community partners island -wide, including the East and West Hawaii Domestic Abuse Shelters. During their 24 month stay, victims and their families receive intensive support services that guide the victims and their families towards independence: to move to a regular home in the community, to secure an income, and to be able to care for the children. By providing weekly home visits, case management, individual family service plans, and information and referrals to community resources, the program allows both the victims and their children the time to heal, and to live safely. The program is in need of part-time Domestic Violence Specialist to provide case management, and the ongoing support that victims need. The Specialist will also work with participants on developing employment and educational opportunities. Funds will also be used to create a client assistance fund to assist victims with the financial hardships they face when leaving an abusive relationship and seeking self determination. This may include deposits or first month's rent when transitioning into a new home, helping with fees and supplies for those seeking to further their education, or assistance with transportation, childcare and rental application fees. The County of Hawaii funding, matched by other funding, will allow for a part-time Domestic Violence Specialist to be hired. Without a part-time Domestic Violence Specialist, positive outcomes for clients are greatly impacted since the time spent with victims to provide support and resources is reduced. The Domestic Violence Specialist gives the victims weekly opportunities to learn about and to enhance their life skills, including budgeting and money management, job training, nutrition, increasing self- esteem, and emotional and physical health. Support groups are also provided by the Domestic Violence Specialist to educate participants on the effects violence can have on victims as well as their children. Groups are beneficial in building a much needed support system for those in the program. In doing so, the Domestic Violence Specialist addresses many of the barriers to establishing income, housing and independence. Page 2 of 3 Attachment Applicant: Child & Family Service Program: The Hale Kahua Pa'a Transitional Apartment Program 6. Explain what plans your agency or program has to increase revenues to support this program: Continued Clients are not turned away if they cannot pay. CFS has a strong history of fundraising and is committed to continue growing our private donations and grants. As of January 15t', 2015, the State of Hawaii Grant -In -Aid funding has not been released. Although the Department of Human Services developed a Request for Proposal that included the scope for Transitional Housing within the Domestic Abuse Shelter proposal, no additional funding was provided in an already sparse budget for the Domestic Abuse Shelter. We continue to apply for alternative funding sources for our programs and have expanded our efforts to receive funding from private foundation sources dedicated to the belief that everyone deserves a violence free life. 8. Table 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? Continued Number enrolled in education program 3 Number with secure employment 4 Number obtained permanent housing 3 12. Council Award Worksheet: Table I Continued Program Performance Measures Applicant Projected Council Proposed (i.e. Number of clients served workshops or events Results Projected Result held, volunteer hours, etc. Describe, be specific.) Number enrolled in education program 3 Number with secure employment 4 Number obtained permanent housing 3 Page 3 of 3 Child & Family Service West Hawai'i Domestic Abuse Shelter 2% County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: child & Family Service Program Name: West Hawaii Domestic Abuse Shelter Agency Director: Howard canal Phone No.: (808)681— 3500 Contact Person: Karen Tan Phone No.: ( 606 ) 661 — 3500 Mailing Address: Address. 91-1841 Ford Weaver Road Address: City, ST, Zip we Beach, HI, 96706 Facility Address: Address: 61$587 Marralahoa Highway Address: City, ST, Zip Kailua Kona, HI 96768 Email Address: ktan&h-hawali.org Fax No.: ( 808) 323 — 2999 Accountant/CPA: N & K CPAs, Inc. Phone No.: ( 808 ) 524 — 2255 Firm (if applicable): N & K CPAs Inc. Mailing Address: Address: 1001 Bishop Street Address: Suitek1700 City, ST, ZIP Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua © North Kona ❑ South Hilo © North Kohala South Kona ❑ North Hilo © South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ youth © Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION Py 2015-2016 Page l of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: West Hawaii Domestic Abuse Shelter 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $8,750.00 $40,000.00 $30,000.00 2. Agency Mission Statement: "Strengthening families and fostering the healthy development of children". Continued on attachment. 3. Program Description: CFS has been providing emergency shelter for domestic violence victims on the Big Island community for 26 years. The West Hawaii Domestic Abuse Shelter (WHDAS) opened in 1988 followed by the East Hawaii Domestic Abuse Shelter in 1995. Continued on attachment. 4. Total Budget & Position Count: Total Program Budget: $512,580.00 Total Program Position Count: 6.50 Total Agency Budget: $4,613,004 Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: West Hawaii Domestic Abuse Shelter S. Program Funding Sources lidentify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Department of Human Services $340,000 County of Hawaii $80,000 HIUW $25,000' DHS-BESSD-HPO Emergency Shelter Grant $12,000 Private Foundation $2,000 TOTAL: $459,000 Attach additional pages, iJneeded. 6. Explain what plans your agency or program has to increase revenues to support this program: We continue to apply for alternative funding sources for our programs. The Domestic Abuse Shelters are primarily funded by the Department of Human Services in the State of Hawaii. Since fiscal year 2009, the DHS funding has decreased from $425,832 to $340,000. Traditionally, the County of Hawaii, HIUW and Emergency Shelter Grants have supported the Domestic Abuse Shelters in the County of Hawaii. For FY 2013 and 2014, CFS secured private funding from the Mcinerny Foundation and the Mary Kay Foundation to fill gaps in funding. We also received VAWA funding for an innovative project that addressed the needs of the population served. These funds were time-limited and helped support staffing needs as well as a pilot project to better serve high-risk clients. Continued on attachment. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. 70% of survivors with no incidents of violence. Violence = physical, emotional, psychological, financial, verbal, sexual, stalking, threats a. Measurements occur weekly with DAS Safety Questionnaire. 2. 70% of survivors who left the shelter for a secure and safe place. a. Measurement occurs during anticipated discharge with DAS Safety Questionnaire. 3. 70% of survivors will enhance their resiliency. a. Measurement: resiliency pre- and post- test. 4. 80% of children/youth (older than 2 years old) who leave the program know their safety plan. a. Measurement: Child's/youth's narrative as documented in progress notes. 5. 70% of children/youth will not witness further family violence in the next quarter after they leave the program. a. Measurement: Follow-up documentation. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: West Hawaii Domestic Abuse Shelter 8. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES e.: Numhero rrerlaerved, wo.isho (i. ) ps or vents held, volunteer hours, etc. Describe, be specific) Applicant Projected Results Number of additional hours of case management and advocacy hours per week. Number of additional hours of parent/children activities per week. 1,000 1,000 Number of additional 10 hours of transportation/warm contacts with partner agencies per week. 500 Number of hotline calls. 200 Number of single women/men served. 60 Number of women/men with children ..,ad. 50 Continued on attachment. $174,131 Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual' 115-16 Total Budget FY 15-16 Grant Req Salary and Wages $303,200 $331450 $fit, 173 Professional Fees $110 $115 Operations $174,131 $177,615 $17,702 Supplies $3,314 $3400 $125 Equipment Other: Other: Other: Other Other. TOTAL $4ao,7ss $512,580 $80,000 'If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: child & Family Service Program Name: west Hawaii Domestic Abuse Shelter to. 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: o 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: ❑✓ If no conflicts exist, check here. Executive VP 8 COO Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 1/30/15 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: child a Family Service Program Name: West Hawaii Domestic Abuse Shelter ti. 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 final payment. 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 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 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 reportusing the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FV 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Child & Family Service Program Name: West Hawaii Domestic Abuse Shelter 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any paymends). I (we) understand that failure to submit the final report within 60 days of June 3011 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 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, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. &- "; Executive VP & COO Signature of Authorized Person (specify title) 1/30/15 Date EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: child & Family Service Program Name: West Hawaii Domestic Abuse Shelter 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of additional hours of case management and advocacy hours per week. 1,000 Number of additional hours of parentichildren activities per week. 1,000 Number of additional 10 hours of transportation/warm contacts with partner agencies per week. 500 Number of hotline calls. 200 Number of single women/men served. 60 Number of women/men with children served. 50 Continued on attachment. TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $62,173,00 Professional Fees Operations $17,70200 Supplies $125.00 Equipment Other: Other: Other. Other: Other. TOTAL $s0,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter 2. Agency Mission Statement: Continued Since 1899, Child & Family Service (CFS) has dedicated its efforts to its mission of "Strengthening families and fostering the healthy development of children." CFS has 38 programs statewide that offer an array of effective and culturally relevant services to Hawaii's residents in need. The broad spectrum of services provided by CFS include: domestic violence intervention, case management, residential group homes, alternative education for alienated youth, prevention and treatment of child abuse, and family, school, and community-based counseling services for children and their families. Infants, children, adolescents, young adults, older adults, individuals, and families in need benefit from these services. In Fiscal Year 2014, CFS directly served 9,509 individuals ranging from infants to elder adults. In addition the organization has "touched" the lives of over 40,000 individuals through hot-line calls, educational presentations, and providing food and clothing to those in need. CFS's programs are responsive, flexible, and focused on positive outcomes. Services are provided in homes, schools and in the community as well as in CFS's offices throughout the State. CFS provides services at 36 sites throughout the State, on the islands of Oahu, Hawaii, Kauai, Maui, Molokai, and Lanai. CFS's strengths lie not only in its size and ability to share expertise and resources statewide, but also in its ability to adapt services so that they are unique and appropriate to the island and communities it serves. CFS has years of experience working with a wide range of target populations and partnering with funding sources to implement new models of service delivery. In recent years, social policy change has presented challenges to human service providers, requiring the development of new skill sets and service delivery models with little time for preparation. CFS has the skills, knowledge and abilities to meet these challenges and remains strong, Flexible and prepared to meet future challenges. CFS demonstrates its commitment to service excellence and quality care through the provision of services that are responsive, effective and efficient. CFS establishes goals to achieve service excellence through its strategic planning process_ This process involves all levels of the organization, including clients, community stakeholders, direct service staff, management and the Board of Directors. CFS's strategic vision is to become a family centered, full-service organization. The organization has established four focus areas to reach this vision. They include: Welcome Families (Develop Family - friendly Points of Entry); Walk With Families (Develop Integrated Family and Community Partnerships); Meet Families Where They Are (Provide Adaptive and Culturally Appropriate Practices); and Prove Effectiveness (Demonstrate Impact and Sustain Gains). The administrative management and service delivery systems of CFS emphasize service excellence. 3. Program Description: Continued CFS's West Hawaii Domestic Abuse Shelter (W HDAS) and East Hawaii Domestic Abuse Shelter (EHDAS) are the only shelters on the Big Island to serve the immediate needs of residents seeking safety due to domestic violence. Funds are requested to provide partial funding for a Domestic Violence Specialist II (DVS II) and Client Advocate at the W HDAS that provides support, advocacy, counseling and referrals to residents. The Page 1 of 3 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter Client Advocate provides case management, support groups and transportation for most clients, and the DVS II provides intensive case management with high-risk clients who present with mental health and substance abuse issues besides domestic violence. In addition, the DVS II and Client Advocate provide children and youth groups. As resources allow, the DVS II or Client Advocate transports and accompanies the residents to provide assistance in obtaining needed services and achieving their service plan goals. Within the first few days of entering the shelter, the domestic violence victim (resident) meets with the DVS II/Client Advocate who assesses the resident's needs and assists him/her in developing service plan goals. Safety issues are discussed further and a personalized safety plan is developed to address the resident's and, if applicable, his/her children's safety while at the Shelter as well as in the community. Weekly meetings are held to review the progress the resident is making in meeting his/her service plan, whether goals need to be adjusted and/or whether additional steps have to be taken to reach the identified goals. Throughout the resident's stay at the shelter, the DVS II/Client Advocate discusses how to transition the resident safely back into the community and in addition, develops an aftercare plan to ensure that needed services are in place. The WHDAS provides emergency shelter to single women/men and women/men with children who are victims of domestic violence (for a maximum of 120 days). The victims flee from the geographic areas of Ka'u to Kona, and from Kona to the greater Kohala area. Victims from East Hawaii often access the WHDAS in West Hawaii for safety reasons. There are no restrictions to enter the WHDAS as long as the circumstances of need are identified within 48 hours as a domestic violence issue. The shelter operates 24 hours a day/365 days a year including holidays. Staff members monitor and oversee the safety and needs of the residents. The victims are from all walks of life and all socioeconomic backgrounds. The main goal of the program is to provide a safe environment. Experienced staff including the DVS II, Client Advocate, and Shelter Workers help families identify their needs, their barriers and develop plans to meet these needs. The WHDAS program offers emergency food, transportation, referrals as needed, case management, individual counseling, advocacy, outreach services, safety planning, Temporary Restraining Order assistance, support groups, and personal planning to all residents. Both the Client Advocate and the DVS II work with the mothers/fathers and children to build heatthy relationships and to strengthen their role as effective parents without using physical and/or verbal violence towards their children. We are committed to raising the consciousness of our society by: educating our families on a violence free lifestyle; promoting family coping and stability; and providing a place of refuge. In addition, the WHDAS operates a 24-hour domestic violence hotline which provides crisis intervention, information, and referral services. During the last 4 years, the hotline utilization by victims of domestic violence has increased due to the added economic stressors in the communities of the Big Island. The staff provides a safety assessment, makes recommendations and provides referral and resource information for the callers. It is expected that the hotline will continue to see a high volume of calls due to the violence resulting from increased poverty and homelessness. The WHDAS provides three bedrooms with a total of 21 beds for families who enter into the program. In addition to the three bedrooms each room has a full bathroom to accommodate the residents who share the bedroom space. One bedroom is specifically geared towards housing single women and women with disabilities. This room is ADA compliant. The facility also has an ADA ramp for easy access in/out of the Page 2 of 3 Attachment Applicant: Child & Family Service Program: West Hawaii Domestic Abuse Shelter Shelter. In addition to the client areas, the W HDAS has two offices, a playground and a children's room. These offices are used for intake and exit interviews to provide client confidentiality, case management, and individual counseling. The Shelter also provides the residents with a laundry facility, full kitchen, a large living room and a dining area. A large Matson container on the W HDAS site holds furniture items, clothing and household miscellaneous items. These items are donated throughout the year from the West Hawaii community. The Shelter also collaborates with local thrift stores to support clients with items needed while in the shelter, as well as during transition into housing within the community. 6. Explain what plans your agency or program has to increase revenues to support this program: Continued As of January 1, 2015, CFS received the new DHS contract with a gap in funding of $85,832 compared to fiscal year 2009. CFS will continue to advocate with the State for increased funding and continue to pursue alternative funding sources. 8. Program Objectives Using County Nonprofit Grant Program Funds: Continued Program Performance Measures Applicant Projected (i.e. Number of clients served workshops or events held, volunteer Results hours, etc. Describe, be specific.) Proposed Number of children served 100 Number of meals served 18,000 Number of bed days provided 6,000 12. Council Award Worksheet: Table I Continued Program Performance Measures Applicant Council (i.e. Number of clients served workshops or events held, Projected Results Proposed volunteer hours, etc. Describe, bespecific. Projected Result Number of children served 100 Number of meals served 18,000 Number of bed days provided 6,000 Page 3 of 3 Daniel R. Sayre Memorial Foundation Makalei Ambulance Grant Proposal nj County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Daniel R. Sayre Memorial Foundation Program Name: Makalei Ambulance Grant Proposal Agency Director: Laura A. Mallery-Sayre, Executive Director Phone No.: ( ane) 325 _ 5456 Contact Person: Same Phone No.: ( ) — Mailing Address: Address: P.O. Box 12x5 Address: City, ST, Zip Kailua-Kona, Hawaii 96745 Facility Address: Address: Same Address: City, ST, Zip Email Address: maileryszyre®hawaiin.com Accountant/CPA: Patricia Shumacher Firm (if applicable): Shumacher Tax 8 Accounting Fax No.: ( 906) 325 — 7516 Phone No.: (81k)325 — 7900 Mailing Address: Address: 530 E. Hunt Highway Address: City, ST, Zip San Tan Vailay Arizona 95143 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua 0 North Kona ❑ South Hilo ❑ North Kohala © South Kona ❑ North Hilo ❑✓ South Kohala ❑ Ka'U Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Youth 0 Victims of Crimes ❑ Culture and the arts © Aged © Victims of Health or Social Crises © Needs of the poor 0 Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page l of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Daniel R. Sayre Memorial Foundation Program Name: Makalei Ambulance Grant Proposal 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 2. Agency Mission Statement: Mission The primary purposes for which this 501 (c) 3 nonprofit corporation was formed were to provide formal recognition and/or awards to members of the Hawaii County Fire Department Search and Rescue teams and individual members thereof for going beyond the call of duty; to provide fire, emergency, and rescue equipment and supplies to the Hawaii County Fire Department, or necessary funding for the purchase of said equipment and supplies and related training in the use of such equipment; and to educate the public regarding ocean and fire safety. 3. Program Description: To provide the district of North Kona with an Advanced Life Support (ALS) Ambulance for the purpose of improving patient outcomes and saving lives. Please see attached description: 4. Total Budget & Position Count: Total Program Budget: $214,000.00 Total Program Position Count: Total Agency Budget: Total Agency Position Count: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawai'i Nonprofit Grant Application Agency Name: The Daniel R. Sayre Memorial Foundation Program Name: Makalei Ambulance Grant Proposal Section 3. Program Description Attachment To provide the district of North Kona with an Advanced Life Support (ALS) Ambulance for the purpose of improving patient outcomes and saving lives. The Makalei Fire Station in North Kona was opened in 2013 and houses a Fire Engine and Hazardous Materials Response unit. The Makalei station fills a gap on Hwy 190 between the Kailua Fire Station and the Waikoloa Fire Station serving one of the fastest growing districts in the state of Hawaii. Unfortunately this station was never equipped or staffed with an Advanced Life Support (ALS) Ambulance to serve the area residents emergency medical response (EMS) needs. EMS response time significantly impacts the overall delivery time of the patient to definitive treatment at an emergency room. The National Fire Protection Association (NFPA) which creates standards for Fire Service has determined that an EMS ambulance crew must respond to a scene within eight minutes to ensure optimal delivery of emergency care. According to NFPA 1710, "This requirement is based on experience, expert consensus and science. Many studies note the role of time and the delivery of early defibrillation in patient survival due to heart attacks and cardiac arrest, which are the most time -critical, resource -intensive medical emergency events to which fire departments respond." Trauma, stroke and other cardiac emergencies are also extremely time sensitive and rapid transport to definitive treatment often makes the difference between life and death. Current EMS response within the North Kona district comes from Medic 7 (8 miles away) out of the Kailua Fire Station, Medic 12 (15 miles away) out of the Keauhou Fire Station and Medic 16 (27 miles away) out of the Waikoloa Fire Station. Medic 7 and 12 account for 17% of the EMS calls in the County of Hawaii and in the best circumstances will manage a response time of 8-15 minutes to the district of North Kona; if neither of these units is available the response time from Medic 16 in Waikoloa Village is approximately 25-30 minutes. To compound this, the approximate transport time from North Kona to Kona Community Hospital is 25-30 minutes. That said, patients treated and transported within the North Kona district are at a disadvantage due to response times and based on this overall patient outcomes suffer. The Hawaii Fire Department's EMS budget has been flat for the past 6 years. With increased cost of operations, the added strain of collective bargaining wage increases and recent funding of expanded operations in Puna due to the impending lava flow, the Hawaii Fire Department does not have the financial ability to support the purchase of an ambulance for the Makalei Fire Station. The Daniel R. Sayre Foundation is hoping to find an alternate funding method to assist HFD in protecting the residents and visitors of North Kona. During last year's State Of Hawaii's Legislative Session, a Bill was proposed by Senator Josh Green and Representatives Nicole Lowen and Cindy Evans to provide for EMS services for the Makalei Station. An ambulance had already been promised to the station through a donation from Brace and Carol Herren to the Daniel R. Sayre Memorial Foundation once the station had their EMS service set up. The Bill passed through all committees without a dissenting vote and was lost in budgetary hearings. Because the Bill did not pass, Mr. Herren retracted the gift of the ambulance. County of Hawai'i Nonprofit Grant Application Agency Name: The Daniel R. Sayre Memorial Foundation Program Name: Makalei Ambulance Grant Proposal Attachment for Section 3, Page 2 This Bill is once again being introduced to the State Legislature and we have been told by Representative Lowen that the loss of the donated ambulance will more than likely have a negative impact on the passage of the Bill supporting the funding for the EMS staff of the Makalei Fire Station. The Foundation is seeking the support for the ambulance that is desperately needed at Makalei from the Hawaii County Council via this grant proposal. County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Daniel R. Sayre Memorial Foundation Program Name: Makalei Ambulance Grant Proposal S. Program Funding Sources (identify all sources of funding applied to this program): FY15-16 Revenue Source Estimate swain County Council Grant Proposal 14,000.00 TOTAL: $214,000.00 Attach additional oases, if needed 6. Explain what plans your agency or program has to increase revenues to support this program: We have sought assistance through the Hawaii State Legislature to provide funding for the EMS staffing during peak hours. EMS are paid through the State budgeting process. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Secure an ambulance for the Makalei Fire Station to provide Advanced Life Support services to the residents and visitors of North Kona. 2. Reduce EMS response times 3. Improve Cardiac Arrest survival rates for the residents and visitors of North Kona 3. Improve overall patient outcomes for the residents and visitors of North Kona. 4. Provide a true sense of security for the residents and visitors of North Kona. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Daniel R. Sayre Memorial Foundation Program Name: Makalei Ambulance Grant Proposal 8. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Q.e.: Number of flomts served, workshops or events held, volunbeer hours, etc. Describe, be specific)) Applicant Projected Results Reduce response time Response times of e min or less Improve Cardiac Arrest survival rates for residents & visitors of North Kona Increased Cardiac Arrest Survival Improve overall patient outcomes fort the residents and visitors of NorthKona Improved pateint outcomes Professional Fees Operations Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages Professional Fees Operations Supplies Equipment $214,000.60 Other: Other: Other: Other: Other: TOTAL $214.000.00 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Daniel R. Sayre Memorial Foundation Program Name: Makalei Ambulance Grant Proposal io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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): QMember 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 an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: As soon as the ambulance is purchased, it will be gifted to the County of Hawaii. 7✓ If no conflicts exist, check here. /✓/,��L� CCFC/c�GrtP Qd�/3C1L2[fo�� rya-r�S Signatur of Authorized Person(specify title)��G'�e,?�Df-C pate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Daniel R. Sayre Memorial Foundation Program Name: Makalei Ambulance Grant Proposal 11. Certification of Understanding (Page loft) 1 (we) have read and understood all of the 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 final payment. 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 Countv Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report using the template provided will impact the evaluation of Your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: The Daniel R. Sayre Memorial Foundation Program Name: Makalei Ambulance Grant Proposal 11. Certification of Understanding (Page 2of2) If awarded a grant from the County of Hawai i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) e� w2rt7�a�l EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: The Daniel R. Sayre Memorial Foundation Program Name: Makalei Ambulance Grant Proposal 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Reduce response times 8 mins or less Improve cardiac arrest survival rates for residents and visitors of North Kona Increased survival Improve overall patient outcomes for the residents and visitors of North Kona Improved pt outcome Supplies Equipment Ambulance $214,000.00 Other: Other: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Ambulance $214,000.00 Other: Other: Other: Other: Other: TOTAL $214,000.00 Additional Council directives regarding award: EXHIBIT B NON PROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 East Hawaii Cultural Council Big Island Slack Key Guitar Program 29 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: East Hawaii Cultural Council Program Name: Big Island Slack Key Guitar Program Agency Director: Lourdw Kimbreli Phone No.: ( 90e) aa1 — 5711 Contact Person: Lourden l(imbreil Phone No.: ( 00e) eat — 5711 Mailing Address: Address: 141 icalaMua Sr Address: City, ST, Zip Hlb, H1967M Facility Address: Address: 141 Kalakaua sr Address: City, ST, Zip Hib, HI 96120 Email Address: adminr@ehcc.org _ Fax No.: Accountant/CPA: Amy Pakml Phone No.: (61M)s61 — 5711 Firm (if applicable): Mailing Address: Address: 141 Kelakaua Se Address: City, ST, Zip Hilo, H196720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: lone or more can be checked) © Puna © Hamakua © North Kona © South Hilo © North Kohala © South Kona © North Hilo © South Kohala © Ka'0 Services or Activities To Be Provided: lone or more can be checked) © Educational concerns © youth ❑ Victims of Crimes © Culture and the arts © Aged ❑ Victims of Health or Social Crises Needs of the poor ❑ Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: East Hawaii Cultural Council Program Name: Big Island Slack Key Guitar Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 N/A N/A $500 2. Agency Mission Statement: The East Hawaii Cultural Council/Hawaii Museum of Contemporary Art was established in 1967 as a non-profit arts and cultural organization with a mission to preserve, promote and perpetuate the arts and cultures of our diverse community on the Big Island. 3. Program Description: The family oriented Slack Key Guitar Program consists of a festival, workshops, and classes. The festival will be held on a Sunday from 12pm to bpm withl2 performances at the Afook Chinen Civic Auditorium. The performers are primarily well known Slack Key Guitar recording artists from all over the State. Lessor known performers from the Island of Hawaii are included in the lineup in order to provide opportunities for local artists to be recognized and perform before an audience. For 12 years, The County of Hawaii Department of Parks and Recreation was a Co -Sponsor of the festival, we plan to ask for their continued support. There are few written books, classes, or performance venues available to Hawaii Island residents in the Hawaiian music tradition of Slack Key Guitar. In the past, we have found Hawaiians are excited and pleased to take a workshop from someone who has achieved the artistic level of a recording artist. We will offer 3, three hour Slack Key Guitar workshops taught by well known Slack Key Guitar recording artists. We hope to further fulfill the need for this program by including 22 weekly, 2 hour, Slack Key Guitar classes taught by a Slack Key Guitar teacher. The workshops and classes will be held at the Hawaii Contemporary Museum of Art. 4. Total Budget & Position Count: Total Program Budget:$38,470 Total Program Position Count: 36 Total Agency Budget: 1$103,8001 Total Agency Position Count: 25 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: East Hawaii Cultural Council Program Name: Big Island Slack Key Guitar Program S. Program Funding Sources (identify all sources of funding applied to this programl: Revenue Source FY15-16 Estimate State Foundation on culture and the Arts - Grant submitted for 2015 7500 County of Hawaii Finance Department - Grant submxted for 2015 18020 Private Individual Donations - Not yet applied for 1500 Non Profit Funding Agencies - Not yet applied for 2500 TOTAL: 29,520 Attach additional pages, iif needed. 6. Explain what plans your agency or program has to increase revenues to support this program As with any public service, we must rely on a diverse source for funding. We plan to submit grant applications to private funding agencies for non profits. We will solicit donations from private businesses and individuals. We plan to sell tickets to the festival and charge for both the workshops and classes. We will charge for festival booths, sell t -shirts, CD's and posters. In the past, this program was able to match funding on a dollar for dollar basis, from State, County, private donations, and through our merchandise sales. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Big Island Slack Key Guitar program goal is to further and expand Hawaiian music opportunities on the Island of Hawaii. Our focus is on encouraging and enhancing Native Hawaiian Culture and the arts through education, by offering slack key guitar workshops, classes, and the Big Island Slack Key Guitar festival, to adults and children, on a year round basis. The Big Island Slack Key Guitar program will foster public involvement and coordinate activities and resources among a coalition of community based organizations and individuals dedicated to preserving the rich cultural diversity and traditional Hawaiian music arts in Hawaii. Our program emphasis is to further and expand opportunities for Hawaiians to perform as well as teach by developing Hawaiian music events. The Big Island Slack Key Guitar Program also hopes to assist in the preservation, perpetuation, and awareness of one of Hawaii's unique forms of music. Our plan is to establish practical partnerships that extend the scope and reach of our programming. It is through our partnerships with the University of Hawaii, Department of Hawaiian Studies. local Hawaiian organizations and community organizations. that we will EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY 2015-2016 East Hawaii Cultural Council Big Island Slack Key Guitar Program 3. Program Description: - Full Text The family oriented Slack Key Guitar Program consists of a festival, workshops and classes. The festival will be held on a Sunday from 12pm to 6pm with 12 performances at the Afook Chinen Civic Auditorium. The performers are primarily well known Slack Key Guitar recording artists from all over the State. Less well known performers from the Island of Hawaii are included in the lineup in order to provide opportunities for local artists to be recognized and perform before an audience. For 12 years, The county of Hawaii Department of Parks and Recreation was a Co -Sponsor of the festival, we plan to ask for their continued support. There are few written books, classes or performance venues available to Hawaii Island residents in the Hawaiian music tradition of Slack Key Guitar. In the past, we have found Hawaiians are excited and pleased to take a workshop from someone who has achieved the artistic level of a recording artist. We will offer 3, three hour Slack Key Guitar workshops taught by well known Slack Key Guitar recording artists. We hope to further fulfill the need for this program by including 22 weekly, 2 hour, Slack Key Guitar classes taught by a Slack Key Guitar teacher. The workshops and classes will be held at the Hawaii Contemporary Museum of Art. We will hire a part time staff to help with various aspects of the program as well as rely on volunteers to ensure this is a community based program. We will employ local businesses to produce market materials and services. We have asked a University of Hawaii -Hawaiian Language program teacher to be a consultant to ensure that the unique Hawaiian traditional community based organizations for their input. The staff and other professionals involve in this program are all 'Independent Contractors' and not employees of the Hawaii Museum of Contemporary Art. The grant being requested is soley for the expenses of the Big Island Slack Key Guitar program. 7. Program Objectives Using County Nonprofit Grant Program Funds: - Full Text The Big Island Slack Key Guitar program goal is to further and expand Hawaiian music opportunities on the Island of Hawaii. Our focus is to encourage and enhance Native Hawaiian Culture and the arts through education, by offering slack key guitar workshops, classes, and the Big Island Slack Key Guitar Festival, to adults and children, on a year round basis. The Big Island Slack Key Guitar program will foster public involvement and coordinate activities and resources among a coalition of community based organizations and individuals dedicated to preserving the rich cultural diversity and traditional Hawaiian music arts in Hawaii. Our program emphasis is to further and expand opportunities for Hawaiians to perform as well teach by developing Hawaiian music events. The Big Island Slack Key Guitar Program also hopes to assist in the preservation, perpetuation, and awareness of one of Hawaii's unique forms of music. Our plan is to establish practical partnerships that extend the scope and reach of our programming. It is through our partnerships with the University of Hawaii, Department of Hawaiian Studies, local Hawaiian organizations and community organizations, that we will reach and serve a wider audience. It is our goal County of Hawaii Nonprofit Grant Application FV 2015-2016 East Hawaii Cultural Council Big Island Slack Key Guitar Program (Cont) to focus and strengthen public support for traditional Hawaiian music by making the festival, workshops and classes available to the public at a minimal cost. The festival, workshops and classes provide an opportunity for economic development, jobs for slack key guitar performers and teachers. We will employ many small business people, giving preference to Hawaiian based businesses, to produce graphic art, printing, website development, sound company, video company, insurance and advertising as well as employ independent contractors to perform work on a temporary basis. Hawaiian cultural and food booths will be offered at the festival. The Island of Hawaii has the largest population of native Hawaiian and part Hawaiians in the State, with few opportunities for the enjoyment of Slack Key Guitar performances or educational venues. It is our hope to provide access for these activities to all of Hawaii Island. The festival fosters special relations among performers as they interact with each other, giving them the opportunity to play with someone they have never met or played with previously. These kind of experiences happen, not by planning or staging, but through the Aloha of all those involved. We will connect with Hawaii's youth through the Hawaiian Language schools and organizations who serve Hawaii's youth, we will include information about our programs and give them free tickets to the festival. We will contact Senior Citizens and Disabilities Organizations with the information about our programs and ask for volunteers. The Afook Chinen Civic Auditorium and the Hawaii Museum of Contemporary Art in Hilo, are accessable and compliant with Title 11 of the Americans Disability Act. Seating, close to the stage will be reserved for the elderly and for persons with disabilities. We are giving out free tickets to Hawaiian Schools and programs serving Hawaii's youth. Ticket prices are kept low to make the festival accessible to families and older adults. One of our community alliances is with the Hawaii Island Food Bank. Tickets are regularly $10, if a canned good is brought in for distribution to the Hawaii Island Food Bank, then the ticket is $8. Workshops and classes are priced reasonable and will be subsidized through support from the State County and our many other fund raising efforts. County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: East Hawaii Cultural Council Program Name: Big Island Slack Key Guitar Program 8. TABLE I: ._ .u..:..ee-aea measLirahle nutnins nr outcomes that would be achieved with this funding? Attach additional pages as necessary. 9 TABLE II - PROGRAM EXPENDITURES FY 14-15 Actual- PROGRAM PERFORMANCE MEASURES Applicant Projected Results (I.e.: Number aJdients awed, workshops arevents beltl, wlunteer hours, Hc.Oearibe, be sp fk ) 0 Festival audience - 2500, Islan vidde Radio Broadcast audience - Win 5500 persons Workshop attendants - 30, ten participants per each of three workshops. 30 persons Workshop volunteers -1 x 6 tours per 3 workshops = 18 hours 18 hours Class attendants - 15, fifteen artici ants for each of 22 week classes. 15 persons Class volunteer -1 x 3 hours x 22 classes = 66 hours 66 hours Festival volunteers - 20 persons, 12 hours 1 da of festival = 240 hours 240 hours Program Director -140 hours, Mansting Director- 140 hours= 280 hours total 280 hours Attach additional pages as necessary. 9 TABLE II - PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-I6 Total Budget FY 15-36 Grant Req Salary and Wages 0 0 0 Professional Fees 0 27,065 8615 Operations 0 0 0 Supplies 0 250 250 Equipment 0 Other: Newspaper Ads, Radio Ads 0 2200 2200 Other: Perfomlers Aldine Tickets 0 3300 3300 Other: Postage 0 '00500 Other: Posters, Post Cards, Festival Tickets, Programs 0 1155 1155 Other T-shirts 0 2000 2000 TOTAL 0 36,470 $18,020 If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: East Hawaii Cultural Council Program Name: Big Island Slack Key Guitar Program So. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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): 7 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 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: d❑ If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: East Hawaii Cultural Council Program Name: Big Island Slack Key Guitar Program 11. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 Expressand be compliant prior to final payment. 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 Iwe) understand 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 reportusina the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: East Hawaii Cultural Council Program Name_ Big Island Slack Key Guitar Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30'6 shall result In loss of all grant funds received during the ¢rant 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-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 forth e purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs, Any funds unused by June 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: East Hawaii Cultural Council Program Name: Big Island Slack Key Guitar Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Projected Resant Projected Resalts Council Proposed Protected Result Festival and Radio Broadcast audience 5500 Persons Workshop attendants30, ten per each workshop 30 Persons Workshop Attendants, Teachers, and Volunteer 18 Hours Classes Attendants -15, for each 22 wkly classes 15 Persons Cless volunteer -1, 31hours for 22 Gasses 86 Hours Festival Volunteers -20, 12 hoursfor 1 day 240 Hours Program Director -140 hours Marketing Dir 140 hours 280 Hous TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 0 Professional Fees 8615 Operations o Supplies 250 Equipment 0 Other: Newspaper Ads, Radio Ads 2200 Other: Performers Aldine Tickets 3300 Other. Postage 500 Other: Posters, Post Cams, Festival Tickets, Programs 1155 Other: T-shirts 2000 TOTAL $16,020 Additional Council directives re¢ardinc award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Epilepsy Foundation of Hawaii Seizure Smart Hawai'i 30 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Epilepsy Foundation of Hawaii (EFH) Program Name: Seizure Smart Hawai'i Agency Director: samanlha West, MSW Phone No.: ( 808) 528 — 8o58 Contact Person: samentnawesl Phone No.: (sos)528— 3o58 Mailing Address: Address: 1060 Ala Mraraalvd. Address: SuI12550 City, ST, ZIP Honolulu, HI 96814 Facility Address: Address: sameasabove Address: City, ST, Zip Email Address: sam@epllepsynewal.cm Fax No.: ( 866) 848 — 8078 Accountant/CPA: James Michishime Phone No.: ( 606 ) 497 — 9002 Firm (if applicable): NIA Mailing Address: Address: 98-1277 Kaahumanu street Address: #155 City, ST, Zip Aiea, H196701 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 840,000.00 Geographical Areas To Be Served: (One or more can be checked) © Puna HSm&kua 7 North Kona © South Hilo ❑ North Kohala © South Kona © North Hilo © South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged © Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Epilepsy Foundation of Hawaii (EFH) Program Name: Seizure Smart Hawaii 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $0.00 $0.00 $0.00 2. Agency Mission Statement: To stop seizures and Sudden Unexpected Death in Epilepsy (SUDEP), find a cure and overcome the challenges created by epilepsy through efforts including education, advocacy and research to accelerate ideas into therapies. 3. Program Description: According to the World Health Organization, 1 in 10 people will have a seizure in their lifetime. One in 26 people will develop epilepsy. Seizure Smart Hawai'i aims to educate, connect and empower community members across Hawai'i Island to learn more about epilepsy through completion of seizure first aid training. Seizure Smart Hawai'i includes educating schools, local leaders, police and fire departments, media, hospitals, community health centers, organizations that serve seniors and key employers. A trained Seizure Smart facilitator will conduct free, 1 -hour workshops throughout Hawai'i Island. This program will be focused on the following: 1. Increasing public knowledge and awareness about epilepsy and seizures. 2. Dispelling myths and mis-perceptions that lead to stigma and discrimination. 3. Creating positive images/messages and role models by and for people living with epilepsy. 4. Implementation of a community-based curriculum to reach various undeserved populations including youth, seniors, minorities and those in rural communities. 4. Total Budget & Position Count: Total Program Budget: $51,000 Total Program Position Count: 1 Total Agency Budget: $161,0001 Total Agency Position Count• I p—1 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Epilepsy Foundation of Hawaii (EFH) Program Name: Seizure Smart Hawaii S. Program Funding Sources (identify all sources of funding applied to this oroeraml: Revenue Source FY15-16 Estimate School Nurses/Perwnnel grant $1,0001 Lundbeck grant $4,000 Seniors and Selzures grant $5,000 Individual donations $1,000 TOTAL: $11,nnn yuycq � neeaea. 6. Explain what plans your agency or program has to increase revenues to support this program EFH plans to host a fundraising event in Hawaii Island in 2016 to raise funds to support continuation of this program. Epilepsy Foundation of Hawaii has successfully raised funds in Oahu through two fundraising events, Sharon's Ride.Run.Walk and Freedom Run. EFH would like to replicate one of these events in Hawaii Island. EFH will also continue to seek grants from private and public institutions. 7. Program Objectives Using County Nonprofit Grant Program Funds: Objective 1: Increase the community's knowledge of seizure first aid by providing Seizure Smart trainings to a minimum of 1,000 community members in Hawai'i Island through free, 1 -hour presentations by a trained facilitator. Objective 2: Network with a minimum of 40 community stakeholders to increase understanding of epilepsy and the services provided by the Epilepsy Foundation of Hawai'i. Objective 3: Increase knowledge of available community resources for individuals, families and communities impacted by epilepsy by responding to information and referral inquiries. Objective 4: Outreach to undeserved communities through networking and attending community activities (health fairs, college events, farmers' markets, parades). EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Epilepsy Foundation of Hawaii (EFH) Program Name: Seizure Smart Hawaii 8. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this fimrifnn) PROGRAM PERFORMANCE MEASURES 0e: Numnerttfnlentsserved, wo.�no ps orevents held, volunteerhoua, etc Describe, be scerlf� 1 o Applicant Projected Results Number of mmmuni members trained 1,000 Number of nemorkin meetings 40 Information and referral responses 200 Community events attended 44 Seizure First Aid posters distributed 2,000 $40,000 $38,000 a pages 9. TABLE It PROGRAM EXPENDITURES FY 14-1S FY 15-16 FY 15.16 Actual* Total Budget Grant Req Salary and Wages $40,000 $38,000 Professional Fees $4,000 $o Operations $1,000 $o Supplies $2,000 $1,000 Equipment $1,000 $1,000 Other Travel $3,000 $0 Other: $0 $o Other: $o $o Other: $o $o Other: $0 $0 TOTAL $sL000 $ao,oao "If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Epilepsy Foundation of Hawai'i (EFH) Program Name: seizure smart Hawaii io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 nggonflicts exist, check ere. Signature of Authorized Person (spe 'fy title) EXHIBITA NONPROFIT GRANT APPLICATION FV 2015-2016 1/28/2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Epilepsy Foundation of Hawaii (EFH) Program Name: Seizure Smart Hawai'i MEMEME u. Certification of Understanding (Page 1 of 2) 1(we) have read and understood all of the 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 final payment. To register, go to httI2;ZZvendors.ehawaii.goy, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a ¢rant 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 Hawari grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end reportusing the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Epilepsy Foundation of Hawaii (EFH) Program Name: Seizure Smart Hawaii 11. Certification of Understanding (Page2 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 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 nttuyly na�va'ru ry Eo ;- no profit a ir'c 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, 2015 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. By signin ow, you are acknow edging that you have read and understood these requirements. 1/2812015 Signature of Authorized Person (spec fy title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County ofHawai`i Nonprofit Grant Application FY2015-16 Agency Name: Epilepsy Foundation of Hawaii (EFH) Program Name: Seizure Smart Hawaii 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Coundl Proposed Projected Rai Number of community members trained 1,000 Number of networking meetings 40 Information and referral responses 200 Community events attended 24 Seizure First Aid posters distributed 2,000 Other: Other: TABLE II: PROGRAM EXPENDITURES Add" FY 1S-16 Grant Request Council Award Salary and Wages $38,000 Professional Fees $0 Operations $0 Supplies $1,000 Equipment $1,000 Other: Other: Other: Other: Other: TOTAL $40,000 tional 1-ouncll directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 Family Support Hawaii Street Outreach - Homeless and At -Risk Youth 31 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Family Support Hawaii Program Name: Street Outreach - Homeless and At -Risk Youth Agency Director: Raywofford Phone No.: ( 808) 334 — wits Contact Person: Ray Wofford Phone No.: ( 808) 334 — 4115 Mailing Address: Address: 75-tv Lunapule Road,sultelt Address: City, ST, Zip Kailua-Kana, Hawaii 96]40 Facility Address: Address: 7s -t 27 Lunapula Read, suite It Address: Gty, ST, Zip Kailua-Kona, Hawaii 96740 Email Address: rwofond@fsdwh.orn Fax No.: ( 608) 326 — 4063 ACCountant/CPA: Rosanne Connell, Manager Phone No.: ( 808) 930 — 6850 Firm (if applicable): camonaro CPA a Associate, Inc Mailing Address: Address: P.0. Box 4372 Address: City, ST, Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua © North Kona ❑ South Hilo ❑ North Kohala .I❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth © Victims of Crimes ❑ Culture and the arts ❑ Aged © Victims of Health or Social Crises © Needs of the poor © Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Family Support Hawaii Program Name: Street Outreach - Homeless and At -Risk Youth 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $O.oO $0.00 $15,000 2. Agency Mission Statement: Family Support Hawaii (FSH) was founded in 1979 by a group of professionals and community members concerned about strengthening families in West Hawaii. Today FSH provides community-based, family -centered, culturally appropriate and individualized services to families on three-fourths of Hawaii Island - over 4,000 square miles. FSH's mission is "to support families and communities in providing love and care for our children". Our mission embodies two key elements: support for families and support for communities. The first guides us in the direct work of supporting families, which we do through our counseling, occupational, speech and physical therapies, home visiting, school programs, parent education, homeless street outreach and support programs. The second is assisting communities to develop the capacity to provide a supportive environment for families and individuals. These are achieved through our community development activities, collaboration building and advocacy work for a better quality of life for the people of Hawaii. 3. Program Description: In accordance with the purpose of the Runaway & Homeless Youth Act, our Street Outreach program (SOP) seeks to: 1. Encourage runaway, homeless and street youth to leave the streets and to make healthy personal choices regarding where they live and how they behave; and 2. Provide street based services to runaway, homeless, and street youth who have been subjected to or are at risk of being subjected to sexual abuse, exploitation, or prostitution. FSH is seeking funding from the County of Hawaii to continue and to expand the work of the SOP so we may focus on the needs and goals of the youth. The SOP increases the immediate safety of Runaway and Homeless youth (RHY) through the provision of street outreach and crisis intervention. Through case management, we assist youth to build skills to better resolve trauma and conflict, have improved communication, and be less likely to deal with problems in unhealthy ways. The program increases the self-sufficiency and independence of RHY through the provision of opportunities for education., employment and leadership. See attached - 4. Total Budget & Position Count: Total Program Budget: 30,000 Total Program Position Count: 1 Total Agency Budget: 26170171 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 Family Support Hawaii Street Outreach — Homeless and At -Risk Youth 1-2015 3. Program Description: By increasing their permanent connections with our outreach staff, RHY develop healthy, positive, trusting and sustainable relationships. Hawaii has the highest rate of homelessness per capita in the United States 46.5 per 100,000 people - an increase from 2013. In 2013 on Hawaii Island, there were 142 unsheltered homeless people in the Kailua Kona area, they constitute 35% of all homeless people on the entire island of Hawaii. 11.4% of unsheltered adults in Hawaii are 18 — 30 years of age, 70% are male and 66% have been homeless for one year or longer. Our staff members collaborate with other agencies and homeless service providers to identify and provide services at new outreach sites. Outreach staff maintains a regular presence at all free hungry and homeless feeding locations including The Friendly Place, a drop-in center for homeless adults. We are active members of several committees to assist the homeless, including Mayor Billy Kenoi's special committee to help the homeless in Kona, the Chronic Homelessness Intervention and Rehabilitation Project (CHIRP). In addition to supporting CHIRP, the Program Manager for the Street Outreach program at Family Support Hawaii has been asked by the Mayor's Managing Director, Wally Lau, to form a special committee to study the plight of homeless youth on Hawaii Island. FSH monitors legislation regarding youth, law enforcement initiatives, and participates in safety activities for special events that impact homeless persons (e.g., the intense security during the Ironman World Championship that drove many youth from their usual gathering places on AN Drive). We collaborate with the police and business owners in Kona to help keep the streets safe for tourists, businesses and the RHY. The youth themselves, as well as homeless adults, help us to identify new RHY on the streets and link them with our services. In general, RHY are most likely to be found in tourist centers, where they are less noticeable and have more opportunities to obtain resources to meet their survival needs. Street outreach primarily occurs on foot on Alii Drive and other youth hangouts in Kona. Our youth do not feel comfortable attending feedings with the adult homeless population and often go without food or services because of the negative interaction between the chronically homeless adults and youth. If this application is fully funded, the program will expand outreach to additional sites including the Honokohou Harbor area, Kealakekua and beaches in south Kona. In addition to outreach, there is a great need for a drop in place for our at risk youth. There is nothing in Kona that offers that type of service and it is much needed. In the coming year we intend to find a place for youth to drop in, even if it is just a few hours a week, to receive assistance — food, restroom, computer, clothes closet, independent living skills training, employment referrals and case management - an opportunity to sit and talk with a case worker in a safe and non -stressful environment. Our youth need to feel cared for, to feel special to someone, our program supplies that to the youth on the street in Kona. Family Support Hawaii is focused on investing in the promotion of the positive assets of our at -risk and homeless youth. In the long term, providing positive support to these individuals is a societal investment in the creation of happy, healthy, productive citizens. County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Family Support Hawaii Program Name: Street Outreach - Homeless and At -Risk Youth S. Program Funding Sources (identify all sources of funding applied to this programl: FY15-16 Revenue Source Estimate No other funding anticipated, our Street Outreach program has been funded in the past b a sub -grant 0 from Hawaii Youth Services Network, they applied this year but were not awarded the grant. TOTAL: o Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program Family Support Hawaii's Street Outreach program is the only program that serves at risk and homeless youth on the island of Hawaii. Our Street Outreach program is funded by the County of Hawaii and a grant from Hawaii Youth Services Network which allows us to serve homelesslat-risk youth. We are currently seeking new sources of funding from such entities as state, federal, and private foundations, as well as solicitations from businesses and the community. We are also expanding our grant searches to focus on specific groups of RHY such as foster youth and gay, lesbian, bisexual, and transsexual youth. The community has been generous in providing our homeless youth with toiletries, clothes, shoes and beach towels (used for blankets). We developed a "Pass the Plate" initiative whereby people can donate via the Family Support Hawaii website to our homeless youth program. This month our agency is holding its first annual tennis tournament, funds to be used for all programs; we continue to look for ways to increase revenue so we may provide services to our community. 7. Program Objectives Using County Nonprofit Grant Program Funds: Objective 1: To increase the immediate safety of RHY through the provision of street outreach and crisis intervention. Objective 2: To increase the well-being of RHY so that they will be better able to resolve trauma and conflict, communicate more effectively, and be less likely to deal with problems in unhealthy ways. This will occur through access to case management, health and social services; and participation in positive activities. Objective 3: To increase the self-sufficiency and independence of RHY through the provision of skill -building activities and opportunities for education, employment, community service, and leadership. Objective 4: To increase the permanent connections of former RHY through the development of healthy, positive, trusting, and sustainable relationships with program staff, other caring adults, and within the community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Family Support Hawaii Program Name: Street Outreach - Homeless and At -Risk Youth B. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Number of cs-B nerved, workshops v events held, volunteer hmurg em. Di be specific) Applicant Projected Results 1. To ensure safety, youth will have access to emergency, transitional, and permanent 100% of the youth will have shelter shelter with continued support from the outreach worker. information 2. To prevent illness or unplanned pregnancy and promote good health, youth will 75% of youth will access primary or access health care services preventative health care services yearly 3. To increase opportunities for education and employment. 50% of youth will obtain full or part time Operations employment or will participate in services 3,000 that lead to employment or education Attach additional pages as necessary, 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual" FY I5-16 Total Budget FY 15-16 Grant Req Salary and Wages 4,177 23,500 23,500 Professional Fees Operations 815 3,000 3,000 Supplies 49 3,500 3,500 Equipment 91 Other: Other: Other: Other. Other. TOTAL 5,132 30,000 30,000 It app hcabie EXH I BIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Family Support Hawaii Program Name: Street Outreach - Homeless and At -Risk Youth io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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: Ray Wofford POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: /I If no conflicts exist, check here. Signature off Auth�erson Wpecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Family Support Hawaii Program Name: Street Outreach - Homeless and At -Risk Youth 11. Certification of Understanding (page 1 of 2) 1 (we) have read and understood all of the 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 final payment. To register, go to htto1/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 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 Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Family Support Hawaii Program Name: Street Outreach - Homeless and At -Risk Youth 11. Certification of Understanding (Page 2of2) If awarded a grant from the County of Hawa!'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 lune 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.gGv/fn-nonprofit-grant-formsI on or about May 30 of the year the final 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 lune 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timelV manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized iers # (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Family support Hawaii Program Name: Street Outreach - Homeless and At -Risk Youth 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result 1. To ensure safety, youth will have access to emergency, transitional and permanent tm i %information shelter with continued support from the outreach worker. 2. To prevent illness or unplanned pregnancy and promote good health, youth will 75%access access health care services. 3,500 3. To increase opportunities for education and employment. 50% participation Other: Other. TARI F II - PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 23,500 Professional Fees Operations 3,000 Supplies 3,500 Equipment Other: Other. Other: Other: Other. TOTAL 30000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 9 of 8 Family Support Hawaii West Hawai'i Fatherhood Initiative 32 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Family support Hawaii Program Name: west Hawaii Fatherhood Initiative Agency Director: Ray woRord Phone No.: ( 809) 334 — 4115 Contact Person: Raywonnm Phone No.: ( 808) 334 — 4115 Mailing Address: Address: 75-127 wnapuls Rd. suite 11 Address: City, ST, Zip Kailua-Kona, Hawaii 96740 Facility Address: Address: ]5-12] Lunapule Rd. Suite 11 Address: City, ST, Zip Kailua-Kona, Hawaii 96740 Email Address: r f.rdQfsswh.or9 Fax No.: ( 808) 326 — 4063 Accountant/CPA: Roxanne Conner, Manager Phone No.: ( 908) 930 — 8950 Firm (if applicable): caruonaro CRA a Aaaorole, mc. Mailing Address: Address: P.0.B114392 Address: City, ST, Zip Hilo, HI 97620 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua © North Kona ❑ South Hilo ✓❑ North Kohala © South Kona ❑ North Hilo © South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth © Victims of Crimes ❑ Culture and the arts © Aged © Victims of Health or Social Crises © Needs of the poor © Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Family Support Hawaii Program Name: West Hawaii Fatherhood Initiative 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 o $o.00 so,000 2. Agency Mission Statement: Family Support Hawai'i (FSH) was founded in 1979 as a grassroots organization providing family support in communities throughout West Hawai'i. FSH incorporated in 1981 as a private, non-profit organization whose mission is "to Support Families and Communities in Providing Love and Care for our Children." As are all mission statements, this one is carefully chosen. It embodies two key elements: support for families and support for communities. The first guides us in the direct work of supporting families, which we do through our counseling, home visiting, school based and parent education and support programs. The second is assisting communities to develop the capacity to provide a supportive environment for families and individuals. These are achieved through our community development activities, collaboration building and advocacy work for a better quality of life for the people of Hawai'i. Our mission statement encompasses our work - Dads, Moms, infants, toddlers, youth, homeless, disabled, disenfranchised, living in poverty, we strive daily to make a long lasting positive difference in their lives. 3. Program Description: This program was started because our community has experienced a change in family structure; more and more children are living in fatherless homes. We saw our fathers willingly or unwillingly separate themselves from their families and have seen the negative effects this has had in our schools and community. Our agency has many programs designed to enhance the well being of families yet none were specifically designed to assist fathers to be a better parent, we saw there was a need to focus on fathers and the important role they play in their family and community. Our West Hawaii Fatherhood Initiative program (WHFI) meets those needs by strengthening families and encouraging and preparing fathers to take an active role in nurturing and raising their children. Research shows involved fathers bring positive benefits to their children such as better educational outcomes, financial and emotional security, families are healthier, and have better social connections with peers and their community. Given the harm caused by father absence and the benefits of father involvement, one of the most important things we can do to improve child well being is to increase the proportion of children growing up with involved, responsible, and committed fathers. See attached - 4. Total Budget & Position Count: Total Program Budget: $65,000 Total Program Position Count: i Total Agency Budget: $2,617,07 Total Agency Position Count: 50 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of Family Support Hawaii West Hawaii Fatherhood Initiative January 2015 3. Program Description continued: These factors drive our desire to work hard to bring the father back into the role of father for the good of their children and for our community. Our mission is for every father on the Big Island to have a productive and positive relationship with his children because FATHERS MATTER. The W HFI responds to escalating social concerns regarding "father absence" by providing our fathers with knowledge and skills designed to prepare them to better meet the emotional, psychological, and financial needs of their children. The W HFI also seeks to increase awareness of the importance of father involvement. In 2012 the State of Hawai'i was ranked the 7th highest in U.S. poverty, and Hawaii County has the highest poverty rate of all counties in the State; research has consistently shown a direct correlation between father absence and poverty, increased school drop-out rates, health issues and social dysfunction. W HFI is committed to contributing to a future where every child in Hawai'i County can grow up with an involved father or father figure who is loving, nurturing, and who helps to provide the basic needs of the child. Our classes use the evidence based curriculum "24/7 Dad" and the accompanying workbook to systematically address some of the underlying issues fathers deal with daily. When a father completes the 12 week program he becomes a Dad who: • Is aware of himself as a man and aware of the significant impact he has in his family. • Is a man who takes care of himself, and has a strong connection with his community, and chooses friends who reinforce his healthy choices. • Is very aware of the significant rale he has in the family, and capitalizes on his knowledge of the unique contributions he and his wife (or mother of his children) brings to raising their children. • Is a nurturing parent who understands and accepts the importance his parenting skills have in developing the physical, emotional, intellectual, social, and creative needs of his children. • Works to build and maintain healthy and supportive relationships with his children, wife, family, friends, and community. The fathers who attend our classes are encouraged to see fatherhood as an honor as well as a responsibility. We teach fathers to recognize they are the strongest advocates for their children and to value the importance of their influence in the lives of their children. In addition to teaching the fathers to be strong advocates for their children, we are also training some to be volunteer coaches for the W HFI program. Once a man completes the program, he can apprentice with our Father Coach to be a volunteer coach. These volunteer coaches broaden our reach in the community so more fathers can become involved with our groups. We have four service areas to date, Kau', Waikoloa, Kona and Ulu Wini Transitional Living Project. We have plans for the coming year, funding permitted, to begin programs at the high schools and to have classes for Marshallese/Micronesian and Latino men. There has been and continues to be an influx of immigrants from the pacific islands, there is a need to reach out to these men to help them not only with issues concerning their new community but the effects of this move on their families; we would like to hire part time coaches to teach these men in their native language. Family Support Hawaii West Hawaii Fatherhood Initiative January 2015 3. Program Description continued: Our Father Coach drives long distances to deliver this curriculum and to provide individual visits to fathers in need to an area which encompasses over 4,000 miles. Our fuel and transportation costs are high, however we recognize the fact that these men need services in their own communities. The Fatherhood meetings are welcoming, culturally sensitive and we provide a light meal. At one of our class sites, the men bring dishes to share, it is not only a learning experience but a bonding experience as well. Our Father Coach is trusted and respected by his clients; many men have expressed gratitude to him for the assistance he has provided so they could change their lives. There are so many success stories — the father that with the help of the Father Coach, realized his lifestyle was hurting his family and himself and sought help to stop using meth and has stayed off meth, is living with his family and is employed. Another story concerns a father who wanted custody of his children but did not feel he could do so, but after attending classes and having individual meetings with the Father Coach, he now has custody 5 days a week and has a healthy family. The fathers learn to be strong, believe in themselves and appreciate having someone believe in them. These men are learning how to be dedicated fathers and men by attending the classes, working through the curriculum and sharing their stories and learning from one another. Yearly we honor one father in the community, he is given a beautiful wooden plaque with his name inscribed and his name is added to our agency's Fatherhood plaque. This program has established its value in the community, there isn't another program like this on this island. We work hard to ensure the needs of the community are met and to provide a better quality of life for all. The Family Support Hawaii Fatherhood program is focused on investing in the promotion of the positive assets of fathers to create happy, healthy, productive citizens and communities. County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Family support Hawaii Program Name: West Hawaii Fatherhood Initiative 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Hawaii Island United Way $15,000 O'Neill Foundation $15,000 Fee for Service Court Referrals $5,000 Please note, there are no carry over grants, the above are new applications. TOTAL: $35,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program The Fatherhood program was launched 12 years ago, today it reaches over 100 men but there is a need to help more fathers on Hawaii Island. These include a substantial number from the Marshall and other Pacific Islands and Mexico who are having severe challenges with parenting, finances, employment, health, social service and educational systems. We intend to expand the basic program area and to add additional services by creating enterprise activities to increase revenue to support the program. We have met with the Family Court judges in Kona and Waimea to offer our Fatherhood program as an option for a parenting class for those men who are court ordered to get parent education training; in the past fathers needing such classes only had the option of web based offerings. By making this class a fee-for-service, we are able to increase revenues to support the program and men can have real time support from other men who are also working to become the best parent possible. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1 — To increase positive attachment between father and child. 2 — To reduce involvement in the criminal justice system. 3 — To increase employment, economic stability and child support payment compliance. 4 — To increase positive behavior. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Family support Hawaii Program Name: West Hawaii Fatherhood Initiative B. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.: NumberaJ d—,, served, workshops or events held volunteer hours, etcaesaibe, be s,eufic) Applicant Projected Results Fathers who complete the program will increase the support of their children. 75% will increase support. Fathers who complete the program will reduce their alcohol/substance use. 50% will reduce use. Fathers who complete the program will increase their families stability. 50% will increase stability. Fathers who complete the program will increase their positive behavior. 75% will reduce negative behaviors. Operations 2,233 4,500 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FV 14-I6 Actual' FV 15-16 Total Budget fV 15-I6 brant Req Salary and Wages 22,162 25,000 Professional Fees 216 Operations 2,233 4,500 Supplies 239 500 Equipment 0 Other: Other: Other: Other. Other: TOTAL 24,850 30,000 •If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Family Support Hawaii Program Name: West Hawaii Fatherhood Initiative io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist' option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in factor appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. '&Lvd,�Q- 1 Signatu of Authori a erson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Family support Hawaii Program Name: West Hawaii Fatherhood Initiative 11. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 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 Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http // endors 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 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 reportusing the template provided will Impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT G RANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Family support Hawaii Program Name: West Hawaii Fatherhood Initiative 11. Certification of Understanding (Page z of z) If awarded a grantfrom 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 30t^ shall result in loss of all grant funds received during the grant period (must be refunded to Counriland 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-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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of uthorized P s (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 ao_ Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Family Support Hawaii Program Name: West Hawaii Fatherhood Initiative 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Fathers who complete the program will increase the support of their children. 75% will increase Fathers who complete the program will reduce their alcohol/substance use. 50% will reduce use Supplies 500 Fathers who complete the program will increase their families stability. 50% will increase stab Fathers who complete the program will increase their positive behavior. 75% will reduce begat Other: Other: Other Other. TOTAL 30,000 TABLE It: FV 15-16 PROGRAM EXPENDITURES Grant Request Council Award Salary and Wages 25,000 Professional Fees Operations 4,500 Supplies 500 Equipment Other: Other: Other: Other Other. TOTAL 30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8 of Food Basket, Inc., The Ensuring Capacity - East Hawai'i 33 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ensuring capacity- East Hawaii Agency Director: Enyoung Phone No.: ( 808) 933 — 6030 Contact Person: En young Phone No.: ( 808 ) 430 — 2554 Mailing Address: Address: 40 Holonnuo Street Address: City, ST, Zip Hilo, H196720 Facility Address: Address. SAME Address: City, ST, Zip Email Address: en@hawaiifoodbasketorg Accountant/CPA: Ann Fukuhars Firm (if applicable): Ann Fukuhara, CPA, Inc Fax No.: ( 888) 934 — 701 Phone No.: ( 808 ) 961 — 5532 Mailing Address: Address: 45 Pchaku street suite 102 Address: City, ST, Zip Hilo, H196]20 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo ❑✓ North Kohala South Kona ❑✓ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ensuring Capacity- East Hawai'i 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FV 14-15 o $30,000.00 20,000 2. Agency Mission Statement: The mission of The Food Basket, Inc. is to feed the hungry in Hawaii County while attending to the root causes of this critical social problem. The Food Basket will accomplish its mission by: Preventing the waste of all edible food in Hawaii County; Feeding the hungry with this food; Educating the community about local hunger and what can be done to solve this social problem; and Collaborating with organizations of partnering missions to eradicate the root of hunger and other social ills: poverty. 3. Program Description: The objective of this program is to retain capacity for the East side of the island. During 2014 several major events transpired which taxed The Food Basket's capacity to provide services. During the events of Tropical Storms Iselle and 'Ana, resources were diverted to emergency services, including trucks and drivers. A extremely tight budget and limited infrastructure forced The Food Basket, Inc. to choose, at times, between emergency runs and regular operating programs. Additional operating activites required an expanded electricity and overtime budget, as well as increased fuel expenses and an accelerated vehicle maintenance schedule. Although not set in stone, The Food Basket is willing and able to continue to assist in Puna relief efforts. However, should a sustained intervention be necessary, this will negatively affect The Food Basket's regular operations. The funds applied for under this program will be used for invoice -based operating expenses and will be matched by The Food Basket with any salary costs associated with this capacity. In the event that emergency costs are not incurred, the requested amount will be used to assist The Food Basket in outreach and increased support of rural areas on the East side of Hawaii County. 4. Total Budget & Position Count: Total Program Budget: 227,328 Total Program Position Count: o Total Agency Budget: 1,036,163 Total Agency Position Count: 13 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ensuring Capacity- East Hawaii S. Proeram Funding Sources (identify all sources of funding applied to this program): — -- - _ Revenue Source FY1S-16 Estimate Individual Contributions 96,280 Corporate Contributions _ _ 31,512 Foundation and Trust Grants 30,361 Fundraising agency mntributions 69,175 TOTAL: _.227,328 Attoch additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This program does not generate revenue. Rather, this application seeks to be forward- looking and ensure that capacity will exist should it become necessary. Because of the acute nature of the situation, The Food Basket does not expect to continue to apply for this type of operating funds beyond FY2016, with the caveat that small businesses, local suppliers, and residents are able to recover and adapt to any additional hardships the current emergency will pose by year end. Operational costs proposed as alternates to the emergency services will be covered by other general revenues in the absence of County funding in the future. 7. Program Objectives Using County Nonprofit Grant Program Funds: The proposed funds will be operations restricted and limited to expenses unrelated to salary. The Food Basket firmly believes that it is our responsibility to have staff available during crises. The objectives of this program are to ensure that our infrastructure is not a limiting factor when serving the public. Funds may pay for additional cold storage of donated goods, fuel for additional trips, additional maintenance incurred through heavy vehicle usage, increased electricity costs, or other operating expenses based on The Food Basket's participation in relief. During the two-month time period, The Food Basket's Hilo branch incurred approximately $5,000 in non -salary capacity expansion costs. At that rate, $30,000 will cover capacity costs for a year of intervention. Should full relief be unneccesary, The Food Basket still believes that staff and salary costs should not be made a part of this application. Therefore, capacity associated with outreach and delivery to rural areas will be defrayed with the granted funds. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ensuring capacity- East Hawaii 8. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.: Number p/tlients served, workshops or events held, volunteer hours, etc Describe, be spent, I Applicant Projected Results Number of Trips to rural areas 3 per week Emergency Trips As necessary Total Clients served 5,000 Professional Fees O Operations 227328 498,000 30,00 0 Attach odditional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual• FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages Professional Fees O Operations 227328 498,000 30,00 0 Supplies -I Equipment Other. Other. Other Other. Other TOTAL 1 227328 498,000 30.000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ensuring Capacity- East Hawaii lo. 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 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 signed regardless of whether a conflict exists. NAME: Chris Schleuter POSITION: Board of Directors May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ 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: Mr. Schleuter will recuse himself from any votes directly associated with County funds. ❑ If no conflicts exist, check here. Signature of Authorized Person (specify title) EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ensuring capacity- East Hawaii 11. Certification of Understanding (page 1 aft) I (we) have read and understood all of the 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 final payment. 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 reportusing the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ensuring capacity- East Hawaii ii. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 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 Litt p:Uwww.hawalicounty.Rov/fn-nonprofit-Brant-forml on or about May 30 of the year the final 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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements Signature of A ized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ensuring Capacity- East HawaPi 12. COUNCIL AWARD WORKSHEET TABLE I: pppli<ant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result TABLE!!: -- FY 15-16 PROGRAM EXPENDITURES Grant Request Council Award Salary and Wages Professional Fees -Operations _. Supplies Equipment Other. - Other: _ Other. Other. �� �_..— Other: Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Food Basket, Inc., The Ensuring Capacity - West Hawai'i 34 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ensuring Capacity- West Hawaii Agency Director: En Young Phone No.: ( 808) 933 — 6030 Contact Person: en Young Phone No.: (floe ) 430 — 2554 Mailing Address: Address: 40 Holumua street Address: City, ST, Zip Hilo, HI 96720 Facility Address: Address: SAME Address: City, ST, Zip Email Address: en@h...,,E.ddasketurs, Fax No.: ( 808) 934 - 102 Accountant/CPA: Ann Fukuhara Phone No.: ( 8081 962 — 5532 Firm (if applicable): Ann Fukuhara, CPA, Inc. Mailing Address: Address: 45 Pohaku street Suda 202 Address: Qty ST,ZIP 110 ,H196]20 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Harl North Kona ❑✓ South Hilo ❑✓ North Kohala South Kona ❑✓ North Hilo ❑✓ South Kohala Q Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑r/ Needs of the poor ❑ Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ensuring Capacity- West Hawaii 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 1 0 $30,000.00 20,000 2. Agency Mission Statement: The mission of The Food Basket, Inc. is to feed the hungry in Hawaii County while attending to the root causes of this critical social problem. The Food Basket will accomplish its mission by: Preventing the waste of all edible food in Hawaii County; Feeding the hungry with this food; Educating the community about local hunger and what can be done to solve this social problem; and Collaborating with organizations of partnering missions to eradicate the root of hunger and other social ills: poverty. 3. Program Description: The objective of this program is to retain capacity for the West side of the island. During 2014 several major events transpired which taxed The Food Basket's capacity to provide services. During the events of Tropical Storms Iselle and 'Ana, resources were diverted to emergency services, including trucks and drivers. A extremely tight budget and limited infrastructure forced The Food Basket, Inc, to choose, at times, between emergency runs and regular operating programs. Additional operating activites required an expanded electricity and overtime budget, as well as increased fuel expenses and an accelerated vehicle maintenance schedule. Although not set in stone, The Food Basket is willing and able to continue to assist in Puna relief efforts. However, should a sustained intervention be necessary, this will negatively affect The Food Basket's regular operations. The funds applied for under this program will be used for invoice -based operating expenses and will be matched by The Food Basket with any salary costs associated with this capacity. In the event that emergency costs are not incurred, the requested amount will be used to assist The Food Basket in outreach and increased support of rural areas on the West side of Hawaii County. 4. Total Budget & Position Count: Total Program Budget: 227,328 Total Program Position Count: 1 0 Total Agency Budget: 1,036,163 Total Agency Position Count: i 13 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ensuring Capacity- West Hawaii Funding Sources (identify all sources of funding applied to this program): Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This program does not generate revenue. Rather, this application seeks to be forward- looking and ensure that capacity will exist should it become necessary. Because of the acute nature of the situation, The Food Basket does not expect to continue to apply for this type of operating funds beyond FY2016, with the caveat that small businesses, local suppliers, and residents are able to recover and adapt to any additional hardships the current emergency will pose by year end. Operational costs proposed as alternates to the emergency services will be covered by other general revenues in the absence of County funding in the future. 7. Program objectives Using County Nonprofit Grant Program Funds: The proposed funds will be operations restricted and limited to expenses unrelated to salary. The Food Basket firmly believes that it is our responsibility to have staff available during crises. The objectives of this program are to ensure that our infrastructure is not a limiting factor when serving the public. It is very likely that during any relief efforts, Kona warehouse resources may be deployed on the Hilo side where they are necessary and the Kona warehouse will service more total area to allow Hilo resources to concentrate on high need areas. Therefore, funds may pay for vehicle rentals, increased costs of transportation due to managing more area, increased vehicle maintenance and fuel, and other associated costs. . $30,000 is estimated to be sufficient to pay capacity costs for a year of intervention. Should full relief be unneccesary, The Food Basket still believes that staff and salary costs should not be made a part of this application. Therefore, normal capacity associated with outreach and delivery to rural areas will be defrayed with the granted funds. On the West side, developing services in remote areas such as Ocean View will be sustained and, if needed, expanded. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of FY15-16 Revenue Source Estimate 96,280 Individual Contributions 31,512 Corporate Contributions 30,361 Foundation and Trust Grants Fundraising agency contributions 69,175 — TOTAL: 227,328 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This program does not generate revenue. Rather, this application seeks to be forward- looking and ensure that capacity will exist should it become necessary. Because of the acute nature of the situation, The Food Basket does not expect to continue to apply for this type of operating funds beyond FY2016, with the caveat that small businesses, local suppliers, and residents are able to recover and adapt to any additional hardships the current emergency will pose by year end. Operational costs proposed as alternates to the emergency services will be covered by other general revenues in the absence of County funding in the future. 7. Program objectives Using County Nonprofit Grant Program Funds: The proposed funds will be operations restricted and limited to expenses unrelated to salary. The Food Basket firmly believes that it is our responsibility to have staff available during crises. The objectives of this program are to ensure that our infrastructure is not a limiting factor when serving the public. It is very likely that during any relief efforts, Kona warehouse resources may be deployed on the Hilo side where they are necessary and the Kona warehouse will service more total area to allow Hilo resources to concentrate on high need areas. Therefore, funds may pay for vehicle rentals, increased costs of transportation due to managing more area, increased vehicle maintenance and fuel, and other associated costs. . $30,000 is estimated to be sufficient to pay capacity costs for a year of intervention. Should full relief be unneccesary, The Food Basket still believes that staff and salary costs should not be made a part of this application. Therefore, normal capacity associated with outreach and delivery to rural areas will be defrayed with the granted funds. On the West side, developing services in remote areas such as Ocean View will be sustained and, if needed, expanded. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: The Food Basket, Inc. Program Name: Ensuring Capacity- West Hawaii 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results Number of d-ts served, .,ksha, or events held, volunteer hours, etc Describe, be spe jcf Clienls Served as necessary 9. TABLE II: PROGRAM EXPENDITURES FY 14 is Actual" FY 1s-16 ,Total Budget FY 15-16 Grant Req Salary and Wages Professional Fees Operations 227328 498,000 30,000 Supplies Equipment _ Other: _-- Other: Other. -- — - Other. Other: TOTAL 2273281 498,0001 30,000 "If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ensuring Capacity- West Hawai i lo. 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: Chris Schleuter POSITION: Board of Directors May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor The Managing Director The Director of Finance F✓ 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: Mr. Schleuter will recuse himself from any votes directly associated with County funds. ❑ If no conflicts exist, check here. .,2 //r /J Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ensuring capacity- west Hawaii 11. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 final payment. 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 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 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 usina the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name; Ensuring Capacity- West Hawaii 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 30t' shall result in loss of all ¢rant 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 hyn.LZwww.hawaiicounty loy/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 lune 30, 2015 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 aoencv's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature uthgG6ed Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 1/-e°/iJ- Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ensuring capacity- West Hawaii 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Resuns Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-I6 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other. Other TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 Food Basket, Inc., The Ho'omana Ka Hua - "SNAP -ping Barriers 35 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ho'olaha Ka Hua- "SNAP -ping Barriers" Agency Director: En Young Phone No.: ( 808) 933 — 6030 Contact Person: En Young Phone No.: ( 808 ) 430 — 2564 Mailing Address: Address: 40 Holomua Street Address: City, ST, Zip Hilo, HI 96720 Facility Address: Address: SAME Address: City, ST, Zip Email Address: eo&va irroodbasketerg Fax No.: ( 806) 934 — 101 Accountant/CPA: Ann Fukuhara Phone No.: ( 806) 961 — 5532 Firm (if applicable): Ann Fukuhara. CPA. mo. Mailing Address: Address: 45 Pohaku Street, Suite 102 Address: City, ST, Zip Hilo, HI 96120 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑✓ North Kona ❑✓ South Hilo Q North Kohala ❑✓ South Kona �✓' North Hilo ✓❑ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXH I BIT A NON PROFIT G RANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ho'olaha Ka Hua- "SNAP -ping Barriers" 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 32-13 FY 13-14 FY 14-15 $30,000.00 20000 2. Agency Mission Statement: The mission of The Food Basket, Inc. is to feed the hungry in Hawaii County while attending to the root causes of this critical social problem. The Food Basket will accomplish its mission by: Preventing the waste of all edible food in Hawaii County; Feeding the hungry with this food; Educating the community about local hunger and what can be done to solve this social problem; and Collaborating with organizations of partnering missions to eradicate the root of hunger and other social ills: poverty. 3. Program Description: The objective of this program is to ensure access for SNAP -eligible individuals to a steady supply of fresh local fruits and vegetables. As many social service agencies can attest, the amount of SNAP dollars is often not enough to cover families' food needs for an entire month, especially larger food households at the higher end of the income scale. The Food Basket's "Ho'olaha Ka Hua" program has shown success in attracting SNAP participants to fresh, local fruits and vegetables as evidenced by the over 100 SNAP enrollments over the first few months of the program. Unfortunately, because SNAP dollars are issued monthly, The Food Basket is prohibited from charging an entire month in advance for produce. At the end of the month, SNAP participants who enjoy the program have often run out of benefits, thus denying them the ability to participate in the program during those times. This program would create a restricted fund specifically to assist these families during this time. As the budget reflects, The Food Basket is asking strictly for funds restricted to food, no salary or overhead is being requested. As an added bonus, because The Food Basket sources 100% locally, any funds allocated for this purpose is spent on local produce from local farmers. 4. Total Budget & Position Count: Total Program Budget: 15000 Total Program Position Count: o Total Agency Budget: 1036163 Total Agency Position Count: 13 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ho'olaha Ka Hua- "SNAP -ping Barriers" 5. Program Funding Sources (identify all sources of funding applied to this program) FY15-16 Revenue Source Estimate United Way (pending) 20000 I TOTAL: 20000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Currently, the program does produce revenue. However, being in its sixth month, the program has not overcome capital costs and costs of scaling associated with the expansion. Once the program surpasses its break-even point, additional revenues will be able to support not only the proposed fund, but other programs such the Keiki Backpack program and numerous Senior programs run by The Food Basket. 7, Program Objectives Using County Nonprofit Grant Program Funds: The proposed funds will be food restricted and limited to expenditure for needy families. As an incentive, the proposal to add a free week of produce will allow SNAP -eligible consumers to cover the final week of the month where ordinarily funds available may have been exhausted. The objectives are crystal clear. At a price of $10/week, we will be able to provide 1500 additional boxes with the funds requested. Depending upon enrollment, this will provide 150 SNAP eligible households with ten (10) months of incentive, or 300 SNAP eligible participants with five (5) months of incentive. The Food Basket will also review budgets with participants to ensure they are maximizing their benefits and receiving as much food as possible. The Food Basket, Inc. has also entered into a partnership with HOPE Services Hawaii, the island's SNAP outreach coordinator, to provide outreach and sign-up services for those who are SNAP -eligible and have not yet enrolled, thereby assisting in increasing participation. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ho'olaha Ka Hua- "SNAP -ping Barriers" 8. TABLE I: ­­ — I.– ... .-- ..,..Nu -L, 41101..,,.,,.,.. Ll�o.111�.ct.J IonLII LI I,s IuI lUi I lgr PROGRAM PERFORMANCE MEASURES Applicant Projected Results (Le.: Number ofclients served, workshops or events held, volunteer howl, eto. Do ..Are, be specific) �Number G' Bgxes for SNAP -eligible households i 1500 r10Useholds receiving assistance 150-300 (TBD) 9. TABLE II: PROGRAM EXPENDITURES FY 1 i Actual" FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages Professional Fees Operations Supplies Equipment Other: Food N/A 35000 15000 Other Other. Other Other: TOTAL 35000 15000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ho'olaha Ka Hua- "SNAP -ping Barriers" io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: Chris Schleuter POSITION: Board of Directors 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 ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑✓ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in factor appearance, any conflicts or potential conflicts of interest: Mr. Schleuter will recuse himself from any votes directly associated with County funds. ❑ If no conflicts exist, check here. Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: The Food Basket, Inc. Program Name: Ho'olaha Ka Hua- "SNAP -ping Barriers" 11. 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 allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and 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 final payment. 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 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 Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ho'olaha Ka Hua- "SNAP -ping Barriers" 11. Certification of Understanding (page z of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of 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 htcp.L/www.hawai roujntov fnonor about May 30 of the year the final 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. A/�l Signature of Auth ' d Perso (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Food Basket, Inc. Program Name: Ho'olaha Ka Hua- "SNAP -ping Barriers" 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Projected ant I Council Proposed Protected Results Projected Result TABLE It: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other.— Other: -Other Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NON PROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Friends of Big Island Drug Court Assistance to Drug Court Clients & Program 36 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of Big Island Drug Court Program Name: Assistance to Drug Court Clients & Program Agency Director: No Paid staff Phone No.: ( ) — Contact Person: Peter Kubota, President Phone No.: ( 808) 935 — 2422 Mailing Address: Address: 505Kilaued Ave. Address: City, ST, Zip Hilo. HI 96720 Facility Address: Address: Nofacildy-only POBox Address: PO Box 6100 City, ST, Zip Hila, HI 96720 Email Address: Peter@kubmao..com Accountant/CPA: Brian Iwats (board member) Firm (if applicable): Takata, Iwata. Hard &Assoc., un Mailing Address: Address: 101 Aupcni se, suae 139 Address: City, ST, Zip Hilo, HI 96720 Fax No.: ( 808) 935 — 9999 Phone No.: ( 696 ) 935 — 5404 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFYTHE FINANCE DEPARTMENT AND COUNCIL OFANYCHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑,/ Puna ❑✓ Hamakua © North Kona ❑� South Hilo ❑✓ North Kohala ❑✓ South Kona 0 North Hilo ✓❑ South Kohala © Ka'u Services or Activities To Be Provided: (one or more can be checked) ❑� Educational concerns ❑✓ youth Victims of Crimes ❑ Culture and the arts ❑✓ Aged Victims of Health or Social Crises Needs of the poor ✓❑ Physical/Emotional Disabilities Q Public Health and Welfare of the People and the Environment EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1ofa County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of Big Island Drug Court Program Name: Assistance to Drug Court Clients & Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 $10,000 FY 13-14 FY 14-15 Total Agency Budget: $14,0001 $8,000.00 $10,000.00 $0 2. Agency Mission Statement: The Mission of the Big Island Drug Court is to help address societal problems related to substance abuse in order to minimize their societal and economic costs and to protect the Big Island community by providing timely and effective treatment for drug offenders with appropriate sanctions and incentives. Simply stated, the "Friends of Big Island Durg Court" is a 501 c3 organization created to provide financial and other support for Drug Court clients and the overall program. 3. Program Description: The Friends of Big Island Drug Court provides funding and other support for the clients and programs of Big Island Drug Court. This includes rewards and incentives to clients during their drug-free journey (such as gift certificates, movie tickets, etc.), loans or awards for tuition to further their education, and loans or awards for housing, travel other such needs. The Friends also sponsors graduation supplies for Drug Court clients and responds to individual requests for support. They also support alumni and support group activities to help ensure long-term success for clients. All programs and activities are conducted by volunteers, as there are no paid employees. The organization is governed by a volunteer board of directors, representing a cross-section of individuals from the community. 4. Total Budeet & Position Count: Total Program Budget: $10,000 Total Program Position Count: 0 Total Agency Budget: $14,0001 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Friends of Big Island Drug Court Program Name: Assistance to Drug Court Clients & Program Funding Sources lidentifv all sources of funding applied to this program): Revenue Source FY15-16 Estimate County of Hawaii Non-profit grant $10,000.00 Donations - businesses, individuals, foundafions, etc. $4,000.00 Donation for new Veterans Drug Court clients only - restricted funds $13,630.00 TOTAL: $27,630.00 Aa.uh additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Friends of Big Island Drug Court will continue to reach out to potential program donors for monetary donations. These include area attorneys, businesses, foundations and individuals who have been in some way affected by the positive impact this program has had on either their own family or community. We will also continue to reach out to non-profit service organizations, such as Rotary, Lions, Kiwanis, etc., for their collaboration and support. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Friends is designed to integrate community/private support into governmental efforts directed at the rehabilitation of adult men and women and juveniles, who are charged with or convicted of felonies and assessed as chemically dependent on alcohol and/or other drugs, by securing financial support for governmental efforts to operate Big Island Drug Court in the Third Circuit. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of Big Island Drug Court Program Name: Assistance to Drug Court Clients & Program 8. TABLE I: ml6v..ro t6o mtoodad measurable cutouts or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.: Number of,hent, served, worYshops or even. h10, volunteer hours, err. Describe, be IM101) Applicant Projected Results Approximately 190 clients, including adults and juveniles, are cumently in the program- Friends'support critical to success. Periodic graduation programs for clients are supported by friends. Graduation defines successful outcome Drug Court clients donate hundreds of hours of labor to community organizations. Opportunity to repay society Clients provided with funds to secure GED or other educational programs. Helps them find employment. Clients supported and rewarded in journey to become drug or alcohol -free. Helps them focus on completing program Upon graduation, court charges dropped and clients return to their communities Avoids huge prison costs. New Veterans Drug Court established in 2014 to target needs of veterans. Working on changes needed to address Attach additional pages os necessary. 0 TARI F IL PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 0.01 0.0 0.0 Professional Fees 0.0 0.0 0.0 Operations $2,210.04 $2,600.00 0.0 Supplies Equipment Other: Loans to Clients $2,693.00 $4,000.00 $3,000.00 Other Community Service Projects $1,357.94 $2,000.00 $2,000.00 Other: Drug Court Month Expenses $238.42 $300.00 0.0 Other Drug Court Graduation Expenses $1,545.52 $1,700.00 $1,000.00 Other Grants & Incentives to Dmg Court Participants $3,371.00 $5,000.00 $4,000.00 TOTAL $11,415.92 $15,600.00 $10,000.00 appacame EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of Big Island Drug Court Program Name: Assistance to Drug Court Clients & Program io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ® If no conflicts exist, check here. Signalture of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of Big Island Drug court Program Name: Assistance to Drug court clients & Program 11. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 final payment. 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 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 veer -end reportusing the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of Big Island Drug Court Program Name: Assistance to Drug Court clients & Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured priorto 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-formsj on or about May 30 of the year the final 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, 2015 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 aaencV's future funding request and moV result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Sig ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of Big Island Drug Court Program Name: Assistance to Drug Court Clients & Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Projeectedcted Results Council Proposed Projected Result Successful completion of graduation requirements for Drug Court Gienls 90% Support for D -ug Court graduates (alumni programs) to reduce recidivism 85% Community projects to instill an attitude of giving back to the community for their support Increase by 10% Supplies 0.0 Equipment 0.0 Other: Loans to Clients $3,000.00 Other Community service Projects $2,000.00 TABLE It: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 0.0 Professional Fees 0.0 Operations 0.0 Supplies 0.0 Equipment 0.0 Other: Loans to Clients $3,000.00 Other Community service Projects $2,000.00 Other: Drug Court Month Expenses O.D Other: Drug Court Graduation Expenses $1,000.00 Other. $4,000.00 TOTAL $10,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Friends of Children's Justice Center EH Special Needs, Enhancement, Support, Education and Training 37 County oCllawai'i Nonprofit Grant Application FY2015-16 Agency Name: Friends of Children's Justice Center EH Program Name: Spcl Needs. Enhncemnt Supprt, Ed & Train Agency Director: Rohn aenecm- Phone No.: ( 808) 955 — 3155 Contact Person: Rohl, sonedmd Phone No.: (808)935— 8755 Mailing Address: Address. P. o. el,. 6908 Address City. ST, Zip Hilo. Hawaii 96116 Facility Address: Address: 1290Kinode S; Address: City, ST, Zip Hiie Hawaii 96720 Email Add ress: fc ehGmhawail rr com Fax No.: (808)961 — 751 Accountant/CPA: aenmrer tosser Phone No.: ( 808 ) 969 — 3115 Firm (if applicable): 2enniferL Gossert Mailing Address: Address: bee Ktocoie sr. Address: City, ST, Zip r , Hawaii 9fi720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds s 25.000.00 Geographical Areas To Be Served: (One or more can be checked) Puna ❑✓ Hamakua ❑ North Kona South Hilo ❑ North Kohala ❑ South Kona �] North Hilo ❑ South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns youth ✓❑ Victims of Crimes © Culture and the arts ❑ Aged ✓❑ Victims of Health or Social Crises ✓❑ Needs of the poor Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of Children's Justice Center EH Program Name: Spcl Needs, Enhncemnt,Supprt, Ed & Train 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 20,000.00 820,000.00 20,000.00 2. Agency Mission Statement: The mission of the Friends of the Children's Justice Center of East Hawaii (aka Friends) is to help sexually, physically, and emotionally abused and neglected children, and children who are witnesses to crime, in partnership with the Children's Justice Center of East Hawaii, with a primary goal of enhancing and protecting their physical and psychological well-being. 3. Program Description: The Program serves children between the ages of 0-18, who are documented victims of abuse, or are witnesses to crime, residing in East Hawaii, filling requests for special needs and enhancements (i.e. clothing, hygiene items, beds, bedding, transportation, school supplies, intercession activities, tutoring, holiday and birthday gifts, Winners Camp, sports.. dance, arts. and music). The Program provides Center support to the Children's Justice Center of East Hawaii.. by providing for resources to help reduce trauma and ensure the safety and comfort of the children that come to the Center for interviews. The Friends maintain the Center's safe, child -friendly and homelike atmosphere, with toys, books, stuffed animals, games, snacks, and a gently used children's clothes closet .Through education and prevention, the Friends educates the community regarding child abuse issues. The Program plans events for the public, and maintains and updates the Friends website, promoting child abuse awareness and prevention. The Program sponsors training, by supporting the attendance of professionals at seminars and conferences, to learn state-of-the-art interviewing techniques to enhance and refine their overall skills. 4. Total Budget & Position Count: Total Program Budget: $179.500 Total Program Position Count: 1 Total Agency Budget: $194.5001 Total Agency Position Count: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 Countyof Hawai' i Nonprofit Grant Application FY2015-16 Agency Name: Friends of Children's Justice Center EH Program Name: Spot Needs, Enhncemnt,Supprt, Ed & Train S. Program Fundine Sources (identify all sources of funding applied to this program): Attach additional page; if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Friends do not collect fees for any of our services. We are continuously researching for additional grant funding, striving to increase donations for our Phantom non-event fundraiser. and expanding participation in our golf tournament fundraiser. 7. Program Objectives Using County Nonprofit Grant Program Funds: Provide funds for emergency needs (i.e clothing, hygiene items, bedding, car seats, baby needs, health related needs) and enhancements (i.e. sports- equipment, fees and registratiomdance, drama, music, art, school supplies, school pictures, tutoring, intercession activities, ground and air transportation, holiday and birthday gifts, prom and graduation expenses). Assist police, social workers, and other professionals in keeping up to date with the latest investigative techniques, sensitivity training, forensics and knowledge of resources.. by helping to sponsor their attendance at training workshops and seminars. Provide privacy, comfort and safety, for children and family members who come to the Center, by maintaining its warm environment. Participate with the East Hawaii Coalition for Child Abuse Prevention in community education activities to increase public awareness. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of FY15-16 Revenue Source Estimate County of Hawaii $25,000 Donations $3.500 Fundraising (net) $16,000 Special Events _ $25,000 Charity walk $10,000 Hawaii Island United Way $5,000 Foundation and Corporate Grants $95,000 TOTAL: $179 500 Attach additional page; if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Friends do not collect fees for any of our services. We are continuously researching for additional grant funding, striving to increase donations for our Phantom non-event fundraiser. and expanding participation in our golf tournament fundraiser. 7. Program Objectives Using County Nonprofit Grant Program Funds: Provide funds for emergency needs (i.e clothing, hygiene items, bedding, car seats, baby needs, health related needs) and enhancements (i.e. sports- equipment, fees and registratiomdance, drama, music, art, school supplies, school pictures, tutoring, intercession activities, ground and air transportation, holiday and birthday gifts, prom and graduation expenses). Assist police, social workers, and other professionals in keeping up to date with the latest investigative techniques, sensitivity training, forensics and knowledge of resources.. by helping to sponsor their attendance at training workshops and seminars. Provide privacy, comfort and safety, for children and family members who come to the Center, by maintaining its warm environment. Participate with the East Hawaii Coalition for Child Abuse Prevention in community education activities to increase public awareness. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of County of Ilawai'i Nonprofit Grant Application FY2015-16 Agency Name: Friends of Children's Justice Center EH Program Name: Spcl Needs, Enhncernnt,Supprt, Ed & Train R. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i e.: Nombtr oftlrentsserved, workshops or events 1,14 -1"1111-11 It, ossmhe, be spun/Ic) Applicant Projected Results Fill "Special Need & Enhancement' Requests 1,200 Serve child victims of abuse and or neglect 650 Maintain holiday gift requests 300 Volunteer hours 900 $10,200 Operations $9.129 $9.500 Attach odditionol pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 1415 Actual' FY 15-16 Total Budget FY 15-16 ^. Grant Req �I Salary and Wages $43,757 $4],000 $4,500 Professional Fees SS625 $10,200 Operations $9.129 $9.500 Supplies $3.457 $3.600 Equipment - Othe❑ Special Needs Requests $97,161 $102,500 520,500 Other Education end Prevention $4,110 $2.000 Other. Center Support $1,725 $2.200 Other OJO Facility Maintenance $2,043 $1.500 Other Training $1.000 TOTAL $ntoz7 $n1 "' szs,9go If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Nagle: Friends of Children's Justice Center EH Program Name: Spcl Needs, Enhncemnt Suppirt, Ed & Train to. 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 signedregardless of whether a conflict exists. NAME: Jay Kimura POSITION. President May have a conflict or potential conflict of interest, including any familial relationship, with any ofthe following (check all that apply): ❑ Member or members ofthe Council ❑ staff appointed by a member of the Council MThe 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 probab8ity 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 uthorized Person (specify title) IF Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of l lawai'i Nonprofit Grant Application FY2015-16 Agency Name: Friends of Children's Justice Center EH Program Name: Spcl Needs, Enhncemnt Supprt, Ed & Train io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed- If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: Jill Jacunski POSITION: Treasurer 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 ofthe Council ❑ Staff appointed by a member of the Council ❑ The Mayor The Managing Director The Directorof Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a subs tan Gal probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruinq 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. Q,a Q a I71 IS Sign ure o Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of llawai`i Nonprofit Grant Application FY2O15-16 Agency Name: Friends of Children's Justice Center EH Program Name: Spcl Needs, Enhncemnt,Supprt, Ed & Train it. Certification of Understanding (Page 1 of z) I (we) have read and understood all of the 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 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 Hawaii, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://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 Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after lune 30 of the 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 o timely, complete and accurate year-end reportusing the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of'] lawai-i Nonprofit Grant Application PY2015-16 Agency Name: Friends of Children's Justice Center EH Program Name: Spcl Needs, Enhncemnt,Supprt, Ed & Train ii. Certification of Understanding (Page 2 of 2) Ifawarded 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 lune 30'h 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.['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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Anatilre of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application PY2015-16 Agency Name: Friends of Children's Justice Center EH Program Name: Spcl Needs, Enhncemnt,Supprt, Ed & Train 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Fill "Special Need & Enhancement" Requests Serve child victims of abuse and or neglect 1200. 650 Maintain holiday glft requests 300 i Professional Fees Volunteer hours 900 Operations Supplies TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $4.500 i Professional Fees Operations Supplies Equipment - Other: Special Needs Requests $20.500 Other: Other: Other: ---- Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 3 Friends of the Children of West Hawai'i Basic Needs and Enhancement Activities M County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of the Children of West Hawai'i Program Name: Basic Needs and Enhancement Activities Agency Director: Beverly Fraser Phone No.: ( 808) 331 — 2425 Contact Person: Beverly Fraser Phone No.: ( 908) 331 — 2425 Mailing Address: Address: Po au. 9o41 Address: City, ST, Zip Kali. Kona, HI 96745 Facility Address: Address: 94-5619 P.i Street Address: Suite 205 City, ST, Zip Kailua Kom, HI 96740 Email Address: merdsc m@gmail.� Accountant/CPA: w&mwtt Firm (if applicable): Ta.A rxates Fax No.: (MB) 315 — 8493 Phone No.: ( 808) 331 — B555 Mailing Address: Address: 95-56561<w iHiymvay Address: Suite302 City, ST, Zip kailua Kona, H196940 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $ to,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑v' North Kona ❑ South Hilo ❑✓ North Kohala ❑✓ South Kona ❑ North Hilo ❑✓ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) v❑ Educational concerns ❑✓ Youth ❑✓ Victims of Crimes Q Culture and the arts ❑ Aged - ❑✓ Victims of Health or Social Crises ❑t/ Needs of the poor ❑✓ Physical/Emotional Disabilities Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of the Children of West Hawaii - Program Name: Basic Needs and Enhancement Activities 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 fs000.00 $0.00 16000.00 2. Agency Mission Statement: The mission of the Friends of the Children of West Hawai'i is: . to provide assistance to children who have been traumatized by sexual assault, physical abuse or neglect, or who have witnessed violent crime; and ' to promote the prevention of child abuse. 3. Program Description: All of the children we serve have been a victim of abuse or neglect. Our Basic Needs program is designed to meet the IMMEDIATE basic needs of children who have been removed from their home without the opportunity to retrieve any of their personal belongings; as well as meeting the ONGOING needs of children who reside in residences where there are financial challenges. Samples of these needs would include clothing or shoes; baby needs such as diapers, car seats, cribs or playpens, safety gates etc; and school supplies. Often as a result of abuse and neglect, child victims experience chaos and instability in their lives, depriving them of the usual supports and positive experiences necessary to grow into self-confident, productive adults. Our Enhancement Program covers the cost of what these children often miss out on such as theater workshops, summer camp, art camp, music or art lessons, organized athletic activities, horse camp, or school intercession activities. Since many of these children reside in foster homes where extra money is often not available, the program also provides funding for items such as graduation expenses; sports equipment; travel for school trips etc. 4. Total Budget & Position Count: Total Program Budget: 47,415.ee Total Program Position Count: .75 Total Agency Budget: 75,3w.00l Total Agency Position Count: .75 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name Friends of the Children of West Hawaii - Program Name: Basic Needs and Enhancement Activities S. Proeram Fundine Sources tidentifv all sources of funding applied to this programl: Revenue Source County of HaeraiQ Giesl Foundation Hughes Foundation j=t3mz1fte Visitor Industry Charity Walk Friends of Hawaii Charities TOTAL• Attach oddidonal pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Friends of the Children of West Hawai'i has been providing our Basic Needs and Enhancement Activities Programs to children in Hawaii for over 25 years, through the generosity of several Hawaii based private Foundations, as well as our own fundraising activities. We currently hold two fundraising events annually, with plans to add a third event in 2015. In addition, our Executive Director has been tasked with finding additional sources of grant funds, as well as working with local businesses to partner with the Friends in a variety of ways. In 2014 we were fortunate to work with a local bank, who provided volunteers to assist with aschool supplies drive held in both Kailua Kona and in Waimea. This partnership allowed the Friends to provide 87 backpacks filled with school specific supplies for children, and it is our hope that we can repeat the activity in 2015. 7. Program Objectives Using County Nonprofit Grant Program Funds: Using funds from the County of Hawaii, along with funds from other sources, our goal is to assist a minimum of 700 children in West Hawaii who have been victims of abuse or neglect by providing either Basic Needs or Enhancement Activities. The Friends does not provide direct services to children; rather we partner with those who do such as Child Welfare Services, Family Support Hawai'i, Catholic Charities, Salvation -Army and others. We also partner with private therapists, guardian ad -litems etc who work directly with these young victims. These individuals have first hand knowledge of the needs of the children they work with, and make the request for funding to the Friends based on each childs specific need. It is also our goal to send three teenagers to Winner's Camp on Oahu, which is a teen leadership camp whose mission is to "provide cutting edge leadership camps for teens, families and teachers; and to awaken teenagers to their highest personal and community potential". The cost per teenager, including travel and tuition, is approximately $1,500.00. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of the Children of West Hawa7i Program Name: Basic Needs and Enhancement Activities 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results Numbesgdiarnurveb, w hopswnenbherq ralwteer Lows, e0: ae=oihe, Lespeaycl Number of Individual Children Served 325 Number of Needs Requests Funded 800 Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual- FY 1536 Tonal Budget FY 15-16 Grant Req Salary and Wages 0 0 0 Professional Fees 16694.00 19.200.00 0 Operations 0 0 0 Supplies 0 0 0 Equipment 0 0 0 Other: Enhantemmd A tivites 07.01.14 to 12.31.14 1624.85 18615.00 4653.00 Other: Bask Needs 07.01.14 to 1231.14 1375.15 5400.00 3247.00 Other. Winners camp 07.01.14 to 12.31.14 4200.00 2100.00 Other: Other: TOTAL 3000.00 47,415.00 10.000.00 `If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of the Children of west Hawaii - Program Name: Basic Needs and Enhancement Activities io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 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. ;24 , irES,tLtrtT Signature dVAuth9rIzWPerson(specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 1 l-2-2J-7-pI� Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of the Children of West Hawai'i - Program Name: Basic Needs and Enhancement Activities ti. Certification of Understanding (Page t of 2) 1 (we) have read and understood all of the 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. 1 (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 final payment. 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 speck, 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 reportusing the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Friends of the Children of West Hawai i Program Name: Basic Needs and Enhancement Activities 11. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant Participation for a minimum of one year or until a written report Is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http�//www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. P�estc�nT ot-Zi-zDis- Signatur uthorize rs .(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of the Children of West Hawaii Program Name: Basic Needs and Enhancement Activities 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant I Council Proposed Projected Results I Projected Result TABLE II: PROGRAM EXPENDITURES FY 1516 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: - Othec Other: - -- Other TOTAL �UU-UUtlo• wurrn• UI Unres re a--awara: EXHIBIT B NONPROFIT GRANT APPLICATION FV 20142015 Page 8 of 8 Friends of the Palace Theater Celebration of Hawaiian Music Series 39 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of the Palace Theater Program Name: Celebration of Hawaiian Music Series Agency Director: rnomen Bahurinsky Phone No.: ( eoe) — 939-7010 Contact Person: Isobel Donovan Phone No.: ( SIN — 936-1328 Mailing Address: Address: 38 Hair straM Address: City, ST, Zip Hilo, Hawaii, 96720 Facility Address: Address: same Address: City, ST, Zip Email Address: Morgen.bahurinsky@mbpalacecom Fax No.: ( BOB) — 969-9912 Accountant/CPA: Phone No.: ( 808) — 930-68M Firm (if applicable): carbonam cA 6 Aaaociates Mailing Address: Address: PO Box 4372 Address: City, ST, Zip Hilo, Hawaii 96729 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua ❑ North Kona © South Hilo ❑ North Kohala ❑ South Kona W] North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns ❑ youth ❑ Victims of Crimes © Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of the Palace Theater Program Name: Celebration of Hawaiian Music Series 1. Prior Year Award of County Nonprofit Grant Program Funds: 1112-13 FY 13-14 1 FY 14-15 $0.00 $0.00 $1500.00 2. Agency Mission Statement: The mission of the Friends of the Palace Theater is to "revitalize, restore and sustain Hilo's historic theater as a venue that educates, entertains, and inspires our diverse community". The Palace Theater is a prime showcase for Hawaii's performing artists, indigenous filmmakers, and for local, multi -cultural events, and has served many generations as a cultural gathering place. 3. Program Description: The Celebration of Hawaiian Music series will feature both well-known and up- and -coming Hawaiian musical performers over the course of 6 concerts, with the intent of highlighting, preserving, and perpetuating the musical legacy of Hawaii and its oral tradition of recording history, culture, and lifestyle. This project has been developed to engage a very diverse audience - from young people who want to learn more about their native heritage and culture, to adults and families visiting from elsewhere who want to learn about the roots of Hawaiian culture, to local families and elderly patrons who merely want to be entertained and 'reminisce". Hawaiians have traditionally used music to define themselves and to celebrate "aloha 'aina", or love of the land, and the Friends of the Palace Theater have endeavored to ensure that a significant part of their annual offering honors and highlights Hawaiian culture through the use of both local talent and international Hawaiian practitioners. As the Theater will achieve 90 years of age in 2015, a free concert is also planned to celebrate its place in Hawaiian cultural history. 4. Total Budget & Position Count: Total Program Budget: 58,235 Total Program Position Count: 6 (pro-raled) Total Agency Budget: 448,7oo Total Agency Position Count: 1 6 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of the Palace Theater Program Name: Celebration of Hawaiian Music Series S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Coutny of Hawaii Grant ( Requested) 29,900 Box office - ticket sales (anticipated) 24,150 Gift and concession sales and Palace reserves (anticipated) 4185 TOTAL: 58,235 Anoch additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program Further funding will be secured through individual donations, grant awards, and corporate donations. County funding to support artists fees (ranging from $1200 - $5000 per concert) lays the framework and encourages other donors to support this important project. The Board of Directors has recently endorsed a robust Strategic Plan with strategies to build a strong financial foundation through increased revenue from individual donors, increased partnerships with local businesses, increased audience numbers and increased revenue from grants. The Board of Directors is actively represented at every Palace event, cultivating audience members and prospective supporters. New branding and marketing strategies (our audience surveys show 22% driven by print and 15% by radio) are already increasing awareness of the Palace Theater; new programs targeted to specific audiences are also increasing audience participation and revenue. 7. Program Objectives Using County Nonprofit Grant Program Funds: The primary objective of this program is to actively encourage and support native Hawaiian culture, art, artists, and practitioners. Specifically, the project seeks to: -provide opportunities to the public to experience and appreciate Hawaiian music -recognize and encourage local artists -encourage and develop target audiences for Hawaiian music -serve as a vehicle for passing on the oral records of history, culture, and lifestyle -promote sustainable cultural tourism by providing authentic, place -based experiences. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of the Palace Theater Program Name: Celebration of Hawaiian Music Series 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES f,r.: Number ofcarnts served, workshops w events held, volunteer hours, etc. Describe, be specificJ Applicant Projected Results Increased revenue from higher ticket sales +$10,000 Increased audience engagement through targeting strategy +10 Increased usage of the Palace Theater as a venue for Hawaiian cultural events +5 Professional Fees 19,500 9,500 Operations Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 6,150 4600 Professional Fees 19,500 9,500 Operations Supplies Equipment 4,000 4.000 Other: Air travel 3600 Other: Artist ground transportation 1,800 1,800 Other: Artist Per diem 1,800 Other: Artist lodging 3.600 Other: Marketing (all associated costs) 17,785 $10,000 TOTAL 58,235 29,900 -if applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of the Palace Theater Program Name: Celebration of Hawaiian Music Series io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑d If no conflicts exist, check here. January 29, 2015 Signature of Authorized Person (specify title) ✓ Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of the Palace Theater Program Name: Celebration of Hawaiian Music Series 11. Certification of Understanding (page 1 of z) 1 (we) have read and understood all of the 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. 1 (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. 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 final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of the Palace Theater Program Name: Celebration of Hawaiian Music Series ii. Certification of Understanding (Page2 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 lune 301h 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.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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. �i�l]nr4�J,✓r/ii�E� %�/e�!/r a7 l��Gecf/v2/� Signature of Authorized Person (specify title) January 29, 2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Friends of the Palace Theater Program Name: Celebration of Hawaiian Music Series 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Increased Revenue from higher ticket sales +10,000 Increased audience engagement through targeting strategy +10% Increased usage of the Palace Theater as a venue for Hawaiian cultural events +5% Supplies Equipment 4,000 Other: Artist ground transportation 1,800 Other: Marketing (all associated costs) 10,000 TABLE It: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 4,600 Professional Fees 9,500 Operations Supplies Equipment 4,000 Other: Artist ground transportation 1,800 Other: Marketing (all associated costs) 10,000 Other: Other: Other: TOTAL 29,900 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Full Life Building Independence & Self -Sufficiency 6s County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Full Life Program Name: Building Independence & Self -Sufficiency Agency Director: stone Woltsong Phone No.: ( 808) 322 — 9333 Contact Person: stone Womisong Phone No.: ( 808) 322 — 9333 Mailing Address: Address: 75-5995 Kuakiru Highway, suite 432 Address: City, ST, Zip Kailua-Kona, HI, 96740 Facility Address: Address: 120 Keawe Street Suite 201 Address: City, ST, Zip Hilo, HI 96740 Email Address: atone@ Full LiteHawaii.org Fax No.: ( 808) 322 — 9334 Accountant/CPA: Ann Fukuhara, CPA, MBA Phone No.: ( 808) 961 — 5532 Firm (if applicable): An Accountancy Corporation Mailing Address: Address: 45 Pohaku Steel, Suite 102 Address: City, ST, Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna ❑ Hamakua © North Kona © South Hilo ❑ North Kohala © South Kona © North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes © Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises © Needs of the poor © Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page l of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Full Life Program Name: Building independence & Self-sufficiency 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14.15 $8000 2. Agency Mission Statement: Full Life assists individuals with developmental disabilities to achieve and enjoy a self -determined quality of life. 3. Program Description: Full Life proposes a broad-based, island -wide program focusing on building skills for independence and self-sufficiency. The diverse opportunities fostering inclusion and skill building include: 1. Asset Training Workshop "Steps to Achieving my Full Life Dream' - A two day workshop, open to the entire community, focusing on learning about personal financial behavior. 2. Artists Deepening Hearts (ADH) Program and Parade- a workshop providing tools for independence and self-sufficiency in an inclusive arts based environment. 3. Lower Puna Microgreen Sustainability Program. The goal of this program is self-sufficiency and independence for individuals with developmental disabilities although the program is open to all residents of lower Puna. 4. Pre-employment Supports including career skill assessments, interest inventories, a personalized Career Discovery Guide and Workbook, specific skill training and job coaching, writing a business plan, GET Tax license and microenterprise support. 5. Tuition subsidies for individuals on the autism spectrum and wage subsidies. 4. Total Budget & Position Count: Total Program Budget: 400,940.00 Total Program Position Count: 130 Total Agency Budget: 2,510,000.00 Total Agency Position Count: 100 EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Full Life Program Name: Building Independence & Self -Sufficiency 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate State of Hawaii Department of Developmental Disabilitie 263,190.00 County of Hawaii 120,150.00 Grants 10,000 Donations 1200 TOTAL: 400,940.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program Full Life anticipates that the seed funds for these programs will increase revenues for the individuals who participate as they learn about building assets, develop employment skills, obtain jobs or create micro -enterprises as well as for the program itself. More clients from the DVR and DOH Employment Supports will be driven to Full Life as a result of the training provided at Thrift and Gift training site and the Ho'omohala Autism Center. This will increase program fees substantially. We anticipate that the second year Asset Development Training can be offered to the community on a sliding fee scale- thus subsidizing the fees for lower income participants. As well, the second annual Artists Deepening Hearts will solicit paying and subsidized artists of all abilities. The Puna Microgreen enterprise can generate income for the program as well. 7. Program Objectives Using County Nonprofit Grant Program Funds: Depending on the specific opportunity participants will: • Demonstrate increased understanding of income exclusions that will allow them to work without losing benefits. Participants will also demonstrate increased understanding of budgeting, tax preparation and asset building. • Leave the program with a personal, copyrighted design and/or the tools to start a micro - enterprise including a business plan and a GET license • Exit the program with an individualized career plan, increased job skills, and experience working with their peers in integrated community work places. • Increase social, communication and sensory regulation skills and be ready to begin employment specific job skills training (for those individuals on the Autism Spectrum). EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Full Life Program Name: Building Independence & Self -Sufficiency 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.: Number ofclients served, workshops or events held, volunteer hours, etc Describe, be sbochc.) Applicant Projected Results Workshop "Steps to Achieving My Dream" 40 attendees Copyrighted design, business plan, GET Licens 25 individuals Tools to Stan a mioroenteryrise 30 individuals Career plan, apprenticehips 15 individuals Ready -to -Work skills (Autism Clients) 10 individuals Work Experience and a paycheck 10 Individuals 14,800 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 1546 Total Budget FY15-16 Grant Req Salary and Wages 43,300 Professional Fees 6,050 Operations 14,800 Supplies 1350 Equipment 10,600 Other: Wage Subsidies 7,750 Other: Tuition Mario Other: Vans 24,000 Other: Travel 1500 Other: TOTAL 120,150.00 `If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Full Life Program Name: Building Independence R Self -Sufficiency io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, reoordless 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): ❑ 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'Cee D,i"eofzY— i�a8/air Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Full Life Program Name: Building Independence & Self -Sufficiency 11. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBITA NON PROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Full Life Program Name: Building Independence & Self -Sufficiency 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 301h 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. jvk� i'dE-ufiye /2 L240 Q*e� Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Full Life Program Name: Building Independence & Self -Sufficiency 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results I Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Goodwill Industries of Hawai'i Job Connections 41 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Goodwill Industries of Hawaii Program Name: Job connections Agency Director: Laura smith - President 8 CEO Phone NO.: ( 808) 836 — 0313 Contact Person: Emily Lau- Sr. Director Mission Svs Phone No.: (808)936— 0313 Mailing Address: Address. 2610 Kilmau street Address: City, ST, Zip Honolulu HI 96819 Facility Address: Address: 200 Kanoelehua Ave AddressSuite 102 City, ST, Zip Hilo, 111 96720 Email Address: elaulcthigoodwilLor9 Accountant/CPA: NBKCPAS Firm (if applicable): Mailing Address: Address: 1001 eiehopst Address: suite 1700 City, ST, Zip Honolulu, HI 96813 Fax No.: ( 808) 933 — Phone NO.: ( 909 ) 524 — 4943 2255 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna V Hamakua ❑ North Kona V South Hilo ❑ North Kohala ❑ South Kona V North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) V Educational concerns ❑ Youth ❑ Victims of Crimes V Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises V Needs of the poor ❑ Physical/Emotional Disabilities V Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Goodwill Industries of Hawaii Program Name: Job connections 1. Prior Year Award of County Nonprofit Grant Program Funds: Y FY 13-14 FY 14-15 0 $20,000.00 $3,000.00 2. Agency Mission Statement: The mission of Goodwill Industries of Hawaii, Inc. (GIH) is to "help people with employment barriers to reach their full potential and become self-sufficient". A nationally accredited human service provider, GIH has served Hawaii as a reputable non-profit organization for over 55 years, providing educational, workforce development, and social services to over 13,000 residents annually. 3. Program Description: GIH's Job Connections Program provides employment services to low-income Native Hawaiians and re -integrating individuals. GIH has a strong relationship with HCCC's Hale Nam, Hawaii Paroling Authority, Probation, Going Home Consortium, UH Hilo, and Hawaii Community College. The strong linkages forged with these organizations has allowed us to serve over 200 individuals in the past three years. We conduct a thorough intake & assessment, provide Job Readiness Training, perform job development, place individuals into jobs, and provide job retention services for 6 months. Additionally, we help support their educational and vocational goals by helping them pay for college tuition or vocational training programs. Over the past two years we have helped subsidize tuition/training costs to over 44 Native Hawaiians. 4. Total Budget & Position Count: Total Program Budget: $13o,oco.00 Total Program Position Count: I Total Agency Budget:. $3,000,000.00 Total Agency Position Count: 80 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Goodwill Industries of Hawaii Program Name: Job Connections S. Program Funding Sources (identify all sources of funding applied to tors program): Fy15-16 Revenue Source Estimate Services TOTAL: 6. Explain what plans your agency or program has to increase revenues to support this program: The requested funding will support an Employment Counselor in GIH's Hawaii County Job Connections program. GIH will leverage its existing resources (i.e. facilities, admin) and grants from OHA and The Office of Community Services that provide employment & educational services to Native Hawaiians and reintegrating individuals. 7. Program Objectives Using County Nonprofit Grant Program Funds: The overall goal of this program is to continue to provide employment services to low-income Native Hawaiians and re -integrating individuals. A minimum of 50 individuals will receive services; of these it is expected that 90% (45) will complete Job Readiness Training; of these, 80% will be placed into employment. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Goodwill Industries of Hawaii Program Name: Job Connections 8. TABLE I: tA)har are the intended measurable cutouts or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (Ce. Number of clients served, worASM1ops or events held, volunreei M1ours, e[c. pesnibe, be sped(m) Applicant Projected Results IntakelAssessment 50 Job Readiness Training _ 45 Job Placement 36 90 -Day Retention _,. 29 180 -Day Retention 22 Operations 58,600.00 $8,600.00 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14 -IB Actual' FV 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $50,000.00 S60, 00000 $30000.00 Professional Fees 51,400.00 $140000 Operations 58,600.00 $8,600.00 Supplies $2.000.00 $2,00000 Equipment $10,000.00 $8,000.00 Other Tuition Assistance 570000.00 $50,000.00 Other: _ Other: Other. _ Other. TOTAL $142,000.00 $130,000.00 $30,000.00, IT appocacie EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Goodwill Industries of Hawaii Program Name: Job connections to. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability, that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. )&t,w-X) ` L Pvesldettit/CFo Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 1/26/2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Goodwill Industries of Hawaii Program Name: Job connections 11. Certification of Understanding (Page 1 of z) I (we) have read and understood all of the 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 final payment. To register, go to http //vendors.ehawaii.g,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 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 o timely, complete and accurate year-end report using the template provided will impact the eyoluot ion of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Goodwill Industries of Hawaii Program Name: Job connections 11. Certification of Understanding (page z of 2) If awarded a grant from the County of Hawai i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to Countyl 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 //w ha aj cunty gcv/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, 2015 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 Vour agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) 1/26/2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Goodwill Industries of Hawaii Program Name: Job connections 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Projected Results Projected Res Council Proposed Projected Result Intake/Assessment 50 Job Readiness Training 46 Job Placement 36 90 -Day Job Retention 29 180 -Day Job Retention 22 Other. Other TABLE II: PROGRAM EXPENDITURES FY 15-16 Gran[ Request Council Award Salary and Wages S30,000.00 Professional Fees Operations Supplies Equipment Other. Other Other: Other Other: TOTAL $30,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Goodwill Industries of Hawaii, Inc. Work Experience Program 42 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work ExperienceProgram Agency Director: Laura smith Phone No.: ( 808) 836 — 0313 Contact Person: David Tomch Phone Nor: ( 808) 961 — 0301 Mailing Address: Address: 500 Kalaniaole Avenue Address: Suits3 City, ST, Zip Hilo, HI 96120 Fact l lty Address: Address: 500 Kalanianaole Avenue Address: Suite 3 City, ST, Zip Hilo, Al 96720 Email Address: dlomich@hi9oodwill.org Fax No.: ( 808) 969 — 3861 Accountant/CPA: NSK caAs he Phone No.: ( 808) sea — 2255 Firm (if applicable): Mailing Address: Address: 1001 Bishop street Address: Suite 1100 City, ST, Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna © Hdm5kua ❑ North Kona © South Hilo ❑ North Kohala ❑ South Kona © North Hilo ❑ South Kohala ❑ l Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes © Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor © Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work ExperienceProgram 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $27500.00 $20,000.00 $10,000.00 2. Agency Mission Statement: The mission of Goodwill Industries of Hawaii, Inc. (GIH) is to "help people with employment barriers reach their full potential and become self-sufficient." A nationally accredited human services provider, GIH has served Hawaii as a reputable non-profit organization for over 55 years, providing educational, workforce development, and social services to over 13,000 residents annually. 3. Program Description: The Work Experience Program provides support and opportunities for individuals with Intellectual / Developmental Disabilities to receive training through Goodwill's Janitorial Program, the Hawaii Design and Art Program, and the Sustainability, and Self -Sufficiency Program. Each program offers dedicated training and support. The Janitorial Program provides skills training with the joy and excitement of receiving a pay check. The Hawaii Design and Art program encourages creative expression and self-sufficiency through establishing and operating a micro -enterprise. The Sustainability and Self -Sufficiency Program will teach the participants the importance of eating healthy and the types of food that they can grow themselves. The participants are learning how to build, maintain, and upkeep a green house nursery. The Work Experience Program offers participants choice in potential career paths with both hands on experience and computer based training. Computer-based pre-employment training is provided for all levels of disability, including persons with more severe physical and learning limitations. 4. Total Budget & Position Count: Total Program Budget: $325,000.00 Total Program Position Count: 7 Total Agency Budget: $3,000,000.00 1 Total Agency Position Count: 80 EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work ExperienceProgram S. Program Funding Sources (identify all sources of funding applied to this program): FY1S-16 Revenue Source Estimate State of Hawaii $280,000.00 County of Hawaii non-profit grant $45,000.00 TOTAL: $325,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program The requested funding will be used to broaden the scope and increase the capacity of Goodwill's Work Experience Program in terms of staffing, supplies, equipment and materials so more participants can be served. An increase in program participants will provide increased revenues to assist in supporting this program. The Work Experience program is part of Goodwill's larger Intellectual / Developmental Disability (Waiver) program which provides services and supports to encourage persons with disabilities to become as independent as possible while being active and contributing members of the Hawaii Island community. Our Waiver program maintains a positive reputation in our community through the success of this program, our accessible computer training program and volunteer involvement in the community. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Work Experience Program provides wage subsidy and self-sufficiency training and support for individuals with intellectual / developmental disabilities. The program provides work training opportunities for individuals who do not have work experience or who need additional supports or training to succeed in their employment goals. Three components of the program include, Janitorial Work Training, Hawaii Design and Art Program Expansion, and continued development of a Sustainability and Self -Sufficiency Program through gardening and healthy food production. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work ExperienceProgram B. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i. e.: Numberofdiennserved, workshops ore.p held, volunteer hours, et, oesvibe, be oreciaO Applicant Projected Results Janitorial Program Number of Participants 10 HI Design g Art Program Number of Participant 10 Sustainability Program Number of Participants 10 Professional Fees $3,000.00 $3,000.00 $2,000.00 Operations $60,000.00 $60,000.00 Attach additional pages os necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual- FY I5-16 Total Budget FY I5 -I6 Grant Req Salary and Wages $170,000.00 $200,000.00 $25,000.00 Professional Fees $3,000.00 $3,000.00 $2,000.00 Operations $60,000.00 $60,000.00 Supplies $8,000.00 $10,000.00 $1,000.00 Equipment $10,000.00 $22,000.00 $17,000.00 Other: Specific Assistance to Participants $30.000M $30,000.00 Other: Other: Other: Other: TOTAL $281,000.00 $325,000.00 $45,000.00 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: work ExperienceProgram io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by 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. AY . Dy� NI 1ci2Y1t/Ceo Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 1/26/2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work ExperienceProgram rt. 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, 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 final payment. 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 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 Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT G RANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work ExperienceProgram 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 301h 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 bv. 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 hawai icounty 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 lune 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timelV manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. V�kk&x & ti pytSa2bi /CEO Signature of Authorized Person (specify title) 1/26/2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Goodwill Industries of Hawaii, Inc. Program Name: Work ExperienceProgram 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Janitorial Program Number of Participants 10 HI Design & Art Program Number of Participants 10 Sustainability Program Number of Participants 10 Supplies $1,000.0o Equipment $17,000.00 Other: Other: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $25,000.00 Professional Fees $2,000.00 Operations Supplies $1,000.0o Equipment $17,000.00 Other: Other: Other: Other: Other: TOTAL $45,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 Grassroots Community Development Group Hawai'i Youth Business Center 43 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center Agency Director: Tana Nahm-Milo Phone No.: ( 808) 640 — 5109 Contact Person: same es above Phone No.: ( 608) 640 — 5109 Mailing Address: Address: Po sox 1772 Address: City, ST, Zip Keaau, H196749 Facility Address: Address: 16-1592Pohaku Circle Address: City, ST, Zip Keaau, 11196749 Email Address: nahmmiio@haw ii.edu Fax No.: ( 808) 974 — 7757 Accountant/CPA: John Caroonaro Phone No.: ( 808 ) 956 — 1002 Firm (if applicable): John carbonam CPA L8 Assoae. Mailing Address: Address: P013e:4372 Address: City, ST, Zip Hilo, H196720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna ❑ Hamakua ❑ North Kona Q South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth ❑ Victims of Crimes © Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $25,000.00 $30,000.00 $15,000.00 2. Agency Mission Statement: To strengthen our communities through the cooperative development of programs and services for all of East Hawaii. To provide quality programs for youth. 3. Program Description: The target population is youth, 12-24 yrs. old, from the Puna and Hilo areas. The program provides After -School entrepreneurial, digital media arts, culinary, and workforce training at the site located in Kea'au as well as collaborating with other youth organizations and schools to provide opportunities for skill development and self enrichment. 4. Total Budget & Position Count: Total Program Budget: $30,0001 Total Program Position Count: 1 2 PT Total Agency Budget: $30,0001 Total Agency Position Count: 1 2 PT EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center S. Program Funding Sources (identify all sources of funding applied to this program): FY1S-16 Revenue Source Estimate County of Hawaii $17,000.00 Donations $6,000.00 Grants $7,000.00 TOTAL: $30,000.00 Attach additional pages, ii needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Looking for more collaborative projects with other organizations and agencies with which we can partner 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Provide skill -building and workforce development opportunities in digital media arts, culinary arts, business entrepreneurships; 2) Produce quality media work products which are youth -driven and youth produced and which are disseminated widely to the general public and educational and human service organizations; 3) Collaborate with other organizations serving youth on activities which contribute to developing pro -social, healthy communication and life choice behaviors; 4) Assist efforts to provide disaster relief for families EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center S. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.: Numberot clients served, workshops or events held, volunteer hour; etc. Describe, be specific) Applicant Projected Results 20 youth will receive training in Digital Mee 90% increase skills 30 youth will receive training in Culinary 90% increase skills 20 youth will receive entrepreneurial train. 90% increase skills 20,000 youth and their families will be ex- Increased healthy posed to pro -social messages behaviors 20+ Families will receive food relief Increased sustainabili $8,000.00 $5,000.00 Attach additional pages as necessary. 9. TABLE 11: PROGRAM EXPENDITURES FY 14-15 Actual" FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $8,000.00 $4,000.00 Professional Fees $4,000.00 $4,000.00 Operations $8,000.00 $5,000.00 Supplies $2,500.00 $1,500.00 Equipment $6,000.00 $1,000.00 Other: Insurance $1,500.00 $1,500.00 Other: Other: Other: Other: TOTAL $30,000.00 $17,000.00 "If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center to. 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 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. 0A MAtop-If .dekft Signature of Auth if, uedrson (sp cify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135-2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to 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 information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability 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 final payment. 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 Procrom's or aaencv's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of 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 3011 shall result in loss of all grant funds received during the grant Period (must be refunded to Countvl 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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authon ed Pe son (sp c0l title) EXHIBITA NONPROFITGRANT APPLICATION FY 2015-2016 t o 15 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Grassroots Community Development Group Program Name: Hawaii Youth Business Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result 20 Youth will receive training in Digital Media 90% increase 30 youth will receive training in Culinary 90%increase 20 youth will receive entrepreneurial training 90%increase 20,000+ youth and their families will be educated Healthier yo 20t families will receive food relief sustain fam. Other: Insurance $1,500 Other. TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $4,000 Professional Fees $4,000 Operations $5,000 Supplies $1,500 Equipment $1,000 Other: Insurance $1,500 Other. Other: Other: Other: TOTAL $17,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Green Will Conservancy Hui Mana'o M County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Green Will Conservancy, Inc Program Name: Hui Mana'o Agency Director: Fmnk Capamh Phone No.: ( 808) 965 — 5349 Contact Person: Sandra Dedorne Phone No.: (808)965 — 5349 Mailing Address: Address: P.O. Sox 1341 Address: 14�803B Seaview Road City, ST, Zip Pohoe, Hawaii 96778 Facility Address: Address: 14-803B seaview Road Address: City, ST, Zip Parona. Hawaii 96778 Email Address: iiandraosbomeClaloud.corn Fax No.: ( 808) 965 — W36 Accountant/CPA: Nancy Jean Kramer. CPA Phone No.: (808)965 — 2729 Firm (if applicable): Mailing Address: Address: 15 2994 Pahoa vn1a9e Road Address: P O. Box 1519 City, ST, Z,p Pahoa, HI 96)18 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 9 24.000.00 Geographical Areas To Be Served: (One or more can be checked) © Puna ❑ Hari ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © youth © Victims of Crimes © Culture and the arts © Aged © Victims of Health or Social Crises © Needs of the poor © Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page l of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Green Will Conservancy, Inc. Program Name: Hui Mana'o 1. Prior year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $500.00 $5,500.00 $5,000 2. Agency Mission Statement: Our mission statement is to inspire in our youth a fiery determination to persevere, sustain and realize their life's potential. Our vision is to our empower our Puna youth and their families with practical knowledge, life skills and expertise that will support fulfilling and productive lives. (see Addendum A) 3. Program Description: Existing Programs (Human Services) Whether self-referred, referred or court mandated, a fully qualified mental health therapist assesses each youth and his/her family. Together, they collaborate on a treatment plan with a focus on overcoming barriers to success. Personal issues such as emotional problems, drug or alcohol use, difficulties at school or at home, and violence are addressed confidentially and individually. Participants attend pro -social groups twice weekly to assist with chores and mentor younger children (kids helping kids) under the guidance of therapists. They also meet on Sundays for their own individual, group counseling and activities. The program is designed to treat each participant individually and as a group member. Interested family/community members are welcomed to provide additional support and participation when appropriate. (Please see Addendum A) 4. Total Budget & Position Count: Total Program Budget:$24,000 Total Program Position Count: IsTotal Agency Budget: $82,000 Total Agency Position Count: T5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Green Will Conservancy, Inc. Program Name: Hui Mana'o S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FYIS-16 Estimate Program Service Revenue 46043 Public Contributions: Hawaii County Grant 24000 Public Contributions: Cash contributions 10000 TOTAL: 80043 Attach oddrionol pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program Hui Mana'o continues to offer professional mental health services and programs on a sliding scale and billable treatment to health insurance agencies. In addition, we will collaborate with charter schools (Hawaiian Academy of Arts and Sciences and Kua o ka la), the American Red Cross, EMDR Institute, Queen Liliuokalani Children's Center (QLCC), Child and Family Services, Hawaii Island Recovery and other community organizations to offer resiliency and trauma treatment training. Green Will also offers consulting services to our experienced and newly trained trauma specialists resulting from intensive trainings hosted by our organization twice in 2014. This year we will introduce in a new concept of Telehealth' which will allow client communication electronically using a safe and secure network at no charge to our clients. Research has shown that impoverished people rely upon smart phones the most and subsequently, will benefit from the ability to communicate remotely, if necessary. 7. Program Objectives Using County Nonprofit Grant Program Funds: In 2015, our principal goal is to train as many youth and families, professionals and lay people as possible in preparation for the impending lava flow. Professional development and psycho- education is key to our services within the Puna community. Program objectives include:'telehealth', community outreach, resiliency training, psychoeducation, EMDR (Reprocessing Therapy), Red Cross Disaster Mental Health Fundamentals for professionals and Psychological First Aid., as well as workshops. (see Addendum A for details) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Green Will conservancy, Inc. Program Name: Hui Mana'o S. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES ([e.: Number of dlents served workshops ar events held, volunteer hone, etc pescribG besee[Iflc.) Applicant Projected Results EMDR Training for Mental Health Professionals Training x 3 American Red Cross Trainings Training x 3 Resiliency and First Responders Workshops _ _ _ Three Workshops _ _ YoFamily Therapy and Group Skills 260 units Fund Raising S10,000 Operations 2000 Attach additional pages as necessary 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15.16 Grant Req Salary and Wages 2500 Professional Fees 2500 Operations 2000 Supplies 2000 Equipment 1500 Other Telehealth Portal train and implementation 2500 Other. Web Tools and Technology Support 3000 Other: Student Stipends 7000 Other. Automotive (client transportation) 1000 Other TOTAL 240001 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Green Will Conservancy, Inc. Program Name: Hui Mana'o ro. 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 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 Author ze Person (s ecify title( II( CC05 1/218/15 Date EXHIBITA \j NONPROFIT GRANT APPLICATION FV 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Green Will Conservancy, Inc. Program Name: Hui Mana'o 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135-2-142.1, 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 programs) 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 final payment. 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 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 Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Green Will conservancy, Inc. Program Name: Hui Mana'o ii. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of 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 30t' shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://"www.hawaiicounty.gov/­fn-nonprofit-grant forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Green Will Conservancy, Inc. Program Name: Hui Mana'o 1z. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result EMDR psychotherapy training for Mental Health Prof Training x 3 American Red Cross Trainings Training x 3 Resiliency and First Responders Workshops 3 Workshops Youth and Family Therapy and Group Skills 260 Units Fund Raising S10AOo Other- Telehealth Portal, training and development 2500 Other. Web Tools and Technology support Other Student Stipends 3000 7000 _ 1 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 2500 Professional Fees 2500 Operations 2000 Supplies 2000 Equipment 2500 Other- Telehealth Portal, training and development 2500 Other. Web Tools and Technology support Other Student Stipends 3000 7000 _ 1 Other Automotive (clienttransporlation) 1000 E. Other. TOTAL 24000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Addendum A & B - County of Hawai`I Non -Profit Grant Application Applicant: Green Will Conservancy FY2015-16 2. Agency Mission Statement Our mission is to inspire in our youth a fiery determination to persevere, sustain and realize their life's potential. Our vision is to empower our Puna youth and their families with practical knowledge, life skills and expertise that will support fulfilling and productive lives. Fulfilling the Mission Green Will's role is to counsel, mentor, advocate for and teach the skills necessary for our youth to survive in today's competitive, complex world. We support skills acquisition and goal -oriented action among our participants to encourage continuing education, mastery of life and business skills and the knowledge and confidence needed to live a fulfilling life. Our qualified, skilled counselors and mentors inspire our at -risk youth to feel motivated to pursue their dreams through behavioral education, skills development and community involvement. Living and Working in the Community We Serve Our Puna community continues to experience deep poverty. The decline of the family and lack of essential life skills demonstrates an erosion of self -sustainability. Adding a natural disaster to this mix will only increase hardship and a lack of accessible resources. As you are aware, social services have decreased and according to statistics the County of Hawai'i has the least manageable caseload of all the islands (Social Services, Hawaii, 2009). The Green Will Conservancy (GWC) was formed in 2009 to address the needs of at - risk youth (aged 12 - 18 years) and their families in the Puna District of the Big Island. GWC was inspired by the Sirius Research Group (SRG), a private social work, counseling support and consulting group. SRG has provided mental health counseling and consulting support to a wide variety of individuals, families, agencies, professionals and organizations on the Big Island for over 30 years. As Green Will mental health counselors, our roles are expanded to advocate for our Puna youth. Many of our participants do not have fundamental social and business skills necessary for the 21'' century. We assist our youth to connect with organizations like the Dorrance Foundation who provide full scholarships to youth who are the first in their families to seek a college degree. We are a bridge to other community/state agencies and services that connect our youth in service to our community. n . The Green Will Conservancy - 14-8036 Seaview Rd. - P.O. Box 1341, Pahoa, Hawaii, 96778 Addendum A & B — County of Hawaii Non -Profit Grant Application Applicant: Green Will Conservancy FY2015-16 3. Program Description Existing programs (Human Services) Whether self-referred, referred or court -mandated, a fully qualified mental health therapist assesses each youth and his/her family. Together they collaborate on a treatment plan with a focus on overcoming barriers to success. Personal issues such as emotional problems, drug or alcohol use, difficulties at school or at home, and violence are addressed confidentially and individually. Participants attend pro -social groups twice weekly to assist with chores and mentor younger children (kids helping kids) under the guidance of therapists. They also meet on Sundays for their own individual, group counseling and activities. The program is designed to treat each participant individually and as a group member. Interested family/community members are welcomed to provide additional support and participation when appropriate. Our model of individual and group counseling combined with practical skills development will significantly improve the quality of the lives of the youths and families we serve. Stipends are offered to our youth as incentives for progress and to ensure continuity in the various programs. Research has shown that the combination of social/work related skills training combined with cash payments shows the greatest improvements in impoverished communities. 6. Explain what plans your agency or program has to increase revenues to support this program: Hui Mana'o continues to offer professional mental health services and programs on a sliding scale and billable treatment to health insurance agencies. In addition, we will collaborate with Charter schools (Hawaiian Academy or Arts and Sciences and Kua o ka la), the American Red Cross, EMDR Institute, Queen Liliokalani Children's Center (QLCC), Child and Family Services, Hawaii Island Recovery and other community organizations to offer resiliency and trauma treatment training. Green Will also offers consulting services to our experienced and newly trained trauma specialists resulting from intensive trainings hosted by our organization twice in 2014. This year we will introduce a new concept of telehealth which will allow client communication electronically using a safe and secure network at no charge to the client. 7. Program Objectives Using County Nonprofit Funds Community Outreach To the best of our knowledge, GWC will be the only mental health out-patient program available to support our community on 'this side' when the lava crosses Highway 130. We have in-house expertise to deal directly with critical incidence training for first responders and the community at large. Our current youth (12-18 years) and family programs specialize in life/social skills training, trauma and first response therapies and t The Green Will Conservancy — 14-8038 Seaview Rd. — P.O. Box 1341, Pahoa, Hawaii, 96778 Addendum A & B - County of Hawai`I Non -Profit Grant Application Applicant: Green Will Conservancy FY2015-16 outreach support in our community. We will define trauma and what first response means to our community. The impending lava crisis will result in critical incident trauma for many individuals who may experience strong emotional reactions that could severely impact their ability to cope with the loss of community and subsequent resources. Anxiety, stress, depression and Post Traumatic Stress Disorder (PTSD) will require professional support for many. Our in-house experts have access to and consult for more than 50 trained trauma specialists on this island. Our cohort of professional therapists is trained in an 8 -phased psychotherapy known as EMDR, an evidence based practice. It is particularly effective for trauma -based disorders including natural disasters. Community outreach and collaboration would include partners such as the American Red Cross and our local charter schools, Kua o' ka la and Hawaiian Academy of Arts and Sciences and local community organizations. Resiliency Training With County support our experts would train para -professionals and community members resiliency traits and resourcing skills in community settings. We can be called upon to work with emergency services, in-home intensives and in our own facilities that are self-contained and fully functional in the event that essential services are cut-off. As advocates for our clients it is our belief that community linking will be a primary resource for the Puna population. Resiliency can be taught. Green Will is committed to interfacing with the community to discover and learn ways to improve our lifestyles and engage with our neighbors: Coping strategies: stabilization and resourcing Dealing with fear and vulnerability Understanding the psychological and physical effects of fear Stress management Family support Responsibility (present safety, future choices, self-esteem/self-efficacy) Preparing for the future Linkages for basic, primary resources Psychoeducation Psychoeducation for first responders, community leaders, youth and their families will be set up in community centers, schools, church halls and our facility as needed to prepare, assist and teach essential stabilization and resourcing skills. Training will include lectures, hands-on practice, consultation and supervision to assist people to integrate their trauma experiences. The Green Will Conservancy - 14-803B Seaview Rd. - P.O. Box 1341,Pahoa, Hawaii, 96778 Addendum A& B- County of Hawai`I Non -Profit Grant Application Applicant: Green Will Conservancy FY2015-16 EMDR (Reprocessing Therapy) GWC will offer fundamental skills to our community members. Our Green Will youth will be involved in working with other youth to offer support and skills to their peers and families. Compassion, stabilization techniques and resourcing will be taught with immediate, positive effect. American Red Cross Green Will is collaborating with Dr. Thom Curtis who is a Professor in the Department of Sociology and chair of the Social Sciences Division at the University of Hawaii at Hilo where he has taught since 1995. His research and much of his teaching has focused on natural and technological disasters as well as various aspects of individual, family and societal responses to crisis. In addition to his academic interest in disasters, Dr. Curtis has participated in numerous disaster responses from Guam to New York and served as a consultant to government and private agencies involved in disasters. He has traveled throughout the country to disaster sites as a researcher or as an American Red Cross Disaster Mental Health Specialist and became Hawaii's first certified Disaster Mental Health Instructor in 1997. In 1995 and again in 2001 following the attacks of 9111, Dr. Curtis was recognized with the American Red Cross Special Citation for Exceptional Volunteer Service: National Award for Outstanding Leadership. American Red Cross Training (ARC) will be offered to mental health professionals in two modules. Disaster Mental Health (DMH) Fundamentals training to mental health professionals to provide for and respond to the psychological needs of people across the continuum of disaster preparedness, response and recovery, and Psychological First Aid Involving our Green Will kids we are also exploring other Red Cross and resiliency trainings for teachers, youth, families and community resiliency at large. Grant Funds will also support hands-on, practical leadership and business skills, training sessions in-person and online. Vocational training in professions such as carpentry, water collection systems, solar, other green initiatives and sustainable environmental practices are examples of areas that youth can explore. Community experts in a variety of fields and occupations will offer new perspectives to youth who have limited access to information. g. The Green Will Conservancy - 14-803B Seaview Rd. - P.O. Box 1341, Pahoa, Hawaii, 96778 Addendum A & B - County of Hawai'I Non -Profit Grant Application Applicant: Green Will Conservancy FY2015-16 i Workshops that focus on behavioral management (anger, violence, depression, etc.) using solution focused therapy, goal setting, teaching new behavioral skills and perspectives as well as topics that youth identify as important/beneficial will be offered regularly. The funds allocated to this project will be used for materials and the development of face-to-face and online resources and tools available to youth on an as -needed basis. We will introduce the concept of Telehealth early in 2015. Practice Unite is a secure and confidential electronically based service that allows easy access to clients and our therapists. In summary, in addition to our existing programs, Green Will is committed to responding to the current ongoing disaster process. According to an informal report from a leading community certified public accountant, up to 25% of established business leaders are considering leaving Pahoa Village due to the protracted psychological impacts of our impending lava flow. Many of our clients are still recovering from the impacts of the last hurricane in August 2014 and others have left Puna altogether. Our first response youth trainers and professional staff will reach out in community volunteerism as needed. We will provide hands on support and linkages to existing resources. Our professional EMDR therapists will provide services to a wide range of community members and business leaders in our community to ameliorate their resilience and commitment as primary business and service providers. eY. The Green Will Conservancy - 14-8038 Seaview Rd. - P.O. Box 1341, Pahoa, Hawaii, 96778 Addendum A & B - County of Hawai'I Non -Profit Grant Application Applicant: Green Will Conservancy FY2016-16 Addendum B includes: • Proof of Authorization • Date of Incorporation • Annual Financial Statements • e -Postcard version (990N) • IRS letter verifying agency's tax-exempt status (IRS 501 (c) (3) • Articles of Incorporation (signed) • By-laws (signed) • Document Page(s) containing nepotism and conflict of interest clause(s) • t, The Green Will Conservancy - 14-8038 Seaview Rd. - P.O. Box 1341, Pahoa, Hawaii, 96778 Habitat for Humanity West Hawaii Hope Begins At Home 45 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Habitat for Humanity west Hawaii (One or more can be checked) ❑ Puna ❑ Hamakua Program Name: Hope Begins At Home ❑ South Hilo ❑ North Kohala ❑ South Kona Agency Director: Patrick F. Harney Phone No.: ( 808) 331 — 8010 Contact Person: Isabel Donovan Phone No.: ( 808) 331 — Bm0 Mailing Address: Address: PO. Box 4619 Address: City, ST, Zip Kallua-Kona, Hawaii, 96745 Facility Address: Address: 73- 5576 Kaohola Street N4 Address: City, ST, Zip Kalue-Kona, HI 96740 Email Address: do@hatatatweslhawaii.org Fax No.: ( 808) 331 — B020 Accountant/CPA: Julie Harrell Phone No.: ( 808) 331 — 8010 Firm (if applicable): Ma iling Address: Address: P,o. Bo.4619 Address: City, ST, Zip Kallua-Kona, HI96745 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 580,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua © North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts L1 Aged ❑ Victims of Health or Social Crises © Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Habitat for Humanity West Hawaii Program Name: Hope Begins At Home 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 24,250.00 $9,000.00 40,000.00 2. Agency Mission Statement: Habitat West Hawaii's mission is to empower families and build community and hope through home ownership opportunities for families earning between 30% and 80% AMI. Habitat for Humanity West Hawaii serves the entire west coast of the Big Island, and is the only affordable home -builder in the area that builds homes on a no -interest, no -profit basis, utilizing volunteer labor and donated building materials and services. 3. Program Description: The Kamakoa NO Affordable Workforce Housing Project is a unique and much needed affordable housing project being undertaken by Habitat West Hawaii in partnership with the County of Hawaii Office of Housing and Community Development. Located in Waikoloa, the project will serve the commuting workforce who is forced to travel extraordinarily long distances ( 45 + miles each way) as a result of the shift of employment opportunities to the resort areas on the west side of the island. Habitat West Hawaii has purchased 10 lots in the project, and will complete the first 6 homes in FY 2015. This request is for funds to go toward the construction of the next 4 homes. Habitat's homes will reach deeper into the needs of the commuting workforce, in that they will be offered to families earning less than 80% AMI. (The County's offerings are to families earning between 80% and 140% AMI.) Each of these homes will provide a low-income family with a new home, breaking the cycle of poverty that accompanies sub -standard housing conditions, a stated focus of the County. 4. Total Budget & Position Count: Total Program Budget: 645,000.00 Total Program Position Count Total Agency Budget: 2,470,17E Total Agency Position Count: 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Habitat for Humanity West Hawaii Program Name: Hope Begins At Home 5. Program Funding Sources fidentity all sources of tundmg applied to tms program) Revenue Source FY15-16 Estimate Count of Hawaii 80,000.00 Habitat For Humanity Restore 80,000.00 New Market Tax Credits 180,000.00 TOTAL: $340.000.00 A troch nddrtinnnl nacres, if needed 6. Explain what plans your agency or program has to increase revenues to support this program Further funding will be secured through individual donors, State and Federal grant awards, and corporate donations. County funding is a key aspect of the program as a monetary commitment will help lay the framework and encourage other private and government donors to support this important project. Habitat West Hawaii's Board of Directors has endorsed a sound 5 year Strategic Plan, aimed at increasing the affiliate's capacity to provide home ownership opportunities to low-income families, as well as to maximize it's potential to support all of its programs through strategic solitication of funds, investment in human resources, and acquisition of land. The Habitat model also provides for all mortgages to be put into a revolving "Fund for Humanity", which is then used for building additional homes, and which allows each family to "pay it forward'. 7. Program Objectives Using County Nonprofit Grant Program Funds: This program will seek to provide safe and affordable housing for four low-income families. By funding a portion of the cost of construction, this program will achieve a priority goal of the County Consolidated Plan by improving the lives of four local families. It is widely recognized that employment, income, and access to housing are widely related. Low-income families first and foremost need to increase their income in order to improve their overall living conditions. Therefore, the production of of affordable housing in close proximity to economic opportunities is a significant and creative step towards eliminating the housing crisis that plagues so many low-income families. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Habitat for Humanity West Hawaii Program Name: Hope Begins At Home 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES be : Number of clients served workshops or events held volunteer houq etcfresvrbe be sibs fic) Applicant Projected Results Number of volunteer participants 135 volunteer work hours donated 96,000 Number of families served _ 4 _ Number of individuals served 20 _ Number of female -headed households served 2 Operations Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 50,000 50,000 Professional Fees 10,000 S10,000 Operations Supplies $500,000 $580,000.00 80,000.00 Equipment _ Other. Other: Contracted site supervisors 5,000.00 5,000.00 Other. Other. Other. TOTAL 565,000, 645,000.00 80,000.00 "If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Habitat for Humanity West Hawaii Program Name: Hope Begins At Home io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 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): ❑ 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 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. "p e' '✓ Signature of Authorized Person (s ecify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 January 28, 2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Habitat for Humanity West Hawaii Program Name: Hope Begins At Home tt. Certification of Understanding (Page 1 o 2) 1 (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135— 2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. 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 Poor program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Habitat for Humanity West Hawaii Program Name: Hope Begins At Home 11. Certification of Understanding (Page 2 oft) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 30e1i 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-//­w--ww.hawaiicounty.gov/­fn-nonprofit-grant-formsZ on or about May 30 of the year the final 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (sped title) Jarl 2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Habitat for Humanity West Hawaii Program Name: Hope Begins At Home 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of Volunteer participants 135 Volunteer work hours donated 96.000 Number of families served 4 Number of individuals served 20 Number of female -headed households served 2 Other: Other: TABLE li: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies 80,000 Equipment Other: Other: Other: Other: Other: TOTAL 80,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 20142015 Page 8 of 8 Hale Kipa, Inc Ka'i Like Program County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hale Kipa, Inc Program Name: Kai Like Program Agency Director: Ernest Fletan-cross Phone No.: ( 888) 589 — 1829 Contact Person: JaPre Keney-uyeoka Phone No.: ( 808 ) 589 — 1829 Mailing Address: Address: 615 Prkri Street Address: Suite 203 City, ST, Zip Honolulu. Hawaii 96814 Facility Address: Address: 622 Hirano Street Address: City, ST, Zip Hilo. Hawaii 96720 Email Address: iagQhalekipa org Fax No.: ( are) 589 — 2610 Accountant/CPA: coay aaretta Phone No.: ( 808) 589 — 1829 Firm (if applicable): Mailing Address: Address: 615 Pukol street Address: SUI1e203 City, ST, Zip Honolulu. Hawaii 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑/ Puna d❑ Hamakua © North Kona © South Hilo F/I North Kohala © South Kona ❑J North Hilo ❑J South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHI BIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hale Kipa, Inc Program Name: Ka'i Like Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 Total Program Position Count: 10 FY 14-15 zas ass Total Agency Position Count: 177 $3,000.00 5,000.00 2. Agency Mission Statement: Hale Kipa provides opportunities and environments that strengthen and encourage youth, their families and communities to actualize their potential and social responsibility. 3. Program Description: Island -wide intensive supervision, mentoring and support services for Family Court youth, ages 12-17 to hold them accountable for behaviors, comply with probation rules, improve academic & social behavior and strengthen families. Staff executes an Implementation Plan, provides education -vocation support, advocacy, skill building, linkages to community resources, transportation, etc. Activities decrease risk and increase protective factors. 4. Total Budget & Position Count: Total Program Budget: 3000001 Total Program Position Count: 10 Total Agency Budget: zas ass Total Agency Position Count: 177 EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hale Kipa, Inc Program Name: Ka'i Like Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY15-16 Revenue Source Estimate DHS-OYS 300,000 TOTAL: 300.000 Attach additional pages, if needed 6. Explain what plans your agency or program has to increase revenues to support this program: Continue to sustain OYS funding which was recently increased due to program waiting lists. Hale Kipa also applies for other relevant grants as appropriate and available. 7. Program Objectives Using County Nonprofit Grant Program Funds: 90% KLP participants will be 1) in compliance with their probation terms & conditions and be positively discharged from the program; 2) engaged in an educational/vocational program and/or become employed; 3) in stable living situation and remain arrest -free 3 months post -discharge. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County ofHawai`i Nonprofit Grant Application FY2O15-16 Agency Name: Hale Kipa, Inc Program Name: Kai Like Program S. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (ie Number of clients served, workshops mevents held, volunteer hours, etc DesvLe, be speciFc) Applicant Projected Results Number of Youth Serviced 90 Number of Contacts with youth, family and collaterals 1000 Program participants will maintain education and/or become employed 85% Program participants_ who will not become pregnant while in program 95% Program participants will be positively discharged 85 Program participants will be arrest -free 6 months after discharge 85% 800 Equipment 7200, Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 155,000 178250 Professional Fees 3,400 3,900 900 Operations 33,000 37,950 1.300 Supplies 1.700 1,950 800 Equipment 7200, 7,920 800 Other: payroll taxes, assessments, fringe benefits 40,000 46,000 Otherstaff training 1,100 1,200 200 Other. mileage 16,900 19,750 2,500 Other: program activities 3,750 5,750 2,000 Other: travel, telecommunication, publishing/printing 8,700 10,000 1.500 TOTAL 270,750 312.670 10,000 'Ifapplicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hale Kipa, Inc Program Name: Ka'i like Program io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: N/A 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 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: Q If no conflicts exist, check here. Board Chair Signature of Authorized Person (specify title) 115/15 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Hale Kipa, Inc Program Name: Ka'i Like Program 11. 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 allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and 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 final payment. To register, go to http://venclors.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 oaencv's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hale Kipa, Inc Program Name: Ka'i Like Program 11. Certification of Understanding (Page z of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grantfunds received duringthe grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by lune 30, 2015 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 moV result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Board Chair 1/5/15 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hale Kipa, Inc Program Name: Ka'i Like Program 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other. Other: Other. TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 9of8 Hamakua Harvest Demonstration Working Farm and Orchard 47 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hamakua Harvest Program Name: Demonstration Working Farm and Orchard Agency Director. rticnaei Gibson Phone No.: ( 90e) 640 — 2506 Contact Person: Lon Beach Phone No.: ( boa) 775 — 8209 Mailing Address: Address: Po aox 1308 Address: City, ST, Zip Honokaa, HI 96727 Facility Address: address: Address: City, ST, Zip Email Address: Irrribeachhawali@gmaitcom Fax No.: Accountant/CPA: Phone No.: Firm (if applicable): Mailing Address: Address-. Address: City, ST, Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES ......... . .... ...... . . Amount of Request for County Nonprofit Grant Program Funds: $47.300 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna © Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns Z Youth Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hamakua Harvest Program Name: Demonstration Working Farm and Orchard 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 1415 $0 $0 $0 2. Agency Mission Statement: HH's mission is to provide a community-based agricultural hub - consisting of a demonstration farm, market and learning center - whose core purpose is to incentivize and facilitate local farming and to serve as a model for other rural communities intent on vitalizing their local economies. The project will offer multifaceted educational opportunities for area residents, youth and small farmers, along with the critical infrastructure needed to enhance the region's sustainable agriculture sector and increase its food self-sufficiency. 3. Program Description: The Demonstration Working Farm and Orchard will encompass a 3 -acre diversified farming system, modeling the most economically and environmentally viable crops for the Hamakua region. Both proven and innovative techniques will be utilized to demonstrate a variety of sustainable agriculture practices, as well as practical business methods to help local family farms succeed. This program is being designed in direct response to clear community demand, expressed through a communitywide survey conducted by Hamakua Harvest (HH) in Fall 2014. It will provide a service currently not offered anywhere on the island. The Farm and Orchard will also integrate hands on learning opportunities for local youth and their families; HH has already established a partnership with the Hamakua Youth Foundation to develop a youth -operated "Community Supported Agriculture" (CSA) project that will provide invaluable educational experiences for kids and their ohana - effectively preparing Hamakua youth for a future career in agriculture or any other skilled job they choose - while supplying healthy, fresh, local produce for residents. Total Program Budget: $87.270 Total Program Position Count: 2 Total Agency Budget $150,0001 Total Agency Position Count: a EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hamakua Harvest Program Name: Demonstration Working Farm and Orchard 'd til all sources of funding applied to this Programl: 5. Program Funding Sources (t an i _ FV16-16 Revenue Source Estimate $15,000 Communi investment secured $6,250 Atherton rant funds to develop educational programs HH volunteer hours ($9/hr x 160h-1—th x 12 months) $18.720 $47 300 Coun nonprofit rant - TOTAL: $87,270 Attach additional pages, if neeaea. 6. Explain what plans your agency or program has to increase revenues to support this program: Product revenues are expected to fully support the program once crops are mature. The Farm and Orchard will produce high quality, all natural products (including some that are certified organic), which will be marketed to area schools and other institutions (i.e. hospitals) and sold through the Hamakua Harvest CSA and Farmers' Market. Excess produce will be made available to charity food banks such as the Hawaii Island Food Pantry. Over the initial 3-5 years, program revenues will be increased through development of a variety of hands-on educational workshops and classes for local residents and visitors. Moreover, the Hamakua Harvest project as a whole is designed as an integrated agricultural hub, which will include a robust Farmers' Market that has already secured startup funds through USDA-FMPP and is scheduled to launch in Spring 2015; this high profile venue will attract ongoing community support in the form of donations, investment and volunteer hours. F. Program Objectives Using County Nonprofit Grant Program Funds: County Nonprofit Grant funds will be used to help establish the Demonstration Farm and Orchard, including site prep, design and planting. This work will set the stage for the program to be fully operational, and thus provide a unique and much-needed service of educating area youth, residents, visitors and small fanners while supporting Hamakua's sustainable agriculture sector and increasing its food self sufficiency. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hamakua Harvest Program Name: Demonstration Working Farm and orchard B. TABLE I: -,..r,., ,..tended measurable outputs or outcomes that would be achieved with this funding? Attach additional pages as necessary. o Tw ulc u• J .. FY 14-15 PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e., Number ofnsrts served, workshops or events held, volunteer hours, etc Describe, be speci)rcJ Actual' Sustainable farmingmethods demonstrated > 3 methods displa ed Volunteer engagement enhanced 2000 hours in 12 month Youth/Adult ag leamin opportunities created 400 residents an a ed Hands-on education courses created 6 workshops held yr 1 Increased visitors to the region _ Exposure to tourists Produce healthy, fresh, local produce Product sales by 7/16 Improve viability of farming in region > 10 farms involved Attach additional pages as necessary. o Tw ulc u• J .. FY 14-15 FY 15-16 FY 15-16 PROGRAM EXPENDITURES Actual' Total Budget Grant Req Salary and Wages $26,250 $5,000 Professional Fees $0 $0 Operations $18,720 $o Supplies $2,500 $2,500 Equipment $3,000 $3,000 Other: orchard design and planting plan $1,500 $1,500 Other. smoothing and terracing, w/ NRCS affiliation $1,800 $1,800 other: irrigation trenching 8 installation $10,700 $10,700 a land and irrigation Other, windbreak design, planting $1,800 $1,800 Other: planting crops (labor 8 seeds/grafted trees) $21,000 $21,000 TOTAL $87,270 $47,300 applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hamakua Harvest Program Name: Demonstration Working Farm and Orchard lo. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interestthat 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 F The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Q If no conflicts exist, check here. Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hamakua Harvest Program Name: Demonstration Working Farm and Orchard 11. Certification of Understanding (page 1 of 2) 1 (we) have read and understood all of the 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 final payment. 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 o timely, complete and accurate year-end report using the template provided, will impact the evaluation "agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hamakua Harvest Program Name: Demonstration Working Farm and Orchard 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 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.hawaticounty.gov/fn-nonprofit-grant-formsZ on or about May 30 of the year the final 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, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in P timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. v Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 3v 9�Ze�5 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hamakua Harvest Program Name: Demonstration Working Farm and Orchard 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Sustainable famring methods demonstrated 3 methods Volunteer engagement enhanced 2000 hNyr Youth/Adult ag learning opportunities created 400 Hands-on education courses created s workshops Increased visitors to the region Exposure Produce healthy, fresh, local produce Sales by 7116 Improve viability of farming in region > 10 farms TAR[ F If - PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $5,000 Professional Fees Operations Supplies $2,500 Equipment $3,000 Other: orchard design and planting plan $1,500 Other: smoothing and terracing, w/ NRCS affiliation $1,800 Other: irrigation trenching & installation $10,700 Other: windbreak design, planting and irrigation $1,800 Other. planting crops (labor & seedstgmfted trees) $21,000 TOTAL $47,300 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 Hamakua Youth Foundation Hamakua Youth Center am County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth center Agency Director: t. MahealaM Melku9 Phone No.: (908)75— 0976 Contact Person: vMahealanirnaikul Phone No.: (8ca)P5— o91E Mailing Address: Address: Poa sea Address: City, ST, Zip Honokae, HI 96727 Facility Address: Address: 45-3396 Mamane St. Address: City, ST, Zip Honokaa, HI 96]2] Email Address: Hamakuayouthcerter@gma0.mm Fax No.: Accountant/CPA: Phone No.: (808 )329 — 9220 Firm (if applicable): Aloha Business Services Mailing Address: Address: ] 5596P.s,Pl.#SE Address: City, ST, Zip Kailua-Kona. HI M740 YOU ARE RESPONSIBLE TO KEEP THEABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds Geographical Areas To Be Served: (One or more can be checked) ❑ Puna © H5m5kua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns © youth ❑ Victims of Crimes W1 Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $11,250 $17,500.00 $32,500 2. Agency Mission Statement: Hamakua Youth Center is a community based non-profit that opens windows to the world for the young people of the Hamakua District. By providing a safe after-school space that offers opportunities for youth to participate in a variety of activities from homework support and creative arts to leadership training and the exploration of the many cultures of Hawaii, the Hamakua Youth Center seeks to empower our youngsters to achieve their dreams. 3. Program Description: Hamakua Youth Center (HYC) provides no -cost drop-in programs open daily after-school, during intersessions, occasional weekends and summer breaks to school age kids in Honokaa. HYC's team continually strives to instill life skills that are guided by traditional Hawaiian values—aloha kekahi i kekahi (to love one another); kokua aku, kokua mai (to give and recieve help); malama i kou kuleana (to take care of your responsibilities); and mahalo i ka mea loa'a (to be thankful for all you have). Our programs include traditional and natural agriculture with weekly visits to Waipi'o Valley; perpetuation of Hawaiian Culture through partnership with Kamehameha School, Honokaa School, as well as other community organizations and community members. We focus on traditional Hawaiian and contemporary arts and crafts such as: lauhala weaving, ceramics, lei making, kihei design, drawing, painting, media/music/video recording/production, t -shirt designs, and holiday themed craft activities. HYC's program includes youth to youth mentoring through homework assistance and leadership training. 4. Total Budget & Position Count: Total Program Budget: $149,065 Total Program Position Count: 2 Total Agency Budget: $149,0691 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 Schrey, Theodore From: Hamakua Youth Center <hamakuayouthcenter@gmailxcar> Sent: Monday, February 02, 2015 1:01 PM To: Schrey, Theodore Subject: Re: NP Grant application Clarification-HYF Aloha e Ted - Please use both page 3 together. The bottom of the column says to use additional pages, that's why there are 2 pages of page 3. The total requested amount is $36,500. Mahalo On Mon, Feb 2, 2015 at 11:52 AM, Schrey, Theodore <pheodore Sehrevna hawaiicountv.eov> wrote: Aloha! Two things need clarification. First, there are two page 3, with different information on each. One has a table with total revenues of $49K, and the other has $124,500. Also, please clarify the amount being requested re: Hawaii County nonprofit grant program. On the page 3 with $134,500,i1 indicates that you are asking for $30K (the other page three has no County listing), and on page 4 $36,500is indicated. Thank You! Ted,5c,rcy County of Hawaii, Finance Department Budget Specialist (808)961-8489 The information contained in this email is confidential and maybe subject to legal privilege. If you are not the intended recipient, you must not use, copy, distribute, or disclose this email, or any part of it's contents, or take any action in reliance on it. If you have received this email in error, please email the sender by replying to this message. County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center s. Prnaram Funding Sources (identify all sources of funding applied to this proaraml: Revenue Source Fy15-16 Estimate Hawaii community Foundation $15,000 County of Hawaii - Non Pmfit $30,000 Service Cluball-ocal Business $2500 state of Hawaii - Office of Youth services $10,000 Hawaii Island United Way $20,000 Fundraising Events / Community Donations $25.000 OHA $22,000 TOTAL: $124,500 Attach additional pages, ifneeded. S. Explain what plans your agency or program has to increase revenues to support this program: HYF will schedule and host community fundraising events throughout the year, including our annual Hula Festival. Currently, we are strengthening our grant writing team so that we car, increase our capabilities for receiving foundation and government support. HYF will strive to build community partnerships that include joint funding with agencies and organizations throughout Hawaii to ensure our keiki learn the value of utilizing the many Hawaiian cultural specialists, community artists, and kupuna that our island peoples' have to offer. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our objectives using County of Hawaii funds are: t) to sustain our existing and increase our program partners 2) to continually promote an environment of Aloha, Kokua, Malama, Mahalo 3) to reconnect youngsters with the land through direct experience with traditional Hawaiian agriculture 4) to build self-confidence in our youth to make healthy independent decisions 5) to develop the confidence in our youth to make group presentations and actively participate in group discussions 6) to kokua in "foundational support" in the lives of our youth EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Fnends of Hawaii Chanties $10,000 Kahilu Theatre -Vagina Monologue Beneficiary $4,000 Hawaii Hotel Industry $5,000 WalMan Fwndation $30,000 TOTAL: $ i000 Attach additional pages, ifa ded. 6. Explain what plans your agency or program has to increase revenues to support this program: HYF will schedule and host community fundraising events throughout the year. Currently, we are working to strengthen our grant writing team. HYF will strive to build community partnerships with agencies and organizations throughout Hawaii to ensure our keiki learn the value of "tapping" into the many resources of Hawaiian cultural specialists, community artists, and specialists in other "specialty area" that our island peoples' have to offer. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our objectives using County funds are: 1) to sustain then increase our program partners 2) to continually promote an environment of Aloha, Kokua, Malama, Mahalo 3) to reconnect youngsters with the land through Hawaiian Culture 4) to build self-confidence that lead to healthy independent decisions 5) to develop the confidence to make group presentations and actively participate in group discussions 6) to kokua in "foundational support" for our youth EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 8. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Numbervjclienrswrved, uarkshops orevenis held, •roIunteerliours, etc. Desanbe, be speeificj Applicant Projected Results Youth evaluation of existing and new programs 20 new participants Expanding pro rams to older youth 10 new older youth Ongoing youth questiobnnaires at random regularly Greater involvement of families a family council Family member questionnaires at random Formation of an ongoing Yount Council at least 5 meetings Youth attend County sponsored events increased numbers Aftach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDRURES FY 24-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 61,116 60,603 9,500 PfOfeS510na1 Fees 10,343 24,320 9,500; Operations 12,741 16,334 6,500 Supplies 9,058 8,700 3,500 Equipment 450 0 0 Other: Admin Costs: BOD Ins, Aucht, Fundraising Exp 2,716 5,090 0 Other: Food/Beverage 5,200 4,500 3,500 Other: Mileage Reimb I Transporation 6,809 6.750 3,000 Other: Emp. Benefits / Health Ins./ Emp. Training 5,110 20,772 1,000 Other. Offsite Facility Rental 2017, 2,000 0 TOTAL $115,560 $14,9069 $36,500 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether 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 CanRkt of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accming 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: rVr bl If no conflicts exist, check here. Signatu a of Authorize erson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 — 2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contact, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability 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 priorto submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. 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 final payment. 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 ear -end report to the County Council within 60 days after Ju ne 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 ear -end report, using the template provided,will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of 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'^ 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://wNw.haNaiicount,i.gov/`f`n-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 lune 30, 2015 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 agenws future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signatu of Authorized PiWson (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 1l/2�7'//� Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hamakua Youth Foundation, Inc. Program Name: Hamakua Youth Center 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE 11: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Hawaii County Economic Opportunity Council (HCEOC) Drop Out Prevention Program T County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HAWAII COUNTY ECONOMIC OPPORTUNITY COUNC Program Name: DROP OUT PREVENTION PROGRAM Agency Director: Jay Kimura Phone No.: ( 608) 961 — 2681 Contact Person: Courtney Hamalom Phone NO.: ( 808) 961 — 2661 Mailing Address: Address: 47 Rainbow Dave Address: 47 Rainbow on,, City, ST, Zip Hilo, Hawaii 96720 Facility Address: Address: 47 Rainbow Drive Address: 67 Rainbow Drive City, ST, Zip Hilo, Hawaii 96720 Email Address: acson2310@honnail.corn Accountant/CPA: Tessie Padam a Firm (if applicable): Fax No.: ( 608 ) 935 — 9213 Phone No.: ( 808) 961 — 2661 Mailing Address: Address: 47 Rainbow Dnve Address: City, ST, Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $ 148,235.00 Geographical Areas To Be Served: (One or more can be checked) © Puna ❑ Hamakua ❑ North Kona Q South Hilo ❑ North Kohala © South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more ran be checked) © Educational concerns © Youth ❑ Victims of crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page l of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HAWAII COUNTY ECONOMIC OPPORTUNITY COUNC Program Name: DROP OUT PREVENTION PROGRAM 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $45,000-00 $5,000.00 $58,500.00 2. Agency Mission Statement: HCEOC's mission is to prevent, alleviate, and eliminate poverty in the County of Hawaii. 3. Program Description: The Drop Out Prevention Program's (DOPP) aim and purpose is to help at -risk and low-income school and court referred high school students at Waiakea, Keaau, and Konawaena to improve in academics, attendance, and behavior by working collaboratively with students, staff, parents, and available resources, agencies, and organizations in the community to prevent students from dropping out and ultimately graduating from high school. ...1 0 et R position rnuntt Total Program Budget: $1a8.z35 Total Program Position Count: 9 Total Agency Budget: 1$3,598,014 Total Agency Position Count: 53 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HAWAII COUNTY ECONOMIC OPPORTUNITY COUNC Program Name: DROP OUT PREVENTION PROGRAM ._J:_.. r.., —c fldon•if..0 smrrps of funding aoolied to this program FY35-16 Revenue Source Estimate STATE OF HAWAII GRANTS-IN-AID $150,000 TOTAL: $150,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The plans for increasing revenues in order to support this program is to continue applying for state grants-in-aid monies as well as forming potential partnerships and funding through the state Department of Education. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives are to have 95% of the senior clients graduate. 75% of the referred student clients will attend school 85% of school days. 75% of the referred student clients will not have suspensions exceeding three consecutive days. 75% of referred underclassmen student clients grades 9-11 will be promoted to the next grade level. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HAWAII COUNTY ECONOMIC OPPORTUNITY COUNC Program Name: DROP OUT PREVENTION PROGRAM 8. TABLE 1: blt uts or outcomes that would be achieved with this funding? What are the Intended measura a ou p PROGRAM PERFORMANCE MEASURES (i. e.: Number of clients served, workshops wevents held, volunteer hours, ea. aescnbe, he speclficI Applicant Projected Results 26 CLIENTS ENROLLED EACH SCHOOL BY 12131/15 90%. ACHIEVED 100% ACHIEVE 50 REFERRALS ASSISTED 0 EACH SCHOOL BY 511116 70% OF PARTICIPANTS THE GPA AVG WILL BE 2.0 BY END OF 4TH QUARTER FY 1516 AVG DAILY ATTENDANCE 85%+ BY END OF 4TH QTR 75% OF PARTICIPANTS 75% OF GRS-11 PROMOTED TO NEXT GRADE LEVEL 75% OF GR.9-11 75% WILL NOT HAVE SUSPENSIONS 3+DAYS 75% OF PARTICIPANTS Attach additional pages as necessary. 9. TABLE II: FY 14-15 FY 15-16 FY 1516 PROGRAM EXPENDITURES Actual• Total Budget Grant Req $124,585 $124,585 Salary and Wages $1,250 $1,250 Professional Fees $4,300 $4,300 Operations $7,600 $7,600 Supplies $o $o Equipment $8,500 $8,500 Other: MILEAGE $1,500 $1,500 Other: FIELD TRIPS $500 $500 Other: ADVERTISING Other: Other, TOTAL $148,235 $148,235 �If vnnlirahle EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HAWAII COUNTY ECONOMIC OPPORTUNITY COUNC Program Name: DROP OUT PREVENTION PROGRAM io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 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 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. Signa re & Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 I 7 IS Date Page 5 of R County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HAWAII COUNTY ECONOMIC OPPORTUNITY COUNC Program Name: DROP OUT PREVENTION PROGRAM t>. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 final payment. To register, go to -' '.--ly-, complete the 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 HawaN grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit o timely. complete and accurate year-end report using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HAWAII COUNTY ECONOMIC OPPORTUNITY COUNC Program Name: DROP OUT PREVENTION PROGRAM 11. Certification of Understanding (Page 2 o 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,_ _ __ ___ — on or about May 30 of the year the final 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Sig4tu4 of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HAWAII COUNTY ECONOMIC OPPORTUNITY COUNC Program Name: DROP OUT PREVENTION PROGRAM 1z. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES I... Applicant Projected ResuHs Council Proposed Projected Result 26 CLIENTS ENROLLED Q EACH SCHOOL BY 12/31/15 90% 50 REFERRALS ASSISTED @ EACH SCHOOL BY 511116 100% DOPP GPA AVG WILL BE 2.0 BY END OF 4TH QUARTER 70% THE AVG DAILY ATTENDANCE WILL BE 85%+ BY 5131114 75% 75% OF GR.9-11 PARTICIPANTS WILL BE PROMOTED 75% 75% WILL HAVE NO SUSPENSIONS 3 DAYS - 75% Other: FIELD TRIPS $1,500 - PROGRAM EXPENDITURES FY 15-16 Grant Request =Award Salary and Wages $124,585 Professional Fees $1,250 Operations $4,300 Supplies $7,600 Equipment $0 Other: MILEAGE $8,500 Other: FIELD TRIPS $1,500 Other: ADVERTISING $500 Other: Other: TOTAL $148,235 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Hawaii County Economic Opportunity Council (HCEOC) Transportation Program 50 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii County Economic Opportunity Counc Program Name: Transportation Program Agency Director: Jay Kimura Phone No.: ( 808) 961 — 2661 Contact Person: Tom Brown Phone No.: ( 806) 961 — 2661 Mailing Address: Address: 47 Rainbow Drive Address: 47 Rainbow Drive City, ST, Zip Hilo, Hawaii 96720 Facility Address: Address: 47 Rainbow Dr1w Address: City, ST, Zip Hilo, Hawaii 96720 Email Address: hoeocdimmor@hmm.net Fax No.: ( 808) 961 — 2612 Accountant/CPA: Mary Namauu, Fiscal officer Phone No.: ( 806) 961 — 2661 Firm (if applicable): Mailing Address: Address: 47 Rainbow Drive Address: City, ST, Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: s 600,000.00 Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua © North Kona © South Hilo © North Kohala © South Kona © North Hilo © South Kohala © Ka'0 Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth © Victims of Crimes ❑ Culture and the arts © Aged © Victims of Health or Social Crises © Needs of the poor © Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page l of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii County Economic Opportunity Counc Program Name: Transportation Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 2. Agency Mission Statement: The mission of HCEOC is to prevent, alleviate, and eliminate poverty conditions in the County of Hawaii. To this end, the transportation program is to provide mobility to the seniors, disabled,eldedy, working poor and youth in the community. 3. Program Description: The program is designed to provide increased mobility for the elderly and disabled by providing at-home pick-up and drop off to doctors offices, hospitals, government offices, financial institutions, and senior centers. This helps to improve independence for our seniors and allows them to enjoy a higher quality of life as many are unable to drive themselves nor can they afford the cost of private taxi or transportation. The youth also benefit by the transportation program as it allows them to take part in after school programs and activities and get transportation home. Many parents do not have the luxury of taking time off from work or paying the high cost of gasoline to transport students home. This is especially problematic in rural communities such as Ka'u, Naalehu, and Hawaiian Beaches. The transportation program will indeed allow for youth in the County of Hawaii to partake in a greater breadth of positive activities after school and parents need not sacrifice hours at theirjob and can save on gas costs. The transportation program will also help to provide transportation to low-income workers who have difficulty obtaining or paying for transportation to work which will assist them in maintaining employment. 4. Total Budget & Position Count: Total Program Budget: 1,058,287 Total Program Position Count: 25 Total Agency Budget: 3,598,014 Total Agency POSItIOn Count: 53 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii County Economic Opportunity Counc Program Name: Transportation Program S. Program Funding Sources (identify all sources of funding applied to this oroeramj: Revenue Source FYIS-16 Estimate Community Services Block Grant $50,000 County of Hawaii Transpartatlon Operating $600,000 County Nutrition Transportation $200,000 LogistiCare $240,000 TOTAL: $1,090,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program HCEOC plans to apportion $50,000 of annual Community Services Block Grant funding (from State Dept. of Labor Office of Community Services to HCEOC Transportation Program (STAFF salaries and fringe benefits. HCEOC will also seek $600,000 of operational funding from the County Mass Transit and $200,000 from County of Office of Aging for daily transportation to County Nutrition centers for congregate dining. Based upon recent experience over the past three years, we expect LogistiCare reimbursements for transportation to generate at least $240,000. LogistiCare reimburses HCEOC for providing medical transportation service for elderly/disabled clients. 7. Program Objectives Using County Nonprofit Grant Program Funds: ELDERLY- a minimum of 3,000 elderly will be provided transportation to medical and other professional services, consumer and recreational, adult care and/or nutrition sites for an estimated total of 1,450,00 trips. DISABLED - a minimum of 300 disabled persons will be provided transportation to rehabilitative and independent centers for an estimated total of 170,000 trips. WORKING POOR - a minimum of 50 employed low-income persons will be transported to and from work for an estimated total of 28,000 trips. YOUTH - a minimum of 60 youth will be provided transportation home from after school activities for an estimated 10,200 trips Passenger trip = Discrete segment of travel from passenger boarding to disem EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii County Economic Opportunity Counc Program Name: Transportation Program B. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this fundine7 PROGRAM PERFORMANCE MEASURES (i.e.: Number 0Jc4 nts served, workshops a events held, vdunreerhours, etc. aeicr e, be spechc.) Applicant Projected Results 3000 ELDERLY transported/1,450,000 trips 3000 elderly/1,450,000 300 DISABLED transported/170,000 trips 300 disabled/170,000 50 WORKING POOR transported/28,000 trips 50 working poor/28,000 60 YOUTH transported/10,200 trips 60 youttV10,200 Operations Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES rri4-15 Actual• FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages Professional Fees Operations Supplies Equipment (�j — 15 rOK"GA;CCA V A k 0 0 $600,000 Other: Other: Other: Other: Other: TOTAL 0 0 $600,000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii County Economic Opportunity Counc Program Name: Transportation Program io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 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): ❑ 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 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. Signatug o Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii County Economic Opportunity Counc Program Name: Transportation Program 11. Certification of Understanding (Pagel of 2) 1 (we) have read and understood all of the 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 final payment. To register, go to `.�:', complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall Include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report using the template provided will impact the evaluation of Your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii County Economic Opportunity Counc Program Name: Transportation Program 11. Certification of Understanding (Page 2of2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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 3011 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 _ ilcu ,r H,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 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. i/�li1 rl. Signat o Authoru d Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 ate Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii County Economic Opportunity Counc Program Name: Transportation Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected It 3000 ELDERLY transported/1,450,000 tips 300011450000 300 DISABLED transported/170,000 trips 300/170000 50 WORKING POOR transported/28,000 trips 50f28,000 60 YOUTH transported/10,200 trips 60110,200 Equipment �rj PgSSENGe'!� IA✓-+� $600,000 OthEOther: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment �rj PgSSENGe'!� IA✓-+� $600,000 OthEOther: TOTAL $600,000 Addiiiunai Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 Hawaii Island Adult Care, Inc. Adult Day Care Centers 51 County of Hawaii Nonprofit Grant Application Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day care Centers Agency Director: Paula uusitala Phone No.: (608) 961 — 3747 Contact Person: some aaao.v. Phone No.: ( ) Mailing Address: Address: 34Rxnbow Dave Address: City, ST, Zip Hilo, Hawaii 96720 Facility Address: Address: sameasabove;addilionallocationin Honomuat Address: Hilo Coast UCG City, ST, Zip Honomu, HI Email Address: Puusioab@hawaiiislandadultcare org Fax No.: ( 606) 961 — 3740 Accountant/CPA: Jennifer Gossed Phone No.: ( 806) 969 — 3115 Firm (if applicable): Jennifer L. Gassed, CPA Mailing Address: Address: sae Kmoole street Address. City, ST, Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua ❑ North Kona © South Hilo ❑ North Kohala ❑ South Kona © North Hilo ❑ South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts © Aged ❑ Victims of Health or Social Crises © Needs of the poor © Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of S County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $ 20,000.00 $30,000.00 $ 30,000.00 2. Agency Mission Statement: To provide quality community-based care for elders and challenged adults and support for their families on Hawaii Island. 3. Program Description: Adult Day Care Centers in Hilo and Honomu provide a safe, socially -active daytime program for aging elders and challenged adults. The programs provide a structured daily schedule which includes exercise, activities for mental stimulation, games, socialization and fun. The goals are to keep our kupuna living at home for as long as possible, have dignity and independence, deter institutionalization, and additionally, to provide support including education and training for the families/caregivers to be able to continue their employment and/or have respite from caregiving to recharge. Hawaii Island Adult Care, Inc. (HIAC) received CARF International accreditation this past March until March 2017. With this recognition, CARF officially recognizes HIAC as an adult day services provider meeting high standards for quality of service and continuous improvement. 4. Total Budget & Position Count: Total Program Budget: 1,510,300 Total Program Position Count: 36 Total Agency Budget: 1,532,350 Total Agency Position Count: 36 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Adult care, Inc. Program Name: Adult Day care centers Fnndine sources ficientifv all sources of funding applied to this program): Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program The tuition assistance program supports those who are above Medicaid income levels, needing daytime supervision and socialization. To increase revenues, we have an annual fee increase planned to go into effect this spring. We write many grants each year to provide financial assistance for this low-income gap group. The best scenario would be if Medicare began paying for low-income adults who require daytime supervision and socialization. The alternative, institutionalization, is very costly for the Medicare/Medicaid programs, is generally medically unnecessary, and creates additional personal restrictions or burdens for the families/caregivers. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objective of this funding is to provide tuition assistance to low-income elderly adults who require adult day care yet who are above Medicaid income levels and thus cannot afford to pay full costs. Tuition assistance funding helps close the gap and allows all of our kupuna who need to attend day care regardless of ability to pay. This program is a cost -share and each applicant is reviewed for income/assets and expenses, so as to maximize the number of participants who can receive assistance. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of FY15-16 Revenue Source Estimate $939,400 Tuition/Fees State/Federal(Medicaid) 238,000 County of Hawaii 30,000 May Templeton Hopper Fund 71,250 Hawaii Island United Way 20,000 Other Tuition Assistance Grants 53,000 Other (See Attachment A) 158,650 TOTAL: $1,510,300 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program The tuition assistance program supports those who are above Medicaid income levels, needing daytime supervision and socialization. To increase revenues, we have an annual fee increase planned to go into effect this spring. We write many grants each year to provide financial assistance for this low-income gap group. The best scenario would be if Medicare began paying for low-income adults who require daytime supervision and socialization. The alternative, institutionalization, is very costly for the Medicare/Medicaid programs, is generally medically unnecessary, and creates additional personal restrictions or burdens for the families/caregivers. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objective of this funding is to provide tuition assistance to low-income elderly adults who require adult day care yet who are above Medicaid income levels and thus cannot afford to pay full costs. Tuition assistance funding helps close the gap and allows all of our kupuna who need to attend day care regardless of ability to pay. This program is a cost -share and each applicant is reviewed for income/assets and expenses, so as to maximize the number of participants who can receive assistance. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Adult care, Inc. Program Name: Adult Day Care Centers B. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.: Number of clients serves, workshops or events held, vpmors,r hours, etc pescnbe, be spedficf Applicant Projected Results Participants able to attend adult day care 18-28 Total units (months) of funding assistance 100-125 Elders who maintainedlimrpoved self care 18-28 Elders who alleviated depression 18-28 Families who receive respite 18-28 Families he are able to continue employment 10-15 Caregiver satisfaction - deterring burnout 18-28 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual` FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $1,021,300 $1,051,690 Professional Fees 8,000 8,500 Operations 202,895 191,930 Supplies 89,091 82,090 Equipment 3,994 1,840 Other: Direct Client Expense 160,780 174,250 30,000 Other: Other: Other: Other: TOTAL $1,486,060 $1,510,300 $30,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers to. 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 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): ❑ 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: r✓ If no conflicts exist, check here. Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 January 26, 2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers 11. Certification of Understanding (page 1 of 2) 1 (we) have read and understood all of the 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 accordingto 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 final payment. To register, go to http'//vendors ehawaii.gov. complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate Year-end report using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Adult care, Inc. Program Name: Adult Day care centers 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant Period (must be refunded to County) and exclusion from future grant Participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at httLj 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. �- Sign ature of Authorized Person(5pecifytitle) 1/26/2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Adult Care, Inc. Program Name: Adult Day Care Centers 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Resant Projected Results Projected Council Proposed Projected Result Number participants able to attend adult day care 16-29 Total units (months) offunding assistance 100-125 Elders who can maintain/improve self care 16-28 Elders who can alleviate depression 18-29 Families who receive respite 18-29 Families who are able to continue employment 10-15 Caregiver satisfaction - deterring burnout 18-29 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Direct Client Expense $30,000 Other: Other: Other. Other: TOTAL $30,000 Additional Council directives resardinl; award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 For Page 2, Attachment A County of Hawaii Human Services Grant - Fiscal Year 201516 Hawaii Island Adult Care, Inc. Additional Program Funding Sources USDA Lunch Reimbursement $ 73,000.00 Donations $ 10,750.00 Friends of HIAC, Combined Federal Campaign $ 5,000.00 Fundraising $ 45,000.00 PIN Management Fees $ 4,900.00 Other Grants (non -tuition assistance) $ 19,300.00 Interest $ 500.00 Other $ 200.00 $158,650.00 Please note: We disburse Persons -in -Need (PIN) grants for the community at large (through referrals), and thus the A, is allowed by the granter Hawaii Island HIV/AIDS Foundation (HIHAF) Conduct a Comprehensive Update of the HIHAF SISTA Program 52 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island HIV/AIDS Foundation Island HIV/AIDS Foundation (HIHAF) Program Name: Conduct a Comprehensive Update of the HIHAF SISTA Program Agency Director: Bruce Merrell Phone No.: ( 808) 331 — em Contact Person: as move Phone No.: ( ) — Mailing Address: Address: Laotian Professional Center Address: 75-5591 Poll Rd, Suite 3001 City, ST, Zip Kailua-Kona, Hl 96740 Facility Address: Address: as tl'wva Address: City, ST, Zip Email Address: bmer.110hirtacor9 Fax No.: ( 808 ) 331 — 8802 Accountant/CPA: Caroonam CPA and Assonia rtes, ma Phone No.: ( 808 ) 930 — 6850 Firm (if applicable): Mailing Address: Address: Po. Box 4372 Address: City, ST, Zip Hdo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES .....__.-_ -.._.. Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (one or more can be checked) ❑ Puna ❑ Hamakua ❑✓ North Kona ❑ South Hilo✓❑ North Kohala ❑✓ South Kona ❑ North Hilo ✓❑ South Kohala ❑✓ Ka'0 Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page I of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island HIV/AIDS Foundation Island HIV/AIDS Foundation (HIHAF) Program Name: Conduct a Comprehensive Update of the HIHAF SISTA Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $15,000.00 $0.00 $20,000.00 2. Agency Mission Statement: The Hawaii Island HIV/AIDS Foundation (HIHAF) is a non-profit organization dedicated to assisting those affected by HIV/AIDS to maximize their quality of life and to ending the spread of HIV. We also utilize the lessons learned in the HIV epidemic to care and advocate for others in the fight against related diseases. 3. Program Description: Critical to HIHAF's Prevention Program is the Sistas Informing Sistas about Topics in AIDS (SISTA) Program which includes role playing, behavioral modification, etc. for young women to help them reduce their risk of HIV/Hep C. This culturally -sensitive program was specifically designed for young Asian/Pacific women and has been well received and highly successful in Hawaii County where it has been used by HIHAF for over 7 years. However, significant social changes and recent advances in HIV/Hep C prevention strategies have occurred in the past several years including the explosion in the use of social media and the internet, advances in gender equality, increased attention to Gay issues, and new openness and pride in Gay communities. Further, new CDC/DOH Prevention Guidelines have significantly modified the focus of HIV/Hep C prevention programs and medical advances such as pre -exposure prophylaxis (PreP) are recommended to reduce the risk of HIV Infection. Thus, it is now crucial that HIHAF's SISTA Program undergo a comprehensive revision to insure its continued high level of culture sensitivity, relevance to the target population of socially aware, modern young women, and the correctness and accuracy of the presented factual material. 4. Total Budget & Position Count: Total Program Budget: $20,0001 Total Program Position Count: a Total Agency Budget: $994,000 Total Agency Position Count: 15 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island HIV/AIDS Foundation Island HIV/AIDS Foundation (HIHAF) Program Name: Conduct a Comprehensive Update of the HIHAF SISTA Program Fundine Sources fidentifV all sources of funding applied to this program): Revenue Source FY15-16 Estimate DOH Prevention Grant - HIV/Hep C Screening only $78,000 Hawaii Women's Legal Fund $2,000 Hawaii Island United Way $17,500 TOTAL: $97,500 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: To increase revenue to support this vital SISTA program, HIHAF will continue to seek and apply for grants to private and corporate sponcers to help underwrite this critical program focusing on prevention of HIV and Hep C in young women. In particular, HIHAF will be seeking grants from organizations that focus on young women's issues such as the Hawaii Women's Legal Fund and the Hawaii Island United Way. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Continue to operate an HIV/STI prevention program in West Hawaii focusing on at -risk young Hawaiian women utilizing the SISTA Curriculum. 2. Develop an comprehensive revision of the SISTA Program for use in Hawaii County. 3. Field test and evaluate the new revision of the SISTA program in focus groups of young women in West Hawaii. 4. Share and distribute the revised SISTA Program to HIV/STI Prevention organizations island -wide. 5. Develop and establish a formal Consortium of organizations, agencies in West Hawaii to facilitate sharing of information, best practices, and resources for the prevention, control, and treatment of HIV and Hep C in individuals who live in our Big Island communities. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of /'4 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island HIV/AIDS Foundation Island HIV/AIDS Foundation (HIHAF) Program Name: Conduct a Comprehensive Update of the HIHAF SISTA Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Ice.: Number ,foherr, served, workshops or events held, volunteer hours, etc. Desrnbe, be spec jc ) Applicant Projected Results 1. Continue the current SISTA program in at least 6 groups of young Hawwaiian women Conduct 6 SISTA Pro rams 2. Conduct an extensive, comprehensive revision of the SISTA Program. Revision of SISTA program 3. Field test and evaluate draft program in 6 locus groups of young womenin West Hawaii. Field test in 6 groups of young women 4. Prepare final version and copies of revised SISTA Program for distribution. Distribute to 6 HIV prevention agenies 5. At least 4 meeting will be organized between HIV/Hep C related service organizations. Hold 4 meetings in West Hawaii Operations $350,000 $2,000 Attach additional pages as necessary. 9. TABLE 11: PROGRAM EXPENDITURES FY 14-11 Actual* FY 15-16 Totalaudget FY 15-16 Grant Req Salary and Wages Not Applicable $550,000 $11,500 Professional Fees $19,500 Operations $350,000 $2,000 Supplies $31,500 $2,500 Equipment $25,000 $2,500 Other: Travel: Mileage $18,000 $1,500 Other: Other: Other: Other: TOTAL $994,000 $20,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island HIV/AIDS Foundation Island HIV/AIDS Foundation (HIHAF) Program Name: Conduct a Comprehensive Update of the HIHAF SISTA Program io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist' option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. January 29,2015 Signature of Authorized Person (specify title) Date EXHI BIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island HIV/AIDS Foundation Island HIV/AIDS Foundation (HIHAF) Program Name: Conduct a Comprehensive Update of the HIHAF SISTA Program 11. Certification of Understanding (page 1 of z) 1 (we) have read and understood all of the 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 final payment. To register, go to _h_ttp://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 reauirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end reportusing the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawai'i Nonprofit Grant Application FY2015- l 6 Agency Name: Hawaii Island HIV/AIDS Foundation Island HIV/AIDS Foundation (HIHAF) Program Name: Conduct a Comprehensive Update of the HIHAF SISTA Program 11. Certification of Understanding (Pagezpf2) 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 paymends). I (we) understand that failure to submit the final report within 60 days of June 30'h 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.goy/fn-nonprofit-grant-forins/ on or about May 30 of the year the final 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 (30%) for administrative and overhead costs. Any funds unused by June 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. January 29, 2015 Signature of Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island HIV/AIDS Foundation Island HIV/AIDS Foundation (HIHAF) Program Name: Conduct a Comprehensive Update of the HIHAF SISTA Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8 of Hawai'i Island HIV/AIDS Foundation (HIHAF) Expanding Case Management Services for HIV and Hep C in East Havvai'i 53 y�PY County ofHawai`i Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island HIV/AIDS Foundation Island HIV/AIDS Foundation (HIHAF) Program Name: Expanding Case Management Services for HIV and Hep C in East Hawaii Agency Director: amcemanen Phone No.: ( 608) 962 — Contact Person: as above Phone No.: ( ) Mailing Address: Address: 16-204 MalaMahiwa PI pl Address: City, ST, Zip Keaau, HI 96749 Facility Address: Address: as above Address: City, ST, Zip Email Address: bmenn@hmel.n19 Fax No.: ( 808) 982 — 8802 Accountant/CPA: Carbonaro CPA and Assiciales, Inc. Phone No.: ( 808) 930 — 6630 Firm (if applicable): Mailing Address: Address: P.o.Box4372 Address: City, ST, Zip Hllo, Hawaii 96]20 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑ North Kona ❑r/ South Hilo ❑ North Kohala ❑ South Kona North Hilo ❑ South Kohala ❑ Ka'O Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ✓❑ youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island HIV/AIDS Foundation Island HIV/AIDS Foundation (HIHAF) Program Name: Expanding Case Management Services for HIV and Hep C in East Hawaii 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $15,000 $0.00 $20,000 2. Agency Mission Statement: The Hawaii Island HIV/AIDS Foundation (HIHAF) is a non-profit organization dedicated to assisting those affected by HIV/AIDS to maximize their quality of life and to ending the spread of HIV. We also utilize the lessons learned in the HIV epidemic to care and advocate for others in the fight against related diseases. 3. Program Description: HIHAF provides essential Case Management services and support through a multi -disciplinary team approach to HIV and/or Hepatitis C (Hep C) infected individuals to link them to all client services with appropriate community-based organization and services, such as medical and dental care, home health services, financial, medical benefits and insurance, federal housing support and other government aid agencies, food bank, etc. The Case Management is client -centered and provides a comprehensive assessment approach to maximize access to available resources and services as efficiently as possible. In addition, HIHAF has undertaken a newly expanded role in risk and harm reduction and prevention of new HIV and Hepatitis C infections within the community. Specific programs are directed towards partner services, risk -reduction education, HIV/HepC testing, behavioral intervention, community outreach, counseling and training in and distribution of appropriate risk -reduction material and methods, etc. HIHAF has recently partnered with The Community Health Outreach Work to Prevent HIV/AIDS (The CHOW Project) on the Big Island to share resources and facilitate programs and harm reduction activities for high risk drug users. 4. Total Budget & Position Count: Total Program Budget: Total Agency Budget: EXHIBITA NONPROFIT GRANT APPLICATION Total Program Position Count: I s Total Agency Position Count: 15 FY 2015-2016 Page 2 of R T'. County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island HIV/AIDS Foundation Island HIV/AIDS Foundation (HIHAF) Program Name: Expanding Case Management Services for HIV and Hep C in East Hawaii 5. Program Funding Sources (identify all sources of funding applied to this program): FY15-16 Revenue Source Estimate Ryan White Grant $9,000 DOH Case Management Grant $152,000 DOH Prevention Grant $6D,000 TOTAL: $221,0o0 Attach additional pages, iifneeded. 6. Explain what plans your agency or program has to increase revenues to support this program: It is the intent of HIHAF to expand Case Management services for Hepatitis C (Hep C) infected indivuduals, prevention activities for Hep C infection, and Hep C awareness within the community. HIHAF is currently working with the Department of Health on a Grant from Janssen Theraputics for "Improving Care and Treatment for People Who Inject Drugs Living with HIV and/or Hep C" This grant will start in 2015, if approved. Further, a portion of the previous HIHAF Shippers Wharf Grant was used for improving Hep C awareness within the community and to develop a Hep C Case Management services model based on HIHAF's very successful HIV Case Managemeent Services. By establishing a successful Hep C Case Management model, HIHAF will be eligible for participation in Hep C Clinical and Prevention Trials in collaboration with two pharmacutical companies/Department of Health in early 2015. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Secure resources to assist linking clients to health insurance for at least 95% People Living with HIV/AIDS (PLWHA) and/or Hep C. 2. Provide food assistance for 100% of all eligible PLWHA or Hep C who request aid and demonstrate need. 4. Continue to a establish a network of physicians and clinics on the east side of the island capable of treating Hep C infections. 5. Finalize, field test and distribute a newly developed Viral Hepatitis Case Management Manual. 3. Develop and establish a formal group of organizations, agencies and foundations in East Hawaii to facilitate the sharing of information, best practices, and resources for the prevention, control, and treatment of HIV and Hep C in our Big Island communities. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island HIV/AIDS Foundation Island HIV/AIDS Foundation (HIHAF) Program Name: Expanding Case Management Services for HIV and Hep C in East Hawaii B. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES 0.e.: Number ofdlenrsserved, workshops or events held, volunteer hours, etc Describe, be spxificf Applicant Projected Results L A minimum of 250 clients will be linked to food assistance. 250 cases linked to food assistance 2. 95 % of enrolled PLWA or Hap C will be linked to an insurance program. 225 will be linked to insurance 3. 100% of PLWA or Hep C clients will be linked to treatment. 225 will be linked to treatment 4. At least 200 eligible individuals will be screened for HIV and Hep C. 200 screened for HIV and Hep C 5. At least 400 individuals will receive transmission prevention education. 400 will be provided education 6. At least 4 meeting will be organized between HIV/Hep C related service organizations. 4 meetings $350,000 $2,000 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Reg Salary and Wages Not Applicable $550,00 $13,000 Professional Fees $19,500 $1,000 Operations $350,000 $2,000 Supplies $31,000 $2,000 Equipment $25,000 $1,000 Other: Travel: Mrage $18,000 $1,000 Other: Other: Other: Other: TOTAL $994,000 $20,000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island HIV/AIDS Foundation Island HIV/AIDS Foundation (HIHAF) Program Name: Expanding Case Management Services for HIV and Hep C in East Hawaii io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in factor appearance, any conflicts or potential conflicts of interest: Q If no conflicts exist, check here. Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 January 29, 2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island HIV/AIDS Foundation Island HIV/AIDS Foundation (HIHAF) Program Name: Expanding Case Management Services for HIV and Hep C in East Hawaii 11. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 final payment. 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 reportusing the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island HIV/AIDS Foundation Island HIV/AIDS Foundation (HIHAF) Program Name: Expanding Case Management Services for HIV and Hep C in East Hawaii 11. 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 30`h shall result in loss of all grant funds received during the grant period (must be refunded to Countyl 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 http://www.hawaiiccunty.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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) January 29, 2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 7of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island HIV/AIDS Foundation Island HIV/AIDS Foundation (HIHAF) Program Name: Expanding Case Management Services for HIV and Hep C in East Hawaii 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE IL PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies _ Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8 of Hawaii Island Home for Recovery, Inc. HIHR Supportive Housing Program 54 County ofHawai`i Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Home for Recovery, Inc Program Name: HIHR Supportive Housing Program Agency Director: airs Saadi Pelma Phone No.: ( 808) San — 7652 Contact Person: arta seam Palma Phone No.: (")S — 9442 Mailing Address: Address: nap Kapioleni St. Address: City, ST, Zip Hilo, HL 96]20 Facility Address: Address: 440 Kapiolani Sl. Address: City, ST, Zip Hilo, HI. 96120 Email Address: nim®haw ii.u.com Fax No.: ( eos) Sas — 7894 Accountant/CPA: Alex J. Smith Phone No.: (0i 26Z — 6464 Firm (if applicable): Mailing Address: Address: t4psrranx Sl. Address: CIty,sT,Zip Honolulu, H1.96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 6 49,I1pp.0p Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua © North Kona © South Hilo © North Kohala © South Kona © North Hilo © South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ youth © Victims of Crimes ❑ Culture and the arts © Aged © Victims of Health or Social Crises © Needs of the poor © Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page l of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 10,000.00 2. Agency Mission Statement: HIHR provides alcohol and drug free independent healthier living residency for chronically homeless. HIHR supportive living environment restores individuals to a sound mind, body and spirit. HIHR emphasis is on serving adults with serious mental illnesses, substance abuse disorders, dual diagnosis and physical disabilities; HIHR provide a broader range of services to address the significant unmet need in the Big Island. 3. Program Description: HIHR program activities, also coordinate with other community services. Assessing and creating an individualized service plan including case management, job training/placement, substance abuse/mental health treatment, healthcare, living skills/financial training, education, housing resources, entitlements, parenting/domestic violence services, recreational activities, holistic spirituality and other social services. 4. Total Budget & Position Count: Total Program Budget: POs,506.00 Total Program Position Count: s Total Agency Budget: 463,6W.001 Total Agency Position Count: 1 5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program S. Program Funding Sources Ildentify all sources of funding applied to this programl: Revenue Source FYIS-16 Estimate State Grant 115,128.00 Program Fees 51,878.00 County Grant 30,000.00 Hawaii Island United Way 5000.00 Other Funds 1500.00 TOTAL: 20a,506.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to supportthis program: Actively research all other possible grant options available 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR will achieve the overall program goals, as stated above in the mission statement and program description. Promoting and strengthening the ability of the chronically homeless with disabilities to live in balance and independently. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.. Number of elieen served, wmFshum memnb held, volunteer hours, etc, aesenbe, be spetilk) Applivant Projected Results Comprehensive assessmentlndividual service Salary and Wages planIcase manager. 100% Linked to health/mental health/substance abuse treatment services. 100 Life skills training in program/other 97,48600 10,000.00 community providers. 90 At exit to obtain/maintain permanent housing 80% Attach additional pages as necessary. 9. TABLE If: PROGRAM EXPENDITURES FY 1x15 Actual- FY 15-16 FY 15-16 Total Budget Grant Req Salary and Wages 81,460.00 30,000.00 Professional Fees 9,300.00 Operations 97,48600 10,000.00 Supplies 21,260.00 9,000.00 Equipment Other. Other: Other: Other: Other: TOTAL 209,508 Do 49,000.00 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program lo. 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`1w- Lpal . Sign Are of Authorized Person (specify title) 01Y29Y2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program tt. 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, 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. 1 (we) understand that applications will not be reviewed by County 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 final payment. 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 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 Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit o timely, complete, and accurate year-end report, using the template Provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Supportive Housing Program u. Certification of Understanding (Page z of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of 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 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.hawaiicountv.Yov/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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. /'/' /e, z, J7 2 Sig ature of Authorized Person (specify title) 01/29/2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Home for Recovery, Inc. Program Nance: HIHR Supportive Housing Program 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Rs Projeected Results Projected Coundl Proposed Projected Result Comprehensive assessmentrindividual service Professional Fees plan/case manager. 100% Supplies Linked to health/mental health/substance Equipment abuse treatment services. 100% Other: Life skills training in program/other Other: community providers. 90% Other: At exit to obtain/maintain permanent housing a0% 49,000.00 TABLE It: PROGRAM EXPENDITURES FY 15-16 Council Grant Request Award Salary and Wages 30.000.00 Professional Fees Operations 10,000.00 Supplies 9,00000 Equipment Other: Other: Other: Other: Other: TOTAL 49,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Hawai'i Island Home for Recovery, Inc. HIHR Transitional Housing Program 55 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Home for Recovery, Inc Program Name: HIHR Transitional Housing Program Agency Director: Ria Saadi Pelma Phone No.: (floe I 934 - 7652 Contact Person: niesandl Palma Phone No.: (") e40 — 9442 Mailing Address: Address: 41 xapiolem st. © South Kona Address: © Ka'u City, ST, Zip Facility Address: Address: 440 Kaploleoi Sl. Address: City, ST, Zip Hilo, HL 96720 Email Address: hihr@ha il.m.com Fax No.: ( 606) sas — 2094 Accountant/CPA: Ale. d. smith Phone No.: (M) — 6404 Firm (if applicable): Mailing Address: Address: 1a Fmnksl. Address: City, ST, Zip Honolulu, 111. 96916 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: S 49,000.00 Geographical Areas To Be Served: (One or more can be checked) © Puna © Harri © North Kona © South Hilo © North Kohala © South Kona © North Hilo © South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth © Victims of Crimes ❑ Culture and the arts © Aged © Victims of Health or Social Crises Needs of the poor © Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page l of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Transitional Housing Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 10,000.00 2. Agency Mission Statement: HIHR provides alcohol and drug free independent healthier living residency for chronically homeless. HIHR supportive living environment restores individuals to a sound mind, body and spirit. HIHR emphasis is on serving adults with serious mental illnesses, substance abuse disorders, dual diagnosis and physical disabilities; HIHR provide a broader range of services to address the significant unmet need in the Big Island. 3. Program Description: HIHR program activities, also coordinate with other community services. Assessing and creating an individualized service plan including case management, job training/placement, substance abuse/mental health treatment, healthcare, living skillsRinancial training, education, housing resources, entitlements, parenting/domestic violence services, recreational activities, holistic spirituality and other social services. 4. Total Budget & Position Count: Total Program Budget: I ::jj:1:8:o:ooT Total Program Position Count: s Total Agency Budget: 1463,686.001 Total Agency Position Count: s EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Transitional Housing Program S. Program Funding Sources (identify all sources of funding applied to this programl: Revenue Source Fy1S-16 Estimate State Stipend 129,960.00 Program Fees ]3)20.00 County Grant 30,000.00 Hawaii Island United Way 12,OOOM Other Funds 8,500A0 TOTAL: 254,160m Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Actively research all other possible grant options available 7. Program Objectives Using County Nonprofit Grant Program Funds: HIHR will achieve the overall program goals, as stated above in the mission statement and program description. Promoting and strengthening the ability of the chronically homeless with disabilities to live in balance and independently. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Transitional Housing Program 8. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (ks.: eumtaro/cdenn servad, workshops or r.ts tale, eM to speuh,.) Applicant Projected Results Comprehensive assessmentlrMividual service Fr 15-16 Grant Req plan/case manager. 100% Linked to health/mental health/substance 30,000.00 abuse treatment services. 100% Lile skills training in program/other community providers. 90% At exit to obtain/maintain pernianent housing 805s Attach additional pages m necessary. 9. TABLE 11: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget Fr 15-16 Grant Req Salary and Wages 143,360.00 30,000.00 Professional Fees 12,200.00 Operations 84,620.00 10,000.00 Supplies 14,000.00 9,000.00 Equipment Other: Other: Other. Other: Other: TOTAL 254,180.00 49,000.00 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Transitional Housing Program io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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. 1. .{, 012912015 Sigcfatnur�je of/Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Transitional Housing Program 11. Certification of Understanding (Page 1 of z) I (we) have read and understood all of the 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 certifythat information supplied herein, including all supporting documents, is correct and that I (we) have the authority and abilityto 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 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 final payment. 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 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 reportusing the template Provided will impact the evaluation of Your Program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Transitional Housing Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of 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" 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.hawaticounty.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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Sig0lature of Authorized Person (specify title) 01/29/2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Home for Recovery, Inc. Program Name: HIHR Transitional Housing Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Comprehensive assesamentrindividual service 3000000 plan/case manager. took Linked to health/mental health/substance 10 00000 abuse treatment Services. 100% Life skills training in Program/other community providers. gp% At exit to obtain/maintain permanent housing 90% TABLE II: PROGRAM EXPENDITURES Fir 15-16 Grant Request Council Award Salary and Wages 3000000 Professional Fees Operations 10 00000 Supplies 9,000.00 Equipment Other: Other: Other: Other: Other -- TOTAL 48,000.00 Additional council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8of8 Hawaii Island Workforce & Economic Development Ohana (HIWEDO) Huana 56 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Island Workforce & Economic Deve Program Name: Huiana Agency Director: Gaye Ishimam Phone No.: ( 808) Tar — B581 Contact Person: Gaye lshimam Phone No.: ( 808 ) 247 — 8581 Mailing Address: Address: 1990 Kmome sl. Address: Ste ia2 City, ST, Zip HIIo, Hl, 9x720 Facility Address: Address: 1990 Kinoole 5t. Address: ste lot City, ST, Zip Hilo, 111, 96720 Email Address: exeWRedor@hiwedohamh.or9 Fax No.: ( 808) 959 — 6300 Accountant/CPA: Cyde T. oshim Phone No.: ( 803 ) 955 — 0665 Firm (if applicable): Clyde T. oshlm, GPA Mailing Address: Address: 319 KInoole st Address: City, ST, Zip Hilo, H1, M720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna © H5m8kua © North Kona © South Hilo © North Kohala © South Kona © North Hilo © South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns Q youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises © Needs of the poor © Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawal l Island Workforce & Economic Deve Program Name: Huiana 1. Prior Year Award of County Nonprofit Grant Program Funds: I FY 12.13 FY 13-14 FY 14.15 $0.00 $0.00 $0.00 2. Agency Mission Statement: "To promote the development of a highly competent workforce in order to sustain a vibrant economy and lifestyle." The organization's purpose is to facilitate the establishment of a workforce development system for the County of Hawaii that will respond pro -actively to the divergent employment and training needs of the County by building community collaboration and by expanding financial resources. HIWEDO bridges economic and workforce development through collaboration and coordinating the efforts of educational institutions, government, labor, community based organizations, businesses, and the community to develop long term plans, directives and solutions for employment and training to meet the needs of Hawaii County, 3. Program Description: The HUTANA is a Student -to -Workplace Initiative encompassing a work -based learning continuum as a whole. Based on the needs of the public school complexes, there are a variety of 5 core services offered to students and educators: CAREER EXPLORATION SESSIONS (K-12) HIWEDO provides industry speakerstexperts, students participate in career/job fairs, interactivelapplied leaming projects: STEAM (Science Technology Engineering Arts (Design) Math) CAREER EXPLORATION SUMMER PROJECTS (K-11 priority to low income/free lunch students- income based sliding fee schedule) offered during the summer, students participate in interactive applied learning career oriented STEAM camps. CAREER PATWAY EXPLORATION INTERNSHIP -Workplace Mentodng (16-18 yo) -Students are paired with a workplace mentor and gain knowledge/skills appropriate to a specific career pathway and general pre-employment orientation. INDUSTRY SECTOR SIMULATED BASED LEARNING (9-12GR}Utilizes simulation and active learning to immerse students with authentic decision making, develop communication skills and collaboration and EDUCATOR EXTERNSHIPS. 4. Total Budget & Position Count: Total Program Budget- 171,6e,1 Total Program Position Co M• 111r,' Total Agency Budget. 1 401,6861 Total Agency Position Count: 8.5 c-rE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2ofg County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawai'i Island Workforce $ Economic Deve Program Name: Huiana 5. Program Funding Sources (identify all sources of funding applied to this programl: Revenue Source FYIS-16 Estimate Private Foundation donation 70000.00 HAEDO Fund raising 5000.00 Ohana Fuels Grant- % of Fuel sales -pending 3000.00 Think Fund -Hawaii Community Foundation (pending) 25000.00 TOTAL: 003000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program HIWEDO is shouldering most of the burden to run this program last year. We were unable to provide all services This is an essential program for the high school students transitioning into a working environment. Fortunately we have a few corporate sponsors who feel alike and have generously supported and shouldered the financial burdens. We are, as everyone else, feeling the overarching effects of the economic crunch but it only exacerbates our strong commitment to this program supporting workforce development. The HUTANA Internship program is not a revenue generating program and relies on the support of the federal, state, local appropriations, fund raising, as well as private support to sustain it. We are applying for other grants and to private foundations for assistance as well. It truly takes a community effort to sustain this program. 7. Program Objectives Using County Nonprofit Grant Program Funds: If granted, we will be utilizing County Nonprofit funds to support the following program expenditure areas: salaries/benefits for program coordination, operations, conduct trainings, support school career fairs/events, develop new STEAM applied learning projects with industries to beta test with rural school students; project supplies for active learning activities and projects; program expenditures -phone w/connectivity and laptops, student support services (uniforms, TB tests, safety goggles and shoes, transportation, display boards, etc); program transportation to provide services to rural areas; prorated office expenditures. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HawaPi Island Workforce & Economic Deve Program Name: Huiana 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (Le.: Number o)clierrm served, worklho0s or events M1eltl, volun[eer hours, eh. aesribq be sped), Applicant Projected Results 4 career oriented Exploration Sessians 100 students Participate in minimum of 3 career fairs 3 schools -min Conduct Workplace Mentor Classes 80 mentors Match High School students in Internships 100 students -min _ Provide 2 (min) Educator -Sector Workshops 80 educators Post student summer employment opportunities 6 high schools Conduct 5 (min) Career Readiness Classes 125 students Attach oddrfronal pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14.15 FY 15-16 Actual` Total Budget FY 15-16 Grant Req Salary and Wages 91000 36400 Professional Fees 7260 2904 Operations 22393 8957 Supplies 2500 1000 Equipment _ 1200 480 Other: Employee Benefits +Payroll Taxes35126 14050 Other: Communications -phones; wireless,fax, etc 2025 810 Other. Occupancy 3630 1452 Other: Participant Support Services/Transportation1750 700 Other Staff Travel 4800 1920 TOTAL 171- 68fi73 *If applicable EXHIBIT A NONPROFITGRANT APPLICATION FY 2015-2016 Page 4of8 8. TABLE I Continued from page 3 of B. PROGRAM PERFORMANCE MEASURES h,o.: Numberof clients served, workshops or events held, volunteer hours, etc. Describe, be specific) Applicant Projected Results Develop 3 beta test applied learning projects for rural schools 60 student test Workplace mentors volunteer hours (60 hrs/student) 4800 volunteer hours HIWEDO, School Counselors, Community volunteers hours 3840 volunteer hours County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawai'i Island Workforce & Economic Deve Program Name: Huiana io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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: asubstantial 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. 4h, - ,ee'e'4r- l-xy-Ii Si nature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Hawaii Island Workforce & Economic Deve Program Name: Huiana ii. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 Hawat'i Compliance Express and be compliant prior to final payment. 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 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 Hawal'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit o timely, complete and accurate year-end report using the template Provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Hawaii Island Workforce & Economic Deve Program Name: Huiana tt. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 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-zrant-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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. bignature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawai'i Island Workforce & Economic Deve Program Name: Huiana 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results I Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Hawaii Meth Project Hawai'i Island Meth Prevention Youth Outreach 61/ County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Meth Project Program Nagle: Hawaii 181,11111 Meth Prevention Youth Outreach Agency Director: t;eorgianna DeCosta Phone No.: ( 808) 356 —8752 Contact Person: Georgianna De( oala Phone No.: (808)356 —8752 Mailing Address: Address: PO Box 3073 Address. City, ST, tip I lonolulu, 111 96802 Facility Address: Address. none - virtual office to maximize statewide reach Address: City, ST, Zip Email Address: genrgi(,hasvaiimethproject.org Fax No.: (808) 556— 8645 Accountant/CPA: Grego iy Wong Phone No.: (808)224 —4848 Firm (if applicable): I luwaii (.arc Service. LLC Mailing Address: Address L88 Ata Moana Blvd., #201 Address: City, ST, Zip I lonnlulu, 111968 14 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑x North Kona South Hilo ❑x North Kohalax❑ South Kona North Hilo ❑ South Kohala ❑x Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑x Educational concerns ❑x Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑x Physical/Emotional Disabilities ❑x Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY2015-2016 Page 1of8 County oY Hawai`i Nonprofit Grant Application FY2015-16 Agency Name: 1 iaw-aii Meth Project Program Name: Hawaii Island Meth Prevention Youth Outreach 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 0 p 0 2. Agency Mission Statement: 8nmpowering the keiki of today for a meth -free lomm itw. 'The Hawaii Meth Project is a statewide prevention program whose goal is reducing methamphetamine use among teens and young adults. Launched in 2009, the Project educates I-Iawaii's young people about the risks and clangers of meth use So that it they are ever presented with the opportunity to try meth, they can make an informed decision. 3. Program Description: We are in classroom and/or on the campus of a public or private high school or middle school 4-5 times a week during the year speaking to teens in health, peer education social studies, journalism, physical education, digital media classes and school assemblies. We participate in atter-school programs un school campuses as well as I3oys and Girls Clubs, Y Centers, and any other venue where the youth of Hawaii hang out. We also spend time reaching out to and educating families, counselors, business and community leaders, and youth - based service groups. The Meth prevention Lesson is our core program which allows a dissctssion with teens around some key topic about Meth - What is Meth, What is it made of, If I try it will 1 become an addict, What does Meth do to the brain and body, I low does it affect those around me, and How, can I be a part of the solution with my peers. Our program provides teens layers of engagement upon the MP Lesson including assemblies with testimony from recovery speakers, Meth Awareness rallies, sign waving and opportunities to Volunteer in the umuuunity. Combined with our Social media public service messaging, direct contact with teenagers and families helps to make the message real, give it context and emphasis. As a result, teens are able to talk about their own experiences, ask questions, share their thoughts and concerns, and we are able to encourage positive social influences and a dialogue with their peers and parents. 4. Total Budget & Position Count: Total Program Budget: I $251,000 Total Program Position Count: Total Agency Position Count: 2,20 FTE Total Agency Budget: $663,yy0 1 FTF. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Meth Project Program Name: Hawaii Island Meth Prevention Youth Outreach 5. Program Funding Sources (identify all sources of funding applied to this program): FY15-16 Revenue Source estimate TOTAL:1 $55,000 pages, If needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Hawaii Meth Project is expanding its donor base to iudude private and public funding sources. In FY2015 these are anticipated to potentially induce bill not be limited to: 1117,1 Charitable Foundation/Maui Fleco is Company/ Hawaii Light & Electric I IMSA Foundation Increased State of Ilawail landing In the past we have been Fortunate to have generous major gifts fi onn two hinders o'hich was intended to lay it foundation for the program and allow staff to tlKnS on building programs. We have been able to sustain our organization beyond the expected timetrame Ibr those initial gifts and are now seeking to diversify our funding base. 7. Program Objectives Using County Nonprofit Grant Program Funds: Program Objectives: Increase Perceived Risk Decease perceived lieneftt Increase Pat ent Child Discussions Increase Social Disapproval In 3013 eOld 2014 we spent approximately 3095, of our efforts rot Iiawaii island. Our school outreadi included Kohala Middle, I holo High and Intermediate, Waial I Iigh School, Konawaena High School, and Kealakehe Intermediate. In the Community we were present at the County Fair, Youth Challenge, and KS Hoolaulea. We seek to revisit 2013 schools which also included Honokaa I-Iigh School and Kamehameha Schools Keaau and reach ant to Keaau I Iigh School since our previous partner, Pahoa High School, is no lunger avai table. Kau schools are also on our to get list for 2015-10. Our goals are to reach 18,000+ teens and 15,000+ adults during 2015-16 through school and community meth prevention outreach. We expect our free online Meth Prevention Lesson to assist in reaching the more remote areas of the island by providing a tout for teachers to deliver. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Meth Project Program Name: Hawaii Island Meth Prevention Youth Outreach 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURESApplicant Projected Results +e,ved, wonsnoos o, h,sr vmunt... t..,,,e.c oescnde, he ,reocc) Lesson haled teen and community Attach additional pages os necessary. 9. TABLE It: PROGRAM EXPENDITURES FY Actual' FY 15-16 Total Budget FY 15-16 Gra n F Req Salary and Wages Professional Fees Operations Supplies Equipment Other 'travel=airfare,lod m tt-anslortation Other Advertising and collateral - online ads, website Other T,nc and development 249,200 24,300 76,000 &4d 25,000 2,350 3,420 5'000 0 I,000� "T 00 10,700 176,500 11,900 U1,000 0 663,990 4,230 0 Other miningand and eo nlu utecs _ Other - TOTAL (1 0 50,000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Meth Project Program Name: I lawali Island Meth Prevention Youth outreach io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Billy Kenoi POSITION: Hawaii Meth Project Advisory Council 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 ❑�y staff appointed by a member of the Council IJv 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 asa substantial probability that action taken by an indivlduoI will result in meosuroble direct benefits accruing to the individual as opposed to benefits accruing in qeneral to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: Mayor Kenoi sits on the Hawaii Meth Project Adyisory Council in a volunteer e upport rule Is)[ uur organization. As an Advisory Council member, Mayor Kenoi has no legal authority or obligation and holds no voting rights. All Hawaii Meth Project governance is managed by our Board of Directors which is a separate entity from the Advisory Council. ❑ If no conflicts exist, check here clki (1-2`21 si ture of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Ifaw^ali Mea, Project Program Name: Hawaii Island Meth Prevention Youth Outreach 11. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 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 Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendorsehawaii.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 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 veor-end report using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: I lawaii Meth PrOjeil Program Name: Hawaii Island Meth Prevention Youth Outreach 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 30t" shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and Instructions are available at http://www.hawaticounty.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, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in o timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. nature of Authorized Person (specif title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 COLlnty of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Ihmaii Mcth Projcct Program Name: Hawaii Island Meth Prevention Youth Outreach 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Meth Prevention Lesson based teen outreach, classroom and assembly 5,000 teen. Active engagement, peer-to-peer anti -meth julhtencc school rallies Awareness and informational hooths, sdrnol and Conmmnity based 2,000 teens 11,000 teens & 5,000 adults TABLE II: PROGRAM EXPENDITURES Salary and Wages Professional Fees Operations Supplies Equipment FY 15-16 Council Grant Request Award 0 uuieu fravel- ai rlare, lodging, t ra nsportanon 10,700 Other: Advertising and collateral - online ads, website 9,230 Other Fundrxrising and development 0 Other: I raining and_onferences Other: Additional Council directives regarding award: 0 _ TOTAL I 90,000 EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Hawaii Montessori Schools Financial Aid Program County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Montessori Schools Program Name: Financial Aid Program Agency Director: Angeline Goldhof Phone No.: ( 60e) 329 — 07M Contact Person: Argeime Geidhof Phone No.: (6oa)lea — tan Mailing Address: Address: 74-91e Mara '.street Address: City, ST, Zip Kailua-Kona, Wweri 96740 Facility Address: Address: Kona:]4-976 Wnawaie'a et. Kailua$oia, Hl 967Q Address: Kamuela. 64 lass Mamalahoa Hwy., Kamuela, HI 96743 City, ST, Zip Email Address: angeiine@hawailmonlessorl. org Fax No.: ( 606) 334 — 327 Accountant/CPA: Hozanne Connell Phone No.: (609)930 — sem Firm (if applicable): Camonaro CPA a Associates Mailing Address: Address: P_o. Bes 43Pd Address: CIty,ST,ZIP Hilo.Hawar19W20 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Giant Program Funds: $20,00000 Geographical Areas To Ee Served: (One or more can be checked) F-1Puna I_-] Ha m3kua ❑✓ North Kona ❑ South Hilo ❑ North Kohala QSouth Kona ❑ North Hilo `jSouth Kohala ❑ Ka41 Services or A,. >4ti, s'na Ce Pr-Aded(Gro or riot, can be c`.ecked) ❑✓ Educational concerns IIJ Vali cf cdmes ❑ Culture and the arts i� I Vict.i, cr health or Soeial Crises ❑ Needs ofthe poor �' ny iCmot r 'sans ❑ Public Health and Welfare of .4 Peep= end the EXHIBIT A NONPROFIT GRANT APPLICATION F1 O'5201:: Page 1of3 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Montessori Schools Program Name: Financial Aid Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $12,500 $7,500.00 $5,000 2. Agency Mission Statement: Our Mission at Hawai'i Montessori Schools is educating children for life by providing a nurturing prepared environment where children, parents, and staff joyfully develop their esteem, inner discipline, independence, motivation and sense of community involvement to their fullest potential. 3. Program Description: We believe that Early Childhood Montessori Education should be available to all children, regardless of their families' income. It is particularly important at this time, since many children end up in unlicensed care situations. In addition, it is essential that the student body be diverse so that optimum learning can take place. HMS provides enriched environments and trained staff to help each child develop their natural gifts and create collaborative classrooms and work communities that enhance every individual's contributions. Currently, for the 2014-2015 school year, we have 99 students enrolled, of which 41 are receiving some kind of financial aid from us. To date, we have provided a total of $49,597 in financial aid for the 2014-15 SY. In order for families to qualify for financial aid, they must fill out our Financial Aid application and provide us with supporting documentation showing income, custody, residency, child's age, and if parent is going to school, a copy of the registration form, or if unemployed a copy of active work search verification. Families are awarded financial aid based on income and number of people in the family unit. Funds are distributed on a sliding scale and on a first-come, first-served basis. 4. Total Budget & Position Count: Total Program Budget: 54,000 Total Program Position Count: 50 Total Agency Budget: 820,0001 Total Agency Position Count: 1126 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii PAonic-sson Schools Program Name: Financial Aid Program S. Program Funding Sources (identify all sources of funding applied to this program): Rrv_=nue Sourco FYIS-16 Estimate part is due to the "push down" of the ' $15,000 Semuel N. and Pilary C_as9_e_Foc_ndA c_n 10,000 G. N. bb'ilcox Trost 5,000 County of Haw=Pi Norl-PYOFlI Grant Innid 20,000 Bill Healy Foundation 4,000 Curriculum Standards, there will be rr , -_._ re rncaeyouro chl!dren to sdccecd in school, and if they have not had the or;_i'.,,-•i:v to a`and sn early learning environment they will start their elementary school career. ", a �.:is_-dvar TOTAL: $54,000 Attach additional pages, if needed, 6. Explain what plans your agency or program has to increase revenues to support this program Through the combined efforts of our Board of Directors, PTA/PTO and our families & staff, we generate financial aid funds by soliciting donations, writing grants and conducting fund-raisers each year. Our fund-raisers have been successful because of the tremendous commitment of our Montessori'Ohana and the overwhelming support of local merchants and countless members of our community. Our mission includes creating a model of the highest quality education and care that can be available to ALL children, thus financial assistance to deserving children is funded in part through the schcol's operating budget. 7. Program Objectives Using County Nonp. nft Grant Picgi am Funds: We feel that it is important for children o have aw � oellari start to their educatcnal caa ear Over the years we have noticed marr-;rarsd r. KindcrgaN m i rh^a in part is due to the "push down" of the ' i .LP..!.ro. ramg chitdlen arr.a-.ec Lo do things that are at times developmen ;and im rz'. i.cl. V; n w, -c!, Hawai'i State School Readiness Ass _ 1 f'cst H .. = r vv:dcn ir,`.des the Honoka'a and Kealakehe Complexes. _, :i.-: er r q ..::e a _,a �.-.�-ter been in an early learning setting. Nov -. ' ,d p �f the Calydnon C.;ra Curriculum Standards, there will be rr , -_._ re rncaeyouro chl!dren to sdccecd in school, and if they have not had the or;_i'.,,-•i:v to a`and sn early learning environment they will start their elementary school career. ", a �.:is_-dvar The Financial Aid Program allows us to assist needy families who are see'.Ing fo F=..nrcll their children ir a quality preschool program, thereby increasing their than-; Par Eo-rnsc !n ;!,el.r fuburc educational career. We hope to give tuition assistance to 50 stcoonts in t'r,e itt6-SS year. EXHIBITA NONPROFIT GRANT APPLICATION Ff201F 20 Page 3 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid Program 8. TABLE I: What are the intended measurable cutouts or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i. e.: Number ofchentrservetl, workshops or events held, volmreer, hours, em Describe, be specific) Students who will receive financial aid so may attend a high-quality early learning cent 50 _ Amount of Financial Aid distributed to 50 students for the 2015-16 School Year. $54,000 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages Professional Fees Operations Supplies _ Equipment other: Financial Aid Program $49,597 $54, OCU 520.000 Other: Other: Other: Other: ---�- -- TOTAL `If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Montessori Schools Program Name: Financial Aid Program iii. ORGANIZATION CONFLICT E -AS ;i_0SURE FORM Please disclose any conflicts or potential conflicts of intarest that any board member, officer, director, or administrator of your organization may have viii the County of Hawaii. Only those listed below need to be disclosed. One form per person er!t!'a o:avliC[ is -E,ded. If no conflicts exist, one form for the organization, with the "No conflicts exist' option chec]:ed needs to be submitted. Please duplicate as needed to fully disclose. All disclosureoirms rLtLsr be_inerf regardless ofwhether 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 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. 4aZL � I' v l�.�1 _x Sl�n,tA of Authorized Person (speci title) �rcc�il/ EXHIBITA 112&2015 Date NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawari Montessori Schools Program Name: Financial Aid Program ii. Certification of Understanding (rage 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 Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to final payment. 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, comolete and accurate year-end report using the template provided, will impact the evaluation of your program's or aaencv's future funding requests. EXHIBIT A NONPROFIT G RANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawai'i Montessori Schools Program Name: Financial Aid Program 11. Certification of Understanding (Page2of2) If awarded a grant from the County of Hawai'i, 1 (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 priorto receiving any payment(s) I (we) understand that failure to submit the final report within 60 days of lune 30" shall result in loss of all grant funds received during the grant period Imust be refunded to CountV) 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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements ss Signat a, Authorized Person (specif ,_ : �_�� D to EXHI BIT A NONPROFIT GRANT APPLICATION 7Y 2015-2015 Page 7of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hawaii Montessori schools Program Name: Financial Aid Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Students who will receive financial aid so they may attend a quality early learning center. 50 Operations Amount of Financial Aid disbursed to 50 students for the 2015-2016 Schaal Vear $54,000 Other: Financial Aid Program $20,000 Other: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Financial Aid Program $20,000 Other: Other Other: Other. TOTAL Aaal lonal Lei directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Wilei Aloha, LLC Sustaining a Health Services Coordinator for KKPCA Students 59 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Program Name: Ci Agency Director: Mona Bernardino Phone No.: (808) 596-8990 5�u�9 Contact Person: Nalani Takushi Phone No.: (808) 596-8990 Mailing Address: Address: 711 Kapi'olani Blvd. Address: Suite 1430 City, ST, zip Honolulu, HI 96813 Facility Address: Address: 1749 Haleolani St. Address: City, ST, Zip Hilo, HI 96720 Email Address: nalanit@hiilei.org Fax No.: (808)596-8992 Accountant/CPA: Jim Hasselman (auditor) Phone No.: (808) 721 - 5483 Firm (if applicable): James P. Hasselman CPA LLC Mailing Address: Address: P.O. Box 11149 Address: City, ST, lip Honolulu, HI 96828 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANYCHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) [Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala a'0 Services or Activtties To Be Provided: (One or more can be checked) [JEducational concems MYouth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ElVictims of Health or Social Crises D Needs of the poor ❑ Physical/Emotional Disabilities ['Public Health and Welfare of the People and the Environment EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page Iof8 County of Hawaii Nonprofit Grant Application Agency Name: Program Name: �1Ge��S�vv.45��Ov��I 1. Prior Year Award of County Nonprofit Grant Program Funds: FY2O15-16 FY 12-13 FY 13-14 FY 14-1 ' Total Agency Budget: C 2. Agency Mission Statement: 3. Program Description: 4. Total Budget & Position Count: Total Program Budget: b pp Total Program Position Count: ' Total Agency Budget: C Total Agency Position Count: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Paget of Agency Name: Hiilei Aloha, LLC Program Name: Sustaining a Health Services Coordinator for KKPCA students Program Description A major priority of the Department of Education, Race to the Top Wraparound Services in the Ka'u Kea'au, Pahoa Complex Area (KKPCA) is the provision of health services for students. KKPCA is composed of 9 schools in three complexes -1) Ka'u High and Pahala Elementary, 2) Na'alehu Elementary of the Ka'u Complex, 3) Mt. View Elementary, 4) Kea'au Elementary, 5) Kea'au Middle and 6) Kea'au High of the Kea'au Complex, 7) Keonepoko Elementary, 8) Pahoa Elementary and 9) Pahoa High and Intermediate of the Pahoa Complex. The students of the KKPCA schools has the highest percentage in the free and reduced lunch program in the State of Hawaii, with Kau ranked In with 88%, Pahoa is second with 85% and Kea'au third at 81%. This complex has a high percentage of chronic absenteeism with Mt. View Elementary with 49% of students with 15 or more absences, followed by Na'alehu Elementary with 40% and Pahoa Elementary with 36°%. KKPCA has the highest percentage of Hawaiian/Part-Hawaiian student population at 46%, with an achievement rate of 49°% proficiency in Reading (compared to 60% non -Hawaiians), and 30% proficiency in Math (compared to 45°%for non -Hawaiians). A major reason for the disparity in attendance and test scores is attributed to lack of health services in keeping the students healthy and engaged in school to learn. This rural complex is he largest in the State covering 95 miles beween Hilo and Ocean View. Services and programs are few and inaccessible due to distance and transportation restraints. If services are available — they are and not aligned to students and school needs. In January of 2012, the KKPCA contracted a Health Services Coordinator for a 6 month contract to develop strategies and implement programs to provide health services for the complex. Much was done and community health providers partnered with complex initiating discussions and planning to meet health initiatives. In July 2012 the contract ended and the initiative and planning stagnated without the leadership of the health services coordinator In September 2013, Hiilei Aloha LLC offered their services as fiscal sponsor for the employment of the Health Services Coordinator using Race to the Top Funds and work continued in the discussions and planning to meet the health initiative. Bay Clinic, Inc. has stepped forward as a major partner in achieving this goal. However, Race to the Top funds, as the program itself, ended in lune 2014. Again the health initiative has terminated and to continue this program, Hiilei Aloha, LLC is requesting assistance from the County of Hawaii Non- profit grant program to fund the health services coordinator position to continue accessing and providing the much needed health services and programs for the students. County ofH�awai`i Nonprofit Grant Application Agency Name: Program Name:iWSv°oV�^° FY2015-16 S. Program Funding Sources (identify all sources of funding applied to this program): Attach oaarnonoi pages, if needeo. FY15-16 Revenue Source Estimate TOTAL: 6. Explain what plans your agency or program has to increase revenues to support this program: 1 � � KY I 7. Program Objectives Using County Nonprofit Grant Program Funds: CQ A � �r�A EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3of8 Agency Name: Hiilei Aloha, LLC Program Name: Sustaining a Health Services Coordinator for KKPCA students Program Objectives Using County Nonprofit Grant Proarams Funds The objective of this program is to acquire a Health Services Coordinator who will be responsible for the following: 1) The Health Services Coordinator will partner with community health provider, Bay Clinic, Inc. who has expressed sincere interest in meeting the initiative of providing health services to the KKPCA. They will have available, a medical and dental mobile van to provide much needed health services at the school sites. They will also have their three Community Health Centers, the Kau Community Health Center, Kea'au Community Health center, and Pahoa Community Health Center, all within 1.5 miles from the KKPCA schools, except Mt. View Elementary and Keonepoko Elementary Schools, available for students to access. 2) The Health Services Coordinator will enlist and partner with the Puna Lions Club in providing vision and hearing screenings for the 6 KKPCA elementary schools. 3) The Health Services Coordinator will partner with the University of Hawaii at Hilo School of Nursing. With the assistance of the Department's Professors, coordinate allowing their Doctor of Nurse Practice, and other nursing candidates to do practicum work in our KKPCA complex. 4) The Health Services Coordinator will be responsible for Program Coordination and Quality Assurance and Assesments of all present KKPCA health services and programs, developing strategies to improve health services in screenings, treatment and followup, with emphasis on education, prevention, intervention and postvention. 5) The Health Services Coordinator will be responsible for communication and alignment — meeting with all team players in Health services, community and government, to develop their roles in school based health, coordinating services available and begin obtaining and comprising data and statistics to target student and school most needed areas of health improvement. 6) The Health Services Coordinator will be responsible for financial management and fund development— researching best methods and strategies to fund school based health for KKPCA. County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Program Name: �,t�c �„vv,i.., c>, Pa ,��e�.�lr✓ �` � 1� �' ��"� 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.c: Nn ber of diemsserved, workshops or events held, vobnteerhours, etc. Describe, be specific) as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 1415 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages e o00 Professional Fees��s<<, Operations Supplies Equipment Other: C O Other: Other: Other: TOTAL OOCi 'If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 Agency Name: Hiilei Aloha, LLC Program Name: Sustaining a Health Services Coordinator for KKPCA students Program Performance Measures The KKPCA has a student population of 5,633 students. We are optimistic that 80% of students, or 4,506 individuals, will use and access all or a portion of services offered at some point in a calendar year. In addition, the following objectives will be used to drive and evaluate the project. OBJECTIVE METRIC (Applicant Projected results) 1. To collaborate and work with Established schedule of Medical and Bay Clinic in accessing their Mobile Dental mobile van service dates at 7 Health vans to provide service at school sites KKPCA school sites. 2. To assist schools in the development of local health fairs offering speakers, demonstrations, displays, and appropriate health information 3. To establish Jump Rope for Heart program in all 7 elementary schools 4. To coordinate a school fun run at each KKPCA school. 5. To coordinate healthy gardens at all Middle and Elementary schools 6. To coordinate with Bay Clinic in referral to their health clinics and establish a youth appointment schedule with clinic schedulers 7. To develop partnership with University of Hawaii Hilo School of Nursing 8. To partner with Puna Lions Club to offer vision and hearing screenings for elementary students. 9. To plan and establish annual Health Career Events at KKPCA high schools Number of health fairs planned and completed Number of programs planned and completed Number of events planned and completed Number of gardens planned and established Number of students referred to clinic for primary care service, immuniza- tions, sports physicals, and other services. Finalize MOA with the School of Nursing and place their students at our schools for practicum work. Number of Kindergarten, Ist, 3rd and 5`" grade students to have their vision and hearing screened Number of events planned and completed County of Hawaii Nonprofit Grant Application FY2015-16 Agency Proeram Nam 4�, �, en , �o J , r I s � v �,v iuv ��t � 1 cl' - ,ergs io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disdose. 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 on individual will result in measurable direct benefits accruing 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. Chief O Signature of Authorized Person (specify title) Officer Jan. 27, 2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2O15-16 Agency Name:Il�t Program Name:7HS�4i„wu,itea�R`, rt ii. 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, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to __. .. _ ; complete the 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 fundino requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Program Name:SHV� 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). 1 (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 Countvl 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Chief Operating Officer Jan. 27, 2015 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application Agency Name: Program Name:Sus�r,, 12. COUNCIL AWARD WORKSHEET TARLE I: FY2015-16 PROGRAM PERFORMANCE MEASURES Applicant Projected RCSUItS Council Proposed Projected Result Salary and Wages �+ Operations C Supplies Equipment Other: Other: TABLE It: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations C Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives rel arding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Agency Name: Hiilei Aloha, LLC Program Name: Sustaining a Health Services Coordinator for KKPCA students Program Expenditure Salary and Wages $60,000 Professional fees (Administrative services for Hiilei Aloha fiscal sponsorship) 7,000 Other: Business trips to Oahu 1,500 Other: Mileage reimbursements and car rentals 1,500 Total grant request: $70,000 Hilo Community Players 2015-16 Theatrical Season We County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hilo Community Players Program Name: 2015-16 Theatrical Season Agency Director: Catherine McPherson Phone No.: ( 808) 934 — 7248 Contact Person: Cah.rim McPherson Phone No.: (908)934 — 7249 Mailing Address: Address: Po sox 4s Address: City, ST, Zip Hilo, H196721 Facility Address: Address: Po aox 46 Address: City, ST, Zip Hilo, HI 96721 Email Address: hilommmunityplayers@gmeil.com Fax No.: ( 808) 933 — 1112 Accountant/CPA: Theresa Ten Eyck Phone No.: (1308)"3 — 7074 Firm (if applicable): Theresa Ten Eydi CPA. «c Mailing Address: Address: 614 Kdauea Ave. ste. tat -u Address: City, ST, Zip Hilo, Hi SWIM YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: E as.000 M Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑ South Kona Q North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑ Victims of Crimes ❑✓ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page Iof8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hilo Community Players Program Name: 2015-16 Theatrical Season 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 0 $5,000.00 6000.00 2. Agency Mission Statement: The mission of Hilo Community Players is to educate, enrich, and entertain the Big Island Community through quality theatrical productions, workshops, and activities for children, youth, and adults. 3. Program Description: The Hilo Community Players theatrical season for 2015-16 will enlist the participation of children, youth, and adults in all aspects of theatre. We aim to reach as wide a section of community as possible providing education, enrichment, and entertainment suitable for all ages. We will present our 38th Annual Shakespeare in the Park and our 2nd Annual Kids Shakes, which takes a light-hearted look at the work of William Shakespeare and uses all ages both on and off the stage and draws crowds of all ages. Other shows in the season will be chosen to fulfill our need to reach underserved populations such as children and women. This year we will reach all people on our ethnically diverse island while giving all interested parties a chance to participate in every aspect of our productions on stage, off stage, and in the audience. We strive to address our island's diverse populations. 4. Total Budget & Position Count: Total Program Budget: E500oo.0o Total Program Position Count: 11 Total Agency Budget: $50000.00 Total Agency Position Count: I I EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hilo Community Players Program Name: 2015-16 Theatrical Season S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Advertising $2500.00 Donations $6500.00 Tickets $6000.00 Membership $500.00 Concessions $500.00 Gants $35000.00 TOTAL: $51000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Hilo Community Players will reach out to the community to widen our participation base by presenting productions of interest to our diverse population. We have revamped our website and can now sell tickets and merchandise like our DVDs of our show The Trial of Liliuokalani, which has netted our organization $1900 this past year. We will have another fund raising event as we did last year when we raised $2000. We have identified multiple granting sources we are actively pursuing for funds. Our goal is to light up the Players for our 2015-16 season. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our goal is to safely light up our acting space and audience areas for our 38th Annual Shakespeare in the Park with new all-weather LED theatrical lighting instruments and related equipment. We also wish to provide our directors and actors with proper sets, costumes, props, and makeup to enhance the value of each production for the audiences. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hilo Community Players Program Name: 2015-16 Theatrical Season S. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES fi.e.: Numberofdkrmserved, wadshoas orevents beld, v.Wtelr o, etc. Describe,bespedhU Applicant Projected Results Email donor database currently at 500 Increase to 7500 Offering internships to 3 high school student Increase to 5 Audience for 4 shows at 4000 Increase to 5000 Volunteer hours of 10000 Increase to 17000 Current scholarship fund at $1560 Increase to $2000 Operations $1010 $1900 0 Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual* FY 15-I6 Total Budget FY 15-16 Gram Req Salary and Wages 0 0 0 Professional Fees $250 0 0 Operations $1010 $1900 0 Supplies $7097 $4900 0 Equipment 0 $35000 $31400 Other:Sets $1200 $3200 $1600 Other. Costumes/props/makeup $600 $2700 $1350 Other: sound 0 $1300 $650 Other: Other: TOTAL $10157 $50000 $35000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County ofHawai`i Nonprofit Grant Application FY2015-16 Agency Name: Hilo Community Players Program Name: 2015-16 Theatrical Season to. 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 h,terest 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) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 January 30, 2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hilo Community Players Program Name: 2015-16 Theatrical Season 11. Certification of Understanding (page 1 of x) 1 (we) have read and understood all of the 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 Hawat' i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.izov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii. I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template Provided, will impact the evaluation of Your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hilo Community Players Program Name: 2015-16 Theatrical Season 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 30" shall result in loss of all grant funds received during the Brant 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 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Jan.30,2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hilo Community Players Program Name: 2015-16 Theatrical Season 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Email donor base currently at 500 7500 Offering internships to 3 high school students 5 Audience for 4 shows at 4000 5000 Volunteer hours of 10000 17000 Current scholarship fund at $1560 $2000 Other: sets $1600 Other Coslumeslprops/makeup $1350 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 0 Professional Fees 0 Operations 0 Supplies 0 Equipment $31400 Other: sets $1600 Other Coslumeslprops/makeup $1350 Other: Sound $650 Other: Other: TOTAL $35000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8 of 8 Ho'omalu Ka'u Native Dry -Land Plants Workshop 61 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HO'OMALU KA'u Program Name: Native Dry -Land Plants Workshops Agency Director: Lehua Copo: Mau, President Phone No.: ( 808) 929 — . 8526 Contact Person: Lehua Lope: -Mau, President Phone No.: ( 809) 929 — 9891 Mailing Address: Address: Po Box Sea Address: City, ST, ZIP Na Men , HI 96712 Facility Address: Address: 94E928Mamalahm Highway ❑ Puna ❑ Hamakua Address: ❑ South Hilo ❑ North Kohala City, ST, Zip No alehu, H1 96772 Email Address: 981hale@gmaiLcom Fax No.: ( ) — Accountant/CPA: None at this Bme, Phone No.: ( ) — Firm (if applicable): However, we arelooting br one here In Ka'u. Mailing Address: Address: Address: City, ST, Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) Educational concerns ❑ youth ❑ Victims of Crimes © Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page Iof8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HO'OMALU KA'u Program Name: Native Dry -Land Plants Workshops 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 0.00 $0.00 0.00 2. Agency Mission Statement: Ho'omalu Ka'u's mission is to perpetuate, protect, and conserve the lands, health, knowledge, cultures and history of Ka'u and its people. 3. Program Description: Ho'omalu Ka'u's program, "Native Dry -Land Plants Workshops," is an educational effort to teach Kau residents (especially the lot owners of the major 7 subdivisions in Ocean View and Na'alehu with more than 12,000 lots) and the general public, about the environmental and cultural values (including cultural and medicinal uses) of native Hawaiian dry -land plants. Across the state, there is only 5% remaining of all the dry -land forests existing at the time of Cook's visit. The forests in Kahuku and Manuka are among the best in the state. Participants will receive (free) a copy of HK's soon -to -be -published booklet, "Native Dry -Land Plants of Ka'u, Hawai i," as the educational text for the workshops (1 and % hours each), to be held bi-monthly in Ocean View or Na'alehu. Plant examples and photos of dry -land species will be included in demonstrations and each workshop will also teach people how to propagate dry -land plants on their lots and demonstrate some of the cultural and medicinal uses by ancient Hawaiians. Lot owners will also receive information about avoiding the destruction of native species on their lots. Workshops will be advertised in newspapers, flyers, websites, email alerts, and word-of-mouth. 4. Total Budget & Position Count: Total Program Budget: 9.750 Total Program Position Count: 2 Total Agency Budget: $24,4501 Total Agency Position Count: 2 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HO'OMALU KALI Program Name: Native Dry -Land Plants workshops S. Program Funding Sources (identify all sources of funding applied to this Program): FY15-16 Revenue Source Estimate Ho'onnalu Ka'u savings 1,700 HK fundraising event4/12/15 in Ka'u 1,000 TOTAL: 2,700 Attach additional Pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Ho'omalu Ka'u (HK) intends to sell its booklet, "Native Dry -Land Plants of Ka'u, Hawai i" to the general public in local stores, on-line, and through volunteer efforts. If successful in attracting participants, HK also intends to request a $5 donation per participant for future workshops. HK also plans to raise funds for this program from environmental foundations. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Educate land owners and residents, as well as the general public (including visitors) about the cultural and environmental values of native Hawaiian dry -land plant species. 2. Encourage the protection of native dry -land species by informing lot owners about native plants that should not be destroyed on their land and by demonstrating ways to avoid damaging native plants. 3. Encourage the preservation and conservation of native species by teaching participants how to propagate native dry -land species appropriate to the environmental and elevation characteristics of dry -land in Ka'u. 4. Demonstrate the cultural values and resources of some dry -land species (used in lei -making, hula instruments, furniture, household items, fencing, etc.) including medicinal uses by ancient Hawaiians. 5. Document the results of workshops with photos of native plant protection and/or propagation by participants within 6 months after completing the workshop. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HO'OMALU ICA'U Program Name: Native Dry -Land Plants Workshops 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES n.e.: Numberofdienrssereedw ddlops or events held, wlunt.1hh.M etc. aefmbe, be s Cifx.) Applicant Projected Results 1. Plan, organize, and implement 6 workshops. 6 workshops in Ka'u 2. Educate at least 20 people per workshop. 120 people educated 3. Protect at least 5 species on lots In Ka'u 20 Plant photos 4. Conserve at least 5 species on Ka'u lots 20 Propagation photos 4,000 3,000 Operations 0 1,200 800 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual" FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 0 0 0 Professional Fees 0 4,000 3,000 Operations 0 1,200 800 Supplies 0 1,000 800 Equipment 0 300 150 Other: Classroom rentals in Ka'u 0 900 500 Other: Advertising (newspaper ads, posters, etc.) 0 750 400 Other: Refreshments, plant examples, lei, photos 0 600 400 Other: Other: TOTAL 8,750 6050 "If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: rfo'oMALLJ KKU Program Name: Native Dry -Land Plants workshops to. 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 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. L—� i Signature of Authorize P rs n ( ecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Ho'ohaALU KA'U Program Name: Native Dry -Land Plants workshops >t. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and 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 final payment. To register, go to hap :/(vendoa,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 reouirement 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 resort using the template Provided will impact the evaluation of your Program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HO'OMALU KA'u Program Name: Native Dry -Land Plants workshops 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured priorto receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 30th shall result in loss off all grant funds received during the arant 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 . ,..,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 for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by lune 30, 2015 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 utune-fundinq request and mov result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements I�aD4'z ol5 si nature of Autho�ieclers specify�title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HO'OMALU KA'U Program Name: Native Dry -Land Plants Workshops 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES APPllcant Projected gesults Council Proposed Proiectetl Result 1. Plan, organize and implement 6 workshops in Ka' 6 Workshops 2. Educate at least 20 people per workshop. 120 people 3. Protect at least 5 species on lots in Ka'u 20 photos 4. Conserve at least 5 species on Ka'u lots 20 Ohoros Equipment 150 _ Other: Classroom rentals 500 Other: Advertising (newspaper ads, Posters, etc.) 400 TABLE 11: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 0 Professional Fees 3,000 Operations 600 Supplies 800 Equipment 150 _ Other: Classroom rentals 500 Other: Advertising (newspaper ads, Posters, etc.) 400 Other: Refreshments, plant photos and examples, lei 400 Other: Other: TOTAL 6,050 Muu¢iyflat Council directives reearalnE award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of HOPE Services Hawai'i, Inc Disaster Relief & Recovery 62 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE services Hawaii, Inc Program Name: Disaster Relief & Recovery Agency Director: Brandee Meninx Phone No.: ( 808) 933 — tai Contact Person: Angela Evans Phone No.: ( 808 ) 933 — 6075 Mailing Address: Address. 296 Kilauea Avenue Address: City, ST, Zip Hlle. Hawaii 96720 Facility Address: Address: 115Kapiolanisbeel Address: City, ST, Zip HiloHl96720 Email Address: bmemno@hopeservlcashawail.org Fax No.: ( 808) 935 — 3794 Accountant/CPA: Shelly Toledo Phone No.: ( 808) 933 — 6008 Firm (if applicable), Mailing Address: Address: 296 Kilauea Avenue Address: City, ST, Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑� Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑ Victims of Crimes ❑ Culture and the artsAged Victims of Health or Social Crises Needs of the poor 0 Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Disaster Relief & Recovery 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 sico.000 FY 13-14 i FY 14-15 ss. l00000l 0 so $0.00 0 2. Agency Mission Statement: HOPE Services Hawaii, Inc. (HOPE), a faith -based organization based on Hawaii Island, dedicated to its mission of "Bring to life gospel values of justice, love, compassion and hope through service, empowerment and advocacy." At HOPE, it's about the journey from hopelessness to opportunities and transformation. We are a non-profit organization that builds individual, family and community resiliency through direct service, community organizing, and intentional partnerships. It's about all of us being part of the solution and how public, private, non-profit and community citizens are working together for stronger families & healthier communities. We are long -trusted and relied upon in our community to be responsive and relevant to the most vulnerable populations, including persons at risk of and experiencing homelessness, persons with mental health and substance abuse disabilities, youth and elderly. Most recently, the traumatic experiences of Tropical Storm Iselle and adjustment to the "new normal" of the June 27 lava flow compounds the everyday stresses of Puna residents. HOPE responded swiftly and mobilized our team to offer relief and housing services to those in need. 3. Program Description: The Disaster Relief & Recovery program provides assistance to individuals and families in the Puna area that are recovering from the devastation of Tropical Storm Iselle and the June 27 lava flow. This program assists displaced families and individuals with securing permanent housing; providing recovery recommendations, referrals and community resources to meet the needs of disaster survivors; and assisting these impacted households with developing a recovery plan to better prepare for any future natural disasters. This is a NEW program developed to address a NEW need in our community. HOPE determined disaster relief and recovery as a priority, in order to prepare and plan for community disaster readiness and response. Over the last six (6)months, HOPE has been called upon by State and County departments and community non-profit partners to provide outreach and housing placement services to vulnerable population Puna residents who have special needs and/or need special accommodation with regard to housing stability. Through the partnership network of providers, a disaster response system was created to assist those in need. HOPE intends to leverage these existing partnerships and resources to continue building community resiliency. 4. Total Budget & Position Count: Total Program Budget: sico.000 Total Program Position Count: i Total Agency Budget: ss. l00000l Total Agency Position Count: so EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Disaster Relief & Recovery S. Program Funding Sources (identify all sources of funding applied to this program): Fy1S-16 Revenue Source Estimate County of Hawaii. County Council Non -Profit (unsecured. NEW ask) _ $50.000 Hawaii Island United Way (unsecured. NEW ask) $50,000 TOTAL: $100,000 Attach additional pages, if needed 6. Explain what plans your agency or program has to increase revenues to support this program This is a NEW ask to increase disaster response capacity to the unique disaster needs of Puna. HOPE will also seek out additional funding to invest in our fund development capacity by hiring a full time employee to help raise and maintain new funds through new government grants, foundation and individual contributions. HOPE will also continue to leverage our community partnerships and volunteers to help offset service costs and consumable goods, as the community has been supportive in providing donated items (furniture, clothing, household essentials), meals and service (landscaping, mentorship and facility beautification/improvement). 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from the County of Hawaii will cover personnel costs (salary & benefits), operational expenses and supplies/direct financial assistance for those in need. Operational costs include office supplies, printing, postage, mileage reimbursement, telecommunication, and staff development expenses. The County's contribution is imminent and timely given the 53% increase in the total number of NEW homeless clients in Hawaii County since last year (University of Hawaii, Center on the Family, Homeless Service Utilization Report 2014). This increase, compounded by the impacts of lava, will only exacerbate the potential for increased homelessness due to the insufficient, current supply of affordable housing. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE services Hawaii, Inc. Program Name: Disaster Relief & Recovery 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES a e.: Number ofdoems served, workshops or events held, scion beer hours, etc Oescnbe, be speer, Applicant Projected Results Number of households served 75 Number of households that received emergency supplies 75% Number of households that received assistance with back due rent and/or utilities 50% Number of households that received relocation assistance 20% Number of households that received assistance to repair home damages 5% Increased client knowledge of community resources 85% Completed service plan with program clients 85% Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 0 $63475 $25,000 Professional Fees 0 0 0 Operations 0 $5.000 0 Supplies $10.000 $50.000 $25,000 Equipment Other 0 0 0 0 0 0 Other 0 0 0 Other: Other 0 0 0 0 0 0 Other. 0 0 0 TOTAL $10,000 $118,475 $50.000 If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Disaster Relief & Recovery lo. 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: Brandee Menino POSITION: Chief Executive Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined asa 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. M.e,.w, - , aEo gnature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 January 29, 2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Disaster Relief & Recovery 13. 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 programis) 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 final payment. 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 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 Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit o timely, complete, and accurate year-end report using the template provided, will impact the evaluation of your program's or agency s future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Disaster Relief & Recovery 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30" shall result in loss of all grantfunds 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.goy/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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. CEa January 29, 2015 r Sig ature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Disaster Relief & Recovery 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of households servetl 75 Award Number of households that received relocation assistance 20 Number of households that received emergency supplies Increased client knowledge of community resources 75% 85% 825,000 Completed service plan with program clients 85% 0 Number of households that received assistance to repair home damages 5 o' Number of households that received assistance with back due rent and/or utilities 50% 0 TABLE II: PROGRAM EXPENDITURES FY 15-16 Council Grant Request Award Salary and Wages 825.000 Professional Fees o Operations 825,000 Supplies 0 Equipment o' Other: 0 Other. 0 Other: o' Other 0 Other: _ TOTAL $50.000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8 of HOPE Services Hawaii, Inc East Hawai'i Emergency Housing 63 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: East Hawaii Emergency Housing Agency Director: 5randea Menina Phone No.: ( BOB) 933 — 6013 Contact Person: Denise ogeme Phone No.: ( 808) 933 — 6035 Mailing Address: Address 296 Kilauea Avenue Address: City, ST, Zip Hilo, Hawan 96720 Faci Iity Address: Address: 116Kapblanisl. Address. City, ST, ZIP Hilo. Hawaii 93720 Email Address: bmenino@hopuservmashawaiion, Fax No.: (808)935 — 3194 Accountant/CPA: sheuy Tolede Phone No.: ( 808 ) 933 — 6006 Firm (if applicable): Mailing Address: Address. 296Kilauea Ave Address: City, ST, Zip Hilo. Hawaii 96]20 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua ❑ North Kona © South Hilo ❑ North Kohala ❑ South Kona © North Hilo ❑ South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) j Educational concerns ❑ youth © Victims of Crimes ❑ Culture and the arts © Aged © Victims of Health or Social Crises © Needs of the poor ✓❑ Physical/Emotional Disabilities ❑J Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: East Hawaii Emergency Housing 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 1 FY 13-14 FY 14-15 o $0,00 0 2. Agency Mission Statement: HOPE Services Hawaii, Inc. (HOPE), a faith -based organization based on Hawaii Island, dedicated to its mission of "Bring to life gospel values of justice, love, compassion and hope through service, empowerment and advocacy." At HOPE, it's about the journey from hopelessness to opportunities and transformation. We are a non-profit organization that builds individual, family and community resiliency through direct service, community organizing, and intentional partnerships. It's about all of us being part of the solution and how public, private, non-profit and community citizens are working together for stronger families and healthier communities. We are long trusted and depended upon in our community to be responsive and relevant to the most vulnerable populations including persons at risk of and experiencing homelessness, persons with mental health and substance abuse disabilities, youth, elderly and persons justice involved. 3. Program Description: At the beginning of the fiscal year, the facility will go through a transition from a transitional housing program to an emergency shelter for single men experiencing homelessness. We intend to expand our emergency shelter capacity by twenty-eight (28) NEW bed spaces. Through our outreach and engagement efforts on the streets, camp sites, parks, beaches and cars, once a person agrees to shelter, it is critical to have a single bed ready for their stay. Having a short stay residence to rest their head at night allows the Homeless Outreach Specialist the ability to follow up with the individual on site consistently. A program participants' stay may range from a night to several weeks. The goal is to rapidly rehouse these individuals into a private rental unit within our community using the "Housing First" strategies, leveraging the rental subsidies (voucher) and supportive services through mainstream community resources that they may be eligible for. 4. Total Budget & Position Count: Total Program Budget: 292,400 Total Program Position Count: a Total Agency Budget: 5,100,000 Total Agency Position Count: so EXHIBITA NONPROFIT GRANT APPLICATION FV 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE services Hawaii Inc. Program Name: East Hawaii Emergency Housing S. Program Funding Sources (identify all sources of funding applied to this programl: Revenue Source FY15-16 Estimate County of Hawaii 50,000 State of Hawaii 204,400 Foundation/Private Contributions 20,000 Program Fees 18,000 TOTAL: 292400 Attach additional pages, ifacetted. 6. Explain what plans your agency or program has to increase revenues to support this program: As this is a new program to help meet an unmet need in our community, we will invest in building our capacity in fund development by hiring a full time employee to help raise and maintain new funds through new government grants, foundation and individual contributions. 7. Program Objectives Using County Nonprofit Grant Program Funds: Program Objectives using county nonprofit grant program funds include: 1. To decrease chronic homelessness in East Hawaii by providing emergency shelter to those most vulnerable in our community; 2. To improve residential stability to men experiencing homelessness; 1 To improve residential stability to veterans experiencing homelessness; 4. To improve the health outcomes and quality of life to men experiencing homelessness and decrease victimization on the streets. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: East Hawaii Emergency Housing B. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES fie Number o)dlents served, worlahops or events field, volunteer hours. etc oex be. be speojl[-1 Applicant Projected Results Number of bed days 7,665 Number of men served 100 Increase resident's knowledge of community and housing resources 80% Complete Individual Assessment Plan with shelter residents_ (housing focus) Moving from shelter to a new home 80% _ 75% - Value of volunteer hours contributed to program 510.000 Value of in-kind donations leveraged to implement emergency housing program _ 525,000 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 0 0 110.000 0 Professional Fees 31,000 0 Operations 0 121,400 50,000 Supplies 0 25,000 0 Equipment Other 0 5,000 0 0 0 0 Other 0 0 0 Other 0 0 0 Other 0 a 0 Other 0 0 0 TOTAL 0 292 400 50,000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: East Hawaii Emergency Housing io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 besianed regardless of whethero conflict exists. NAME: Brandee Menino POSITION: Chief Executive Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ 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. A) t&4I Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 January 28, 2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE services Hawaii Inc. Program Name: East Hawaii Emergency Housing ii. Certification of Understanding (page 1 of 2) 1 (we) have read and understood all of the 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, 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. Fazed 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 final payment. 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 VOur program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE services Hawaii Inc. Program Name: East Hawaii Emergency Housing 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured priorto 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 Countyl 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, 2015 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 moV result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. lig J lL2zfL� cFo Signature of Authorized Person (specify title) January 28, 2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE services Hawaii Inc. Program Name: East Hawaii Emergency Housing 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of bed days 7,665 Number of men served too Increase resident's knowledge of community and housing resources 80% Complete Individual Assessment Plan with shelter residents 80% Move from shelter to a new home 75% Value of volunteer hours contributed to program $10,000 Value of in-kind donations leverage to develop new emergency shelter program $25,000 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 0 Professional Fees o Operations 50,000 Supplies 0 Equipment 0 Other 0 Other 0 Other 0 Other o Other 0 TOTAL 50,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT G RANT APPLICATION FY 2014-2015 Page 8 of HOPE Services Hawaii, Inc East Hawai'i Homeless Outreach M County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: East Hawaii Homeless Outreach Agency Director: grandee Menino Phone No.: ( 606) 933 — 6013 Contact Person: Denise Oguma Phone No.: ( 808) 933 — 6035 Mailing Address: Address: 296Kiiauea Avenue Address: City, ST, Zip Hilo. Hawaii 96720 Facility Address: Address'. 116 Kepiolani Street Address' City, ST, Zip Hilo HI 96720 Email Address: bmenuo@hopeserviceshawaii org Fax No.: ( 808) 935 — 3794 Accountant/CPA: Shelly Toledo Phone No.: ( 808) 933 — 6008 Firm (if applicable): Mailing Address: Address: 296 Kilauea Avenue Address. City, ST, Zip Hilo. Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna ❑ Harri ❑ North Kona (] South Hilo ❑ North Kohala ❑ South Kona 0 North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) W] Educational concerns ❑ Youth ❑✓ Victims of Crimes ❑ Culture and the arts Q Aged © Victims of Health or Social Crises ✓❑ Needs of the poor © Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: East Hawaii Homeless Outreach 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 Total Program Position Count: FY 14-15 Total Agency Budget: 0 Total Agency Position Count: $0.00 0 2. Agency Mission Statement: HOPE Services Hawaii, Inc. (HOPE), a faith -based organization based on Hawaii Island, dedicated to its mission of "Bring to life gospel values of justice, love, compassion and hope through service, empowerment and advocacy." At HOPE, it's about the journey from hopelessness to opportunities and transformation. We are a non-profit organization that builds individual, family and community resiliency through direct service, community organizing, and intentional partnerships. It's about all of us being part of the solution and how public, private, non-profit and community citizens are working together for stronger families and healthier communities. We are long -trusted and relied upon in our community to be responsive and relevant to the most vulnerable populations, including persons at risk of and experiencing homelessness, persons with mental health and substance abuse disabilities, youth, elderly and persons who are justice -involved. 3. Program Description: HOPE homeless outreach specialists mobilize daily to locate and provide basic necessities and encourage housing placement - with three (3) specialists that cover the entire east side of Hawaii island, and three (3) specialists that cover the entire west side. Specialists travel to areas that are often not easily visible or accessible by vehicle - in unpaved areas, trees/bushes, caves, and under bridges. At encounter, specialists provide emergency supplies - food, clothing, blankets, and basic hygiene items (soap, shampoo, toothpaste/toothbrush, deodorant). The journey to housing placement poses many challenges, as many homeless consumers suffer some form of mental illness and/or substance abuse. Specialists establish and maintain a positive rapport with consumers - providing continued encouragement and necessities, with the ultimate intent of permanent housing placement and access to mainstream services and resources. With the highest rate of chronic homelessness of any county in the state, at 34%, assisting this population in securing and maintaining stable housing is critical in reducing homelessness of the vulnerable. 4. Total Budget & Position Count: Total Program Budget: $370.73126 Total Program Position Count: a Total Agency Budget: $5.100.000 00 Total Agency Position Count: so EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: East Hawaii Homeless Outreach S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate State/Dept of Human Services. Homeless Program Office $295,731.26 State/Dept of Health. Adult Mental Health Division $50,000 Hawaii County $25,000.00 TOTAL: $370731.26 Attach additional pages, i) needed_ 6. Explain what plans your agency or program has to increase revenues to support this program HOPE will seek out additional funding to invest in our fund development capacity by hiring a full-time employee to help raise and maintain new funds through new government grants, foundations and individual contributions. HOPE will also continue to leverage our community partnerships and volunteers to help offset service costs and consumable goods, as the community has been supportive in providing donated items (furniture, clothing, household essentials and hygiene products), meals and service (mentoring, academic and social enrichment). Individuals and organizations in the community have leveraged tremendous help in either providing donated items, services or manpower in the coordination of huge awareness activities, including the annual homeless awareness events (in both East and West Hawaii) and the islandwide homeless point -in -lime count where the homeless population is surveyed - providing the critical data that demonstrate funding need for our increasing homeless population. 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from the County of Hawaii will cover personnel costs (salary & benefits) to increase capacity of our outreach team by one (1) specialist. The County's contribution is critical and timely, given the 53% increase in the total number of NEW homeless clients in Hawaii County since last year. As articulated previously, Hawaii County is further challenged with the highest rate of chronically homeless persons in comparison to any other county in the state - at an astonishing 34% (University of Hawaii, Center on the Family, Homeless Service Utilization Report 2014). HOPE needs the resources to serve the most vulnerable persons in our community, in order to securing housing and facilitate stability so that this population can experience a higher and safer quality of life. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: East Hawaii Homeless Outreach 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i. p.: Numbe/Of CIiP�n SPNPd, wofkthaps c,1111n11 held, volun(p, h., ek DPsc/ibp, be tp"'fic) Applicant Projected Results Number of persons served 800 Number of counseling contacts 2,200 Number of service plans completed 80% Number of persons linked to mental health or substance abuse treatment services 10% Increase knowledge of community resources 80% Number of persons placed in permanent housing 20% Number of persons placed in emergency or transitional shelter 10% Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $302,34800 $305,740.26 $25,000.00 Professional Fees $0.00 $0.00 $0.00 Operations $59,991.00 $59,99100 $0.00 Supplies $500000 $5000.00 $0.00 Equipment $0.00 $0.00 $0.00 Other: $0.00 $000 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 TOTAL $367,339.00 $370,731.26 $20,000.00 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: East Hawaii Homeless Outreach io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 whethero conflict exists. NAME: grandee Menino POSITION: Chief Executive Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ 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: QIf no conflicts exist, check here. Jeremy McComber Director of Operations sig ture of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 January 29, 2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: East Hawaii Homeless Outreach 11. Certification of Understanding (page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, 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 final payment. 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 veer -end report using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE services Hawaii. Inc. Program Name: East Hawaii Homeless Outreach 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 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 htty://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 lune 30, 2015 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 Vour agency's future funding request and may result in actions token to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Jeremy McComber �Q ir ce..... _ .Q(lO Director of Operations Sig hneture'-"`ooPrA-utthVorized Person (specify title) January 29, 2015 Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: East Hawaii Homeless Outreach 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of persons served 800 Number of counseling contacts 2200 Number of service plans completed 80°% Number of persons linked to mental health or substance abuse treatment services 10% Increased knowledge of community resources 80% Number of persons placed in permanent housing Number of persons placed in emergency or transitional shelter 20% 10°% $0.00 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $20 000.00 Professional Fees $0.00 Operations $0.00 Supplies $0.00 Equipment $0.00 Other. $0.00 Other $0.00 Other $0.00 Other $0.00 Other $0.00 TOTAL $20.000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of HOPE Services Hawaii, Inc Friendly Place Resource Center County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Friendly Place Resource Center Agency Director: Brandee Meninx Phone No.: ( 606) 933 - 6013 Contact Person: Cerise oyuma Phone No.: ( 808) 933 — 6035 Mailing Address: Address: 296 Kilauea Avenue Address: City, ST, Zip Hilo. Hawaii 96720 Facility Address: Address'. 74-5593 Pawai Place Address'. City, ST, Zip Kailua-Kona, Hawaii 96740 Email Address: bmenin @hopeserviceshawaii or, Fax No.: ( 808) 935 — 3794 Accountant/CPA: Shelly Toledo Phone No.: ( 808 ) 933 — 6008 Firm (if applicable): Mailing Address: Address: 296 Kilauea Avenue Address'. City, ST, Zip Hilo. ,we 96]20 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can he checked) ❑ Puna ❑ Hamakua © North Kona ❑ South Hilo Q North Kohala❑ South Kona ❑ North Hilo ✓❑ South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ❑ Youth Victims of Crimes ❑ Culture and the arts © Aged © Victims of Health or Social Crises Q Needs of the poor © Physical/Emotional Disabilities ❑�/ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2015-I6 Agency Name: HOPE Services Hawaii, Inc. Program Name: Friendly Place Resource Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 Total Program Position Count: FY 13-14 Total Agency Budget: $5,100 coo oo FY 14-15 60 0 $0.00 0 2. Agency Mission Statement: HOPE Services Hawaii, Inc. (HOPE), a faith -based organization based on Hawaii Island, dedicated to its mission of "Bring to life gospel values of justice, love, compassion and hope through service, empowerment and advocacy." At HOPE, it's about the journey from hopelessness to opportunities and transformation. We are a non-profit organization that builds individual, family and community resiliency through direct service, community organizing, and intentional partnerships. It's about all of us being part of the solution and how public, private, non-profit and community citizens are working together for stronger families and healthier communities. We are long -trusted and relied upon in our community to be responsive and relevant to the most vulnerable populations, including persons at risk of and experiencing homelessness, persons with mental health and substance abuse disabilities, youth, elderly and persons who are justice -involved. 3. Program Description: The Friendly Place Resource Center (Friendly Place) is a daytime service site that serves persons who are experiencing homelessness. Consumers can access essential services such as restroom, bathing and laundry facilities, lockers and mail. Also available is access to internal referral for other program services - Supplemental Nutrition Assistance Program (SNAP) assistance; healthcare enrollment, housing application, placement and financial support; and representative payee. Other services coordinated on-site through community partnership include basic medical and/or dental treatment, mental health services, substance abuse treatment, and employment readiness and training. The Friendly Place experiences an average of 60-70 homeless persons on a typical day, as the site functions as a "safe" place for homeless consumers. Individual and community groups sponsor lunches to consumers, and St. Michael's Church manages a scheduled pantry for consumers to access food items. 4. Total Budget & Position Count: Total Program Budget:.. 5654,706.00 Total Program Position Count: 12 Total Agency Budget: $5,100 coo oo Total Agency Position Count: 60 EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Friendly Place Resource Center S. Program Funding Sources (identify all sources of funding applied to I FY15-16 Revenue Source Estimate I State/Dent of Human Services. Homeless Pmoram Office 5554,706.001 TOTAL: I $654,700.001 6. Explain what plans your agency or program has to increase revenues to support this program This is an additional ask to our historical request which directly correlates to our capacity to increase program operations to include eight (8) hours of operation on both Saturday and Sunday, as encouraged by the Mayor's Office. There is great need and desire by the community to have the program open for a longer duration, in order to provide additional access to resources and a safe weekend environment for our homeless consumers. Increased capacity will allow HOPE to meet the needs and demand of an increased vulnerable and aging population that is compounded by co -morbid disabilities (general health impacted by severe mental illnesses and substance abuse challenges). HOPE will seek out additional funding to invest in our fund development capacity by hiring a full-time employee to help raise and maintain new funds through new government grants, foundations and individual contributions. HOPE will also continue to leverage our community partnerships and volunteers to help offset service costs and consumable goods. 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from the County of Hawaii will cover the added personnel costs (salary & benefits) to operate on the weekends. This is the only financial contribution asked of the County to help offset operational costs for a program operated from a County -owned facility and property. As lessee, HOPE is responsible for program operations to meet the demands of our community. The County's contribution, which is less than 8% of the program's overall operating budget, is critical and timely given the 53% increase in the total number of NEW homeless clients in Hawaii County since last year. In addition, Hawaii County is further challenged with the highest rate of chronically homeless persons in comparison to any other county in the state - at an astonishing 34% (University of Hawaii, Center on the Family, Homeless Service Utilization Report 2014). HOPE is the lifeline to the most vulnerable persons in our community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE services Hawaii. Inc. Program Name: Friendly Place Resource Center 8. TABLE is What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Number of,lienl, servetl, workshops or events h6d, volunteer baun, etc. D,s,obe, be s,oft') Applicant Projected Results Number of persons served 1.000 Number of encounters 6,000 Number of persons linked to medical/dental services 80% Number of persons completed housing applications 80% Number of persons referred to employment opportunities 25% Increased knowledge of community resources 80% Number of persons attended life skills education workshops 40% Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages Professional Fees $513.623.13 $484.046.00 $50.000.00 $0.00 $0.00 $0.00 Operations $201.876.87 $158,660.00 $0.00 Supplies $12.000.00 $12.000.00 $0.00 Equipment $0.00 $000 $0 00 Other: $0.00 $000 $0001 Other. $0.00 $0.00 $0.00 Other $0.00 $0.00 $0.00 Other $0.00 $0.00 $0.00 Other. $0.00 $0.00 $0.00 TOTAL $722500.00 $654,706.00 $50.000.00 'If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE services Hawaii, Inc. Program Name: Friendly Place Resource Center iii. 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 o conflict exists. NAME: grandee Merino POSITION: Chief Executive Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ 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. ���q� �] leremv McComber YU{lr - ,. of Operations Sig ature of Authorized Person (specify title) EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 January29 2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Friendly Place Resource Center 11. Certification of Understanding (Page 1 t z) I (we) have read and understood all of the 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 final payment. 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 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 Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of S County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE services Hawaii. Inc. Program Name: Friendly Place Resource Center 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 30`^ shall result in loss of all grant funds received during the grant period (must be refunded to Countvl and exclusion from future grant participation 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 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Jeremy McComber cs' , wa&-- Director of Operations Sig ature of Authorized Person (specify title) January 29, 2015 Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Friendly Place Resource Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of persons served 1000 Number of encounters 6.000 Number of persons linked to medical/dental services 80% Number of persons completed housing applications 80% Number of persons referred to employment opportunities 25% Increased knowledge of community resources 00% Number of persons attended life skills education workshops 40% TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $50.000.00 Professional Fees $0.00 Operations $0.00 Supplies $0.00 Equipment $0.00 Other. $0.00 Other Other: $0.00 $0.00 Other. $0.00 Other'. $0.00 TOTAL $50000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 HOPE Services Hawaii, Inc Going Home Consortium LLJ County of I Iawai`i Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc Program Name: Going Home Consortium Agency Director: Brandea Menne Phone No.: ( 80e) 935 — 3050 Contact Person: Les Estrella Phone No.: ( 608 ) 937 — 6257 Mailing Address: Address. 296 Kilauea Avenue Address City, ST, Zip Hilo. HI 96721 Facility Address: Address. 296 Kilaaaa Avenue Address City, ST, Zip Hire -H196720 Email Address: bruenmo@hopeser,ershawaii.org Fax No.: ( e06) 935 — 3794 Accountant/CPA: Shelly ruled. Phone No.: ( 808 ) 933 — 6109 Firm (if applicable): N/A Mailing Address: Address- 296 Kilauea Avenue Address. City, ST, Zip We, H196720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: E 17 500.00 Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua © North Kona © South Hilo North Kohala © South Kona © North Hilo © South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns ❑ Youth © Victims of Crimes ❑ Culture and the arts ❑ Aged © Victims of Health or Social Crises © Needs of the poor © Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Going Home Consortium 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $0.00 $0.00 $15,000.00 2. Agency Mission Statement: HOPE Services Hawaii, Inc. (HOPE), a faith -based organization based on Hawaii Island, dedicated to its mission of "Bring to life gospel values ofjustice, love, compassion and hope through service, empowerment and advocacy." We are a non-profit organization that builds individual, family and community resiliency through direct service, community organizing, and intentional partnerships. It's about all of us being part of the solution and how public, private, non-profit and community citizens are working together for stronger families and healthier communities. We are long trusted and depended upon in our community. Being a fiscal agency to the Going Home Consortium is one example. Going Home Consortium's Mission is: "To assist Hawai'i Island men and women released from correctional institutions with re -integration into community life through employment, training, and appropriate supportive services." 3. Program Description: "E Ho'i I Ka Mole" ...Return to that from which it came: Going Home (GH) is the name given to efforts on the Big Island to reintegrate former offenders into the community and the workplace. GH was established to be involved in organizing, coordinating, facilitating and developing services for persons going home after being released from incarceration. These tasks are accomplished by being the central point of communication among over 50 public and private entities and their representatives, with an island -wide network of over 300 members. GH members offer solutions and support for one another as providers, legislators, volunteers and citizens who are committed to maintaining safer communities. GH remains focused on efforts that provide more cost effective and innovative programs leading to a decrease of recidivism and overcrowding ofjails and prisons through offering reintegrating inmates various opportunities to become contributing members of society. 4. Total Budget & Position Count: Total Program Budget: 25,500 Total Program Position Count: 05 Total Agency Budget: 5 l00000l Total Agency Position Count: 60 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Going Home Consortium S. Program Funding Sources (identify all sources of funding applied to this program): FY15-16 Revenue Source Estimate County of HawaPi Nonprofit Grant 15,000 Annual Benefit Fundraiser Dinner 5,000 Other Contributions 5,500 TOTAL: 25,500 Attach additional poves, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: At this time, Going Home (GH) is applying to become its own 501 (c)(3) nonprofit organization. GH has a current memorandum of agreement with Hawai'i Alliance for Community -Based Economic Development (HACBED) to complete our 2014-2019 strategic plan, that includes the development of GH's new 501 (c)(3) nonprofit organization, which will be known as "Going Home Hawaii". Upon completion and approval by the IRS, GH would like to hire an Executive Director or contract a consultant that will continue to drive the mission forward while simultaneously applying for grants to increase the revenue of the organization and provide long-term sustainability. This position/contractor will also be responsible to assist with increasing legislative, judicial and community engagement. The annual benefit fundraiser, honoring a community member that has shown continuous support of GH efforts, will still be held; which will also generate revenue. 7. Program Objectives Using County Nonprofit Grant Program Funds: Following the approval of a 501(c)(3) application, GH would like to hire an Executive Director or contract a consultant that will continue to drive the mission forward and be responsible for applying for other sources of funding to support GH efforts. This position/contractor will be the champion of the organization, with additional support from the consortium and executive committee members, focused on achieving the goals of the 2014-2019 strategic plan, which include: increased community engagement, prevention service development to focus on youth offenders and substance and mental health treatment, increased geographic reach, increased engagement with Judiciary, increase programmatic opportunities to reduce recidivism, establish well-defined referral paths among community resources, marketing/branding, implement the Employer Support Network, and to assess training/education needs. A portion of funds would be allocated to fill this Executive Director position and would also fund each GH committee's activities that directly support the goals of the strategic plan. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Going Home Consortium B. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES p.e. Numb—f,fiente served, —kor, er events bl d, vefv tI, r hours, etc oezuNe, be 11'll Applicant Projected Results 1. Organizational statistical evaluation 1. Quantity outcomes: recidivism rate variance -,comparisons of impact on recidivism those provided wl services versus individuals include all GH members that received no intervention. 14,000 _ 2. At least six training events to be 2. Increase in overall conducted by committees community engagement. 3. All meeting minutes accurately recorded 3. Organized plans. A tech additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual* FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 0 13,000 13,000 Professional Fees 14,000 5,000 5,000 Operations 1,000 4,000 2000, Supplies 0 500 0 Equipment 0 3,000 0 0 Other. 0 0 Other Other 0 0 0 0 0 0 Other 0 0 0 Other. o 0 o TOTAL 15,000 25,500 20.000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Going Home Consortium >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 c conflict exists. NAME: grandee Merino POSITION: Chief Executive Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as a substantial probability that oction 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. jS� e ��!Ki a1x t c'r o Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 January 28. 2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE services Hawaii, Inc. Program Name: Going Home Consortium 11. 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, 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 final payment. 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 veor-end report using the template provided will impact the evaluation of your program's or agency s future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE services Hawaii, Inc. Program Name: Going Home consortium it. 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 lune 30" shall result in loss of all grant funds received during the grant period (must be refunded to Countvl 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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. 51ature of Authorized Person (specify title) January 28,2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE services Hawaii, Inc. Program Name: Going Home Consortium 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result 1. Organizational statistical evaluation -recidivism recidivism rate variance - comparisons of those 5,000 provided w/ services versus individuals that 2,000 received no intervention. 0 2. At least six training events to be conducted by Awareness committees. 0 3. All meeting minutes accurately recorded . engagement TABLE If: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 13,000 Professional Fees 5,000 Operations 2,000 Supplies 0 Equipment a Other. 0 Other 0 Other. 0 Other 0 Other 0 TOTAL 20,000 Additional Council directives reearding award: EXHIBIT B NONPROFIT GRANT APPLICATION PY 2014-2015 Page 8 of HOPE Services Hawaii, Inc Interim/Bridge Housing 67 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc Program Name: interim/Bridge Housing Agency Director: Brander merino Phone No.: ( 868) 935 — 3050 Contact Person: An9rla Evans Phone No.: ( 808 ) 937 — 6257 Mailing Address: Address: 296 Kilauea Avenue Address: City, ST, Zip Hilo. HI 96720 Facility Address: Address: (1) 110 Ululani St,(2) 21 W. ohea St. Address: (3) 771walani St. (4) 1495 Kocana Place. City, ST, Zip (5) 189 Wilder Rd Hilo. A 96720 Email Address: bmemno@hopeservlceshawar org Fax No.: ( 808) 935 — 3794 Accountant/CPA: Shelly Toledo Phone No.: ( 898) 933 — 6006 Firm (if applicable): NIA Mailing Address: Address. 296Kilauea Avenue Address. City, ST, Zip Hilo, HI96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: s 17500.09 Geographical Areas To Be Served: (One or more can be checked) ❑,� Puna ✓❑ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑ South Kona Q North Hilo ❑ South Kohala ✓❑ Ka'. Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑✓ Aged © Victims of Health or Social Crises ❑� Needs of the poor © Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Interim/Bridge Housing 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 0 $0.00 0 2. Agency Mission Statement: HOPE Services Hawaii, Inc. (HOPE), a faith -based organization based on Hawaii Island, dedicated to its mission of "Bring to life gospel values of justice, love, compassion and hope through service, empowerment and advocacy." At HOPE, it's about the journey from hopelessness to opportunities and transformation. We are a non-profit organization that builds individual, family and community resiliency through direct service, community organizing, and intentional partnerships. It's about all of us being part of the solution and how public, private, non-profit and community citizens are working together for stronger families and healthier communities. We are long -trusted and relied upon in our community to be responsive and relevant to the most vulnerable populations, including persons at risk of and experiencing homelessness, persons with mental health and substance abuse disabilities, youth, elderly and persons who are justice -involved. 3. Program Description: HOPE's Interim Housing program consists of five (5) residential housing sites in East Hawaii: Chea, Iwalani, Kuleana, Wilder and Beyond Shelter. These programs provide housing and support services for an interim period, in order to transition back into the community. This safe and drug-free setting allows individuals in recovery from substance abuse to stabilize on psychotropic medications in the least restrictive and dignified housing environment. Safe and clean housing allows individuals to equip and prepare for financial self-sufficiency and housing stability. Consumers receive case management services that assist in service plan and goal development geared for a healthier and stronger self. Services include linkages and referrals to community resources, court advocacy, life skills classes, support groups, counseling and emergency food assistance. HOPE partners with the Department of Public Safety, Adult Probation, Parole, Child Welfare Services, Big Island Substance Abuse Council and other community partners to provide a continuum of care for this high-risk population. 4. Total Budget & Position Count: Total Program Budget: $238.028' Total Program Position Count: i Total Agency Budget: $s.ioozo Total Agency Position Count: 60 EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Interim/Bridge Housing S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Program Fees (based on ability to pay at 70%) $46,020 Rental Revenue (based on ability to pay at 80%) $43,008 County of Hawaii, Non -Profit (unsecured. NEW ask) $25,000 State of Hawaii, DHS, Homeless Programs (transfer) $99,000 Hawaii Island United Way (unsecured NEW ask) $25.000 TOTAL: $238,028 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HOPE will seek out additional funding to invest in our fund development capacity by hiring a full-time employee to help raise and maintain new funds through new government grants, foundations and individual contributions. HOPE will also continue to leverage our community partnerships and volunteers to help offset service costs and consumable goods, as the community has been supportive in providing donated items (furniture, clothing, household essentials), meals and service (mentoring, academic and social enrichment). The program also has a consumer -driven governing structure, referred to as PILLARS of HOPE (PILLAR), which provides a platform for consumers to establish protocols and expectations among peers. PILLAR is active in providing service to the community, and fundraises to leverage resources to fund peer requests for vital documents, transportation, family reunification, and socialization activities. 7. Program Objectives Using County Nonprofit Grant Program Funds: Program Objectives using county nonprofit grant program funds include: 1) To decrease chronic homelessness in East Hawaii by providing interim/bridge housing to those most vulnerable in our community as they transition back into our community. 2) To improve residential stability to individuals (men and women) experiencing homelessness. 3) To improve the physical and financial health and quality of life of individuals experiencing homelessness. Funding will allow HOPE to continue these critical programs and maintain housing inventory for this population. County funds will be used for salary and wages, and rent for the various sites. EXHIBIT A NONPROFIT GRANT APPLICATION 12015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Interim/Bridge Housing 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (r e.: Nuniner o)nlen is served, w kshopz,events held,wrwteer Hours, etc, oescrme, de speCrf, Applicant Projected Results complete service plan for participants 95% Number of individuals proposed to serve 65 Number of adults that will obtain employment 30% No of persons that will enroll in educilob tr 11 30% Moving from interim housing to a new home 60% Increase knowledge of community resoures 85% Number of counseling contacts 500 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 0 $60.000 $10,000 Professional Fees 0 0 0 - Operations 0 $168028 $15.000 '1 Supplies 0 $10.000 0 Equipment 0 0 0 Other 0 0 a Other. 0 0 a Other. 0 0 0 Other 0 0 0 Other --_— -- 0 0 a TOTAL $238.028 $250001 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Interim/Bridge Housing io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: Brandee Merino POSITION: Chief Executive Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council staff appointed by a member of the Council F1 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: Q If no conflicts exist, check here. Signature of Authorized Person (specify title) January 28 2015 Date EXHIBIT A NONPROFITGRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Interim/Bridge Housing tt. Certification of Understanding (Paget of 2) 1 (we) have read and understood all of the 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 1 (we) have the authority and ability 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 priorto submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. 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 final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Interim/Bridge Housing 11. Certification of Understanding (Page 2of2) If awarded a grant from the County of Hawa i'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 30" shall result in loss of all grant funds received during the grant period (must be refunded to Countvl and exclusion from future gran t 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Si nature of Authorized Person (specify title) January 28,2015 Date EXHIBIT A NONPROFITGRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Interim/Bridge Housing 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Complete Service Plan of Program Participants 85% Number of individuals proposed to serve 65 Number of adults that will obtain employment 30% No of persons that will enroll In education/job tr 30% Moving from interim housing to a new home 60% Increase Client Knowledge of Community Resources B5% Number of counseling contacts 500 TABLE It: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 10.000 Professional Fees Operations 15.000 Supplies 0 Equipment 0 Other. 0 Other Other 0 0 Other 0 Other 0 TOTAL 25.000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of HOPE Services Hawaii, Inc Kihei Pua Homeless Emergency Shelter M County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: Kihei Pua Homeless Emergency Shelter Agency Director: Brandee Meolno Phone INC.: ( 808) 933 — 6013 Contact Person: Denise Dguma Phone No.: ) 808 ) 933 — 6035 Mailing Address: Address: 296 Kilauea Avenue Address: City, ST, Zip Hilo. Hawaii 96720 Facility Address: Address: 115 Kapioiaoi St. Address: City, ST, Zip Hilo, Hawaii 93720 Email Address: dmenino@hopeserviceshawan Dig Fax No.: ( 808) 935 — 3794 Accountant/CPA: Snauy Toledo Phone No.: ( 808 ) 933 — 6008 Firm (if applicable): Mailing Address: Address: 2%Kilauea Ave Address- City, ST, Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua ❑ North Kona 0 South Hilo ❑ North Kohala ❑ South Kona © North Hilo ❑ South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth ❑✓ Victims of Crimes ❑ Culture and the arts 0 Aged Victims of Health or Social Crises ✓❑ Needs of the poor Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Kihei Pua Emergency Homeless Shelter 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $15,000.00 $15,000.00 $15,000.00 2. Agency Mission Statement: HOPE Services Hawaii, Inc. (HOPE), a faith -based organization based on Hawaii Island, dedicated to its mission of "Bring to life gospel values of justice, love, compassion and hope through service, empowerment and advocacy." At HOPE, it's about the journey from hopelessness to opportunities and transformation. We are a non-profit organization that builds individual, family and community resiliency through direct service, community organizing, and intentional partnerships. It's about all of us being part of the solution and how public, private, non-profit and community citizens are working together for stronger families and healthier communities. We are long -trusted and relied upon in our community to be responsive and relevant to the most vulnerable populations, including persons at risk of and experiencing homelessness, persons with mental health and substance abuse disabilities, youth, elderly and persons who are justice -involved. 3. Program Description: Kihei Pua Emergency Homeless Shelter is a service -enriched emergency housing program that serves families with children who are experiencing homelessness. At initial intake an individualized service plan is developed with the family. An assessment is conducted to determine current housing and employment challenges, from which goals are then established to promote and strengthen family housing and financial sustainability. Internally, consumers are provided with life skills trainings, including basic budgeting and tenant readiness, in addition to internal referral for other program services - Supplemental Nutrition Assistance Program (SNAP) assistance: healthcare enrollment; and housing application, placement and financial support. Other needed services, basic medical treatment, mental health services, substance abuse treatment, child support enforcement and reunification, and employment readiness and training - are coordinated by referral to community partner organizations. With a targeted stay of three (3) months, service plans and goals are reviewed frequently, and families are encouraged to be diligent in pursuing their goals. The program leverages civic, academic and community groups to facilitate academic, enrichment and socialization opportunities for both adults and youth. 4. Total Budget & Position Count: Total Program Budget: sszt,o35 Total Program Position Count: 11 Total Agency Budget: Ss.ioo.000 Total Agency Position Count ee EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Kihei Pua Emergency Homeless Shelter 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate County of Hawaii, County Council Non -Profit $25.000 State of Hawaii, Department of Human Services, Homeless Programs Office $440,190 Program Fees (Fees collected from families is $5/family per night if family has income to pay) $16.060 Federal (passed through the State) - Emergency Solutions Grant. Shelter Operations $39,785 TOTAL: $521,035 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HOPE will seek out additional funding to invest in our fund development capacity by hiring a full-time employee to help raise and maintain new funds through new government grants, foundations and individual contributions. HOPE will also continue to leverage our community partnerships and volunteers to help offset service costs and consumable goods, as the community has been supportive in providing donated items (furniture, clothing, household essentials), meals and service (landscaping, mentoring, academic and social enrichment, and facility beautification/improvement). 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from the County of Hawaii will cover operational expenses and client supplies to maintain program operations. This program is staffed 7 days a week/24 hours a day. Operational costs include facility repair and maintenance, equipment lease, printing, and vehicle repair and maintenance costs. This is the only financial contribution asked of the County to help offset operational costs for a program operated from a County -owned facility and property. As lessee, HOPE is responsible for program operations to meet the demands of our community. The County's contribution, which is less than 5% of the program's overall operating budget, is critical and timely given the 53% increase in the total number of NEW homeless clients in Hawaii County since last year. Further, 27% of the homeless population are children - the highest rate of all counties in the entire state (University of Hawaii, Center on the Family, Homeless Service Utilization Report 2014). HOPE needs the resources to be able upkeep this County -owned facility from the wear and tear from this new, transient population. HOPE is the lifeline to the most vulnerable persons in our community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015- l6 Agency Name: HOPE Services Hawaii Inc. Program Name: Kihei Pua Homeless Emergency Shelter 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES e ¢..-Number ofdienb served workshops pram(, held valent.. hours, etc. Oesoibe, be ipeGfic f Applicant Projected Results Number of bed nights 16,376 Numberof individuals served at the homeless emergency shelter 380 Numberof individual counseling contacts 2,500 Numberof persons participanting in eduljob training assistance 20% Increase Client Knowledge of community resources 85% Complete Service Plan with shelter clients 80% Moving from the emergency shelter to a new home environment 30% Attach additional pages os necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $323.79993 $328,800 $0.00 Professional Fees $1 200.00 $1200.00 $0.00 Operations $161268.20 $171,267 $15,000.00 Supplies $19766.87 $19,768 $10,000.00 Equipment $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other: $0.00 $0.00 $0.00 Other. $0.00 $0.00 $0.00 Other $0.00 $000 $0.00 TOTAL $506.035.00 $521.03500 $25.000.00 If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: Kihei Pua Homeless Emergency Shelter io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Brandee Merino POSITION: Chief Executive Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ 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 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. lYlk ru "_ dI I Si nature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 January 29, 2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: Kihei Pua Homeless Emergency Shelter 11. 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 allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and 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 final payment. To register, go to http://vendars.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 templote provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: Kihei Pua Homeless Emergency Shelter 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawa i'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 grantfunds 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Sig ature of Authorized Person (specify title) January 29, 2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: Kihei Pula Homeless Emergency Shelter 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of bed nights 16.316 Number of individuals served at the homeless emergency shelter 380 Number of individual counseling contacts Number of persons participating in edu/job training assistance 2500 20%'. 1, Increase Client Knowledge of Community Resources 85% Complete service Plan with shelter clients 80°% Moving from the emergency shelter to a new home evironment 60% TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $0.00 Professional Fees $0.00'. Operations $15.000 AO 1, Supplies $10000.00 Equipment $0.00 Other: $0.00 Other: $0.00 Other. _ $0.00 Other: $0.00 Other: $0.00 TOTAL $25000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of HOPE Services Hawaii, Inc Shelter Plus Care Programs 19 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: Shelter Plus care Programs Agency Director: Grandee Menino Phone No.: ( 908) 933 — 6013 Contact Person: Angela Evans Phone No.: ( 808 ) 933 — 6075 Mailing Address: Address: 296 Kilauea Avenue Address: City, ST, Zip Hilo, Hawaii 96720 Facility Address: Address: 115Kapiolarh Street Address City, ST, Zip Hilo, HI 96720 Email Address: bmenlno@hopeserviceshawaa. org Fax No.: ( 608) 935 — 3794 Accountant/CPA: Shelly Toledo Phone No.: ( 808 ) 933 — 6008 Firm (if applicable): Mailing Address: Address: 296Kilar Ave Address: City, ST, Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua © North Kona Q South Hilo Q North Kohalad❑ South Kona © North Hilo © South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns ❑ Youth Q Victims of Crimes ❑ Culture and the arts Aged 71 Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑� Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Shelter Plus Care Programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 1 FY 14-15 1 o $20,000.00 60 $20,000 2. Agency Mission Statement: HOPE Services Hawaii, Inc. (HOPE), a faith -based organization based on Hawaii Island, dedicated to its mission of "Bring to life gospel values ofjustice, love, compassion and hope through service, empowerment and advocacy." At HOPE, it's about the journey from hopelessness to opportunities and transformation. We are a non-profit organization that builds individual, family and community resiliency through direct service, community organizing, and intentional partnerships. It's about all of us being part of the solution and how public, private, non-profit and community citizens are working together for stronger families and healthier communities. We are long -trusted and relied upon in our community to be responsive and relevant to the most vulnerable populations, including persons at risk of and experiencing homelessness, persons with mental health and substance abuse disabilities, youth, elderly and persons who are justice -involved. 3. Program Description: The Shelter+Care (S+C) programs provide permanent supportive housing for persons experiencing homelessness and have a targeted disability, primarily individuals with a severe and persistent mental illness. Preference is given to individuals that score a 10 or higher on the Vulnerability Index Assessment and meet the U. S. Departent of Housing and Urban Development's definition of "chronically homeless". HOPE partners with community organizations to provide supportive services, which facilitate dignified and independent living among our consumers. This program is solely funded through a federal grant that limits personnel and operational costs to no more than 7% of the award. With 93% of the grant reserved for rental assistance, including rent and rental deposit, funding of even one (1) staff person to implement the program is a constant challenge. Yet, with the highest rate of chronic homelessness of any county in the state, at 34%, assisting the chronic homeless population in obtaining and maintaining stable housing is critical in reducing homelessness among the most vulnerable. Thus, our ask is for funding for a Housing Case Manager position to assist 10 new households, while maintaining the existing 68 households currently served by the program. 4. Total Budget & Position Count: Total Program Budget: $450,775 Total Program Position Count: Total Agency Position Count: 1 Total Agency Budget: $5,100.000 60 EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Shelter Plus Care Programs S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY1S-16 Estimate County of Hawaii. County Council Non -Profit (unsecured, additional ask) $50,000 Federal (passed through the State DHS. Homeless Programs Office) (secured) $353,087 Federal (passed through the State DHS. Homeless Programs Office) (secured) $47r688 TOTAL: $450.775 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: As an increased ask compared to previous years, as HOPE struggles each year to secure sufficient funding for a full-time employee and operational costs assocated with case management services. Housing without services decreases a person's chances to maintain stable housing in the community. This population is the most difficult to serve, as many suffer multiple risk factors compounded by co -morbid disabilities (general health impacted by severe mental illnesses and substance abuse challenges). This is the only program of its kind in Hawaii County due to unique needs of the population being served. HOPE asks for your help in leveraging funding so that this resource will remain on -island. HOPE will also seek out additional funding to invest in our fund development capacity by hiring a full-time employee to help raise and maintain new funds through new government grants, foundations and individual contributions. HOPE will also continue to leverage our community partnerships and volunteers to help offset service costs and consumable goods. 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from the County of Hawaii will cover personnel costs (salary & benefits) and operational expenses needed to maintain current program operations. Operational costs include office supplies, printing, postage, mileage reimbursement, telecommunication, and staff development expenses. The County's contribution is imminent and timely, given the 53% increase in the total number of NEW homeless clients in Hawaii County since last year. As articulated previously, Hawaii County is further challenged with the highest rate of chronically homeless persons in comparison to any other county in the state - at an astonishing 34% (University of Hawaii, Center of the Family, Homeless Service Utilization Report 2014). HOPE needs the resources to serve the most vulnerable persons in our community, in order to securing housing and facilitate stability so that this population can experience a higher and safer quality of life. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: Shelter Plus Care Programs 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES c e.l Number o)dlents servetl, wIiklhops or even6 held volunteer hams, etceescvibe, be syeuficf Applicant Projected Results Number of individuals served 80 Number of persons that will increase their income 30% Number of persons participating in edu/job training programs 6% Increase Client Knowledge of community resources 85% Complete service Plats with program clients 85% Number of individuals that will maintain permanent housing 85% $8.937 $8,937 Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Reg Salary and Wages $66.38620 $67,270 $41.063 Professional Fees 0 0 0 Operations $5,179.20 $8.937 $8,937 Supplies $374,56820 $374,568 0 Equipment 0 0 0 0 0 0 Other: Other 0 0 0 Other. 0 0 0 0! Other 0 0 Other: 0 0 0 TOTAL $446,1336 $450.775 $50.000 9f appli cable EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: Shelter Plus Care Programs io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether o conflict exists. NAME: Brandee Merino POSITION: Chief Executive Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interests defined asa substantiol 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. gnature of Authorized Person (specify title) January 29, 2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 9 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: Shelter Plus care Programs 11. Certification of Understanding (Pagel of z) I (we) have read and understood all of the 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 final payment. 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 reportusing the template provided will Imooct the evaluation of Pour program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-I6 Agency Name: HOPE Services Hawaii Inc. Program Name: Shelter Plus Care Programs 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of 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'h 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 lune 30, 2015 must be returned to the County of Hawaii with the final report. Failure to return these funds in o timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Y9 nature of Authorized Person (specify title) January 29, 2015 Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 9 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: Shelter Plus Care Programs 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of individuals served 80 Professional Fees Number of persons that will increase their income 30 Operations Number of persons participating in ec iob training assistance Increase Client Knowledge of Community Resources 6% Supplies 85% Complete Service Plan with shelter clients 85% Number ofindividuals that will maintain permanent housing 85% Other 0 TABLE It PROGRAM EXPENDITURES FY 15-16 Council Grant Request Award Salary and Wages $at 063 Professional Fees 0' Operations $8.937 Supplies -- 0 Equipment 0 Other'. 0 Other 0 Other 0, Other 0 Other TOTAL $50.000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of HOPE Services Hawai'I, Inc Tenant Solutions: Housing Specialist 70 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Tenant Solutions: Housing Specialist Agency Director: eraodee Merano Phone No.: ( 808) 933 — 6013 Contact Person: Angela Evans Phone No.: ( 808 ) 933 — 6075 Mailing Address: Address: 296 Kaauea Avenue Address: City, ST, Zip Hilo. Hawaii 96720 Facility Address: Address: 14-5593 Address: City, ST, Zip Knill -Kona , HI 96740 Email Address: bmenino@hopeserviceshawan and Fax Pi ( 808) 935 - 3794 Accountant/CPA: Saelly Toledo Phone No.: ( 808 ) 933 — 6008 Firm (if applicable). Mailing Address: Address: 2% Kilauea Avenue Address: City, ST, Zip We Hawaii 96120 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua © North Kona ❑ South Hilo F71 North Kohala 0 South Kana ❑ North Hilo © South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts © Aged © Victims of Health or Social Crises Needs of the poor F/I Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page Iof8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Tenant Solutions: Housing Specialist 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 0 $0.00 0 2. Agency Mission Statement: HOPE Services Hawaii, Inc. (HOPE), a faith -based organization based on Hawaii Island, dedicated to its mission of "Bring to life gospel values of justice, love, compassion and hope through service, empowerment and advocacy." At HOPE, it's about the journey from hopelessness to opportunities and transformation. We are a non-profit organization that builds individual, family and community resiliency through direct service, community organizing, and intentional partnerships. It's about all of us being part of the solution and how public, private, non-profit and community citizens are working together for stronger families and healthier communities. We are long -trusted and relied upon in our community to be responsive and relevant to the most vulnerable populations including persons at risk of and experiencing homelessness, persons with mental health and substance abuse disabilities, youth, elderly and persons who are justice -involved. 3. Program Description: HOPE is seeking to expand its housing capacity to add a NEW position based in West Hawaii. The Housing Resources Specialist (HRS) will utilize outreach strategies that align with "Housing First", a national best practice approach to ending homelessness. Outreach strategies to recruit new landlords and property managers include face-to-face presentations of the "Tenant Solutions" program and its benefit to landlords. Landlords that are willing to rent to our referred consumers will be assured that selected tenants have completed renter education training, which prepares consumers to be ideal tenants and model neighbors: be timely in paying rent and utilities, and maintaining a clean and kept unit. The HRS will work closely with property management associations to increase collaboration and networking among professional property managers in West Hawaii - establishing formal memoranda of agreement that facilitate a rental inventory for our referred consumers. The HRS ensures that all identified housing and providers are in compliance with applicable federal, state and county housing regulations, laws and standards. As an incentive and free service to landlords, HOPE offers 24/7, on-call accessibility to landlords that need assistance with any tenant conflicts and/or lease compliance issues that may arise. 4. Total Budget & Position Count: Total Program Budget: $793,725 Total Program Position Count: s Total Agency Budget: r $5, 100.000 Total Agency Position Count: 60 EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Tenant Solutions: Housing Specialist 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate County of Hawaii, County Council Non -Profit (unsecured. NEW ask) $50,000 Hawaii Island United Way (unsecured. NEW ask) $50,000 State - Department of Human Services. Housing Placement Program (secured) $528,000 Federal (passed through State DHS) Emergency Solutions Grant, Homeless Prevention 8 Rapid Rhsg $112,785 Roman Catholic Church in the State of Hawaii (secured) $15,000 Federal (passed through US Vets) Support Services for Veteran and their Families $15,000 Private - Foundation and fundraising (unsecured) $22,940 _ TOTAL: $793,7251 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: HOPE will seek out additional funding to invest in our fund development capacity by hiring a full-time employee to help raise and maintain new funds through new government grants, foundations and individual contributions. HOPE will also continue to leverage our community partnerships and volunteers to help offset service costs and consumable goods, as the community has been supportive in providing donated items (furniture, clothing, household essentials) and service (life skills training, mentoring). 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from the County of Hawaii will cover personnel costs (salary & benefits). The County's contribution, which is less than 7% of the program's overall operating budget, is critical and timely given the 53% increase in the total number of NEW homeless clients in Hawaii County since last year. The need is further supported by the current rate of chronic homelessness in Hawaii County, at 34% - the highest rate of any county in the state (University of Hawaii, Center on the Family. Homeless Service Utilization Report 2014). EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Tenant Solutions: Housing Specialist B. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (.e : Number afth,fs s,d, workshops ar e—Is heltl, volunteer hours, e[[ Oesctlbe, 6e ,'fir ) Applicant Projected Results Number of inte,,ews/presentations with community and faith groups 24 Number of landlord readiness presentations 24 Number of landlords entered into a memorandum of agreement to dedicate specific units 12 Number of new units acquired for HOPE clients 45 Coordinate an annual landlord appreciation event to raise awareness 100 attendees at one event Number of indi,duals completed Renters Education Curriculum 75 Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $480.320.00 $492.145 $50.000 Professional Fees 0 0 0 Operations $35,765.00 $291.580 0 Supplies $251.948.00 $10,000 Equipment 01 0 0 Other: Other: 0 0 0' 0 0 0' Other: 0 0 0 Other 0 0 0 Other. 0 0 0. TOTAL $768,033.00 $793.725 $50.0001. 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Tenant Solutions: Housing Specialist iii. 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: Brandee Menino POSITION: Chief Executive Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ 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) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 January 29. 2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Tenant Solutions: Housing Specialist ti. Certification of Understanding (page t of 2) 1 (we) have read and understood all of the 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, 1 (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Tenant Solutions: Housing Specialist 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 301" shall result in loss of all grant funds received during 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 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Aapt , 1 eEo ignature of Authorized Person (specify title) January 29, 2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: Tenant Solutions: Housing Specialist 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of mterviewslpresentations with community and faith groups 24 Number of landlord readiness presentations 24 Number of landlords entered into a memorandum of agreement to dedicate specific units 12 Number of new units acquired for HOPE clients 45 Coordinate an annual landlord appreciation event to raise awareness 100 attendees Number of individuals completed Renter's Education Curriculum 75 Other: 0 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $50,000 Professional Fees o Operations 0 Supplies 0 Equipment 0 Other. 0 Other: 0 Other: __- �— 0 Other 0 Other TOTAL $50,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 HOPE Services Hawaii, Inc West Hawai'i Emergency Housing Prog. 71 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: West Hawaii Emergency Housing Program (WHEHP) Agency Director: Brandee sl Phone No.: ( 808) 933 — 6013 Contact Person: Denise Ogunna Phone No.: ( 808 ) 933 — 6035 Mailing Address: Address: 2% Kilauea Avenue Address. City, ST, Zip Hilo, Hawaii 96720 Facility Address: Address. 74-5593 Pawai Place Address. City, ST, Zip Kailua-Kona. Hawaii 96740 Email Address: bnnerno®hopeserviceshawaii. or, Fax No.: ( 808) 935 — 3794 Accountant/CPA: Shelly Toledo Phone No.: ( 808 ) 933 — 6008 Firm (if applicable): Mailing Address: Address: 296 Kilauea Ave Address: City, ST, Zip Hilo. Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna © Hari 7 North Kona ❑ South Hilo ❑ North Kohala South Kona ❑ North Hilo © South Kerala © Ka'u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns ❑ Youth Q Victims of Crimes ❑ Culture and the arts✓❑ Aged Victims of Health or Social Crises ❑✓ Needs of the poor Physical/Emotional Disabilities ❑� Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: HOPE Services Hawaii, Inc. Program Name: West Hawaii Emergency Housing Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $15,000.00 $15,000.00 $15,000.00 2. Agency Mission Statement: HOPE Services Hawaii, Inc. (HOPE), a faith -based organization based on Hawaii Island, dedicated to its mission of "Bring to life gospel values ofjustice, love, compassion and hope through service, empowerment and advocacy." At HOPE, it's about the journey from hopelessness to opportunities and transformation. We are a non-profit organization that builds individual, family and community resiliency through direct service, community organizing, and intentional partnerships. It's about all of us being part of the solution and how public, private, non-profit and community citizens are working together for stronger families and healthier communities. We are long -trusted and relied upon in our community to be responsive and relevant to the most vulnerable populations including persons at risk of and experiencing homelessness, persons with mental health and substance abuse disabilities, youth, elderly and persons who are justice -involved. 3. Program Description: The West Hawaii Emergency Housing Program (WHEHP) is a service -enriched emergency housing program that serves single men and women who are experiencing homelessness. At initial intake an individualized service plan is developed with the consumer. An assessment is conducted to determine current housing and employment challenges, from which goals are then established to promote and strenghten consumer housing and financial sustainability. Internally, consumers are provided with life skills trainings, including basic budgeting and tenant readiness, in addition to internal referral for other program services - Supplemental Nutrition Assistance Program (SNAP) assistance; healthcare enrollment; housing application, placement and financial support, and representative payee. Other needed services - basic medical and/or dental treatment, mental health services, substance abuse treatment, and employment readiness and training - are coordinated by referral to community partner organizations. With a targeted stay of three (3) months, service plans and goals are reviewed frequently, and consumers are encouraged to be diligent in pursuing their goals. 4. Total Budget & Position Count: Total Program Budget: $371 610 Total Program Position Count: 6 T , Total Position Count: 60 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii, Inc. Program Name:West Hawaii Emergency Housing Program S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate County of Hawaii, County Council Non -Profit (unsecured, additional ask for expansion) $50,000 State of Hawaii. Department of Human Services, Homeless Programs Office (secured) $214,965 Program Fees (based on client's ability to pay Wright. revenue based on historical collection of fees) $22,487 Federal (passed through the State) - Emergency Solutions Grant. Shelter Operations (secured) $23.000 Hawaii Island United Way (unsecured, new ask for expansion) $50.000 Foundation/Other fundraising (unsecured) $11,138 TOTAL: $371,610 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This is an additional ask to our historical request which directly correlates to our capacity to increase shelter operations from a 14 -hour night-time program to a 24 hours/7 days a week program as encouraged by the Mayor's Office. There is great need and desire by the community to have the program open throughout the day to meet the needs and demand of an increased vulnerable and aging population that is compounded by co -morbid disabilities (general health impacted by severe mental illnesses and substance abuse challenges). HOPE will seek out additional funding to invest in our fund development capacity by hiring a full-time employee to help raise and maintain new funds through new government grants, foundations and individual contributions. HOPE will also continue to leverage our community partnerships and volunteers to help offset service costs and consumable goods, as the community has been supportive in providing donated items (furniture, clothing, household essentials), meals and service (landscaping, mentorship and facility beautification/improvement). 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding from the County of Hawaii will cover new personnel costs (salary & benefits), operational expenses, and clients supplies to EXPAND current program operations. When funded, it is our intention to increase service hours to 24 hours a day/7 days a week. Operational costs include increased cost in facility repair and maintenance, utility costs, and telecommunication expenses. This is the only financial contribution asked of the County to help offset operational costs for a program operated from a County -owned facility and property. As lessee, HOPE is responsible for program operations to meet the demands of our community. The County's contribution, which is less than 6% of the program's overall operating budget, is critical and timely given the 53% increase in the total number of NEW homeless clients in Hawaii County since last year (University of Hawaii, Center on the Family, Homeless Service Utilization Report 2014). HOPE needs the resources to be able to upkeep this County -owned facility from wear and tear by this new, transient population. HOPE is the lifeline to the most vulnerable persons in our community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: West Hawaii Emergency Housing Program (WHEHP) 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES p e: N—b—finern served, --,now --1, h,ld, �ow�ree.no�.,, err. oe.,nbe, be,necf,,) Applicant Projected Results Number of bed nights 9.291 Number of individuals served at the homeless emergency shelter 100 Number of individual counseling contacts 500 Number of persons padicipanting in edu/job training assistance 10% Increase Client Knowledge of community resources 80 Complete Service Plan with shelter clients 80 Moving from the emergency shelter to a new home environment 60% Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual* FY 15-16 Total Budget FY I5-16 Grant Req Salary and Wages $201,677.67 $278,302 $35.000 Professional Fees Operations $13,307.33 $13.307 0 $51.287.00 $60.000 $10.000 Supplies $9200.00 $20,000 $5,000 Equipment Other: $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Other. $0.00 $0.00 $0.00 Other: Other $0.00 $000 $0.00 $0.00 $0.00 $0.00 Other: so 00 $0.00 $0.00 TOTAL $275472.00 $371.610 $50.000.00 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE services Hawaii Inc. Program Name: West Hawaii Emergency Housing Program (WHEHP) io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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: Brandee Menlno POSITION: Chief Executive Officer May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ 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. �f2J C�L�2� t 0 Signature of Authorized Person (specify title) January 29. 2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: HOPE Services Hawaii Inc. Program Name: West Hawaii Emergency Housing Program (WHEHP) 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 — 2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. 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 Fact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE services Hawaii Inc. Program Name: West Hawaii Emergency Housing Program (WHEHP) 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 30`h 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.goy/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 lune 30, 2015 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 ogenc✓s future funding request and moy result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. —" Iti1L41�t- Ctl; Si nature of Authorized Person (specify title) January 29, 2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: HOPE Services Hawaii Inc. Program Name: West Hawaii Emergency Housing Program (WHEHP) 12. COUNCIL AWARD WORKSHEET TABLE 1: I PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of bed nights 9251 Number of individuals served at the homeless emergency shelter 100 Number of individual counseling contacts 590 Number of persons participating in eculjob training assistance 10% Increase Client Knowledge of Community Resources 80% Complete Service Plan with shelter clients 80% Moving from the emergency shelter to a new home evironment 6o% TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $35,000 Professional Fees Operations Supplies Equipment ffigvu Other Other: Other.Other: Other. - TOTAL 850.00000 ACICI tlonal Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 Hospice of Hilo Hawai'i Palliative Care Center Expansion %2 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hospice of Hilo Program Name: Hawaii Palliative Care Center Expansion Agency Director: series S. He MS, RN Phone No.: ( 808) 969 — 1733 Contact Person: Aoumamoto Phone INC.: (sea 1969 — 1733 Mailing Address: Address: 1111 waianusriae Ava. Address: City, ST, Zip Hilo, Al 96720 Facility Address: Address: 590 Kapioleni Street Address: City, S7, 21p Hllo, H196720 Email Address: arthuynolhospiceothilo.or9 Accountant/CPA: loam Ayase, CPA Firm (if applicable): Mailing Address: Address: 231 Kspaalani are, Address: City, Sr, 2ip Hil0. H196720 Fax No.: ( 606) 969 — 4663 Phone No.: (816)961 — 2405 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: S 60, 000 Geographical Areas To Be Served: (One or more an be checked) m Puna © H9m5kua North Kona © South Hilo © North Kohala South Kona m North Hilo m South Kohala © Ka% Services or Activities To Be Provided: (One or more on be checked) ❑ Educational concerns ® Youth ❑ Victims of crimes ❑ Culture and the arts m Aged m Victims of Health or Social Crises m Needs of the poor m Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hospice of Hilo Program Name: Hawaii Palliative Care Center Expansion 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $62,250.00 $45,000.00 $45,000.00 2. Agency Mission Statement: To improve the lives of those we touch by offering support, guidance and compassionate care of body, mind and spirit. 3. Program Description: The Hawai'i Palliative Care Center (HPCC) is designed to increase the quality of life for those facing any life threatening illness or injury, with a prognosis of 12 months or less. HPCC addresses the increasingly complex needs that can easily overwhelm clients with acute conditions, affecting the quality of their daily lives. HPCC provides a comprehensive layer of support through care coordination, emotional support and severe pain management, preventing seriously ill patients on Hawai'i Island from falling through cracks in the healthcare system. Continuity of care is provided by a certified Palliative Care Physician, an APFIN, a Care Coordinator and volunteers. 4. Total Budget & Position Count: Total Program Budget: sms,omo01 Total Program Position Count: Total Agency Budget: $6,888,217.001 Total Agency Position Count: 28 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hospice of Hilo Program Name: Hawaii Palliative Care Center Expansion S. Program Funding Sources (identify all sources of funding applied to this program(: Revenue Source FY15-16 Estimate State Grant In Aid $150,000 County Non -Profit $60,000 Harry & Jeanette Weinberg Foundation $50,000 Fee for Service $61,440 Indivdual Donations $15,000 'Sources are possible funding support TOTAL: 1 $336,440 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Outreach to specialists & partnerships with health care providers, such as the Hawai'i Pacific Oncology Center, has allowed fee for service to begin. As HPCC's census grows, HOH anticipates the HPCC program to be sustained by fee for service, and private donors. Continued County support will ensure the program's success. 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding will pay for the vital Full Time Care Coordinator who builds program awareness, assists In client health care & resource navigation, and volunteer coordination. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hospice of Hilo Program Name: Hawaii Palliative Care Center Expansion 8. TABLE I: vvnat are tae in tenueu nreaaurdrne uutpuu or outcomes mai wows oe dmeVeo Wim in Is TunaIng f PROGRAM PERFORMANCE MEASURES Applicant Projected Results (Le.: Number of tllentrserve$ workshops orevents helq volunteerhours, etc. aezmbe, 6e spenfc) nddifinnnl nnnaz nz ­­- 9. er - 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget FY" e6 Grant Req Salary and Wages $253,994.59 $186,855.00 $60,000 Professional Fees $1,781.72 $1,000.00 0 Operations $36,335.72 $28,230.00 0 Supplies $8,092.34 $8,450.00 0 Equipment 0 0 0 Other: $213.22 $500.00 0 Other: Other: Other: Other: TOTAL $304-417.59 $205,035.00 $ 60,000 -If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hospice of Hilo Program Name: Hawaii Palliative Care Center Expansion io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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: Brenda S. Ho, MS PIN POSITION: CEO May have a conflict or potential conflict of interest, including any familial relationship, with any ofthe 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. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Hospice of Hilo Program Name: Hawaii Palliative Care Center Expansion 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135— 2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express. and be compliant prior to final payment. 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 (wel understand 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 Proorom's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Hospice of Hilo Program Name: Hawaii Palliative Care Center Expansion 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the Countyof 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 lune 30`^ shall result in loss of all grant funds received durine 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 far 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 lune 30, 2015 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 mov result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 o'b -15 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hospice of Hilo Program Name: Hawaii Palliative Care Center Expansion 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result 'See anached performance measures document TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $60,000 Professional Fees 0 Operations 0 Supplies 0 Equipment 0 other: 0 Other: Other: Other: Other: TOTAL 60 000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 20142015 Page 8 of 8 Hospice of Hilo S. Table 1: Attachment: What are the intended measurable outputs or outcomes that would be achieved with this funding? County Funding will be used to support the Hawaii Palliative Care Center (HPCC) Program's Enhancement and Expansion, specifically providing funding for Care Coordination Position. Program Performance Measures Applicant Pro ected Results Provided education on Advance Health Care -Increased number of presentations delivered, a minimum of Directives (AHCD) & Physicians Orders for Life twelve (24) for grant year Sustaining Treatment(POLST), as well as general *Increased awareness/understanding evident by post presentation education about options for improved quality of surveys to determine knowledge gained life when facing a serious illness *Track number AHCD distributed to interested community members Education of Community & Providers *Continue updating education, survey and implementation tools *Partner with Hilo Medical Center to provide monthly in -services for team Collaboration and Increase in Referrals from *The HPCC Program in it's current design launched in February of Community Partners such as: 2014. In this year, the program received 221 referrals from community Private Practice Palma Family Health Physicians Ctr providers. The program will show strong growth in grant year 2015-2016, by a minimum of 25% patients referred. Public Health Nurse HMC Patient Services American Lung Assoc. Services for Seniors HIV Foundation Evercare Kaiser Ohana Health Queens Medical Ctr Hui Malama HPOC Liberty Dialysis United Healthcare Patient Navigation & Support Services * As the Care Coordinator moved from Transitions to the newly formed HPLC in 2014, this position has continued to be an invaluable source of support for patients. 2011=39 patients served 2012=57potiensMserved 2013=77patienisserved 2014=132 new patlents served. Total of268 face -to face visits. *The program will show growth in grant year 2015-2016, by a minimum of 25% number of patients served. Expanded Care Coordination/Palliative Care *Increased number and utilization of volunteers and student volunteer/student intern training program interns specially trained in Care Coordination/Palliative Care *Track number of volunteers and student interns m demonstate increase numbers, as well as increased skills shown by pre/post training tests *Will offer at least two (2) volunteer/student intern trainings in ant year Cultivated and Implemented Volunteer care giving *The program will continue to utilize the compassionate service of support network volunteers to bring support to patients in need. Z011=199 volunteer hours 2012=298.35 volunteer hours 2013=490.15 volunteer hours 2014=363.5 volunteer hours Hui Malama Ola Na 'Oiwi 15th Annual Ladies Night Out Event 73 County of Hawai` i Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama Ola Na 'Ow Program Name: 15th Annual Ladies Night Out Event Agency Director: Michelle Marie Hiraishl Phone No.: ( 806) 969 — 9226 Contact Person: Kelsey Hiraishl Phone No.: ( 868 ) 969 — 9220 Mailing Address: Address: 69 Railroad Avenue Address: City, ST, Zip Hilo. Hawaii 96720 Facility Address: Address: 69 Railroad Averue Address: City. ST, Zip Hllo Hawaii 96720 Email Address: kslseyehulm lent ewai. com Fax No.: ( sae) 961 — 6796 Accountant/CPA: Phone No.: ( 608) 861 — 1176 Firm (if applicable): CW Associates Mailing Address: Address. Topa Firaneial center Address'. 700 Bishop Street STE. 1060 City, ST, Zip Honolulu. Hawaii 99613 YOU ARE RESPONSIBLE TO KEEP THEASOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: s s Co6.00 Geographical Areas To Be Served: (One or more can be checked) 7/1 Puna ✓❑ Hamakua © North Kona Z South Hilo ❑✓ North Kohala © South Kona Q North Hilo © South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises I✓ Needs of the poor i] Physical/Emotional Disabilities ❑� Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY20 L5-16 Agency Name: Hui Malama Ola Na'Oiwi Program Name: 15th Annual Ladies Night Out Event 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $0 $0.00 $5,000 2. Agency Mission Statement: Our mission is: Ho'oulu ola o ka Ishui Hawaii - To uplift the health of the Hawaiian nation. We will: Malama is Moku o Keawe -Take care of Hawaii Island, Malama i na kua'aina -Take care of country and rural areas. Malama I kou olakino -Take care of your physical, spiritual, and mental body. Malama I na mea Hawaii - Take care of Hawaiian culture and practices. We envision a strong and healthy Hawaiian nation. 3. Program Description: Ladies Night Out (LNO) is a wellness program event conducted annually by Hui Malama Ola Na Oiwi. The year 2015 will mark our 15th anniversary for this event. LNO is focused on providing pampering services for identified women 18 years and older who find it financially difficult to pay for professional services such as manicures, haircuts, pedicures, variety of massage therapy, make overs and a host of other grooming experiences. The event also a testament to the power of our island community to come together and take care of our island population of women who are less fortunate in acquiring health wellness services. In 2014, the LNO event committee congregated 176 community service providers and 69 community volunteers who worked with Hui Malama staff to provide pampering services, health resource information, hands-on arts and craft, entertainment and numerous drawing of donated gifts and services from many community businesses and agencies. Unfortunately, the total attendance count was 405 women and post event debriefing pointed to post effect of Hurricane Iselle and lava Flow as underlying reasons for many not attending. It is expected that the 2015 event will bring in 500 plus women. Please see Program Description Addendum #1 for more information. 4. Total Budget & Position Count: Total Program Budget: 53, .3,2 Total Program Position Count: 39 -ail staff Total Agency Budget 5z, 300 874 Total Agency Position Count: 39 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama Ola Na Oiwi Program Name: 15th Annual Ladies Night Out Event S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate 11 Department of Health & Human Services - HRSA $23,150 Courtly of Hawaii $5,000 T-shirt sales from the event 31.500 Restricted donations for the event 31.000 TOTAL: I $31,250 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program Hui Malama Ola Na 'Oiwi will continue to seek financial support from the County and State Commission on the Status of Women as well as continued allocation of Health Resources Services Administration (HRSA) to support our LNO event. Tee-shirt sales, monetary donations and in-kind materials and services will continue to support our event as well. The ability of event planning committee members to tap into local resources for in-kind contributions has been one of the most successful means to leverage program event delivery and minimizing cost associated with carrying out the event. The LNO planning committee will also work with the agencies Operations Director to identify and submit applications for small event based grant opportunities. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objective for use of county funds will focus on logistical line items in program event supplies such as copy paper, food and water, decoration supplies, supplies needed for community providers and miscellaneous small item purchases. In addition, tables, chairs and other event equipment to comfortably sit 500 plus women is a requirement for our size and type of event. Professional fee allocation of county funding will support event security and professional sound system to ensure a safe and welcoming event venue. County funds will support an event that brings community providers together for one purpose in taking care of women ages 18 and older with pampering service that if not for this event, they would struggle to afford activities that promote positive self esteem and self care. The event is a small price for such high dividends. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama Ola Na'Oiwi Program Name: 15th Annual Ladies Night Out Event S. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results Nr tuber rfch,ft servee rvrrksnoo: or=vents held, vmunfeer nomy e1 oesrnbe. Ge sp,oflcl 1, Identify and provide health and welldes Fv 15-16 Total Budget activities far women with financial hardship. 1500 2. Community providers will provide specific $21,0001 pampering services for attending women, 170 3. Participating women will report that "[f $900 not for this event" they would not be able to get a specific pampering service. 375 Attach additional pages as necessary, 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual- Fv 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $20,962 $21,0001 Professional Fees $858 $900 $500 Operations Supplies Equipment Othercost of T-shirts $1,747 S1.800 I Others event supplies) food decorations, prizes 1 $7,249 360001 $40001 Other rental of tables 8 chairs $936 51.000 $500 Other dandle ad for event providers $524 $550 Other s'^NOTE . FV 14-15 actual Is final. SEP14 event TOTAL I 32276 $31,250 $5.000 'If applicable EXHIBITA NONPROFIT GRANT APPLICATION For 2015-2016 Page 4 of 8 County of Hawai'i Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama Ola Na'Oiwi Program Name: 15th Annual Ladies Night Out Event ro. 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 ofthe 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 asa substantial probability that action token by an indfviduol 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. rraokExec �S— Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: 15th Annual Ladies Night Out Event tt. 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 allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and 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 final payment. To register, go to http: vendors.erawai:.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 Ha ail I (we) understand 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 o timely, complete and accurate Year-end report using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Hui Malama Ola Na'oiwi Program Name: 15th Annual Ladies Night Out Event ti. Certification of Understanding (Page z of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payments) I (we) understand that failure to submit the final report within 60 days of June 30'h 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 -ttp /wwti Fawai icounrz aov%fn-non prof .t 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. CK6-Cur(VE Dl(kf, 9- o 1 aq(- Signature of Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawai` i Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama Ola Na OW Program Name: 15th Annual Ladies Night Out Event 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result 1 J Identify and provide health and wellness Professional Fees 55001 acWM1.es for women with financial hardship. 500 2) Community providers will provide specific pampering services for attending women_ 170 Other: 37 Participating women will report that 'if Other event suppliesfooddecorations. prizes not for this event' they would not be able to Otherrental of tables & chairs get specific pampering service. 1, 375 Other., TABLE II: PROGRAM EXPENDITURES FY 15-16 Council Grant Request Award Salary and Wages Professional Fees 55001 Operations Supplies Equipment Other: Other event suppliesfooddecorations. prizes 84,000' Otherrental of tables & chairs $500! Other., Other TOTAL 55.000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 Agency Name: Hui Malama Ola Na 'Oiwi Program Name: 15" Annual Ladies Night Out Event Addendum #1— Program Description Program Description continued from Application Exhibit A Section 3. Hui Malacca Ola Na'Oiwi has planned, organized and implemented the Ladies Night Out event far the past 13 years. This special event is held annually in memory of Nancy Everett, RN, who as our consultant at Hui Malama Ola Na'Oiwi, guided our organization in providing women and children the opportunities for health awareness and care as she envisioned it. At her untimely passing in 2000, her family desired that her love and vision be expressed through our Ladies' Night Out health awareness and pampering event and donated her memorial funds for us to continue this event in her honor. Through the years, the Ladies Night Out event has grown to be a signature event for the less fortunate women of aur island community. Over the past 14 years, this event has grown in size from the 2000 event at the old Bay Clinic site in Keaukaha to the Afook-Chinen Civic Auditorium. The event committee is comprised of representative from various community organizations who over the years have spent numerous hours in planning all facets of the event. One of the significant aspects of our event is having each partnering agency provide input on identifying those clients or population within their respective organization that are identified women who would benefit from the pampering services available during the event. On September 26, 2014, Hui Malama Ola Na'Oiwi sponsored our 14t' annual women's health and wellness event: Ladies' Night Out 2014. Pampering services included haircuts, facial waxing, manicures, pedicures, hand massage, foot massage, table and chair massage and an array of art and crafts. Community based health organizations provided information on health resources, clinical education and screening and insurance providers shared information on their respective insurance companies and the expected changes in health care coverage plans. Another significant aspect of the Ladies Night Out evening is the door prizes that are 100% donations from an array of community businesses and agencies. The success of this annual event could only be achieved with a consortium of community organizations and service providers. Event partners in 2014 were Hilo Medical Center, queen Lili'uokalani Children's Center, Kamehameha Schools, UH School of Nursing and Pharmacy, Bay Clinic Inc., and the Men of Pal a. We were fortunate to have co-sponsors; Hawai'i State Commission on the Status of Women, Hawaii County Committee on the Status of Women, East Hawai'i Local Area Consortia, HMSA, and Aloha Care. It is important to note that each of the co-sponsoring partners and event partners also play a part in the identification of women their organizations work with to provide tickets for attending the event. The 405 women who attended LNO 2014 is comprised of women identified by partnering agencies and from all parts of Hawaii Island. In addition, we could not have done it without the 176 "pampering service" providers and the 69 volunteers who selflessly gave of their time and amazing talents! In 2014, event planners were diligent in capturing the scope of service provider and all entities involved in accounting for "in-kind" donation. Financial reports for the 2014 Ladies Night Out event showed 1 Agency Name: Hui Malama Ola Na'Oiwi Program Name: 15`h Annual Ladies Night Out Event Addendum #1— Program Description income of $1,575 in t -shirt sales, $1,800 in cash donations, $24,737 of in-kind services donations, and $15,266 of in-kind materials donated. The impact of county funding has supported our mission through the LNO events to provide wellness activities for our less fortunate women population and fosters our community coming together to plan, organize and implement this program event. We consider the Ladies Night Out event an example of how resilient our island communities are in coming together for a specific purpose. As seen with recent community representation and response following Hurricane Iselle, Tropical Storm Ana and the current threatening lava flow, it is evident when a village comes together, our island can prosper. It is our hope that the County of Hawaii can invest in our event for the purpose intended. Hui Malama Ola Na 'Oiwi Cancer Program MI County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama Ola Na Ow Program Name: Cancer Program Agency Director: Michelle Mara Hiraishi Phone No.: ( 608) 969 — 9220 Contact Person: Kelsey Hiraishi Phone NO.: ( 808) 969 — 9220 Mailing Address: Address: 69 Railroad Avenue Address: City, ST, Zip Hilo. Hawail 96720 Facility Address: Address: 69 Railroad Avenue Address'. City, ST, ZIP Hilo Hawaii 96720 Email Address: volaeyrahuimalemahawar cam Fax No.: ( 606) 961 — 4794 Accountant/CPA: Phone No.: ( 606 ) 861 — 1174 Firm (if applicable): CeN Associates Mailing Address: Address'. Topa Financial center Address: 700 Bishop Street STE 1040 City, ST, Zip Honolulu. Hawaii 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: S 1670009 Services or Activities To Be Provided: (One or more can be checked) © Educational concerns ❑ youth ❑ Victims of Crimes © Culture and the arts ✓❑ Aged © Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 1of8 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna © Hamakua ✓❑ North Kona © South Hilo✓❑ North Kohala ❑✓ South Kona ❑✓ North Hilo © South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns ❑ youth ❑ Victims of Crimes © Culture and the arts ✓❑ Aged © Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama Ola Na'Oiwi Program Name: Cancer Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 ` FY 14-15 $0 $10,000.00 $0 2. Agency Mission Statement: Our mission is: Ho'oulu ola o ka lahui Hawai'i - To uplift the health of the Hawaiian nation. We will: Malama is Moku o Keawe -Take care of Hawaii Island, Malama i na kua'aina -Take care of country and rural areas. Malama I kou olakino -Take care of your physical, spiritual, and mental body. Malama I na mea Hawaii - Take care of Hawaiian culture and practices. We envision a strong and healthy Hawaiian nation. 3. Program Description: Hui Malama Ola Na 'Oiwi's - Cancer Program will provide cancer patient navigation services that support prevention, early detection and the need for regular annual and/or age appropriate diagnostic screening. Early detection of cancer can be enough to prolong one's life and survive with a higher level of success. Program staff help those men and women with abnormal screening results, diagnostic testing and a cancer diagnosis by navigating them through the health and social spectrum to care for themselves. The need for cancer patient navigation services has become a national movement in the fight against cancers of all kinds. Our cancer program has struggled to expand program staffing specific to cancer navigation and has relied on trained Outreach Case Managers who have served as cancer patient navigators. Our cancer program continues to provide in-depth navigation services via one Cancer Program Manager CPM) who covers the entire island. Recent grant proposals to Susan G. Komen for the Cure National and Hawaii Affiliate will hopefully help us expand navigators dedicated to cancer. See Program Description Addendum #1 for continuance of this section. 4. Total Budget & Position Count: Total Program Budget: $45.830 Total Program Position Count:: r L_ Total Agency Budget: $2300.874 Total Agency Position Count: 39 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 9 County of Hawai `i Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama Ola Na'Oiwi Program Name: Cancer Program 5. Program Funding Sources (identify all sources of funding applied to FY15-16 Revenue Source Estimate Human Services - HRSA TOTAL: i 566.679 Attach additional pages, 6. Explain what plans your agency or program has to increase revenues to support this program Our organization's cancer program's primary means of funding is via Health Resources Services Administration (HRSA) funding. Annual HRSA applications are submitted for all programs including the cancer program. Hui Malama has submitted additional grant funding from Susan G. Komen National and Hawaii Affiliates to support the sole position dedicated entirely to cancer program services. If granted, emergency medical assistance funds would be available for those women needing annual mammography exams or diagnostics screening but struggle to cover cost in co -payment or full exam cost. Expanding cancer navigators by 1,5 FTE is also proposed in grants submitted to Susan G. Komen. Hui Malama plans to continue searching for funding that supports our cancer program and the need to expand scope of services. Administration will continue to build collaborations and partnerships that brings our communities together thus increasing impact that results in stronger applications for larger federal dollars in cancer patient care. 7. Program Objectives Using County Nonprofit Grant Program Funds: HRSA funding will support a .75 FTE Cancer Program Manager position and it is the intention to allocate 25% FTE funding using county funding specific to this position. County funding will also support the development and creation of a DVD to be used in helping diagnosed cancer clients through their continuum of care if abnormal screening results are part of the diagnosis. The DVD resource will highlight the journey of a Hawaii Island cancer survivor and the many obstacles they had to work through as they moved from abnormal breast screening result to survivorship. Included will be identifying barriers to care and working with island and off island professionals and services involved in the continuum of care framework. Additional factors to be included in a survivors journey is understanding cancer, stages of cancer, "what happens next" and factors that effect their mental and physical self. Insurance benefit coverage and cost has always affected clients who are economically challenged. The DVD will help patients see that they are not alone and there is much that can be done to manage and fight their cancer disease. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama Ola Na'oiwi Program Name: Cancer Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results f.e Number aflilevts served,worksnoI, of evena nelgwlunreer noir; etc. 01,11, be sOeGfic) Women X40 years old will complete mammography FY 15-16 Grant Req exams. _ 140 women diagnosed with cancer will be connected Professional Fees directly with a Cancer Patient Navigator who $3,400 will serve as theiradvocate through the dia- Operations gnostic and treatment stages. 120 Cancer clients will attend our support group 130 Attach oddirianal pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 1 FY 15-16 Actual Total Budget FY 15-16 Grant Req Salary and Wages $8.007 $53.218 $13,300 Professional Fees $3,400 $3400; Operations $1 040 Supplies $142 $4221 1, Equipment Other Travel ! 51.015 $4800 Other Other. Other Other'"NOTE.FY14-15 actual low due to vacancy TOTAL $9,164 $66679 $16.700 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama Ola Na'Oiwi Program Name: Cancer Program io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 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): ❑ 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 measuroble direct benefits accruing to the individuol 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. l fes/ l i F)(J CUTI V6 b(aG;CrV2- Ud 1 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama ole Na 'Oiwi Program Name: cancer Program tt. Certification of Understanding (page loft) I (we) have read and understood all of the 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 final payment. To register, go to http:/'vendors.e hawaii.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 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. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama Ola Na'Oiwi Program Name: Cancer Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s) I (we) understand that failure to submit the final report within 60 days of lune 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 hnp r,www.-.awa gym,-. [y.400rfn-nonpro.`it grant-for^son or about May 30 of the year the final 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, 2015 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 moV result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements C ° ''6 ExtcunyE l�(2��vF- o� a9 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama ole Na Oiwi Program Name: cancer Program 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Women >40 years old will complete mammography Professional Fees exams. 40 Operations Women diagnosed with cancer will be connected Supplies directly with a Cancer Patient Navigator who Equipment will serve as their advocate through the dia- Other gnostic and treatment stages. 2s Other. Other: Cancer clients will attend our support group 30 Other:... TABLE II: PROGRAM EXPENDITURES FY 15-16 Council Grant Request Award Salary and Wages $13.300 Professional Fees 53,400 Operations Supplies '. Equipment Other Other. Other: Other:... Other: TOTAL $16.700 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Agency Name: Hui Malama Ola Na'Oiwi Program Name: Cancer Program Addendum #1— Program Description Program Description continued from Application Exhibit A Section 3. The Cancer Patient Manager (CPM) is responsible for an array of cancer related activities. The CPM represents the point of contact for referrals from Hui Malama staff, community health providers and people walking in the door wanting and/or needing help in dealing with any cancer issues. Besides early detection, the CPM works with Hui Malama's 11 Outreach Case Managers on addressing the needs of cancer diagnosed clients. Our CPM is a Certified Nursing Assistant and experienced in Case Management services. She is also trained by Imi Hale Native Hawaiian Cancer Network in Cancer Patient Navigation. 'Imi Hale is one of 23, NCI -funded Community Network Program Centers in the nation. Their evidence -based Cancer Patient Navigation training program has provided training, continuing education and technical support in Hawai'i since 2006. The 48 -hr training program includes 14 competencies utilizing 30+ faculty from Hawai'i's cancer care hospitals and programs and exposure to culturally tailored and clinically relevant breast cancer information. Annual conferences and updated training sessions has been instrumental in keeping our staff fully updated in the latest developments in the world of cancer. Equipped with this knowledge and possessing best practice navigation skills, our program staff helps cancer clients and their family deal with cancer in their family. Specific output activities of the cancer program include: • Providing a variety of educational material and information on cancer for clients and the entire family (if appropriate) • Providing the support and advocacy between cancer clients, their'ohana and health professionals. • Assisting cancer clients in identifying the appropriate resources for dealing with all aspects of maintaining a continuum of care as they deal with their cancer. • Providing financial emergency medical assistance funding for cancer clients when funds are available. • Accompanying requesting clients to cancer appointments providing support services. • Participating in community health fairs and events providing cancer related information and educational materials. • Establishing positive rapport and relationships with community health professionals with a focus of caring for those affected by cancer. • Participating in the State-wide Imi Hale Native Hawaiian Cancer Network/Queens Medical Center Advisory Group on a quarterly basis. The registration of cancer diagnosed clients at Hui Malama has increased over the past year within each of our 5 satellite sites. Health assessments completed by Outreach Case Managers has generated increased referrals to the cancer program requesting transportation to chemo- therapy and other treatment appointments, cancer education information and the need for Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Cancer Program Addendum #1— Program Description strengthening the support system surrounding each client. This has resulted in increased the demand for transportation, cancer patient navigation activities and commitment of case management hours focused on assisting clients with insurance coverage, scheduling multiple health appointments, locating needed resources and working with each client through the difficult decisions facing them. Hui Malama's Molamo Ko Pili Pa 'a (MKPP) Cancer Support Group has grown in participating members. As current cancer patients and survivors of cancer, this group provides the kind of support needed for anyone going through cancer. MKPP meets twice a month and has been very, very active in the community educating, advocating for survivorship and sharingtheir personal stories. The success of the cancer program involves an increased connectivity between our CPM and community health agencies and professionals. Established rapport with Hawaii Radiologic, Clinical Laboratories of Hawaii, Pacific Oncology Center, Primary Care Providers, Queens Medical Center, Bay Clinic Inc., West Hawaii Community Health Center, Hamakua Community Health Center and other specialist involved in patient care has helped in the continuum of care for cancer clients. Hui Malama Ola Na 'Oiwi Kokua Hali Health Transportation 75 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama Ola Na'oiwi Program Name: K6kua Hali Health Transportation Agency Director: Michelle Malia Hireshi Phone No.: ( 608) 969 - 9220 Contact Person: Kelsey Hirtnshi Phone No.: ( 608) 969 - 9220 Mailing Address: Address: 69 Railroad Avenue Address. City, ST, Zip Hilo Hawaii 96720 Facility Address: Address: 69 Railroad Avenue Address. City, ST, Zip Hit. Hawaii 96720 Email Address: kelseyahuimalamahawaii com Fax No.: ( 808) 961 — 479c Accountant/CPA: Phone No.: ( 808 ) 861 — 1174 Firm (if applicable): CWAssociates Mailing Address: Address: Topa Financial Center Address'. 700 Bishop Street STE 1040 City, ST, Zip Honolulu, Hawed 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: s so oco 00 Geographical Areas To Be Served: (One or more can be checked) Z Puna Z Hart North Kona © South Hilo North Kohala 0 South Kona North Hilo 0 South Kohala Q Kau Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns © Youth Victims of Crimes ❑✓ Culture and the arts © Aged Victims of Health or Social Crises 0 Needs of the poor Physical/Emotional Disabilities 7 Public Health and welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama Ola Na'Oiwi Program Name: K6kua Hall Health Transportation 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 _ I FY 14-15 $12,500 $30,000.00 $40,000 2. Agency Mission Statement: Our mission is: Ho'oulu ola o ka lahui Hawaii - To uplift the health of the Hawaiian nation. We will: Malama is Moku o Keawe -Take care of Hawai'i Island, Malama i na kua'aina -Take care of country and rural areas. Malama I kou olakino -Take care of your physical, spiritual, and mental body. Malama I na mea Hawai'i - Take care of Hawaiian culture and practices. We envision a strong and healthy Hawaiian nation. 3. Program Description: The "K6kua Hall" Health Transportation program provides access to essential health care on Hawaii Island. Transportation is provided for clients living in all districts on the island to get to health related appointments. A 7 -vehicle fleet is used to transport clients in Ka'u, Kona, Hilo, Puna, Kohala,Waimea and Hamakua. The hours of operation for K6kua Hall is Monday through Friday with scheduling flexibility to accommodate client needs. Transportation outside of the normal operating hours is approved on a case by case basis. The need on Hawaii Island for transportation continues to be an issue of need. Hawaii Island faces a failing infrastructure that supports mobility for much of the population. Recent disasters and imminent dangers and threats has been an on-going concern in the transportation world addressing the needs of the population. Socio-economic barriers and the added 'baby boomer" population reaching the age where there are limitations available for effective health related transportation for the older aged population. The challenges remain in our island communities for access to health care with a large number of our transportation clientele dependent on our provided transportation services island wide. Please refer to Addendum #1 - Program Description 4. Total Budget & Position Count: Total Program Budget: $272.747Total Program Position Count s Total Agency Budget: $2.300.874 Total Agency Position Count: 39 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama Ola Na'Oiwi Program Name: Kokua Hall Health Transportation 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source Fy15-16 Estimate U.S. Dept. of Health 8 Human Services -HRSA $226A30 County of Hawaii 550,000 I �._ TOTAL: 5276, 430''.. Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program Hui Malama Ola Na 'Oiwi has relied on our Health Resources Services Administration (HRSA) funding to cover most of the cost associated with the Kokua Hall Health Transportation Program. HRSA funding allocation provides personnel cost and most of the non -personnel cost. Hui Malama has focused this past year on finding capital grants and funding sources that would support replacement vehicles for the growing high mileage fleet and the need to reduce cost associated with repairs and maintenance. Hui Malama has submitted a 2015-16 state Grant In Aid (GIA) application for replacement vehicles in the Puna district. We are also waiting to apply for the County of Hawaii CDBG grant once the RFP is made public. All other health grants submitted for Hui Malama programs include budget allocation amounts that support the operational cost for transportation. Administration plans to search for opportunities to update our fleet and apply cost savings to other program needs. 7. Program Objectives Using County Nonprofit Grant Program Funds: The funds acquired with county funds will be used to support the need to keep our transportation program vehicles operational to provide transportation of those population throughout the island that struggles to get to medically related appointments. Statistics over the past years demonstrate the effectiveness of our ability to take people to health appointments to better care for themselves. The effort to acquire replacement vehicles has been very difficult to accomplish and leaves our program with no choice but to maintain vehicles as best we can to provide services. Funds will be used exclusively for fuel, repairs and maintenance and insurance cost attributed to keep program thriving and serving the population in Hilo, Ka'u, Kona, North Hawaii and Puna. Island wide services include transportation to the more health professional services in Kona and Hilo often resulting in travel out of districts for health services. Our services support the overall transit needs identified by the county especially in access to health care services. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama ala Na'Oiwi Program Name: Kokua Hall Health Transportation B. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results f.e. c-11 of rlcIrl serveo, xorxsfiaos arevents heI1 1,1111, hours, err 1, 1,, be soec/fc Hilo residents Uansported for health service 1 a4n d,nnfc I Ka'u residents transported for health service 120 clients North Hawaii resitlents Transported for HS 100 chents Puna residents transported for health service 150 clients Afford additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 ! Actual' FY 15-16 Total Budget 115-16 Grant Req Salary and Wages $83.108 $207.076 Professional Fees Operations $543 $240 Supplies 348 $400 Equipment Othercell phones for drivers 51,692 $2.980 Other fuel for vehicles 5122741 $3a 000 1 $30.000 Othervehicle repair 8 maintenance $9.073 $20.000 515.000 Other aum Insurance 54.949 S+1,634. $5.000 Other '" NOTE '.16 actual is AUG14 through DEC14 TOTAL $111,687 $2764301 $50,000 'It applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama ole Na 'Ow Program Name: Kckua Had Health Transportation iii. 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 conflictexsts. 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 banned as: a subston tial probability thot action taken by., 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: ❑J If no conflicts exist, check here. iYUCunyt bI(Z- 01 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama Ola Na'Oiwi Program Name: Kokua Hall Health Transportation ii. Certification of Understanding (page 1 of 2) 1 (we) have read and understood all of the 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 Chapter92F, 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 final payment. To register, go to htt v_endors.ehawa, .aov, complete the 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 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 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 recluests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malama One Na'oiwi Program Name: Kokua Hali Health Transportation ti. Certification of Understanding (Page z of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of 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 nttu www rawer Cc, on or about May 30 of the year the final 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 lune 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will moact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. `--4qI "- , t 6XCCIA II VC U(acroII o .I/r Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Malanna ole Na Oiwi Program Name: Kokua Hali Health Transportation 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result Hilo residents transported for health service 240 Kona residents transported for health service 120 Ka'u residents transported for health service 120 Operations North Hawaii residents transported for HS 100 Puna residents transported for health service 150 Equipment - Other Fuel for vehicles 530,000 Other. Vehicle repairs & maintenance TABLE II: PROGRAM EXPENDITURES FY 15-16 Council Grant Request Award Salary and Wages Professional Fees Operations Supplies Equipment - Other Fuel for vehicles 530,000 Other. Vehicle repairs & maintenance S15000 Other- auto insurance $5.000 Other_.. Other. �I TOTAL $50 000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Agency Name: Hui Malama Ola Na'0iwi Program Name: Kokua Hali - Health Transportation Program Addendum #1— Program Description Program Description continued from Application Exhibit A Section 3. Highlights from our program for 2014 demonstrate the effectiveness of our ability to support the needs of our island residents. A total of 122,961 miles were recorded on odometer reading from all vehicles used to provide direct service transports of island residents. Mileage distribution varied across the island with the Puna vehicles reporting a total of 21,571 miles of travel with Kona at 22,364, Ka'u at 28,114, Hilo at 26,946 and Waimea at 23,966 miles of travel. There were 696 unduplicated clients that used our transportation services at least 1 time though -out the year compared to 693 in 2013. The distribution of community residents showed that 233 individual clients used our Hilo transportation service, 139 in Puna, 110 in Kona, 114 in Kau and 100 in Waimea. This continues to play a major role in HMON'O recognizing the importance of maintaining this program. Data reports demonstrate some of the significant details of transport destinations that reflect the on- going need for our Hawaii Island population's access to health care: 2485 passengers were taken to island Physicians and Primary Care providers 712 passengers were taken to pharmacies for medication 318 passengers were taken to island laboratories as referred by client PCP for lab work. 247 passengers were taken to our 3 Community Health Centers. 737 passengers were taken to Chronic Disease Management & Health Education classes. 105 passengers were taken to dentist. 328 passengers were taken to other related needs such as social services, mental health, housing & DHS 5,132 passengers were picked up and drooped off at their home residence Total Passengers (Duplicated) in Calendar year 2014 = 10,064 Please note that most transports begin and end at each passenger's home residence. It is our belief that our program supports the effort the County of Hawaii to build our transit infrastructure and is in alignment with other transportation programs in helping those with the need to have a mode that allows them to better care for their health. The transportation program also played a significant role in the district of Puna in 2014 in relief and outreach efforts following the damaging effect of Hurricane Iselle. 5 vehicles were staffed and deployed in relief/outreach efforts in collaboration with the County of Hawaii's Office of Aging, Hawaii Island United Way, Big Island Substance Abuse Council, Hope Services and a host of others. Vehicles were deployed for transport of groups of multi -disciplined individual in mental health, medical and housing. Groups conducted assessment of our elderly population in the Puna district as well as our program vehicles provided transport of identified population needing medical emergency visits with urgent care in Pahoa. Our transportation program vision continues to be focused on preparation for the growing need of Puna residents that may become isolated from the rest of the population should the lava flow currently occurring cross Highway 130. We are committed to working with the County of Hawaii and other agencies to ensure caring for any population affected when this happens. Agency Name: Hui Malama Ola Na 'Oiwi Program Name: Kokua Hali - Health Transportation Program Addendum #1— Program Description Year after year HMON'O continues to seethe need for acquiring support for this program as there have been limiting funding for such as robust service. Our current vehicles are registering high numbers of miles and pose some financial challengesfrom yearto year. High mileage means constant maintenance, increased fuel cost and insurance cost. It is our hope that the County of Hawaii supports this program and see's the viability of transportation services that services our entire island community. County funding would be allocated only towards fuel, repair/maintenance and insurance costs for our transportation fleet. Hui Pono Holoholona Subsidized Low Cost Spay/Neuter Clinics 76 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay/Neuter Clinics Agency Director: FraouesP Fire. Phone No.: ( 806) 968 - 8279 Contact Person: Frances P. Fusin Phone No.: ( 808) 769 — 1128 Mailing Address: Address: FO Box 943 Address: City, ST, Zip M,. Vie,. Hi 96771 Facility Address: Address: 11-3436 Hibiscus Street Address: City, ST, Zip Mt. View. Hi 96771 Email Address: wi,b. st ess@hphhervell.up Accountant/CPA: Vivian s Toeuner Firm (if applicable): Mailing Address: Address: '0121 6894 Address: City, ST, Zip HII.. H196720 Fax No.: ( ) — Phone No.: ( 808) 345 — 2753 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 525,00000 Geographical Areas To Be Served: (One or more can be checked) © Puna © Hari ❑ North Kona © South Hilo ❑ North Kohala ❑ South Kona © North Hilo ❑ South Kohala © Kao Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © youth ❑ Victims of Crimes ❑ Culture and the arts ✓❑ Aged ❑ Victims of Health or Social Crises © Needs of the poor © Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay/Neuter Clinics 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $10,000.00 $10,000.00 $15,000.00 2. Agency Mission Statement: HPH is an all volunteer, non profit 501 (c) (3) animal organization, dedicated to providing Low Cost Spay/Neuter for Cats/Dogs in the communities of East Hawaii. HPH found homes to over 700 cats. We also trap, Spay/Neuter, Examine, Vaccinate, Release & Manage (TNRM) feral & abandoned cat/kittens in various locations to prevent uncontrolled breeding & overpopulation. 3. Program Description: HPH advertises periodic Spay/Neuter clinics & works directly with the community to provide traps, transportation & assists individuals with trapping when necessary. We also have daily phone contact & maintain lists of people in need of our assistance. From 2007 until end of 2014 we spayed/neutered over 3000 Dogs & Cats. Recently we spayed/neutered Cats rescued from the Pahoa Lava threatened area. These grant funds we are requesting will be used to maintain & increase our efforts as our operation is outgrowing our donations. 4. Total Budget & Position Count: Total Program Budget: Total Agency Budget: $25000,001 Total Program Position Count: $14,167571 Total Agency Position Count: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay/Neuter Clinics S. Program Funding Sources (identify all sources of funding applied to this programl: Revenue Source FY15-16 Estimate General/Donation Box'Cllnle Donations $9,052.41 Give Aloha & Program Matching Donations $2.139.25 Spay Day Rally Donations _$2.974.91 County Fair Donations $50.00 Yard Sale $51.00 TOTAL: $14,167.57 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Continuation of donations & fundraising as we have been doing since our inception. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1 -Sponsor monthly low cost Spay/Neuter clinics for the public. 2 -Transport Animals weekly to & from Spay/Neuter clinic. 3 -Transport traps & bait food to and from homes of individuals. 4 -Purchase medical supplies for the Spay/Neuter clinic. 5 -Coordinate with UHH Pre -Veterinary students & High School students interested in animal husbandry to attend our clinics. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Porto Hoioholona Program Name: Subsidized Low Cost Spay/Neuter Clinics B. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Numbero)clien[s served, worksdops or events held, volunteer hours, etc Desrlbe, be specl/icl Applicant Projected Results Dr. Castro /Hilo Vat Clinic 112 Dr. Seeske /Kilauea Vet Seryices 54 Aloha Veterinary Center or Bill Sanfilipo or. Agnes Horvath 55 248 Professional Fees Operations $0.00 50.00 S0.00 518,000M $30,000.00 Supplies Attach additional pages as necessary. 9. TABLE If: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Tatal Budget FY 15-16 Grant Req Salary and Wages Saw $0.00 50.00 Professional Fees Operations $0.00 50.00 S0.00 518,000M $30,000.00 Supplies 56,00000 $3,00000 $4,000.00 Equipment $3.000.00 Other Other: Other: Other: Other: TOTAL 1 $39.000.00 $25,000.00 If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of Countyof Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay/Neuter Clinics to. 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'n Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts 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 regordless of whethero 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: o substpnuol probobibry chat action taken be on individual will result in measurable direr[ benefits ocouiag to rhe individual os opposed robe nejet, 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. nature of Authorized Person (specify title) EXHIBIT A i/6//s Date NONPROFIT GRANT APPLICATION FY2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency -Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay/Neuter Clinics 11. Certification of Understanding (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, 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 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 final payment. 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. ff awarded a grant from the County of Hawaii I (we) understand and will comply with the requirement to submit a ear -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 ear -end report, using the template Provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of'Haxvrai`i Nonprofit Grant /application FY2015-16 /agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost spay/Neuter Clinics it. Certification of Understanding (page z of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly Indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 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 LnL,/>_c_r it ., ,-i war -rcart �-ns'on or about May 30 of the year the final 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, 2015 must he returned to the County of Hawai'i with the final report. Failure to return these funds in o timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. silature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION Fy 20152016 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Hui Pono Holoholona Program Name: Subsidized Low Cost Spay/Neuter Clinics 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Rnt Projected Projected Resoles posed Council d Result Projected Result Dr. Castro/Hilo Val 12 Dr. Seeske /Kilauea Vat Services 54 Aloha Veterinary Center 55 Dr. Bill Sanfilipo /Dr. Agnes Horvath 248 Equipment $3,ODO.00 Other: Other: TABLE It: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $0.00 Professional Fees $0.00 Operations $18,000.00 Supplies $4,000.00 Equipment $3,ODO.00 Other: Other: Other. Other: Other: TOTAL $25,000.00 Additional Council directives reaardinR award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8 of 8 Innovative PCS Foundation Canoe Gardens of Ancient Hawai'i 77 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Innovations PCS Foundation Program Name: Canoe Gardens of Ancient Hawai i Agency Director: Jannder Hiro Phone No.: ( 808) 327 — 6205 Contact Person: Julie'Lee' Nelson Phone No.: ( 806) 756 — 5492 Mailing Address: Address: 75-5815 Queen Ka'ahumanu Hwy. Address: City, ST, Zip callus- Kona, Hawaii 96740 Facility Address: Address: 75-5815 Queen Keahumanu Hwy, Address: City, ST, Zip Kailua Kona, Hawaii 95740 Email Address: leenelson.ipm@gmeil.com Fax No.: (floe) 327 — 6209 Accountant/CPA: John caibonaro Phone No.: ( 808) 930 — 6850 Firm (if applicable): carhonarc CPAs Mailing Address: Address: P.0. Box 43M Address: City, ST, Zip Hilo, Hawaii, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ H9makua ❑✓ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓ Youth ❑ Victims of Crimes ❑✓ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Innovations PCS Foundation Program Name: Canoe Gardens of Ancient Hawai'i 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13.14 FY 14.15 $5000.00 $10,000.00 $5,000.00 2. Agency Mission Statement: To provide support for Innovations Public Charter School and the community by helping nutmre the body, mind and spirt of the children of West Hawaii. Innovations Foundation provides facilities for Innovations Public Charter School and the Community. Innovations Foundation strive to teach students to make responsible choices that will lead to developing a strong body, mind and spirit. The goal of the Foundation is to support the school in developing children into responsible young adults that are community contributors and life long learners. Innovations Foundation supports on campus community gardens, sustainabllty initiatives (recycling, composting), art and technology integration in education. 3. Program Description: The program slated for the 2015-2016 school year is for the development of permanent Hawaiian cultural gardens for school and community use. The school has dedicated a 112 acre parcel to Hawaiian Canoe Plants and Mau Loa canoe -building plants on its new Middle School Campus which was completed in January 2015. The canoe garden will include plants that grow at our school elevation including awapuhi. hau, ipu, kalo, ko, mora, noni, ohi'a ai, olnea,'uala, uhi'uhi, and wauke. Mau Loa plants include kukui, hala, hau, ko, and nui. Students in all grades will study the plants in a project based multi -subject integration. science curriculum that will include indigenous vsendemic vs. Native plants, photosythests, soil studies, sustainability and nutrition. In art, students will study artist Herb Kane and his famous Hawaiian cultural paintings. Kane played a key role in demonstrating that Hawaiian culture arose not from some accidental seeding of Polynesia, but that Hawaii was reachable by voyaging canoes from Tahiti able to make the journey and return. In garden class, edible and medicinal plants will be explored by students as they create nutritous snacks, teas, and 'A Porto foods to support the world wide voyages of Hokule'a and eventually MakaliVi. In tech class, students will design power points, brochures and digital slide shows exploring each of the plants and creating an interpretive guide. In humanities, students will discuss the history of the plants, rituals around food, and relations of food with the earth_ Ghana and appreciation of'aumakua (ancestors) will also be discussed. Students will lead tours and share out their knowledge four times during the year at community and school focused, Zero Waste breakfasts. Guest will share foods from the garden as students lead lours while sharing knowledge about Canoe Plants of Ancient Hawaii. There is no organization providing this information to the public in Kailua-Kona. Living gardens will provide invaluable education for Hawaii Island's West side biggest urban center. 4- Total Budget & Position Count: Total Program Budget: 200001 Total Program Position Count: 3 howdy Total Agency Budget: lootiol Total Agency Position Count: z hourly EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Innovations PCS Foundation Program Name: Canoe Gardens of Ancient Hawai'i S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY1S-16 Estimate Healy Foundation 7000 USDA 3000 County of Hawaii 10000 TOTAL: 20000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program Innovations Foundation has extensive on campus gardens and recycling 1 sustainability programs. The master plan calls for fruit, ornamental, adornment, canoe, Mau Loa and imu gardens. Each year that we add a garden, the new garden becomes a school -wide project base focus. Great care is taken in the site selected, preparation of the land (pig proofing, inigatim, sail) and plant selection. All students and staff are educated in facets of the gardens (plant history, origin, food, water and sunlight needs as well as other care such as pruning and space). It takes funds, volunteers and teachers to establish a successful garden. Since we put such great rare into the development phase, sustainablity is not an issue. The school reaps the twits of its labor as the plants can be used for food celebrations, daily aftercare snacks, as well as overall campus beautification. Innovation's Foundation creates its own compost and reclaims water so that gardens are low cost and low maintenance over time. We rely heavily on volunteers. This month alone we had 50 volunteers from Kaiser and 40 parent volunteers donate an entire day in the garden. Many hands make light work. This program will not be expensive to sustain, but it will be an invaluable learning space for students and the community for years to come. 7. Program Objectives Using County Nonprofit Grant Program Funds The county funds will go entirely to materials, supplies and learning specialists for the gardens. All gardens require pig proof fencing which encompasses a combination of netting, traditional lava stacked rock walls and gales. About half of the plants will be received via local gardener donations, but some plants will need to be procured. Drip irrigation will be net in place. Additionally, materials are needed for a covered outdoor learning lab with seating for 24 students. The objective is to have the county support us with the infrastructure. Additionally, funds for speciality resource leachers will be allocated to this project. We plan on employing technology, an and garden specialists to manage this endeavor. Each specialist allocated stipend is $2,500, The art specialist will teach students about artist Herb Kane by visiting a large collection of his finest works at King Kamehenni Kona Beach Hotel. Kona -grown Kane is regarded as one of the principal figures in the renaissance of Hawaiian culture in the 19701 was a celebrated artist-histodnan and author with a special interest in seafaring traditions of the ancestral people of Hawaii. Students will create there own canoe garden paintings and additionally study Kane's techniques. The technology specialist will work with students to create a slide -show of the creation of this new school garden. They will also create brouchures and powerpoints to display learning across grades, to guide community and their chana- The garden teacher will organize volunteers, community planting days and guide children daily in design and implementation of the gardens. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Innovations PCS Foundation Program Name: Canoe Gardens of Ancient Hawai'i 8. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Ae.: Numberof tlients served, workshops prevenU M1elq roi.nn elh.rl, elc. aesmbe, be spe (cJ Applicant Projected Results Community Canoe Garden Workshops 100 in attendance Tours Led By Students to Parents & Community 250 in attentlance Volunteer planting and maintenance days (4) 60 in attendance (4) Aft Curriculum Share in Spnng 250 in atterdarc. Tech Curriculum Share in spring 250 in aftendance Blessing of Gardens Sharing of History 250 in attendance Student served Weekly Lessors 200 in adendance Atrnch additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-I6 Total Budget FY 15-16 I Grant Req Salary and Wages 7500 5000 Professional Fees Operations Supplies 5000 3000 Equipment Other: Grading Land Preparation 1000 Other: Pig Proof Fencing 5000 1000 Other: Irrigation 1000 1000 Other: An Supplies 5000 Other: TOTAL 20000 10000 `If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Innovations PCS Foundation Program Name: Canoe Gardens of Ancient Hawai'i io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interestthat 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 sianed, regardless of whether a conflict exists. NAME: lie}1ULOILE 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. QG✓trw�t.- l - F vsrrzcts oundatio>, Sccruiwry Signature & Autho zed Person (specify title) Date EXHIBIT A NON PROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Innovations PCS Foundation Program Name: Canoe Gardens of Ancient Hawai'i 11. 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, 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 1 (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. 1 (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 final payment. 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 veer -end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Innovations PCS Foundation Program Name: Canoe Gardens of Ancient Hawaii 12. Certification of Understanding (Page 2of2) 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 htti),//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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. dL na..',-3 i. - Yoyrul"orr Secrcl-an� Signat a of AdYhorized Person (specify title) 1/27/2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Innovations PCS Foundation Program Name: Canoe Gardens of Ancient Hawai i 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Projected Resant Projected Results Council Proposed Projected Result Community Canoe Garden Workshops 100 attend Tours Led By Students to Parents & Community 250 attend Supplies 3000� Volunteer planting and maintenance days (4) 60 attend- i Art Curriculum Share in Spring 250 attend Other: Irrigation 1000 Tach Curriculum Share in Spring 250 attend Blessing of Gardens Sharing of History 250 attend Other: Students served Weekly Lessons 250 attend TABLE II: FY 15-16 PROGRAM EXPENDITURES Grant Request Council Award Salary and Wages 5000 Professional Fees Operations Supplies 3000� Equipment Other: Pig Proof Fencing 1000 Other: Irrigation 1000 Other: Other: Other: TOTAL 10000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 Kahua Pa'a Mua Palili'0 Kohala 79 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kahua Pa'a Mua Program Name: Palilii'o Kohala Agency Director: Darin Fumes Phone No.: ( 606) me — 5391 Contact Person: AMrea Deee Phone No.: ( 906 ) 960 — 3727 Mailing Address: Address: P.D. ao, 8% Address: City ST, Zip Kapaau, HI 96755 Facility Address: Address: 55370 H.'ea Road Address: City, ST, Zip He.. H196719 Email Address: andm@andmadean.com Fax No.: ( ) — Accountant/CPA: 6nan Iwau, CPA Phone No.: ( 606) 935 — 5eoa Firm (if applicable): akara. Lada. Ham aaa Aaaociates, uc Mailing Address: Address: 101Aupuolstreetsu1te139 Address: City, ST, Zip 1-140.1-11%720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: s 5o,0oo.00 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑✓ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka -6 Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page I of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kahua Pa'a Mua Program Name: Palili'O Kohala 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 0 $50,000.00 $50,000.00 2. Agency Mission Statement: Kahua Pa'a Mua, Inc. is a North Kohala based 501-c-3 with a mission to: "Enhance communities through economic, conservation/preservation, social and educational programs for youth and adults." 3. Program Description: Palili'0 Kohala is a project of Kahua Pa'a Mua, Inc. The Palili'O Kohala project is a family -based taro growing cooperative that addresses food self-sufficiency, food security and economic development in North Kohala. The project provides training (workshops, mentoring) and resources (land, water, equipment) for the growing, processing and distribution of taro and value added products from taro, pigs, chickens and vegetables. 4. Total Budget & Position Count: Total Program Budget: 92,094 Total Program Position Count: 2.5 Total Agency Budget: 103,586 Total Agency Position Count: 1 2.5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kahua Pa'a Mua Program Name: Palili `O Kohala S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate County of Hawaii (applied) 50,000 Dorrance Family Foundation (secured) 2,261 USDA- Farmers Market Promotion Program (secured) 27,666 USDA -Small Disadvantaged Producer (w Kohala Center) 11,967 TOTAL: 92,094 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This project is a social venture that is intended to provide economic development for the community, as well as increasing food self-sufficiency and strengthening families. In FY 2014-15 we formed an agricultural cooperative and began making and selling kulolo from taro. We estimate that three years from now sales of poi and kulolo will generate enough income for the agricultural cooperative part of the project to be self-supporting. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Maintain and grow the Natural Farming Learning Lab for the benefit of the farming families and the North Kohala community. 2. Provide development assistance to the Agricultural Cooperative in order to ramp up for processing and marketing of taro, sweet potato and other crops, and pigs. 3. Provide on-going mentoring support for youth farmers and participating farming families, as well as Natural Fanning training for the wider community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kahua Pa'a Mua Program Name: Palili'O Kohala 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.: Number oftllennservetl, workshops a .rua held, wlun[eer hours, etc. oesrnbe, be scedf�cJ Applicant Projected Results Hamesling and processing taro 500 pounds Harvesting and sellling corn and sweetpotato 300 pounds Processing/sales taro into kulolo and/or poi 500 pounds Mentoring of fanning families 300 hours Natural Farming training 100 people Volunteer hours on NF Learning Lab 3,000 hours 10,600 7,500 Attach additional pages as necessary. 9- TABLE II: PROGRAM EXPENDITURES kSa71aa7n7d77W7ages FY 14-15 Actual- FY 15-15 Total Budget FY 15-16 Grant Req 23,940 46,463 25,536 Professional Fees 2,050 20,069 6,500 Operations 6,778 10,600 7,500 Supplies 8,116 5,730 3,964 Equipment 2,116 1,500 1,500 Other: Admin 5,000 7,532 5,000 Other: Other: Other: Other: TOTAL 50,000 92,094 50,000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kahua Pa'a Mua Program Name: Palili'O Kohala io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council The Mayor The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. SignatOre of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 1127/15 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kahua Pa'a Mua Program Name: Palili'C) Kohala ii. Certification of Understanding (Page 1 of z) I (we) have read and understood all of the 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 expendingloversight agency) full, free, and unrestricted access and authority to examine and 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 final payment. 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 reportusing the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kahua Pa'a Mua Program Name: Pelili'O Kohala 11. Certification of Understanding (Page z of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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 Brant 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.goy/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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) 127.15 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kahua Pa•a Mua Program Name: Palili'O Kohala 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Resulss council Proposed Projected Result Harvesting and processing taro 500 Pounde Harvesting and selling com and sweetpolato 300 pounds Processing/sales taro into kulolo and/or poi 500 pounds Mentoring of farming families 300 hours Natural Farming training 100 People Volunteer hours on NF Learning Lab 3,000 hours Other: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 25,536 Professional Fees 6,500 Operations 7,500 Supplies 3,964 Equipment 1,500 Other: admin 5,000 Other: Other: Other: Other: TOTAL 50,000 Additional Council directives reaardinjL award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Kailapa Community Association Community Resilience and Self -Reliance County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kailapa Community Association Program Name: Community resilience and self-reliance Agency Director: Diane M. Kanealil Phone No.: (�) 640 — 3195 Contact Person: Dlare, M. Kanealn Phone No.: ( ace) 660 — 9796 Mailing Address: Address: 61-4016 Kai'Opae PI ❑ South Kona Address: ❑ Ka'u City, ST, Zip Kamuela, HI 96143 Facility Address: Address: 61-4016 Kai'Opae Pl Address: City, ST, Zip Kamuela, H196743 Email Address: dkanealii020gmail com Fax No.: ( nla) _ Accountant/CPA: Lynne Paranada Phone No.: (808 )989 _ 6762 Firm (if applicable): Hilinat bookkeeping Mailing Address: Address: PO Box 42670 Address: City, ST, Zip Hilo, HI 96]20 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $71,000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo 0 South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) 0 Educational concerns 0 Youth ❑ Victims of Crimes 0 Culture and the arts 0 Aged ❑ Victims of Health or Social Crises Needs of the poor ❑ Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of9 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kailapa Community Association Program Name: Community resilience and self-reliance 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 0 0 $15,000 2. Agency Mission Statement: Vision: Ehuehu i ka pono (Thriving in balance) Mission:The Kailapa Community Association (KCA) exists to empower Native Hawaiians living in Kohala, specifically the Kailapa Community, by supporting physical, mental, spiritual, and cultural health and well-being through: 1 -Promoting and disseminating information on health and wellness: personally, locally, and globally. 2 -Educating and strengthening cultural identity and self-esteem through instruction in Hawaiian history, culture, and values. 3 -Preserving and protecting the natural environment through stewardship of our islands that are appropriate to traditional practice and perspective. 4 -Strengthening and engaging community relationships 3. Program Description: Kailapa is creating a resilient community. The focus of this program is on health, safety, food security and protection of environment. This programs will provide training and the resources needed for residents of S. Kohala to respond to disasters, promote health, safety and promote self -sustainability through land and aquaponic based food source. The food security program will focus on training participants to design, operate and maintain both land and aquaponic systems. The training will include sales and marketing for economic sustainability and will also incorporate composting, creating natural fertilizers and perpetuating the art of dry stacking rocks for raised beds. The garden wastes will be used to perpetuate the cultural practice of feeding the fishing ko'a. Kailapa's Community Emergency Response Team (CERT) promotes safety with disaster and emergency response training & re -certifications. Purchase of a HAM radio and support equipment and incorporate it's use in training, practice and response to natural disasters is necessary. 4. Total Budget & Position Count: Total Program Budget: 71.000 Total Program Position Count: t.5 Total Agency Budget: 374,140 Total Agency Position Count: 2.5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kailapa Community Association Program Name: Community resilience and self-reliance S. Program Funding Sources (identify all sources of funding applied to this programl: Revenue Source FY15-16 Estimate NAHADSA grant 20,000 OHA ae ina gran not yet aware 100,000 grant 5,000 TOTAL: 725,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: KCA will continue to seek private foundation grant funds for special events, programs, classes that provide education and promote health, safety and food security in an effort to promote self -sustainability and economic prosperity for our future. The food security program includes an economic development piece. The program will place aquaponic tanks throughout the neighborhood as well as tanks for the association, and provide maintenance support. The food produced by residents to be used home consumption and/or to sell at a community lead Tamers market or any market they choose. The associations tanks the land based garden (Mala) will be on the community property to be sold to supplement the maintenance of the garden and landscaping of the area. 7. Program Objectives Using County Nonprofit Grant Program Funds: Promote natural farming in communities and eliminate the need to use of chemical fertilizers Provide food to families and community while developing economic development on a small scale to start off Provide food safety net in event that disaster or emergency strikes i.e. barge strike, tsunami Provide source of income to maintain and expand production and/or to supplement income Provide education on various way to grow & distribute food and learn about starting, running and maintaining a business using a hands on approach Decrease dependance on food imports Promote value and cohesiveness in community Support the HI County's emergency response teams for safety and security by providing a universal, reliable way of communicating during an emergency Learn about and perpetuate Hawaiian traditional & cultural practices and utilize garden wastes to feed the fishing ko'a and promote the value of "Malama'aina" EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kailapa Community Association Program Name: Community resilience and self-reliance 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES fle.: Number ofdilrts served.orkshoos or events held, volunteer hours, etc. p.4o ,be specific Applicant Projected Results Number traine 60 Number of working systems 30 Small usinesses started 10 Number of HAM operators 5 certified mer protecting enwornment 100+ Food security in disaster 500+ residents SEE A] [AUHIzU 10,000 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages Project manager, maintenance personnel 13,269 50,000 30,000 Professional Fees Contractorsftramer5 9260 20,000 6,000 Operations Support for programs 5714 25,000 10,000 Supplies Emergency 0 20,000 5,000 Equipment 0 0 Other: Grass for work/training area 0 25,000 5,000 Other: Administration-utilities,lnsurance legal fees 12,137 15,000 3,000 Other Compost bins, aquaponic supplies 0 10,000 10,000 Other: Other: 0 TOTAL 40,400 145,030 71,000 "If applicable EXHIBIT A NONPROFIT G RANT APPLICATION FY 2015-2016 Page 4of6 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kailapa Community Association Program Name: Community resilience and self-reliance ill. 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 ❑ 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 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. Dianei Director Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 1232015 Date Page 5 of B County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kailapa Community Association Program Name: Community resilience and self-reliance 11. Certification of Understanding (Page loft) I (we) have read and understood all of the 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 abilityto 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 final payment. 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 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 Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit o timely. complete and accurate year-end reportusina the template provided will impact the evaluation of your proarom's or aaencv's future fundina requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kailapa Community Association Program Name: Community resilience and self-reliance ii. Certification of Understanding (Page 2 o 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 reportwithin 60 days of June 3& shall result in loss off all want funds received durinit 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:llwww.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, 2015 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 reauest and may result in anions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Diane M Kanealii Executive Director 1/232015 Signatureof Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kailapa Community Association Program Name: Community resilience and self-reliance 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results I Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Attachment: What are the intended measurable outputs or outcomes what would be achieved with this funding broken down into 3 sections 8. Table I: Participants from S.Kohala will be trained in all phases of building and maintaining an aquaponic system, 20 of those participants from Kailapa that attend and complete the trainings will be provided a complete system with up to one year of fee technical support Free Trainings include 1. Aquaponic system overview 2. Purchase of needed supplies or collecting recyclable products 3. System set up and adjustments 4. Getting each system operational, planting, adding fish 5. Fertilizer making an use of, with natural by-products 6. Basic business requirement ( GET license, reporting income, filing taxes, etc) 7. Basic business sales & marketing 8. Food handling for sale 9. Dry stacking rocks for raised beds 10. Community Emergency Response -HAM radio operations Each of the business trainings will take approximately 2-4 hrs, totally 12-16 hours per participant x 40 , 480 volunteer firs 20 families to receive free system, average family size of 4, totals 80 direct beneficiaries of the community placed tanks A local farmers market will be created to give the 20 family farmers a venue to sell their produce to the general public and all Kawaihae residents and visitors will have the opportunity to buy fresh, healthy produce grown locally within our community. Produce can also be marketed at other venues including the Waikoloa weekly farmers market. Thus impacting an additional 50-80 people IF each tank only produced 2 extra bags of produce a week This program provides Kailapa a food security within our community if and when isolation occur in a disaster which can provide food for our 140 homes and can continue to produce without power or additional water for several weeks. This program will support community cohesiveness by bringing people together for a greater cause. Each resident who gets a free system will be required to maintain their system and volunteer in the land based community garden and help another family to set up their system in the following year. This portion of the program will collaboratively touch another 20 residences which computes to an average of 80 additional direct recipients of the program in the next phase. The recipients will also be required to choose one resident Kupuna or family in need, to provide a bag of fresh produce to on a weekly bases. This way of giving back helps to build relationships within the community and promotes a sense of responsibility. That adds an minimum of 20 more people that will receive a direct benefit Page 1 of 2 Part 11, Association owned and operated aquapontc and land based garden The association owned and operated aquaponic tanks and land based garden will provide produce for sale to support the funds needed to maintain the land and building that will support the maintenance and expansion of the program in later years. The indirect benefit will impact a minimum of 500 S. Kohala residents from within and outside of Kailapa. It will take many volunteers to get the land based garden completed and operational. The initial aquaponic tank recipients will provide a minimum of 10 hrs. each of volunteer work to give back to the community total of approx. 200 hrs The raised beds will be done under the direction of cultural rock builder to use our natural resources and to perpetuate the traditional skill of dry stacking rocks for building. The produce waste to be used to perpetuate the cultural tradition of feeding the fish to attract to a certain area ( fishing ko'a) or used for composting. This will train and/ or attract an additional 15+ participants Part III, Safety and emergency response The HAM radio to complement the CERT program will provide a benefit for the entire S. Kohala coast from N. Kohala, Kawaihae, Puako, Waikoloa and up to Waimea. In case of emergency or natural disaster It is very difficult to estimate the number of people that could be impacted by the ability to contact the outside world and agencies in a true emergency. Having the HAM radio has the potential of impacting thousands of residents and visitors alike. The overall future plan for Kailapa is to build a disaster evacuation center and emergency shelter for this area. We have received funding to purchase most if the needed equipment for the CERT minus the radio and antenna. It is an essential part of disaster response. HAM radio training occurs around the island at intervals determined by the County of Hawaii. KCA plans to have at least 3 certified. Page 2 of 2 Kalani Honua Market At Kalani, The 131 County ofHawai`i Nonprofit Grant Application FY2015-16 Agency Name: Kalani Honua Program Name: The Market at Kalani Agency Director: u Races ul Phone No.: ( 808) 965 — 468 Contact Person: U Bates III, Drew Delaware Phone No.: ( 808) 965 — 468 Mailing Address: Address: 14.6860 Kalapana Kapoho Beach Road Address: City, ST, Zip Pahoa, H196]]8 Facility Add cess: Address: same as above Address: City, ST, Zip Email Address: l) � Mlanl COCl) Fax No.: Accountant/CPA: Sandra lima, CPA Phone No.: ( 808) 965 Firm (if applicable): Mailing Address: Address: sameasabove Address: City, ST, Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'a Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ✓❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page Iota County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kalani Honua Program Name: The Market at Kalani 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13FY 13-14 FY 14-15 0 $0.00 0 2. Agency Mission Statement: Kalani, located on Kalapana-Kapoho Road in lower Puna, is a 501(c)(3) educational nonprofit with a 40 -year track record of service, and currently the largest nonprofit organization (NGO) serving Puna, the poorest district in Hawai'i. Kalani hosts workshops, stewards several festivals, preserves three archaeological sites, and is a major economic driver for the district of Puna. Our weekly Community Arts Program provides over 50 classes and events each week, free or by donation to our community, ranging from Hawaiian culture classes and natural studies, to multiple styles of yoga, volleyball, dance and visual arts. Kalani's mission is to present nature, culture and wellness in sustainable, educational programs that honor Hawaii's native and diverse heritage. 3. Program Description: With the threat of isolation due to the lava flow in Lower Puna, the call has heightened from the local community to provide additional services at Kalani, which serves as a major community hub. Vendors and community members have stepped up to support the accelerated launch of a nonprofit market, which would provide the essential groceries and bulk products our community needs. The market will feature fresh local produce from area farmers, and focus on healthy, organic food that is environmentally -friendly. 20 jobs will be created in an area where jobs are desperately needed. All proceeds from the market will be funneled into our core nonprofit programming and emergency services, including our community center (50+ classes weekly, delivered free or by donation to community members), Hawaiian culture programming, emergency response efforts, events and festivals, and educational offerings. Once launched, the market is expected to be sustainable, and as a nonprofit, prices will be kept affordable for all. EBT will be available, and a pay -it -forward system in place to support those in greatest need. 4. Total Budget & Position Count: Total Program Budget: 1es,20o Total Program Position Count: 20 Total Agency Budget: 4,197,000 Total Agency Position Count: 112 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kalani Honua Program Name: The Market at Kalani S. Program Funding Sources (identify all sources of funding applied to this pmeraml- 6. Explain what plans your agency or program has to increase revenues to support this program We are working with David Mangel, a pioneer in the natural foods industry with a successful track -record launching small, rural markets. His conservative projections show the market sustaining itself after the hurdle of our launch. The ability for the market to self -sustain, and to provide additional revenue to support the extensive nonprofit programming we provide the community, means that we are able to focus the market pricing and design around accessibility, and supporting local, island farmers and vendors. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our sole objective for this request for County Nonprofit Grant Program Funds is to assist us with the launch of the nonprofit market. Once launched, the market is self-sustaining, contributes 20 jobs to our local economy, and further supports the important services Kalani provides to the lower Puna community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of FY15-16 Revenue Source Estimate U Casts Exle�F.ndraisin'_' 8,000 InterUp14,000 Ccun Donations of Equipment 10,000 32,000 Advance Order Discounts from Vendors 25,000 OF.ratin Fund -In House Renovations and Upgrades 20,700 O gratin Fund -Stack and 3t.ffinij First Month 57,000 TOTAL: 166,700 6. Explain what plans your agency or program has to increase revenues to support this program We are working with David Mangel, a pioneer in the natural foods industry with a successful track -record launching small, rural markets. His conservative projections show the market sustaining itself after the hurdle of our launch. The ability for the market to self -sustain, and to provide additional revenue to support the extensive nonprofit programming we provide the community, means that we are able to focus the market pricing and design around accessibility, and supporting local, island farmers and vendors. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our sole objective for this request for County Nonprofit Grant Program Funds is to assist us with the launch of the nonprofit market. Once launched, the market is self-sustaining, contributes 20 jobs to our local economy, and further supports the important services Kalani provides to the lower Puna community. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kalani Honua Program Name: The Market at Kalani B. TABLE I: What are the intended measurable outputs or outcomes that would be achieved v.,ith rhic 9. TABLE 11: PROGRAM EXPENDITURES Fy 14-15 Actual- PROGRAM PERFORMANCE MEASURES w 1546 Grant Req f.e.: Numberohrenu served, work,nap, r, rv-111d, vobnwer hau. em. pertlbe, he specfe) Applicant Projected Results Number of Shoppers week) 1000 wkly transactions Natural Foods Educalion 1 Class Weekl Local Food Producers Educating Members 1 Class Weekly Discounts Given to Com ni Members 10-12%oH reg prices New Jobs to the Community I 20 New Jobs Supplies 50,000 9. TABLE 11: PROGRAM EXPENDITURES Fy 14-15 Actual- FY 15-16 Total Budget w 1546 Grant Req Salary and Wages 32,000 Professional Fees Operations Supplies 50,000 Equipment 64,150 Other: Start up Building Costs 20,550 Other: Other: Other: Other: TOTAL ts6,Too It applicable EXHIBITA NONPROFIT GRANT APPLICATION FV 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kalani Honua Program Name: The Market at Kalani to. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, Ora dministrator 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: LJ Bates III POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. �y=L✓11 JY 11rRCC.-2 1/30/15 Signature of Authorized Person (specify title) Date i EXHIBIT A - NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kalani Honua Program Name: The Market at Kalani 11. Certification of Understanding (page 1 of 2) 1 (we) have read and understood all of the 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 final payment. To register, go to hhht�,//vendors h w fi a complete the 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 vear-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 time/y complete, and accurate ear -end re ort using the template provided, will impact the evaluation of your aroaram's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kalani Honua Program Name: The Market at Kalani 13. Certification of Understanding (Page 2 of 21 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 priorto 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 accented 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 hawaiico tv o /fn -n profit -era t 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) 1/30/15 Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kalani Honua Program Name: The Market at Kalani 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results council Proposed Prolected Result Building will commence Before 12115 sional Fees Number of Members Shopping weekly 1000 wkly tions Natural Foods Education Wkly Class es Local Food Producers Educating Members My Class ent t.Other Discounts Given to Members -10-12G : Stan up building New Jobs to the Community 20 New : TABLE II: ROGRAM EXPENDITURES FY 15-16 Grant Request Council Award and Wages sional Fees tions es ent t.Other : Stan up building 10,000 : TOTAL Additional r.......:r a:._�:..__ _____ 10,000nal e, ves re drain¢ aware: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 Ka'u Rural Health Community Association, Inc. K5'u Rural Health Academy County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Ka'n Rural Health Community Association, Inc. Program Name: Ka'u Rural Health Academy Agency Director: Jessanle Marques Phone No.: ( soe) Sze — o1o1 Contact Person: J wane, Marques Phone No.: ( eos ) 92e — 0101 Mailing Address: Address: P.o. a ,,87a Address: City, ST, Zip Petrel.. Hi 96777 Facility Address: Address: 96-6126 Puahala street Address: City, ST, Zip Pahala, Hi 9677 Email Address: krhow(Pyahoocom Fax No.: (aoe)9za — 0101 Accountant/CPA:Nona Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City, ST, Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL MANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (one or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala El South Kona ❑ North Hilo ❑ South Kohala ✓❑Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns ❑r/ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ✓❑ Needs of the poor ❑ Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A nlnuoanrJT raA MT A oonrerinN ry JlHC_TM6 D-1 nfR County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Ra'u Ruxal Health Community Association, Inc. Program Name: Ka'u Rural Health Academy 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 N/A N/A 2. Agency Mission Statement: Ka'u Rural Health Community Association, Inc. Mission Statement: "To Do Whatever It Takes To Keep Ka'u Healthy', best describes our commitment to support and promote community empowerment, capacity building, collaborative partnership and a healthy community through education and economic development opportunities that improve the quality of life in rural communities. 3. Program Description: Ka'u Rural Health Community Association, Inc. (KRHCAI) is seeking $86,376 funding to support the Ka'u Rural Health Academy (RHA)Program in Ka'u. The RHA is located in Pahala at the Ka'u Resource & Distance Learning Center and is open Monday through Friday B:OOam - 4:30pm. Presently, Hawaii Community College / Office of Continuing Education & Training conducts a Fast Track Career and Workforce Certification Program (iCAN) Monday through Thursday 9:00am-12:noon, Allied Health & Practical Nursing Program Ka'u Cohort utilizes video teleconference for classroom lectures and clinical lab site. UHManoa John A. Burns School of Medicine Environmental Vog Project equipment is set up and maintained at the Resource Center as part of the RHA. We anticipate UHH/HCC to use our VTC equipment for pre requisite courses i.e. Math and English 100 in the Fall semester The RHA has been providing access to health, education research opportunities and economic sustainability programs in collaboration with publc/private sectors since 2013. The RHA has video teleconference fiber optic connectivity and routing equipment, 10 computers, 3 laptops and iPads, printers and conference room that are utilized by high school and HCC students, community organizations and individuals who need access at no cost. Our collaborative 4. Total Budget & Position Count: Total Program Budget: $8e,376 Total Program Position Count: 1 2 Total Agency Budget: 1$54X0 Total Agency Position Count: 13 EXHIBITA hInWVQn9 IT r P A NT ADD I I rATInM cv'mtcnnia D.—I of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kalu Rota, Health Community Association, Inc. Program Name:Ka'u Rural Health Academy S. Program Funding Sources (identify all sources of funding applied to this programl: Revenue Source FYIS-16 Estimate Hawaii Community Foundation Flex Award $17,00 University of Manna John A Burns School of Medicine $2,40 Puanani Woo $2,40 Membership Dues $2,00 Donations $2,00 TOTAL: $23,800 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Ka'u Rural Health Community Association (KRHCAI) plan to create and implement a public awareness campaign through social media (website/blog and newsletters), an annual giving program, signature events, develop a marketing fund plan and establish a donor data base. 7. Program Objectives Using County Nonprofit Grant Program Funds: By the end of FY15-16 at least 500 residents will have access to the RHA program and participate in our Health & Wellness: Education / Prevention Programs (i.e. health and financial literacy, chronic disease self management, youth internship, higher education, research, workforce development & training classses, workshops, training seminars and annual rural health conference), resulting in raising awareness of healthier lifestyles, improve the quality of life for individuals, families and the community, decrease the high cost of healthcare, increase enrollment in college and employment opportunities. EXHIBIT A MnMDR(1CIT rR A NT 4DDI 1reTInki FV JntS_1n19 Dvau?nfR County of Hawai `i Nonprofit Grant Application FY2015-16 Agency Name: Ra'u Rural Health Comunity Association, Inc. Program Name: Ka'u Rural Health Academy 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (le.: Numboofdmub served, aoubhopsor eensts held, volunteer hours, etc D ocnhe, be specific) Applicant Projected Results annual rural health conference sur-very questionnairesand Progress; include but are not limited to chronic disease self progress evaluations. management, diabestes education, Hawaii Community College Individualized Certification Achievement Network, Legal Se a Hawaii, Hawaii County Prosecutors Office/Task orce. etc. $60,000 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES Ft 1415 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages Professional Fees $30.000 $60,000 $60,000 Operations $10.938 $27.876 21,876 Supplies $2,500 $5,000 5,000 Equipment Other: Other: Other: Other: Other: TOTAL $83,438 $86.376 $86,376 -if applicable EXHIBITA KIMIDDr1CIT rP A W A DDI IrATn7N rV 7ntCOn76 Dees A -+R 1 at County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: xa'u Rural Health Community Association, Inc. Program Name: Ka -u Rural Health Academy io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Ham i'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 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 Authorize Person (specify title) Date EXHIBITA NnK1DPn91Tf.DANT ADDI IrATIr1N i,V JnICJOl6 D—C.SQ County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Ka'u Rural Health Community Association, Inc. Program Name: Ka'u Rural Health Academy 11. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 certifythat information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability 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 final payment. 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, usina the template provided, will impact the evaluation of your Program's or agency's future funding requests. EXHIBITA ninnioannT ran nm a poi 1r4TlnN runic ->nu n.00 a,.ry County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Ka'u Hotel Health Community Association, Inc. Program Name: Ka'u Rural Health Academy 11. Certification of Understanding (Page 2of2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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.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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. �eRcHi �oEtit�xeel, �dLf,�te� /ty�rzec% nature of Authorized Person (specify title) EXHIBIT A hynhlDDrICITrPANT a DDI IfhTIMI rV lntC-lnlg Date Doug 7 ..f s County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: K.,u xurual Health community Association, Inc. Program Name:Ka'u Rural Health Academy 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant I Council Proposed Projected Results Projected ResuR TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NnMD nP1T r P ANT ADD] IrATInN FV JnlA-In15 Doae RnfR Keaukaha One Youth Development RISE 21st Century Aker School Program ® COPS` County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program Agency Director: Shedd Keahi Warfeld Phone No.: (floe) 895 — 8666 Contact Person: Naomi Ahu Phone No.: ( boa) 756 — 5659 Mailing Address: Address: 67 Keokea Loop Address: City, ST, Zip Hilo, Hawaii. 96720 Facility Address: Address: same as above Address: City, ST, Zip Email Address: naomi koyddst@gmad com Fax No.: Accountant/CPA: Carbonaro CPA's and Management Group Phone No.: (808)968 — 1002 Firm (if applicable): same as above Mailing Address: Address: 136wnaolestreet Address: City, ST, Zip Hilo, Hawaii, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: E 12,000.00 Geographical Areas To Be Served: (One or more can be checked) © Puna 0 Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑ South Kona Q North Hilo ❑ South Kohala ❑ Kao Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns QYouth ❑ Victims of Crimes © Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 0.00 $9,000.00 0.00 2. Agency Mission Statement: The mission of Keaukaha One Youth Development (KOYD) is to contribute toward developing the future leaders of Hawaii County through offering programs that help youth ages 8-18 recognize their strengths and passions and the importance of team work, goal setting, physical, mental, and spiritual well-being, and cultural identity. 3. Program Description: See attached 4. Total Budget & Position Count: Total Program Budget: $37,00000 Total Program Position Count: o Total Agency Budget: $ae,000.0o Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program S. Program Funding Sources (identify all sources of funding applied to this programl: Revenue Source FY15-16 Estimate County of Hawaii Grant (reflects our current request) $12,000.00 Hawaii Community Foundation - THINK Fund $25,00000 TOTAL: $37,000.00 Attach additional pages. if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The RISE 21st Century After School continues to rely on contributions and grants from the public and private sector. We continually strive for community support in these sectors to expose the great accomplishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: See attached EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.: Numbi,,vfdven serve4.mAhops or event:held, volunreerbaur:, eh. 0esnbe, he speci(rc.) Applicant Projected Results Number of Hawaii County youth served 30 youth Volunteer hours of 13 people 2520 hours Individual Student Success Plans Implementation stages "'See attached $100000 $1,000.00 $1,000.00 Operations 0.00 $25,00000 0.00 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-I6 Total Budget FY 15-16 Grant Req Salary and Wages 000 0.00 0.00 Professional Fees $100000 $1,000.00 $1,000.00 Operations 0.00 $25,00000 0.00 Supplies 0.00 000 a.00 Equipment $5,500.00 $8,000.00 $8,000.00 Other: Food/Snacks 0.00 $1,000.00 $1000.00 Other: Travel $1,500.00 $2,000.00 $2,000.00 Other: 000 OM 000 Other. 000 000 000 Other. 0.00 000 000 TOTAL $8.000.00 $37,00000 $12,00000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program to. 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 he 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: See By -Laws attached, page 14 & Exhibit A on page 15-16 0 If no conflicts exist, check here. PresiCI&W-1 Difec'44- 112_4P1-JVI`5 G Signature of Authorized a on(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 11. Certification of Understanding (page 1 of z) I (we) have read and understood all of the 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 final payment. 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 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 Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Keaukaha One Youth Development Program Name: RISE 21 st Century After School Program 11. Certification of Understanding (Page 2 o 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 301h shall result in loss of all grant funds received during the grant period (must be refunded to Countyl 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.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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. g2b4drrfEj2VyllU e Signature of Authorized Person (specify title) /relow'G Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Keaukaha One Youth Development Program Name: RISE 21st Century After School Program 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of Hawaii County youth served 30 youth Volunteer hours of 13 people 2520 hours Individual Student Success Plans Implement Supplies 0.00 Equipment $8,000.00 Other: Food $1,000.00 Other: Travel $2,000.00 0,00 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 0.00 Professional Fees $1,000.00 Operations 0.00 Supplies 0.00 Equipment $8,000.00 Other: Food $1,000.00 Other: Travel $2,000.00 0,00 Other: Other: 0.00 Other: coo TOTAL $12,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 County of Hawaii Non -Profit Grants Program — Attachment Keaukaha One Youth Development (KOYD) Revealing Individual Strengths for Excellence (R.LS.EJ Reference to Page 2, Question 3: Program Description RISE, an acronym for Revealing Individual Strengths for Excellence, is a 21 st Century After School Program that was created in 2011 to serve as a community resource bank for underprivileged, Native Hawaiian youth ages 12-17 in the Hilo district to aid in revealing their individual strengths and passions for future career and academic success. A variety of mediums will be used to help youth build Individual Student Success Plans (ISSP) .such as but not limited to: apprenticeships, Hawaiian cultural practice, internships, multimedia, performing arts, project exhibitions, student exchange, and work study initiatives. Once youth discover their potential strengths and passions, RISE will help connect them with voluntary mentors from the immediate community and abroad who share similar .strengths and passions to share knowledge, foster and develop self-esteem, and to bridge the generational gap between adults and youth. RISE will also provide opportunities to support physical well-being, cultural identity, and leadership. By implementing this mission, RISE envisions that when the youth participants graduate from high school, they will have a clear and strong idea of what their future career and academic pursuits will be and the relationships they have gained through our program will help motivate and encourage them to become valuable contributors to the well-being and sustainability of the Hilo community. Reference to Page 3, Ouestion 7: Program Objectives Using County Non -Profit Grant Program Funds Our key objectives for the RISE 21" Century After School Program are the following: I) To reveal the strengths and passions of youth participants to contribute toward overall student engagement and confidence. 2) To help youth participants develop Individual Student Success Plans (ISSP) to track monthly goals and expectations and to contribute toward building responsible, respectful, and reliable students. 3) To provide individual mentoring for encouragement, motivation, self-esteem, and to increase knowledge of future career and academic paths. 4) To implement Hawaiian cultural practices such as the art of ho'ola hot, (balance discipline) and hoe na'a (canoe paddling) to teach values and encourage discipline, balance, and leadership for physical, mental, and spiritual well-being. Reference to Page 4, Question 8: Table I — What are the intended measurable outputs or outcomes that would be achieved with this funding? Reference to Page 8, Question 12: Table I — Council Award Worksheet Program Performance Measures Applicant Projected Results L) Number of Hawaii County youth served Approximately 30 youth 2) Volunteer hours of three people: Executive Approximately 2160 hours (see breakdown Director, Executive Assistant, and below): Fiscal/Administrative Coordinator 4 60 hours per month x 12 months = 720 hours Contracted Grant Writer— erson x 3 eo le = 2160 hours 3) Number of volunteer mentors and hours _11er 10 volunteers, 360 hours (see breakdown served below): Generation 10 volunteers x 3 hours = 30 hours per month x Equipment 12 months = 360 hours _ 4) Implementation of Individual Student Evidence of beginning stages of Success Plans (ISSP) for youth participants implementation such as goal setting and recorded support from mentors and parents Reference to Page 4, Oueslion 9: Table li — Program Expenditures for County Grant Request Reference to Page 8, Question 12: Table II — Council Award Worksheet Program Expenditures Additional Details Budget Administrative/Professional CPA— Year End Financial $800.00 Fees: _ Statement Generation Contracted Grant Writer— $200.00 Application and Final Report Generation Equipment Waiaka Hawaiian Koa Canoe $1,000.00 Restoration/*S.T.E.M. Project supplies (2) Laptops for student use $3,000.00 Monthly 3G data plan for (2) $1,000.00 _ RISE staff' iPad's _ Xerox machine expenses $2,500.00_ _ Other office & ISSP supplies $500.00 Food: Snacks/other food sI lies $1,000.00 Travel: Airfare, ground transportation, S2,000.00 and fact expenses Science, I echnotogy, Engineering, and Mathematics Keaukaha One Youth Development Youth Paddling Program D COPY County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program Agency Director: Shedd Keahi Warfeld Phone No.: ( 808) 895 — 8666 Contact Person: Naomi Adu Phone No.: (808))56— 5659 Mailing Address: Address: 6]Keokea Loop Address: City, ST, Zip Hila. Hawaii, 96720 Facility Address: Address: same as above Address: City, ST, Zip Email Address: naomi koydnse@gmaitcom Fax No.: Accountant/CPA: carbonam CPAs and Managemerdcmup Phone No.: 808 %8 — 1002 Firm (if applicable): sameas above Mailing Address: Address: 136 K,noole Street Address: City, ST, Zip Hilo, Hawaii, 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $ 12,000 00 Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua ❑ North Kona © South Hilo ❑ North Kohala ❑ South Kona ✓❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ youth ❑ Victims of Crimes © Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises © Needs ofthe poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $10,000.00 $8,000.00 0.00 2. Agency Mission Statement: The mission of Keaukaha One Youth Development (KOYD) is to contribute toward developing the future leaders of Hawaii County through offering programs that help youth ages 8-18 recognize their strengths and passions and the importance of team work, goal setting, physical, mental, and spiritual well-being, and cultural identity. 3. Program Description: The Youth Paddling Program was established in 2006 to offer Hawaii County youth ages 8-18 Native Hawaiian cultural opportunities that reconnect them to historic ocean experiences, particularly the Hawaiian Canoe. 4. Total Budget & Position Count: Total Program Budget: $12,000.00 Total Program Position Count: 0 Total Agency Budget: $49,000.00 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 5. Program Funding Sources (identify all sources of funding applied to this program): FY15-16 Revenue Source Estimate County of Hawaii Grant (reflects our current request) $1200000 TOTAL: $12,000.00 Attach additional pages, if needed 6. Explain what plans your agency or program has to increase revenues to support this program: The Youth Paddling Program continues to rely on contributions and grants from the public and private sector. We strive for community support to expose the great accompllishments of our youth participants and to create additional interests from our local and extended communities to subsidize our cause. 7. Program Objectives Using County Nonprofit Grant Program Funds: See attached EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (.e.. Number of clients served, werksho0s ore,,0,held, volunteer hours, etc. 0 ... nse, be ,e,,f,, Applicant Projected Results Number of Hawaii County youth served 120 youth Volunteer hours of four people 850 hours "'See attached 000 Professional Fees $500.00 $500.00 $500.00 Operations 0.00 0.00 0.00 Attach additional pages as necessary. 9. TABLE 11: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages coo coo 000 Professional Fees $500.00 $500.00 $500.00 Operations 0.00 0.00 0.00 Supplies 000 coo 0.00 Equipment $3,500.00 $5,500.00 $5,50000 Other. Travel $5,000.00 $6,000.00 $6,000.00 Other: coo coo 0.00 Other coo coo 0.00 Other: coo coo 0.00 Other: 000 0.00 000 TOTAL $9.000.00 $12,000.00 $12,00000 'If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: See By -Laws attached, page 14 & Exhibit A on page 15-16 ❑✓ If no conflicts exist, check here. �rW a- 016eift4-re Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 1/26/000 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 11. Certification of Understanding (Page 1 of 21 I (we) have read and understood all of the 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 final payment. 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 veor-end report using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. 1 (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.goy/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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. `/1nl GvO 7/-Q Q7Gi Pitt/(�J��f Cf7A� Signature of Authorized Person (specify title) I /Z&/20/S Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agen Cy Name: Keaukaha One Youth Development Program Name: Youth Paddling Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of Hawaii County youth served Volunteer hours of four people 120 youth 850 hours $500.00 Operations 0.00 Supplies 0.00 Equipment $5,500.00 Other Travel $6,000.00 TABLE II: PROGRAM EXPENDITURES FV 15-16 Grant Request Council Award Salary and Wages 0.00 Professional Fees $500.00 Operations 0.00 Supplies 0.00 Equipment $5,500.00 Other Travel $6,000.00 Other. 0.00 Other. 0.00 Other. Other. 0.00 TOTAL $12000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of County of Hawaii Non -Profit Grants Program — Attachment Keaukaha One Youth Development (KOYD) Youth Paddling Program Reference to Pape 3, Question 7: Program Objectives Using County Non -Profit Grant Program Funds The Youth Paddling Program will strive to reach the following objectives: I) Teach the values of team work, goal setting, commitment, physical, mental, and spiritual well-being, and cultural identity through the use of the Hawaiian Canoe. 2) Utilize the Hawaiian Canoe to present the metaphoric message of ones journey through life: "you steer your own waa (life), but not without the help of others (KOYD and our extended communities)." 3) Help offset the high risks of drug and alcohol exposure/abuse among our Hawaii County youth through fostering after school canoe paddling practices and weekend regatta races, a healthier alternative for the utilization of their time. 4) Teach the values and processes necessary for the maintenance of Keaukaha Canoe Club's historic ken canoes and other equipment for current and future generations. Reference to Page 3, Ouestion 8: Table I - What are the intended measurable outputs or outcomes that would be achieved with this funding? Reference to Page S, Question 12: Table I - Council Award Worksheet Program Performance Measures Applicant Projected Results 1) Number of Hawaii County youth served Approximately 120 youth _ 2) Volunteer hours of four people: Youth Approximately 850 hours (see breakdown Division Head Coach, two Youth Division below): Assistant Coaches, and one Youth Division * 16 two hour practices per month x 5 months Program Assistant (March -July) = 160 hours x 3 coaches = 480 hours $2,000.00 * 9 ten hour Saturday regattas x 3 coaches = and supplies - 270 hours $1,000.00 * 20 hours per month for Program Assistant x maintenance 5 months = 100 hours Reference to Page 4, Question 9: Table II - Program Expenditures Reference to Page 8, Question 12: Table II - Council Award Worksheet Program Expenditures Additional Details Budget Professional Fees: CPA- Year End Financial $500.00 Statement Generation Equipment: Paddle and canoe repair $1,500.00 Various paddling equipment $2,000.00 and supplies - Escort boat repair and $1,000.00 maintenance Portable toilet rental for _ $1,000.00 program site Other: Travel Costs (bus rentals, $6,000.00 gasoline expenses, airfare, ctc.) Kohala Animal Relocation and Education Service (KARES) Canine Spay and Neuter M County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay and Neuter Agency Director: Deborah M. Cravat, President 8 Founder Phone No.: ( 808) 333 — 6299 Contact Person: Deborah M. Cravat Phone No.: ( 808) 333 — 6299 Mailing Address: Address: KARES Address: P,O.Box44610 City, ST, Zip Kamuela, Hawaii 96743 Facility Address: Address: KARES Address: 59-241 kKpa Mai Place City, ST, Zip Kamuela. Hawaii 96743 Email Address: pate@kabaIaanirmaorg Fax No.: ( 808) eao — 1925 Accountant/CPA: Raaridall Maduso Phone No.: (ace)881 — loao Firm (if applicable): Kamuela TaxP Mailing Address: Address: Kamuela Paxiams Address: 54_1190 Mamalot Highway City, ST, Zip Kamuela, Hawaii 96732 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES ,tr Amount of Request for County Nonprofit Grant Program Funds: #30, D00 Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua © North Kona © South Hilo © North Kohala © South Kona Q North Hilo © South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts E] Aged ❑ Victims of Health or Social Crises © Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County ofHawai`i Nonprofit Grant Application FY2015-16 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay and Neuter 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $12,500 $0.00 $10,000 2. Agency Mission Statement: The interest to establish a "no kill" philosophy organization led to the creation of KARES. KARES' primary focuses are community education and relocation of healthy, adoptable animals throughout the entire island of Hawaii. KARES believes that by bringing knowledge and awareness of the causes of overpopulation and providing humane alternative solutions are the keys to changing the attitudes towards dealing with the animal overpopulation problem. KARES provides cat and dog food to low income families and to homeless people who might otherwise surrender their companion animals to shelters because they cannot afford to feed them. KARES works with veterinarians to offer low cost or no cost spay/neuter for pets of low income residents, establishes trap/neuter/release and maintain programs with feeding stations for feral cats, and maintains a network of volunteers to foster cats & dogs until they are safely adopted. 3. Program Description: Provide free spay and neuter (S/N) surgeries for 400 companion dogs that are owned by low income or economically troubled families, and the elderly and infirm who cannot afford these services, however, we never will turn anyone away because the goal is to humanely control the overpopulation of dogs. S/N surgeries will primarily be performed in clinics that KARES hosts in order to make these services readily available within various communities throughout the island. Since initiating the Canine SIN Program in 2010 KARES has been responsible for sterilization of 2,926 dogs including a total of 1,520 in 2012-13 and 950 in 2014. All surgeries were provided free to pet owners. 4. Total Budget & Position Count: Total Program Budget: $102,000 Total Program Position Count: 10 Total Agency Budget: $1ao,000 Total Agency Position Count: 30 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay and Neuter S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Includes applications submitted for potential funding in 2015-16 and other anticipated revenues Corporate Foundaions (e.g., Petco Founation and PetSmart Charities) restricted to canine S/N $55,000 Community Foundations and County of Hawaii $30,000 Private Foundations (e.g., Milan Fdn, Anna Weidner Fdn, Gus Hawthorne Fdn) and Individual Donors $13,500 Fund raising events (garage sales, dog washes, T-shirt sales) $3,500 TOTAL: $102,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: KARES will continue to apply for community, corporate and private foundation grants, as well as conducting community fundraising events. In past years the majority of our grants have been awarded by Mainland USA organizations to support the Hawaii Canine SIN Program. Because KARES has exceeded performance expectations for this program and we anticipate renewed funding for spay/neuter from the Petco and PetSmart Foundations. In 2012 and 2014 we obtained grants from the County of Hawai'i to support a portion of our life -sparing work; we hope the County will again assist with this important work. Since 2009 KARES has realized increased revenues from private donations as people become aware of our contributions to the people and animals of Hawai'i. These KARES' Programs also include animal rescue, foster care/adoptions and the Pet Food Bank. We anticipate an increased donor base through our enchanced visibility on the KARES website and FaceBook page. 7. Program Objectives Using County Nonprofit Grant Program Funds: The KARES Canine SIN Program objectives will provided benefit to the people of Hawai'i 1) by making available free SIN surgeries for pets belonging to low income and economically troubled residents, an expense that most cannot afford, 2) by taking MASH -style spay/neuter clinic resources directly into communities to assist residents with limited transportation or limited opportunities for time away from work or home, 3) by encouraging canine "birth control" through spay and neuter which allows families to keep the pets that they have without the additional economic burden of unwanted puppy litters for which they cannot cover the costs of food and veterinary care, and 4) by reducing the number of feral/stray dogs which cause damage to property and livestock and could cause potential health risks to humans due to bites and the spread of disease. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay and Neuter B. TABLE I: . I Pat aI c uIc Duca wcu nicao I euro uuLPuu Of Uurcurnes tnac wows oe acnievea wan ims PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.. Numherofdierawe d,, workshops orewn6 held,, wlonteerhom,, etc pesrnbe, be specfc.) Please see attached Daaee for Proaranh Perfoanance Maaalnea and Pr P&M Reeues ooaec nc nereimN 9. TABLE 11: PROGRAM EXPENDITURES Fr 14-15 Actual' yr 15-15 Total Budget Fr 15-16 Grant Req Salary and Wages o 0 0 Professional Fees Operations Supplies Equipment Other: Please see attached pages for Table II expenditures Other: Thankyou Other: Other: Other: TOTAL 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 d E m z a V c d Q d z a C A m CL (A d C C O U d E m z E R rn O a` m a H 00 o V o m O 3 N ?N V L m N 9 C L m �. m N O = N m 3.Z Z N N r O O O C C O N d d d L N T C � T E o o E c16 o U N J C V N E a m N S C C C N C O E C m U w v u 0 �a c w 0 moo. t Q 3 J c g o v a odo c v � w M m N y O J N Z y O O L N C= 2 v m° 7 N O Vml N O m L U U C N Z' m .m. C 0.2 C m l0 v N m N N G N O m y -0 m U C J— :_. V m v 3 C C O ? N m y 0 J T N 3 E.G .g D V .S. 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N E N C N 0 C N O N a n C t ON U N C On O N E O 4 0 T v V aN° N y C O O N U N J O G a -0i N O U C � 0 °a N ate•- d'0 = o n z - a o .- L - 0 0 a C E 6 T C p C N n C B O E N L a`3N O 3106a° 40 a m c2 me c > m a o 0�d w 'c° u d N mOD > o o >- ��aNi of c O T C ° N E n 0 O 6 T N N N U Z Y aO o u0 A o c � � c 0.2 90 E E ° r > °v o n 0 E nN N n M - c M d o v 3 U >c OI ° ° N 2 c p O C C E 0 U 0,2 C0 o m e o 6 > ._ f 6.0 W N O W N CSO O ° O _TN C L 0 N O w _ o m nc C Ec N> W y0 L 0.0 U U O U O p E M T Z 0 on o m N O U W N O Nt0 0 0`� N U1 O C OLN N C O Q v$ 9 U m D n 0 t o !°- k } ƒ \ / § | E tm2 \ \} }\ Tie 12-9 \\ \0 !«s 2] }V0 \} )],)es@§ES \\E \0 rl })0 /- 46 _ [ ([ \\\ \\ k E ` } E o 06 06 Z ;\2. 0 ±<r -- M \ >k0 k j / £ lla kƒ§ 4 §alfa / \ \ �\\} `°`�K*§> QuZ ( 3\(J±f$Z; o / }}}\\m \ 0 00 \ \} }\ \\ \0 !«s 2] }V0 \} \\E \0 })0 /- _ [ ([ \\\ \\ E Z ;\2. 0 ±<r -- M \ >k0 k j / £ lla kƒ§ \ County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay and Neuter io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: KARES has no intent or plans to involve any of the above specified County of Hawai'i administrative staff in our organizational operations. KARES has only one volunteer that is also an employee of the County of Hawai'i. This KARES volunteer is Daylynn Kyles, Clerk III, Puna District (dkyles@co.hawaii.hi.us). She volunteers with KARES for animal rescue, fostering of dogs, adoption events and participation in spay/neuter clinics. We do not perceive her volunteer activities to have any substantial probability of having a direct benefit with regard to grants awarded by the county. Therefore we report - no conflicts exits. ✓❑ If no conflicts exist, check here. Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay and Neuter ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 — 2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: canine spay and Neuter 11. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured priorto receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30t' shall result in loss of all ¢rant 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 (30%) for administrative and overhead costs. Any funds unused by June 30, 2015 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 aaencv's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. i� ion i Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kohala Animal Relocation and Education Service (KARES) Program Name: Canine Spay and Neuter 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projec[etl Result Please see attached pages for an expanded listing TABLE It: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Please we attached pages for specific expenditures Other: Other: Other: Other: TOTAL $30,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of d V) V) Y 13 V m a u 3 O u N N d a F Y d d V u d O L a v N O CL0 O a` 'u c 3 O u T r N R t N U C L U 3 N C E d oNgy-`"° R R _ 5 VI jU 0 d 3 a n d i"° w d N Nab r mtEa ad 2t REE m o c h d'm o 8 E'a c R d R- c u R z d N Y j R C R 41 >i d`° a O c N d L 0= p N d C d_ c >i n d U J Vd_ CN (0 L j 1'3 N L nN d w C d R J 3° R d a° d° O w 0 w L C'Ip O.dO a �CUT`°iv�'UN:.. 3i�Q'C c t°Z dcccER3:vc m'm3 oc.. Cn_d �d�E o.E°i0�rnmmm -dd cDn U C?"''O g 12 - 'pC •CL d° > Z' NONCFwN-OdXNOdT U d E d w C J R N w d J d Q ¢U C7>E U��dST 1?'f CO) z12. mLL c ° ° TO OI yd U O d � d , D d R o 3 Z pR1 y c E N o mm o i Eva U N E N T a d y O LL j d y 0 L Va c� O O 6.d. N C 6 d d C v E d C oc O) p d y n� c E m v u om 0W.0 ism dt_"mui m m m m m C Z O O°$ r U m 3 r E cm VO 0 d y y'O ` N C U i p 10 3 010 Ed o, a� `° Q E d d N O a y N c m E;O r=_ 3 G'-° 0 vi d .�`oI�oa°c E ESE �'� wSLw N C N T O x d E Y O° H U C T C w- O C N O- �(°J R�Np2a m DdyH"V O�yCjd O t O J a O N R 9 C Y OI OIO L Ynl� a` 0' 3 a` ° E N E = x m m aJ m a I I y C C C mm U m M a T 0-' c 6 � a Jw a m J o m crnTmt ao Baa oaaiN J�' '. C `m T¢3a C Emmy. -a cN °x v�Em Nm Ea9 a COIN U a ma 12m a O E J m 4 a a N m J E F- N O m m N m m 6 ¢ K¢A> O W K C O O O a O T• m. O C¢ C J w m E a 12 ••• O N C w c m O _T L m �' W O L m y 3 .0 d m m c m m VO a c m o n on i d o n E a L U n a m C O L V N J .o m N m L p 2 m N pO m N P N Y y O Eng a ¢ oNmN mo >a may -mo w oEmJa« Sym E£�m y o m>.O m a o o c oa z N C O mm0 a N mm.� j0 U 0 V' LN 0a00) Eo mC C', UFM JCN OJ d ¢ c Q C C N¢ a Y m m n E ¢E o.p FES I d E m z T V C d a d 3 d z V C m T m CL N d c 'c m U d E m z E I 07 O a` d :n Fd - a m a 0 d N p o 0 0 0 0 0 N � v m c a o N i N V F m w v v E N c y « c ^ m cL i+ a m L N N E J f v m ¢ —- a 2 0 °' 3 ry f0 N N V "O d M y a CWW W x x m C J 'o 00 o O o z` a` nz� a„'oao Kohanaiki 'Ghana Environmental and Cultural Stewardship Program M County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kohanaiki'Ohana Program Name: Environmental and Cultural Stewardship Program Agency Director: Rebecca Villages Phone No.: ( 806) 960 — 2605 Contact Person: Kaleo Pllago Phone No.: ( 606) 996 — 1507 Mailing Address: Address: P. o. ay. 4153 ❑ North Hilo ❑ South Kohala Address: City, ST, Zip Kailua-Kona, HI 96145 Facility Address: Address: 13-1224 Kairrinani Drive Address: City, ST, Zip Kailua-Kona, HI 96740 Email Address: pila90@hawan.edu Fax No.: (808) 992 — 1421 Accountant/CPA: Jen Turner, CPA Phone No.: ( 506 ) 329 — 9220 Firm (if applicable): Mailing Address: Address: 14-559613awai Plare STEE Address: City, ST, Zip Kailua-Kona, HI 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua © North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'0 Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth ❑ Victims of Crimes ❑/] Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kohanaiki'Ohana Program Name: Environmental and Cultural Stewardship Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 2 Total Agency Budget: Total Agency Position Count: $15,000 2. Agency Mission Statement: The mission of our organization is to remain active in the care and preservation of the cultural and natural resources at the Kohanaiki Beach Park. To accomplish this, our organization fosters community engagement and support through the development and implementation of innovative stewardship programs that are specific to the Kohanaiki and 'O'oma areas. 3. Program Description: This program will apply an integrated and innovative approach to monitoring the near -shore reef ecology at the Kohanaiki and'O'oma areas. Included within the Hawai'i Island Marine Managed Areas, there are safeguards from commercial activities in these areas. To support this, our program will provide consistent monitoring and maintain / provide data that will reflect the ecologic health of both these areas. 4. Total Budget & Position Count: Total Program Budget: s3o,000 Total Program Position Count: 2 Total Agency Budget: Total Agency Position Count: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Kohanaiki'Ohana Program Name: Environmental and Cultural Stewardship Program 5. Program Funding Sources (identity all sources of funding applied to tris program) FY15-16 Revenue Source Estimate County of Hawaii Nonprofit Grants Program 30,000 TOTAL: $30.000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Kohanaiki 'Ghana operates at a grassroots level and generates funds through nonprofit grant support and our annual Keiki Surf for the Earth surf contest. 7. Program Objectives Using County Nonprofit Grant Program Funds: The main objective is to engage in consistent monitoring of the coastal resources impacted by commercial harvesting and State regulations. Another objective is to encourage stewardship activities the Kohanaiki and O'oma areas by teaching the youth and community members why stewardship is important, and how to be effective stewards. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: KohanaiRi'Ohana Program Name: Environmental and Cultural Stewardship Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES rre.: Number ovdwrn z,rvetl, workshrl, ar evente held, volunteer hr,,1 etc eemribe, be specific) Applicant Projected Results Number of monitoring / data collection activities 12 Number of volunteers per monitoring / data collection activity 10 Number of hours per monitoring / data collection activity 8 Total number of volunteers 60 Total number of monitoring / data collection hours 960 Number of monitoring / data collection rapers 4 Number of community informational / findings presentations 2 Attach additional pages as necessary. 9. TABLE If: PROGRAM EXPENDITURES FY 14 -IS Actual' FY 15-16 Total Budget FV I5-16 Grant Req Salary and Wages $6 6,000 6,000 Professional Fees $0 2,000 2,000 Operations $4,000 4,000 4,000 Supplies $5,000 6,000 6,000 Equipment $6,000 12,000 12,000 Other: Other: Other. Other. Other. TOTAL $15,000 30,000 30,000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kohanaiki'Ohana Program Name: Environmental and Cultural Stewardship Program io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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: GARY EOFF POSITION: DIRECTOR, KOHANAIKI'OHANA May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): F✓ 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 asa 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: Council Member Karen Eoff will refrain from making recommendations on this application. ❑ If no conflicts exist, check here. Signature o Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 I Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Kohanaiki'Ohana Program Name: Environmental and Cultural Stewardship Program 11. Certification of Understanding (Page 1 of z) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. To register, go to http://vendDrs.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kohanaiki'Ohana Program Name: Environmental and Cultural Stewardship Program 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 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, 2016must 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Aut o ae erson (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 ( Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kohanaiki'ohana Program Name: Environmental and Cultural Stewardship Program 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Projected Resant Projected Results Council Proposed Projected Result Number of monitoring / data collection activities 12 Number of volunteers per monitoring / data collection activity 10 Number of hours per monitoring / data collection activity 8 Total number of volunteers 60 Total number of monitoring / data collection hours 960 Number of monitoring / data collection reports 4 Number of community informational/ findings presentations 2 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 6,000 Professional Fees 2.000 Operations 4,000 Supplies 6,000 Equipment 12,000 Other: Other: Other: Other: Other: TOTAL 30,000 Additional Council directives reeardine award: EXHIBIT B NON PROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Kona Adult Day Center, Inc Adult Day Care County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: KONA ADULT DAY CENTER, INC Program Name: ADULT DAY CARE Agency Director: R.r. t Tigm Phone No.: ( e03) 322 — 7917 Contact Person: Rowena ITpW Phone No.: ( 608 ) 322 — 7971 Mailing Address: Address: PO Box 1360 Address. City, ST, Zip Kealakekua HI 967M Facility Address: Address: 81-999 Haleltii street Address: City, ST, Zip Kealakekua HI W750 Email Address: kadaavane�fawen.n.apm Fax No.: (eoa) 32s — 614 Accountant/CPA: Rooald G. Hawke:, CPA Phone No.: (808) 939 — 7392 Firm (if applicable): Mailing Address: Address: POBox2030 Address: City, ST, Zip Kealakekua HI 901.50 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) El Puna IQI IHiimakwa Z North Kona Q South Hilo North Kohala South Kona C] North Hilo ]] South Kohala Kau Services or Activities To Be Provided: (One or more can be checked) Educational concerns j[] Youth El Victims of Crimes El Culture and the arts Aged Victims of Health or Social Crises Needs of the poor Physical/Emotional Disabilities Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kona Adult Day Center, Inc Program Name: Adult Day Care 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 15000.00 $15,000.00 10000 00 2. Agency Mission Statement: "Our mission is to provide health, social and recreational programs and activities that enable impaired adults to experience feelings of belonging, friendship, acceptance, accomplishment and independence in a caring and secure social environment". 3. Program Description: KADC is the only 501 C 3 organization in West Hawaii providing impaired adults, their families and other caregivers with an alternative to premature institutionalization. Since opening in1987, service has been provided to over 600- families in our community. A comprehensive program provides a variety of social and related support service groups of adult clients in a Protective and less restrictive setting during the day. Day Care allows caregivers to continue working. Day Care also provides a more cost effective program than Home Care or Institutionalization. 4. Total Budget & Position Count: Total Program Budget: t5000.0o Total Program Position Count: q_5 Total Agency Budget: I s000.00 Total Agency Position Count: a.5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kona Adult Day Center, Inc Program Name: Adult Day Care S. Program Funding Sources (identify all sources of funding applied to this proxram): FY15-16 Revenue Source Estimate 6. Explain what plans your agency or program has to increase revenues to support this program: We will continue to seek grants. We will plan our Fundraiser to attract more people. Increase our client census, especially those who pay privately. Seek donations through a membership drive. Increase awareness in the community about our services. 7. Program Objectives Using County Nonprofit Grant Program Funds These County Grant Program Funds will be used to help us attain the following objectives by maintaining skilled, caring and efficient staff: For individuals: a) Mentally and physically impaired adults are maintained at their highest level of functioning, thus preventing or delaying further deterioration. b) Maximum level of independence is assessed and maintained through an individual care plan. c) Client is able to associate with place and time. d) Defer premature or inappropriate institutionalization. e) reduce isolation. For Caregivers: a) Respite b) Continue working c) Have access to elderly services d) Safe and secure environment. For Community: Part of a long term continuum as our population ages. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: KONA ADULT DAY CENTER, INC Program Name: ADULT DAY CARE 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this fundine? PROGRAM PERFORMANCE MEASURES Numaerofclien"s ,w hops or evenhheid, u uof rho, eh. Oesoihe, be spechcf 2x 9. TABLE It: PROGRAM EXPENDITURES Salary and Wages Professional Fees Operations Equipment Other:'BrWbyae Benefits fir: 13 1 T. 6-0Ufiltes Otl/er: RbN-in;ICi� fitYner: treurenre TOTAL EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Applicant Projected Results FY 14-15 J FY 15-16 I FY 15-16 Actual' Ted8alan Grant Req 31 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kona Adult Day Center, Inc Name: Adult Day Care io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or ad!tmWsitraMr of Voir organvalinn may hame viM the fmniy a6 Ha...BiS. Only Mrose ksted beJ. need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organrzatmtt" v'ft dw -No cw"ch east' gpoorl d waked creeds to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: ROWENA L. TIQUI POSITION: EXECUTIVE DIRECTOR May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ElMember or members of the Council Staff appointed by a member of the Council L� 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 „ban 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. ` r 1 Do Signature of A Ithorize Per on (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant .Application FY2015-16 Agency Name: Kona Adult Day center, Inc Program Name: Adult Day care Il. Certification of Understanding (page loft) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135-2-1421, 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 N Revised Statutes. I (we) understand that applications will not be reviewed by County 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 frorn the fmmq of Hawai% I (we) understand and will comply with the requirement to enroll with Hawai i fomrsIWIC • Express, and be compliant prior to final,paymrytt. To register, go to http://vendors ehawaii Roy, complete the 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 % 11") understand and will comply with the r,guirement 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, nteawrrable oWilaxa ses), a awfil ete aocotopgg of aY emmaditures w4warted by Cow ay of Hawan grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely. complete, and accurate ear -end re ort using the template provided will Maarf the evatuatum ofyourproaroms or angor✓ A&" fieurm requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit (Grant Apptication FY2015-16 Agency Name: Kona Adult Day Center, Inc Program Name: Adult Day Care 72. Certification of Understanding (Page 2 If 2) tt awarded agrant from the County of Har r,' 4 (+ )'understand that a current Certificate of Liability 51-IWAO(t general rRibAity, $50,4100 each commence) must be provided to the County of Hawaii F,inanoe Oeyar7meny 101sich specifically and exp'lic* sndicafes that the County of Haw, 1,, k an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 3P 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 rnstruxIDgos ane ayadabie at httj2:j/www.havvaiicounty ov/fn-no profit a ant 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 Posts. Any hands wwsed by hate 30, 2015 rrusst be mWmed to the County at ntaavai"i with the final r!port-rm'I" to Mown daese funds Ma tknely "XIIgner *0 joyart thea 2f Vo OIL- *'' future funding, request and malt result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. r t�%`i�C-t�`ttJE ro�C�Ta� Signature of Authorized r n (specify title) 1/23/2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii dVOWI CII APPlication FY2015-16 Agency Name: KONA ADULT DAY CENTER, INC Program Name: ADULT DAY CARE lz. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES APPlicant I"dworweed Pleje[ted ResuRs Projected ResuR Maintain or improve 98% Maintain or improve hygiene 96% 'Age in Place' at home of 6 months 96% Survey of caregivers sa6sfaclion 98% Interaction with community groups 2:r month 99% Increase client census N 00 average daily 98% TABLE 11: PROGRAM EXPENDITURES FY 15-16 Council "a blr�es C Award 1 Feces $15,OOp.00; Other: Other: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Kona Choral Society KCS Youth Chorus M County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kona Choral Society Program Name: KCS Youth Chorus Agency Director: Jullal-ester. Pmeidemof the soD Phone No.: (606)326— 7121 Contact Person: Tom Daniel. Member Boo Phone No.: (e06) 325 — 7323 Mailing Address: Address: P.D. aox 50m Address: City, ST, Zip Keilua-Kona, H1 96745 Facility Address: Address: crone Address: City, ST, Zip Email Address: pilester@bewarantel.net Fax No.: ( ) — Accountant/CPA: Deb Simms Phone No.: (808) 640 — 2001 Firm (if applicable): Mailing Address: Address: 77�2o0 Hoowamai Place Address: City, ST, Zip Kallua-Kona, HE 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $5,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hdm3kua © North Kona ❑ South Hilo ❑ North Kohala © South Kona ❑ North Hilo © South Kohala ❑ Ka'D Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth ❑ Victims of Crimes © Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kona Choral Society Program Name: KCS Youth Chorus 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 1415 0 $0.00 0 2. Agency Mission Statement: Founded originally as the Kona Community Chorus in 1990, the not-for-profit organization was reincorporated in 2002 as the Kona Music Society, and as a result of its recent strategic planning process has emerged as the Kona Choral Society (KCS) as it begins its third decade of "promoting excellence in choral and other musical arts for adults and children in our community." Although anyone from anywhere is always welcome, the Kona Choral Society primarily serves the residents of West Hawaii where its members and its audience live. 3. Program Description: In 1994 KCS decided to develop a Children's Chorus and then a Teen Chorus. In 2006, they were combined as the KCS Youth Chorus, the older participants acting as mentors for the younger. The KCS Youth Chorus provides an outstanding opportunity for West Hawaii youth to develop their musical talents in a warm, nurturing environment and to participate in performances ranging from holiday entertainment to formal concerts with the Adult Chorus. The goal of the KCS Youth Chorus is to provide an exceptionally positive choral music experience and musical training for up to 50 children and teens in West Hawaii. It is the only extracurricular secular chorus available to youth in West Hawaii, and it has grown to become a dynamic group of children and teens who come together each week to share their joy of singing supported by experienced professional music educators and caring volunteer members of the KCS Adult Chorus. A 2003 study reported that students who participated in music education stated that they felt that they were "part of something much greater than what the individual could produce alone," In addition, research has shown support for a positive correlation between being involved in extracurricular activities and staying in school (Bowman). 4. Total Budget & Position Count: Total Program Budget: I I %000.00 I Total Program Position Count: o Total Agency Budget: I sioo,000.00l Total Agency Position Count: o EXHIBIT A County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kona Choral Society Program Name: KCS Youth Chorus 5. Proeram Funding Sources (identify all sources of funding applied to this Programj: Revenue Source FYIS-16 Estimate Hawaii Community Foundation $2,500.00 Private Donations (primarily adult chorus members) $2,500.00 Hawaii County request $5.000.00 TOTAL: $10,000.00 Attach additional pages, if needed 6. Explain what plans your agency or program has to increase revenues to support this program While the Kona community has shown its support of the Kona Choral Society in so many ways, West Hawaii families have not yet recovered from the difficult economic consequences they have faced since 2008. KCS has made a commitment to ensure that all West Hawai"i children who wish to participate and sing can do so, and with assistance this past year from the Hawai'i Community Foundation, provided free tuition. The enrollment doubled. Over the next three years, KCS will increase its capacity to continue to provide this community service through additional fundraising activity and through community collaborations. In addition, KCS has recently been invited to apply for a Hoosie Martin Foundation Fund Development and Capacity Building grant to promote excellence in choral and other musical arts for the enrichment of children and adults in the community. 7. Program Objectives Using County Nonprofit Grant Program Funds: The primary outcome of this proposal is that the opportunity to participate in The KCS Youth Chorus will be extended to all youth who wish to participate, regarless of a family's socio-economic conditions. This is to be measured by the number of outreach presentations made through community organizations serving the families, the number of low-income children participating and the number of subsidies awarded. Participants in the KMS Youth Chorus will learn basic information about choral music, develop their natural musical talents and build on their love of music under the guidance of well-established music education professionals. They will experience the joy that comes from practicing and improving their skills, much as in a sport. In addition, the children will have the opportunity to perform with the Kona Choral Society Adult Chorus and experience the varied sounds of an orchestra in performance. They will also have the opportunity to experience the pleasure of "giving back" by providing a holiday concert in December that will be free to the West Hawaii community. EXHIBIT A County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kona Choral Society Program Name: KCS Youth Chorus 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.: Number of clients serveq workshops or events held, volunteerhours, etc oesmbe, be spedf .) Applicant Projected Results children will enroll in KCSYC each sem. 50 per semester KCS will provide info to W.H families re prog 2,000 families KCS volunteers make community presentations 3 W.H. comm. present. KCSYC attendance at performances 135% will attend KCSYC returning for 2nd semester 85% will return parents antl/or youth satisfied with experienc 85% satisfied KCS adults will provide volunteer support 1200 hours per semester Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 1415 Actual• FY 15-16 Total Budget FY 15-I6 Grant Req Salary and Wages Professional Fees $8,000.00 $5,000.00 Operations Supplies Equipment Other: Concertexpenses $ 500.00 Other: KCSYC Retreat $ 1,500.00 Other: Other: Other: TOTAL $70,000.00 '11 applicable EXHIBIT A County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kona Choral Society Program Name: KCS Youth Chorus io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist' option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. 61 t Signa ure of Authorized Person (specify title) EXHIBIT A /3� ,fir. 1.111,4:11-0IV. Date County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kona choral Society Program Name: KCS Youth Chorus ii. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 1 (we) have the authority and ability 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 Expressand be compliant prior to final payment. 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. 1 (we) understand 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 tirneiy complete, and accurate ear -end report, using the template provided,will impact the evaluation of your Program's or agency's future funding requests. EXHIBIT A County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kona Choral Society Program Name: KCS Youth Chorus 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawal'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 301^ shall result in loss of all Brant 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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. ignature of Authorized Person (specify title) EXHIBIT A 01/28/2015 Date County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kona Choral Society Program Name: KCS Youth Chorus 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result children will enroll in KCSYC each semester 50 per semes KCS will provide info to W.H. families re enrollme 2,000 famili KCS volunteers make comm. presentations 3 W.H. pmse KSCYC attendance at performances 85% will an KCSYC return for 2nd semester 85%will ret parents/youth satisfied w experience 85%satisfie KCS adults provide volunteer support 200 has. sem TABLE It: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees $ 81000.00 Operations Supplies Equipment Other: Concert Expenses $ 500.00 Other: KSCYC Retreat $ 1,500.00 Other: Other: Other: TOTAL $ 10,000.00 Additional Council directives regarding award: EXHIBIT B Kona Historical Society Living History Programs County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kona Historical Society Program Name: Living History Programs Agency Director: Joy Holland Cesca Phone No.: ( 806) 923 — 3222 Contact Person: Joy Holland Cali Phone No.: ( bob) 323 — 3222 Mailing Address: Address: n.o. sox 398 Address: City, ST, Zip Captain Cook, HI 96704 Facility Address: Address: 81-6551 Mamalahoa Hwy Address: City, ST, Zip Kealakii HI 96750 Email Address: joyakonahisloricatorg Fax No.: ( 608) 323 — 2998 Accountant/CPA: sono cronwali Phone No.: ( 806) 323 — 3222 Firm (if applicable): Mailing Address: Address: l'i Box398 Address: City, ST, Zip Captain Cook, HI 96704 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua © North Kona © South Hilo ❑ North Kohala © South Kona © North Hilo ❑ South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns © Youth ❑ Victims of Crimes © Culture and the arts © Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment sRIH County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Kona Historical Society Program Name: Living History Programs 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $9,250.00 $8,000.00 $10,000.00 2. Agency Mission Statement: The Kona Historical Society will preserve the history of Kona to enrich our community and inform our visitors by nurturing an understanding of, and inspiring an appreciation for, Kona's unique sense of place in Hawaii's history. 3. Program Description: KHS operates three living history programs on two historic landmark sites: The Kona Coffee Living History Farm is 1920's era coffee farm homesteaded by Japanese immigrants from 1913 to 1994, and tells the story of Kona's coffee pioneers. The 1870 H.N. Greenwell Store offers the visitor an authentic 19th century shopping experience. The Portuguese Bread Program invites visitors and local residents to assist with bread baking in the Portuguese lava stone oven each Thursday. One crucial goal of our programs is to provide to school groups an opportunity to experience Kona's history through hands-on, shared activities. In 2014, KHS welcomed over 700 students from public and private schools from Hawaii and the mainland. Our programs are age appropriate and we accommodate students up to and including college age. In these visits, KHS strives to educate learners about Kona's and Hawaii's unique history and culture in a way that is fun, interactive, and dynamic to facilitate comprehension and retention. KHS values its collaboration with the County in presenting the annual Hanohano O Kona free lecture series at West Hawaii Civic Center, and appreciates the County's providing the parking shuttle for the Nov 2014 Open House at the Kona Coffee Living History Farm. 4. Total Budget & Position Count: Total Program Budget: 330,239 Total Program Position Count: 18 Total Agency Budget: 558,000 Total Agency Position Count: 23 EXHIBITA County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Kona Historical Society Program Name: Living History Programs S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FYIS-16 Estimate Earned Income (Tours, Coffee Sales, Bread Sales, etc) 229,800 Fundraising 15,000 Donations 2,500 Grant Income 50,000 TOTAL: 297,300 attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Visitor numbers are expected to continue to increase in 2015 and we continue to receive increased numbers of large tour group reservations for the coming year. Increased visitor numbers will improve sales of coffee and other items. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Teach students and visitors about Kona and Hawaii's history and culture in a way that is fun, hands-on, and dynamic to facilitate learning and appreciation. 2) Provide authentic and engaging programs at our historic sites. 3) Demonstrate themes of sustainability, family values, and independence to all visitors. EXHIBITA County ofHawai`i Nonprofit Grant Application FY2015-16 Agency Name: Kona Historical Society Program Name: Living History Programs 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES fie.: Number of clients served, worishops or events held, wlunteer hours, etc. Describe, be specter) Applicant Projected Results School Groups (number of students) 900 Group Tours: 45 large groups (8 of visitors) 2000 Free and Independent Travellers 3599 Bread Program Visitors 2500 Volunteer Support at history sites (hours) 1360 Operations 16,555 25,125 10,000 Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual- FY I5-16 Total Budget FY 15-16 Grant Req Salary and Wages 132,230 176,332 10,000 Professional Fees 24,820 47,820 2,500 Operations 16,555 25,125 10,000 Supplies 6,836 4,350 2,500 Equipment o 0 0 Other: Cost of Goods Sold 50,868 45,600 1,000 Other: Employee Benefits & Payroll Taxes 18,610 26,612 2000, Other: General Liability Insurance 4,277 4,400 500 Other: Other: TOTAL 254,196 330,239 28,500 `If applicable EXHIBIT A County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kona Historical Society Program Name: Living History Programs io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be 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 ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest - 0 If no conflicts exist, check here. lUtj ke" I/?TI S Signatur of A it orized Person (specify title) Date EXHIBIT A County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Kona Historical Society Program Name: Living History Programs 11. Certification of Understanding (page 1 of z) I (we) have read and understood all of the 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 final payment. 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 Hawat'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, usina the template provided, will impact the evaluation of your program's or aaencv's future fundina requests. EXHIBIT A County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kona Historical Society Program Name: Living History Programs 11. Certification of Understanding (Page z of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of 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 lune 3011 shall result in loss of all grant funds received during the grant Period Imust be refunded to County) and exclusion from future Brant 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. 1qV �W Sign(tur-A Authorized Person (specify title) Date EXHIBITA County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Kona Historical Society Program Name: Living History Programs 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result School Groups (number of students) 900 Group tours: 45 large groups I# of visfiors) 2000 Free and Independent Travellers 3599 Bread Program Visitors 2500 Volunteer support at history sites 13W Other: Cost of Goods Sold 1,000 Other: Employee Benefits and Payroll Taxes 2,000 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 10,000 Professional Fees 2,500 Operations 10,000 Supplies 2,500 Equipment 0 Other: Cost of Goods Sold 1,000 Other: Employee Benefits and Payroll Taxes 2,000 Other: General Liability Insurance 500 Other: Other: TOTAL 28,500 Additional Council directives regarding award: *AwIF.I AGENCY NAME: Kona Historical Society PROGRAM NAME: Living History Programs 3. Program Description Additional Information KHS is a Smithsonian Affiliate with the only permanent National Endowment for the Humanities exhibits in the State. KITS is the recipient of dozens of awards and commendations for its museums, National and State registered historic structures, and its historic public programs. KITS operates three living history programs on two historic landmark sites. Kona Coffee Living History Farm On a sunny morning, the bus bearing local 4" graders arrived at the Kona Coffee Living History Farm for a scheduled tour. The children's excitement was evident as they passed through the 100 -year old stonewall and into the 1925-1945 era. Following the scent of burning wood, one group entered the kitchen where they found the "housewife" cooking rice on a traditional open hearth stove. Another set to work washing clothes with tubs and washboards, as the hot Kona sun beat down upon their necks. One group met Charlie, the "Kona Nightingale" donkey, and learned to pick coffee, as children were required to do in those olden days. Some children settled around a lauhala mat under the orange trees to learn to play Ojyame, a Japanese children's game from long ago. Each group experienced the whole farm by turns, along the way learning how coffee was processed, exploring the vegetable patch, and pausing under a tree to crack macadamia nuts with a rock. The happy students departed the site, taking with them an understanding of the critical role of children in the success of the coffee farm, and the contrast between their own modem life and the family of 1930's Kona mauka. H.N. Greenwell General Store "E komo mai to the H.N. Greenwell General Store," greets the "storekeeper" as the patron enters the dim interior of the 1870 stone structure. The smell of roasted coffee, tobacco, dried fish, and saddle leather are among the many sensory inputs that flood visitors upon entering this histone store. The Store's cool interior, original counters and shelving, and fascinating merchandise quickly immerse visitors in an authentically recreated late 19`s century shopping experience. Kama'aina, school children, and visitors from across the globe assume the persona of an actual store patron, choosing from Kekoanui, a Hawaiian paniolo; Manuel Golarte, a Portuguese dairy farmer; or Mrs. Louisa Todd, a French woman who runs a small and tasteful hotel nearby. As the "customers" pick up mail and select items from their shopping list, the story of Kona's mercantile enterprises emerges. The very act of touching and smelling and learning about the use of historic items that visitors may never have seen, leads to a unique experience not found in a more traditional setting. Portuguese Stone Oven Baking Program It's 6:00 a.m. and still dark at Kalukalu on bread baking day, as the head baker arrives to light the Kiawe wood fire in the community -size traditional Portuguese stone oven. Three hours later, local families and visitors begin arriving to take part in the rolling and shaping of authentic Portuguese sweet bread. In the broad green pasture below the Greenwell Store, participants gather around the baking table as the two bakers and volunteers explain the process and demonstrate the correct technique. Laughter and lively conversation mingle with bird songs drifting down from the huge monkey pod trees that cast shade upon the proceedings, while a makai breeze blows softly. When ready, the rolls are placed in pans that, when the temperature is just right, will be put into the lava stone oven to bake. During the process, the staff share stories of Portuguese immigrants and their important roles as dairymen and ranchers in Kona. Once the bread starts baking, the delicious scent of sweet bread drifts over the pasture, rising up to the parking lot above where customers are waiting to purchase this delectable piece of Kona's history. Through its historic sites, unique and authentic programming, and highly trained staff, the public derives the benefit of history education through hands-on and interactive programs. Through participating in these programs Kama'aina, students, and visitors depart our sites inspired by the richness of culture that diversity provides, and with an understanding of the hard work and resourcefulness of early settlers to Kona. EXHIBIT A 1129/15 Ku Aloha Ola Mau Hui Ho'ola O Na Nahulu O Hawai'i nIj County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: KU ALOHA OLA MAU Program Name: Hui Ho'ola O Na Nahulu O Hawaii Agency Director Lisa cook Phone No.: ( 808) 566 - 8234 Contact Person: Kelaukua caner Phone No.: ( 808 ) 982 — 9555 Mailing Address: Address: 1136N_ N1nnlrewghway Room Ca02 Address: City, ST, Zip Honolulu_ Hawarl 96817 Facility Address: Address: 15 -192630th Padre. Address. Hawaiian Paradise Park City, 9T, Zip Keaau, Hawaii 96749 Email Address: kaarter@kualona or, Fax No.: ( 808) 982 — 9554 Accountant/CPA: Jay Mryaki, CPA Phone No.: ( 808 ) 522 — 1042 Firm (if applicable): Jay M,yaki, CPA, LLC Mailing Address: Address. 600 oaten sinner. suaa C-4 Address City, ST, Zip Honolulu. H,,ai 1. 96613 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 536962.00 Geographical Areas To Be Served: (One or more can be checked) © Puna ❑ Harl ❑ North Kona ❑�/ South Hilo ❑ North Kohala ❑ South Kona © North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑✓ Victims of Health or Social Crises Q Needs of the poor ❑✓ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: KU ALOHA OLA MAu Program Name: Hui Ho'ola O Na Nahulu O Hawai i 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 5000 $10,000.00 0 2. Agency Mission Statement: Ku Aloha Ola Mau restores meaningful, healthy lives for individuals and families coping with substance abuse. The name means "to stand in advocacy, from the deepest part of ourselves, and give everlasting compassion and love." The mission of Ku Aloha's program, Hui Ho'ola O Na Nahulu O Hawaii (Hui) on Hawaii island, is, "to create a healing community, grounded in the spirit and culture of Hawaii that reaches out to Hawaiians of all ethnicities suffering from the disease of addiction". The author of this is the original Policy Steering Committee who birthed the program. Kupuna Abigail Napeahi gave the Hui its name and focus. The Hui's name means "We are the group that gives life back to the people of Hawai'i." Through Kupuna teachings, we have come to believe that "Every Haumana is a precious gift that walks the face of the earth" and that there is potential within every Haumana for self-sufficiency and to become a valuable resource to their ohana and the community. 3. Program Description: The Hui is the only cultural substance abuse recovery program in Puna. It typically serves 25 persons at any given time and an average of 100 persons per year and their families. The program integrates evidence based practices with cultural wisdom, traditions, healing, olelo, values, heritage and ceremonies to promote healing and positive changes toward recovery. Its outcomes are typically well above or at the level of the State Alcohol and Drug Abuse Division's averaged statewide outcome percentages. The Hui has been in operation for over 15 years. It has become nationally accredited by CARF International, under an application funded by the County in 2011 Recently, certain events have highlighted the need for security and to maintain uninterrupted program services at the Kapoho Cultural Educational Center (KCEC) in Kapoho (TMK 1-4-008-004-0000). Recent thefts on the property threaten its continued safe usage for the program participants. See Attachment A for Program Project Request 4. Total Budget & Position Count: Total Program Budget: 396,033 OFF Total Program Position Count: 3.5 Total Agency Budget: 2,358,282.00 Total Agency Position Count: 23 5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: KU ALOHA OLA MAu Program Name: Hui Ho'ola O Na Nahulu O Hawai'i 5. Program Funding Sources (identify all sources of funding applied to this proeramt: Revenue Source FY15-16 Estimate Hawaii -Alcohol and Drug Abuse Department(ADAD) 234,071.00 Medicaid Managed Can. 125,000.00 Hawaii County 36.962.00 TOTAL: 396,033.00 A(tach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program The agency has been contracted by the Alcohol and Drug Abuse Division for services from the Hui program since inception of the Hui. In 2013, the Hui became accredited by CARF International, a pre -requisite by managed care to contract. Now the program can move forward and is eligible to receive managed care funding. The Hui staff are learning KO Aloha Ola Mau's agency's electronic health record and billing system. Once the staff learns the system and is proficient at using it. The agency will pay for the additional programming and licensing to be effectively connected with the larger organization. The program will then begin requesting authorization, providing services and billing managed care. Two managed care contracts are in place as soon as the electronic system is ready to be implemented. 7. Program Objectives Using County Nonprofit Grant Program Funds: The land is essential to teaching the program's curriculum and for the Haumana to integrate concepts of connection and conservation, relationship to the'aina and to each other and their spirituality especially in Hawaiian culture. The grant objectives will thus includes: 1. Purchase and set up the catchment and protective wall to provide access to water. 2. Install a fence and secure gate to prevent thieves from bringing their vehicles on to the land making stealing large items much easier. These objectives will results in creating a safe, appropriate place for cultural services: 1) Provide services at the Kapoho Center's site weekly for 100 persons per year. 2) Provide teachings through Kupuna and evidenced based curriculum by staff on self-awareness, Kuleana, Hawaiian values and mokuau'hau as well as planting, cultivation, etc. to 100 individuals per year. 3) 100% of these Individuals will participate in farming and learn 3 additional basic skills and knowledge about self -sustainability. 4) Outcomes will meet the State averages or higher. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: KU ALOHA OLA MAU Program Name: Hui Ho'ofa O Na Nahulu O Hawaii B. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i. e.' Number of clients served. worksfio05 ar r vents h,ld, volunteer h—, art. Oesrribe. be speclfi[.f Applicant Projected Results Catchment Construction Completed Fence and Gate Installation Finished Number of Haumana Served 100 Employed Pan time/Full Time _ _ No Arrest Since Discharge 84.7 % 927% No Substance use in 30 days prior - Followup 69,7% Stable Living Arrangement 89.3 % Attach additional pages as necessa, 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 156,884.00 6238,00 176424.00 6,238.00 Professional Fees Operations 128,056.00 145,515 00 Supplies 5.831.00 5,831.00 Equipment Other- Catchment for Kapoho Cultural Education Ctr. 25,063.00 25,063.00 12,150 00 12,150.00 Other: Fence & Gate for Kapoho Cultural Educ. Car, 24,812.00 24,812.00 _.—_. Other. Other. Other TOTAL 322.07200 396,033.00 36,962.00 'I( applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: KU ALOHA OLA MAU Program Name: Hui Ho'ola O Na Nahulu O Hawai'i io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 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): ❑ 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 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. January 20, 2015 Signature of Authoriz Person (specs title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: KU ALOHA OLA MAU Program Name: Hui Ho'ola O Na Nahulu O Hawai'i 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 — 2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Fazed 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 final payment. To register, go to hupWvendors.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 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 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 im2oct the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: KU ALOHA OLA MAU Program Name: Hui Ho'ola O Na Nahulu O Hawai'i 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all ¢rant funds received durine 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 htttp Z/wwwhawailcounty,Qov fn -nonprofit grant-Loinlsz on or about May 30 of the year the final 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 lune 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will impost the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. i Signature Au o1rized Person (specify title) v-e,si as" -r txQc..iiv e_ �ir«tur 01120/2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: KU ALOHA OLA MAU Program Name: Hui Hoi O Na Nahulu O Hawai'i 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES ApplicantCouncil Projected Results Proposed Projected Result Catchment Construction Completed Fence and Gate Installation Finished Number of Haumana Served 100 Employed Pail time/Full Time 64.7 % No Arrest Since Discharge 92,7% No Substance use In 30 days prior- Followup 697% Stable Living Arrangement 893% TABLE 11: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Othee Catchment for Kapoho Cultural Education Ctc $12,150.00 Other: Fence &Gate (or Kapoho Cultural Edon. Ctr. $24,812.00 Other: Other Other: TOTAL $36,962.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Attachment A This proposal is requesting the replacement of a water catchment, fencing around KCEC in Kapoho and a security gate. Replacement of a water catchment. The catchment is vital for the use of one acre of land in Kapoho, named the Kapoho Cultural Educational Center, owned by the agency and central to the Hui s success in using cultural approaches to address substance abuse. The request includes security measures to minimize the catchment from being stolen and the property vandalized. We are specifically requesting funds to purchase and install a cement water catchment, o chain link fence around the property, and o security gate preventing unwanted people and wild animals from entering the property. The land is a significant and core element of providing successful cultural services to help Haumana (meaning students in Hawaiian) recover and heal from devastating drug and alcohol addictions. Teaching them to plant, to respect the'aina, and practice conservation, perpetuates the culture and increases their sustainability as they demonstrate the values, skills, practices, and spirituality of the culture. This is what will sustain the teachings and long-term recovery. Healing for themselves and their families, teaching the next generations about responsible community life and culture, strengthens the ohana and community. The land is also owned by the agency as a gift by an ohana to help others heal, recover and restore their lives and ohana from this devastating illness. The property was blessed with a purpose and a gift meant to heal by its owners to KAOM-Hui. Without the practice, role models, and re -connecting to their spirituality that working on the 'aina provides, it is very difficult for Haumana in rural areas to integrate the knowledge learned and to truly understand the concepts and to change. Sitting in classes is insufficient for most Haumana. 90% of the population of substance abusers has histories of trauma and 2/3 of them have mental health issues. Interventions must be creative and experiential for Haumana transform their lives to those of purpose, responsibility, health and recovery. Access to water on the land in Kapoho, now a 20 minute drive from the Hui's facility, it can be a safety hazard for Hacri and staff who are also working the land. The use of weed -whackers, farming equipment, and restroom and cleaning functions highlight the need. In the interim, the staff has been bringing water to drink. Because gasrunequipment is utilized there is always a potential danger of accident or fire. Access to water is vital. The Kapoho land has a 16x16 pavilion where Haumana have practiced hula, have had community meetings, sharing lunches, overnight retreats, farming and graduation celebrations. Initially, in 2002, the federal government through the Center for Substance Abuse Treatment, provided funds to build the pavilion, catchment and restrooms when they heard that Haumana and staff were camping without electricity, water or restroom. The catchment eventually collapsed due to wear and tear in 2010. For "Live Aloha Day", organized by Kano Hawaii, a local non-profit organization selected Ku Aloha Ola Mau — Hui Ho'ma 0 Na Nahulu 0 Hawaii to Kokua in the need to install a new plastic water catchment Attachment A tank at Kapoho Cultural Educational Center. On lune 19, 2010, Kano Hawaii work crew of 20 volunteers arrived at the Center to install the catchment, Malama Aina to restore the Mala'ai, and to clear the overgrowth of grass and bushes. (Live Aloha Day was a statewide event in celebration and to honor sites in need of Kokua to care for the broader communities and people served. Hui Ho'ola felt honored to have been selected for Hawaii Island. The group of volunteers and Kano Hawaii knew the significance of the Hues approach with the'aina and were invested in the program to achieve sustainability. Up to this time, the Hui staff and haumana have been diligent about taking care of the land, and growing crops of taro, breadfruit, sweet potato, pineapple, etc. The catchment will be a 5000 gallon ferro, cement water catchment system built on the property. All materials and labor is included in the quote. Water cost will be $400. We are requesting fencing around the property, a security gate. Recently wild pigs have been digging up and destroying the crops grown by the Haumana who have painstakingly planted them. In the past neighboring horses also came on the property and also ate the fruits and vegetables from the garden which was quite disheartening. A concrete base on a 5 -foot high chain link fence for the one acre lot and 14 foot entry gate would prevent wild pigs or other animals from digging under or going over it. This will also discourage trespassers from destroying the property. Last year, the restroom was broken into and it sustained some damage. The materials, posts, supplies and labor for installation is included in the quote. When Iselle felled 15 albesia and ironwood trees which blocked the entry to the Kapoho Cultural Educational Center, Haumana and staff spent 40 hours to clear the trees to regain access to their beloved'aina. They expressed a great appreciation for caring for others beyond themselves; the values instilled and life restored for them. The road clearing also benefitted the residents who were also unable to access their homes and vice versa. The Haumana of the Hui are taught the value of reciprocity and the meaning of taking care of their communities. Ku'ikahi Mediation Center Community Conflict Resolution Services 91 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Resolution services Agency Director: Jure Mitchell, Executive Director Phone No.: ( 808) 935 — 7844 Contact Person: Julie Mitchell, Executive Director Phone No.: ( 808 ) 935 — 7844 Mailing Address: Address: 101 Aupuni street Address: Suite PH 1014 3-2 City, ST, Zip Hlla, HI 96720 Facility Address: Address: 101 Aupuni Street Address: Suite PH 10148-2 City, ST, Zip Hilo, HI 96720 Email Address: info@hawaiimediation.org Fax No.: ( 808) 961 — 9727 Accountant/CPA: Gretchen Kremeyer, CPA Phone No.: ( 808) 968 — 1002 Firm (if applicable): Carbunaro CPAs Associates Mailing Address: Address: P0eox4372 Address: City, ST, Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $12,000.00 Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua ❑ North Kona © South Hilo ❑ North Kohala ❑ South Kona © North Hilo ❑ South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises © Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application Agency Name: Ku'ikahi Mediation Center Program Name: community Conflict Resolution Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY2015-16 FY 12-13 FY 13-14 FY 14-15 $11,250.00 $5,000.00 $5,000.00 2. Agency Mission Statement: 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. 3. Program Description: Ku'ikahi is the sole non-profit mediation center serving East Hawai'i and 1 of only 5 in the state. Our agency helps individuals, families, organizations, businesses, schools, and others to find creative solutions to challenging situations. Mediation resolutions tend to be long lasting and help to improve relationships, promote understanding, and ultimately strengthen our community. Our mediation services are provided on an affordable sliding scale, with no one turned away for lack of funds. Over 50% of our mediation clients have annual household incomes of under $20,000. Last year, our foreclosure mediation program helped dozens of homeowners stay in their homes. Our large group facilitations assisted community organizations with sensitive issues. And our skills -building workshops taught community members how to communicate better, negotiate and resolve problems, and facilitate meetings. This year, we launched an exciting Peer Mediation Elementary School Pilot Project in East HawaPi. In peer mediation, students of the same -age group are empowered to mediate disputes between their classmates. 4. Total Budget & Position Count: Total Program Budget: s3i q,7sz Total Program Position Count: 5 Total Agency Budget: $3tq,762 Total Agency Position Count: 5 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Resolution Services 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Direct contributions 15,000 Foundationitrust grants 35,000 United Way contributions 10,000 County of Hawaii nonprofit grant 12,000 Hawaii state contracts Judiciary & attorney general) 172,762 Program fees mediation, facilitation & trainings) 40,000 special events 30,000 TOTAL: $314,7s2 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: 1) Hold more community workshops/trainings that are tuition -based. 2) Hold our third annual fund drive to solicit direct contributions. 3) Market our services to local businesses and community groups. 4) Research and apply for new and continuing grants from foundations. 5) Cultivate strategic partnerships and community collaborations. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Provide low- or no -cost mediation and facilitation services to self-, community-, and court -referred clients. 2) Offer a critical alternative to litigation. 3) Provide conflict resolution education to mediators and community members. 4) Expand the Peer Mediation Elementary School Pilot Project. 5) Promote peaceful solutions in East Hawai'i. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Resolution Services 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES fi.e.: Nurnberofclients served, workshops ar events held, volulls, hours, etc 0esvibe, be specific) Applicant Projected Results # of mediation cases opened 400 # of mediation clients served (cases closed) Boo # of mediation sessions held 250 # of mediator volunteer hours donated 800 %of clients who are satisfied with mediation 90 of clients who would recommend mediation 90% # of peer mediators trained in schools 140 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FV 14-15 Actual' FY 15-16FV Total eudget 15-I6 Grant Req Salary and Wages 205,789 210,000 8,000 Professional Fees 15,580 16.000 1.000 Operations 65,170 66,900 2,000 Supplies 10,290 11,362 1,000 Equipment 2,400 2,500 0 Other: Special events 7,984 8,000 0 Other: Other: Other: PLEASE NOTE: FY 14-15 figures are estimates Other: since we are only 7 months into the FY TOTAL $307,213 $314,762 $12,000 If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Resolution Services lo. 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 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): ❑ 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: ❑d If no conflicts exist, check here. I �GJJ Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 ,12920,5 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Resolution Services ll. Certification of Understanding (Paget of z) 1 (we) have read and understood all of the 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 final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency s future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Resolution Services 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 301" 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-for-5/ on or about May 30 of the year the final 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. pp J�IrI �y/ I12 Signa re f Authorized Person (specify title) 1/29/2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Ku'ikahi Mediation Center Program Name: Community Conflict Resolution Services 12. COUNCIL AWARD WORKSHEET TABLE 1• PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result # of mediation cases opened 400 # of mediation clients served (cases closed) 800 # of mediation sessions held 250 # of mediator volunteer hours donated 800 %of clients who are satisfied with mediation 90% %of clients who would recommend mediation 90% # of peer mediators trained in schools 40 TABLE II: PROGRAM EXPENDITURES FY 35-16 Grant Request Council Award Salary and Wages 8,000 Professional Fees 1,000 Operations 2,000 Supplies 1.000 Equipment 0 _ Other: special events 0 Other: Other Other PLEASE NOTE: FY 14-15 figures are estimates Other: since we are only ] months into the FY TOTAL $12,000 Additional Council directives regarding award: EXHIBIT B NONPROFITGRANT APPLICATION FY 2014-2015 Page 8 of LaiOpua 2020 Sustainability From Soil to Soul 0-1 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Laiopua 2020 Program Name: SOS - sustainability From Soil to soul Agency Director: Craig-WKahui Phone No.: ( 806) 327 — 1221 Contact Person: Daisy Mi 611 Phone No.: ( 806) 960 — 3966 Mailing Address: Address: 76-5599 Whia street, AE -5 Address: City, ST, Zip Kallua-Kana, Hawaii, 96760 Facility Address: Address: Keilskehe High school Address: 74sco0 Puohulihuli streat City, ST, ZIP Kailua-Kana, Hawaii 96740 Email Address: Fax No.: ( 008) 327 — 1223 Accountant/CPA: Isaac sylva Phone No.: (floe) 3n — 1221 Firm (if applicable): Mailing Address: Address: 74s599Luhl street, eE-5 Address: City, ST, Zip KaOua-Kone, Hawaii 96740 YOU ARE RESPONSIBLE TO KEEP THEABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more an be checked) ❑ Puna ❑ H3m2kua 0 North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'D Services or Acttvitles To Be Provided: (One or more an be checked) 0 Educational concerns [✓] youth ❑ victims of Crimes ❑ Culture and the arts ❑ Aged ❑ victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015.7016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: LaiOpua 2020 Program Name: SOS - Sustainability From Soil to Soul 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12.13 FY 13-14 FY 14-15 none none none 2. Agency Mission Statement: To identify community needs, foster the creation of community facilities, and coordinate planning with service providers and partners for a variety of programs for residents of the Villages of LaiOpua and broader West Hawaii Region. 3. Program Description: Retrofit and revitalize the aquaponics and hydraponics farm at Kealakehe High School, in order, to engage 6% of the youth population at the high school to attend workshops on how to build, produce, and maintain a aquaponic and hydroponic system. The product of the program would be sold to surrounding communites, such as, the Villages of LaiOpua, and possible store vendors in efforts to help offset food expense. Most important, this program is intended to offer the students at Kealakehe High School and community stakeholders, which, will produce an outcome, such as reduce food expense, which, will generate savings, increase disposal income, which may be applied towards education, athletics, performing arts, and household expenses. 4. Total Budeet & Position Count: Total Program Budget: $601,000 Total Program Position Count: 1.5 Total Agency Budget: $16,0001 Total Agency Position Count: 3 EXHIBIT A NONPROFIT GRANT APPLICATION FY 20152016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: LaiOpua 2020 Program Name: SOS - sustainability From Soil to Soul 5. Program Funding Sources (identify pit sources of funding applied to Will program); FY15-16 Revenue Source Estimate TOTAL: Attach 6. Explain what plans your agency or program has to Increase revenues to support this program: Our agency plans, include, food production to offset the continued funding for the program. Potential sales to KTA Superstores and Villages of LaiOpua Homstead will recycle back to the program. The food production projection is estimated 800 lbs per month. Sales estimated at $2.00 per pound. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Retrofit/Revitalize the Hydroponic and Aquaponic farm at Kealakehe High School. 2. Provide workshops for our highschool youth and families from surrounding communities, about aquaponics and hydroponics system for on-going food production. 3. Engage the community to take ownership through a volunteer program and assist with food production to help offset monthly food expense. 4. Collaborate with the culinary arts program at Kealakehe High School to host a non-profit, in-kind, salad bar at the cafeteria to promote healthy food choices. 5. Market and sell produce in order to generate revenues to sustain the farm fiscally. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: LaiOpua 2020 Program Name: SOS - sustainability From soil to soul 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURESI Applicant Projected Results (l.e:Numberofclients served, venuhapsarevero)eld, volunteerhours, etc. pescdbe, hesped/k.) 156 month 9 TABLE II: PROGRAM EXPENDITURES FY 1415 Actual• FY 15-16 Tonal Budget FY 15-16 Grant Req Salary and Wages 0 0 0 Professional Fees 0 3000 3000 Operations 0 4793 4793 Supplies 0 12836 12836 Equipment 0 6486 6488 other: Independent contractors 0 29010 29010 Other: 0 0 0 Other: 0 0 0 Other: In-kind Donations 0 6000 6000 Other! In -Kind Omatons o -6000 -6000 TOTAL 0 56125 56125 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Laiopua 2020 Program Name: SOS - Sustainability From soil to Soul lo. 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 membersofthe Council Staff appointed by a member of the Council �I The Mayor F-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 measuroble 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 uthorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: LaiOpua 2020 Program Name: SOS - Sustainability From Soil to Soul 11. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 final payment. To register, go to http•//vendors ehawail.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 Hawal'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit d, complete,and accurate year-end report. „dna the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: LalOpua 2020 Program Name: SOS - Sustainability From Soil to Soul 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 3011 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 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-nont)rofit-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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements Signature Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: LaiOpua 2020 Program Name: SOS - Sustainability From Soil to Soul 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of Clients Served 156 Volunteer Hours (in-klyd,student.community) 10 In. Workshops min 1 mo. Supplies 12836 Equipment 6486 Other: Independent Contractors 29010 Other: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees 3000 Operations 4793 Supplies 12836 Equipment 6486 Other: Independent Contractors 29010 Other: Other: Other: In -Kind Donations 6000 Other: In -Kind Dornnons '6800 TOTAL 561251 Additional Council directives rejtardinjt award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2035 Page 8 of 8 Legal Aid Society of Hawaii Legal Pathways to Self -Sufficiency 93 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Legal Aid Society of Hawaii Program Name: Legal Pathways to Self -Sufficiency Agency Director: M. Nalanl Fuiimon Koine Phone No.: ( 608) 521 — 8014 Contact Person: Joanna Sokolow, Managing Attorney Phone No.: ( 808 ) 329 — 3910 Mailing Address: Address: 924 Botha[ Street Address: City, ST, Zip Honolulu, HI 96813 Facility Address: Address: 75-5656 Kuakini Hwy, Ste 202, KailuaKona, HI 96740 Address: 305 Wailuki Drive, Hilo, HI 96720 City, ST, Zip Email Address: Joanna.aokolow@10galaidhawanarg Fax No.: ( 808) 334 — 9650 Accountant/CPA: Wayne Kri comptroller Phone No.: ( 808) 527 — 8060 Firm (if applicable): Mailing Address: Address: Legal Aid Society or Hav,u Address: 924 Bethel Street City, ST, Zip Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $40,000.00 Geographical Areas To Be Served: (One or more can be checked) © Puna © Hart © North Kona © South Hilo © North Kohala © South Kona © North Hilo © South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts © Aged © Victims of Health or Social Crises © Needs ofthe poor © Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Legal Aid society of Hawaii Program Name: Legal Pathways to Self -Sufficiency 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 1 FY 13-14 1 FY 14-15 $30,000.00 1 $20,000.00 $20,000.00 2. Agency Mission Statement: Legal Aid Society of Hawaii (Legal Aid)'s mission is to address critical legal needs through high quality legal advocacy, outreach and education in the pursuit of fairness and justice. Legal Aid, a community-based, non-profit law firm, has empowered low-income and disadvantaged people throughout our state for nearly 65 years. It is the only legal service provider in the state, and one of the few non -profits with statewide coverage through ten offices on each of the islands, from Lanai to urban Honolulu. Legal Aid has two offices on the island of Hawaii. Hilo's office was established in the 1950's and the Kona office opened its doors in 1979. Both offices are a vital part of their communities, providing free legal assistance to low-income individuals and families in the areas of consumer, family, public benefits, housing, and elder law cases. 3. Program Description: Legal Aid requests $40,000 in funding to continue to provide critical civil legal services in the Hilo and Kona offices ($20,000 allocated to each office). In addition to addressing critical legal needs, Legal Aid will take the additional step of providing individualized, holistic poverty exit strategies to lead our citizens to self-sufficiency. Examples include: additional legal services to seek judgments for monies owed, applications for Federal Social Security benefits, and enforcement of child support; but also providing personalized information and referrals for e.g., vocational services, community college applications, internships, GED, English language classes, etc. This additional step benefits the community and the County on the whole, by ending the cycle of poverty. As the demand for Legal Aid's services increases, the organization continues to face reductions in funds from major funding sources. Legal Aid needs support to continue to provide access to justice for Hawaii s most vulnerable individuals and families. Legal Aid is the only provider of free legal services to those populations in all of Hawaii County. See Continuation Page 1. 4. Total Budget & Position Count: Total Program Budget: I s4o,000 Total Program Position Count: I Total Agency Budget: 1 $7,375,191.00 Total Agency Position Count: tos EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Legal Aid Society of Hawaii Program Name: Legal Pathways to Self -Sufficiency S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Hawaii Island United Way $5,000.00 Judicial -Guardian Ad Litem $4$000.00 Hawaii County Office of Aging -Title III -E $85,290.00 State of Hawaii - Domestic Violence, Disability $215,553.00 Weinberg Foundation Seniors Grant $50,000.00 Hawaii County Nonprofit Grant Program $20,000.00 Total from Continuation Pages $321,329.00 TOTAL: $745,172.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Legal Aid continues to apply for Federal, State, and other grants to provide services to low-income individuals and families in need. 7. Program Objectives Using County Nonprofit Grant Program Funds: Under this grant in FY 2015-16, Legal Aid will provide screening, intake, counsel & advice, brief services and/or full representation in 75 cases. The services will be provided free to low-income individuals and families whose incomes are less than 125% of the poverty level. See attached continuation page 1 for breakdown of cases per individual subject area. In addition, upon completion of the critical legal assistance requested, Legal Aid will screen each client for additional legal or other services to put that client on the pathway to self-sufficiency, providing an individualized plan/referrals/additional legal services to that end. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Legal Aid Society of Hawaii Program Name: Legal Pathways to Self -Sufficiency 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e. Number oftlients served, workshops or events held, rolunteer hours, on, aettribe, be specific) Applicant Projected Results Support for families 26 cases Keeping Children Safe and Secure 3 cases Preserving the Home 15 cases Maintaining Economic Stability 16 cases Protecting Consumers 3 cases Promoting Safety, Stability, and Health 12 cases $116,417.00 $4,500.00 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 1415 Actual" FY 15-16 Total Budget FY 15-I6 Grant Req Salary and Wages 1$7,500.00 $611,430.00 $35,500.00 Professional Fees $10,938.00 Operations $2,500.00 $116,417.00 $4,500.00 Supplies $12,700.00 Equipment $7,400.00 Other: Other: Other: Other. Other: TOTAL $20,000.00$758,884.00 $40,000.00 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Legal Aid Society of Hawaii Program Name: Legal Pathways to Self -Sufficiency >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 ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel conflict of Interest is defined as: o 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: ❑✓ If no conflicts exist, check here. M oiaiiomTw Vi Afi i �at�A Signature of Aut rued Per n(specify title) �X�,G- �'�\yAVV EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 1/2312015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Legal Aid Society of Hawaii Program Name: Legal Pathways to Self -Sufficiency 11. Certification of Understanding (Paget 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 final payment. 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 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 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 reportusing the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Legal Aid Society of Hawaii Program Name: Legal Pathways to Self -Sufficiency 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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, 2015 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 reauest and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements MVW,b1^11 I+MWI�\UA 1/23/2015 rso Signature of Authorized n(spe ytitle) eG.l, \\Uq-16kyttA.—Y Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Legal Aid Society of Hawaii Program Name: Legal Pathways to Self -Sufficiency 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Projeectedcted Results Council Proposed Projected Result Support for Families 26 cases Keeping Children Safe & Secure 3 cases Preserving the Home 15 cases Maintaining Economic Stability 16 cases Protecting Consumers 3 cases Promoting Safely, Stability, and Health 12 cases Other: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $35,500 Professional Fees Operations 54,500 Supplies Equipment Other: Other: Other: Other: Other: TOTAL $40,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Legal Aid Society of Hawai i Project Name: Legal Pathways to Self -Sufficiency 3. Program Description (Continued) According to the 2013 American Community Survey, more than 19.50% of Hawai'i's population lives below 125% of the federal poverty guidelines and is eligible for Legal Aid's services based on their income. Through this grant Legal Aid will provide critically needed legal services, community education and outreach services to: • Maintain or secure affordable housing • Help families become safe and stable with family law services, including protection from domestic violence, child custody and support • Protect families and individuals from a consumer problems such as mortgage "rescue" scams or illegal debt collection practices Obtain public benefits such as disability benefits from the Social Security Administration or Medicaid • Eliminate barriers to being homeless • Secure appropriate placement and services for abused and neglected children • Provide critical legal services to assist immigrants and those in need of language access. 5. Program Funding Sources (Continued) Revenue Source FY15-16 Estimate Federal Funding $245,529.00 State of Hawaii Attorney General Foreclosure Settlement Grant $20,000.00 Indi ent Legal Assistance Fund $44,800.00 Fee for Service $11,000.00 Subtotal $321,329.00 Grand Total $745,172.00 7. Program Objectives (Continued) Breakdown of projected number of cases per subject area: 1. Provide support for families (26 cases): Assist clients with child custody, child support, domestic violence, visitation, divorce, property division and in some cases ex -military spouse issues. A domestic violence victim may require assistance in obtaining a temporary restraining order or establishing temporary custody, visitation, and support. Paternity cases are accepted to determine custody, visitation, and child support rights and obligations. Continuation Page 1 of 3 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Legal Aid Society of Hawai i Project Name: Legal Pathways to Self-Sufficiency 2. Keeping children safe and secure (3 cases): Provide guardians ad litem services for abused and neglected children; assist with guardianships and adoptions; and advise family members and others about their rights and responsibilities in caring for abused and neglected children. 3. Preserving the home (15 cases): Assist clients with private landlord eviction defense or negotiation; foreclosure assistance; mortgage predatory lending practices, housing discrimination; public housing applications, evictions, grievances, rent issues, and security deposits; and, habitability, repairs, illegal lockouts, or illegal utility shutoff. 4. Maintaining economic stability (16 cases): Provide assistance with denials, appeals and terminations of SSI, General Assistance, Temporary Assistance for Needy Families (TANF), SNAP (flea Food Stamps) and other public benefit programs. Unemployment and Veteran's benefits are also areas in which assistance is provided. Public benefits may be the only source of income for an individual or family. 5. Protecting consumers (3 cases): Assist clients with consumer issues including predatory lending, debt collection, bankruptcy, consumer credit matters, repossession, and unfair or deceptive practices. 6. Promoting safety, stability and health (12 cases): Provide assistance with program denials of services or eligibility as well as terminations from the health insurance programs, district court restraining orders, individual rights, immigration, powers of attorney and advance health care directives. Program Highlights In FY2013-14, the Hilo and Kona offices closed more than 1,384 cases, assisting individuals and families on the island of Hawaii with their civil legal needs. Because of the lack of affordable legal services in Hawaii County, without the assistance of Legal Aid, many of these individuals' cases could result in homelessness, abuse of a child or domestic violence victim, or financial instability. The impact of Legal Aid's services upon the community is best exemplified in client testimonials: "They are very understanding, respectful, and they put all their effort into helping YOU." "It is amazing. My lawyer had integrity, was extremely knowledgeable and kept me informed throughout the whole process. I appreciate her more than she knows." "No matter how big or small or what and how difficult your situation may be, if your [sic] looking for excellent outstanding professionalism, call [Legal Aid Paralegal's name]." "Legal Aid has been my life saver." Continuation Page 2 of 3 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Legal Aid Society of Hawai i Project Name: Legal Pathways to Self -Sufficiency "Never lose hope. Legal Aid [Legal Aid Attorney's name] will do all in her power to make sure the appropriate action is taken. I am proud to say that being a client of Legal Aid helped me to get my child back." "After getting help from Legal Aid now I understand and know Legal Aid is helping hands for Hawaii." "The staff is very helpful, efficient, courteous and I am very grateful for this service. Thank you." "I highly recommend Legal Aid." "The staff at Legal Aid will do everything they can to help you. They sure did for me and my family!!" "This is the second time I have had help from Legal Aid and each time I thank the Lord God for this service. Please continue to help people that otherwise couldn't afford this service." Continuation Page 3 of 3 Lokahi Treatment Center Adolescent Substance Abuse Treatment Program M County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Lokahi Treatment Centers Program Name: Adolescent Substance Abuse Treatment Program Agency Director: Dr. Jamal F. wasan, CEO Phone No.: ( Bos) 695 - o44a Contact Person: Carol Matayoshi. Grant Programs Administrator Phone No.: (808)936 — 9328 Mailing Address: Address: 400 Hualam St., Bldg, 10, Suite 1956 Address: City, ST, Zip Hilo, HI 96120 Facility Address: Address: 400 Hualani St., Bldg. 10, Suite 1956 Address: City, ST, Zip Hilo, HI 96120 Email Address: cmatayoshi@IokahitmaMentcenteisnet Fax No.: ( 606) 969 — 1331 Accountant/CPA: CaroonarocPAs Phone No.: ( 606) 930 — 6650 Firm (if applicable): same alai Mailing Address: Address: P.O. B. 4312 Address: City, ST, Zip Hilo, HI 96120 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (one or more can be checked) ✓❑ Puna ❑ Hari ❑ North Kona ✓❑ South Hilo ❑ North Kohala ❑ South Kona ❑✓ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ✓❑ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑✓ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Lokahi Treatment Centers Program Name: Adolescent Substance Abuse Treatment Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 1 FY 13-14 FY 14.15 $0.00 $0.00 $0.00 2. Agency Mission Statement: Lokahi Treatment Centers' (hereinafter referred to as *LTC') mission is to provide the highest quality mental health and substance abuse treatment services that are culturally appropriate to Big Island adults, adolescents, and chiklren. 3. Program Description: The Adolescent Substance Abuse Tim. art Program receives referrals from various sources (i.e., schools, Teen Court, Juvenile Probation, Chltd Welfare Services, etc.) and provides the following substance abuse treatment services for adolescents, aged 12 to 17 years: 1. Substance abuse assessments; 2. Drug testing; 3. Intensive Outpatient Program (IOP), which uKludes a two hour group session three times weekly; 4. Limited IOP, which incudes a two hour group session two ImISe weekly; 5. Out- patient Program (OP), which includes a two hour group session once a week; 6. Aftercare Program, which includes a two hour group session every other week or as needed; 7. Individual Counseling (IC) as needed. LTC is accredited for treatment of the special population of children and adolescents. We utilize three (3) evidence based Hazelden program models; Hazelden is one of the world's largest and most reepec[ed private non-profit alcohol and drug addiction centers. The three models are Adolescent Recovery Program, Teen Invention, and Adolescent Co-occuning Disorder Sanas. The Adolescent Recovery Program is a comprehensive intensive outpatient treatment program that utiles cognifive-behavioral therapy in four phases: 1. Accepting responsibility; 2. Deciding to make a change; 3. Making important charges; 4. Preventing relapse. Teen Intervention is specifically designed for teenagers, aged 12-19, who are involved in the early stages of alcohol and drug abuse and encourages parental or guardian participation. Adolescent Co-occurring Disorder Series is designed to assist in treating substance abusing adolescents exhibiting symptoms of other behavioral problems that may interfere with their recovery, 4. Total Budget & Position Count: Total Program Budget:$65,000.00 Total Program Position Count: 3 Total Agency Budgat: $1,064,395.79 Total Agency Position Count: 25 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Lokahi Treatment Centers Program Name: Adolescent Substance Abuse Treatment Program s. Program Funding Sources (identify all sources of funding applied to this program) FY15-16 Revenue Source Estimate Managed Core eillkg 7$65.000.00 — E TOTAL: r $65,000 oo Attach addhionelpages, if needed 6. Explain what plans your agency or program has to increase revenues to support this program: LTC's plan is to secure funding to pay for rant and utilities for a larger space, which will enable us to run two group sessions simultaneously for up to twelve adolescents in each group. If we can obtain funds to Pay for these expenses for one year, we hope to get a "haw Starr and become self -sustainable thereafter through managed care billing. 7. Program Objectives Using county Nonprofit Grant Program Funds: Curte dy, our Adokscant Substance Abuse Program in Hilo(East Hawaii has 6-8 par8dpants. Due to the small size of the group room, we are unable to accommodete a larger group. The Program objeclim for the use of County Nonprofit Grant Program funds is to sawn a larger ofice space with two group rooms that can hold up to 12 participants each. This will allow LTC to hold two groups simultaneously and increase the number of adolescents served from 8 at any given time to 24. As each complete session is 12 weeks, we can hold 4 sessions in one year. The larger space will allow us to increase the number of adolescents served from 32 to 96. The larger space will also allow us to host a motivational speaker to come and speak to each group. We have several former substance users who are able to share powerful stones of addiction, relapse, and recovery. These real life stories make a great and lasting impression on our young people. Furthemgre, the larger number of participants will enable us to sponsor one community pmjecl, such as an environmental dean up, per group. This will give the adolescents a Sellae of accomplishment and connection to the community. We would also like to provide our adolescents with healthy snacks. We find that they are very hungry during the group times, which occur after school. Due to the expense of healthy snacks, they have been eatlng snacks that are high in sodium and saturated fat. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Lokahi Treatment Centers Program Name: Adolescent Substance Abuse Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? Le&PRuOrvGe4RwAMrlsMPpEr RarFeOwRmMsbeAWN, vCdEuMEArnx,be+ceaPclSURES a tuna PtltaM Projected Results Increase number of diene served from 32 18 diem x 4 sessions) to 96 (24 diems x 4 sessions) 96 cients eerved in one year sponsor Pour (4) community projects (i.e., beach or park dean up) —one (1) per session Host four (4) motiva8wral speakers for Leers witll suDstsnra use Pmdermabna (1) per sesspn 4 commun" M Projects s heated 4 motivatbnal speakers hoped 9nndae &r � M! Professional Fees t fluids aX IKac h ddlt 1 Pages os necessary. 9. TABLE It: PROGRAM EXPENDITURES 15 Actual• �ss16 Total BudBat FY 15-16 Gars Rey Salary and Wages Professional Fees Operations Supplies Equipment Other: Rent—$1,198.18monthlyxl2months=$14,378.16 $14,378.16 $14,378.16 Other: Utilities (eieahidtY, water, cable/intemet) $300 month x 12 months= $3,600 $3,800.00 $3,600.00 Other: Healthy snacks (i.e., fruits, sandwiches, luice) $100week x 52weeks=$5,200 $5,200.00 $5,200.00 Other: Other: TOTAL $23,178.16 $23,178.16 'R applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Lokahi Treatment Centers Program Name: Adolescent Substance Abuse Program io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by 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: Donna Gueipo is Lokahi Treatment CentersHuman Resource Director; she is based in our Waikoloa office. Her sister is Councilmember Valerie Poindexter. ✓❑ If no conflicts exist, check here. CE0 / f January28,2015 SP(.w �' Sign re of Authorized Person (specify title) I t `� Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Lokahi Treatment Centers Program Name: Adoloescent Substance Abuse Treatment Program ii. Certification of Understanding (Page t of z) 1 (we) have read and understood all of the 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 final payment. To register, go to http://vendors.ehawaii gov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end report using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBITA NON PROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Lokahi Treatment Centers Program Name: Adolescent Substance Abuse Treatment Program 21. 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 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 hh,tp:f/www hawaiicounty gov/fn-no profit -grant -forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in o timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements GEA /QJanuary 28, 2015 /, reSl�cn� SignatU re of Authorized Person (specify title Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Lokahi Treatment centers Program Name: Adolescent Substance Abuse Treatment Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant ICouncil Proposed Projected Results I Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies . Equipment Other: Other: Other: Other: Other: TOTAL: Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Pages of8 Malamalama Waldorf School Hui'Ano'Ano Parent/Child Development 95 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Hui'Ano'Ano Parent/Child Development Agency Director: Kelley Lacks. School Director Phone No.: ( 808) 982 — 7701 Contact Person: Kelley Lacks, School Director Phone Ni ( 606) 962 — 7701 Mailing Address: Address Hca Box 13068 Address: City, ST, Zip Kea au. HI 96749 Facility Address: Address. HC 3Box 13068 Address: City, ST, Zip Kea au. HI 96749 Email Address: Kelley@hawailwaldort.org Fax No.: ( e08) 982 — 7806 Accountant/CPA: Ron Dolan Phone No.: ( 809 ) 986 — 5433 Firm (if applicable): CPA aAssodates Mailing Address: Address. 16Raoroad Ave Address: City, ST, Zip Hilo. HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) Q Puna ❑ Hamakua ❑ North Kona © South Hilo ❑ North Kohala ❑ South Kona © North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) d❑ Educational concerns ❑x/ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor Q Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page S of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Hui'Ano'Ano Parent/Child Development 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 2. Agency Mission Statement: The mission of Malamalama Waldorf School (MWS) is to improve the quality of the educational experience by providing Waldorf Education in East Hawaii. 3. Program Description: MWS seeks to provide guidance and instruction to parents/caregivers & children ages 1-3. Groups meet 2 days per week for 2-3 hours in six week blocks. In keeping with Waldorf educational philosophy, teachers provide an example of a rhythmic, structured day that parents are encouraged to incorporate into the routines of family life, providing parents & children with healthier home environments that are appropriate for their child's development. Teachers and parents cooperate in purposeful activities and modeling, which inspire the children in their play. Special attention is given to supporting the child's interests, motor development, social interactions, and problem -solving skills. Through reading and discussion, parents gain an understanding of ways in which seeds planted in early childhood blossom in later years. Teachers answer questions and make recommendations for parents. 4. Total Budget & Position Count: Total Program Budget: 121,000co Total Program Position Count: j a Total Agency Budget: $686,668.00 Total Agency Position Count: I23 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Hui'Ano'Ano Parent/Child Development 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Course Fee ($300/6 -wk Block', 30 Fam/Block. 5 Blocks) $45,000.00 Hawaii County Grant $13,500.00 Other Grants (Private Foundation & Corporations) $46,000.00 In -Kind $16,500.00 TOTAL: $121,00000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This is the first year of the Hui 'Ano 'Ano Parent/Child Development Program and therefore will incur some initial start-up costs, expenses are expected to be lower in subsequent years due to this fact. Malamalama Waldorf School plans to continue increasing revenue through additional grant funding source, as well as consider future expansion in duration and number of blocks offered each year. 7. Program Objectives Using County Nonprofit Grant Program Funds: MWS objectives: 1) Offer education/development classes to parents/caregivers and their children, 2-3 hours per day, 2 days a week 2) Enroll 30 parent child participants per 6 -week block 3) Offer five 6 -week blocks coinciding with the 2015/2016 "school year" 4) Parents will establish a rhythm with their day to better support their child's development 5) Under the guidance of teachers, parents will gain understanding of child development and behavior modeling 6) Educate parents in early child development, provide them with tools for success, increase parenting practices & confidence EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application Agency Name: Malamalama Waldorf School Program Name: Hui'Ano'Ano Parent/Child Development FY2015-16 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Number of II, I, served workshops or eve,t, h0s,, volunteer hours, etc. 01,11;6, be,pllif, Applicant Projected Results Parents feeling supported 100% _ Parent satisfaction for safe/nurturing enviro 100% Increased parent and child confidence 100% Parents implementing practices in home 100 Re -enrollment in the program 100% _ _ Parent referrals _ 100% 100% Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 71,000 4,000 Professional Fees 9,000 1,000 Operations27,000 1,000 Supplies 5,000 2,500 Equipment----_--_--�-_ ------_ ----9,000 5,000 Other. Other: Other: Other: Other. TOTAL 121,000 13.5001 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Hui'Ano'Ano Parent/Child Development to. 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 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): ❑ 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 asa 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: `nQ If no conflicts exist, check here. hi/ ,, ,f x�tt i'�/�.�✓;t/(--�'!-lct-7 eir6,[= ) / 5' nature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Hui'Ano'Ano Parent/Child Development 11. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 final payment. To register, go to http://vendorsehawaii.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 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 o timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Hui'Ano'Ano Parent/Child Development ti. 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 priorto 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 hUP /h,vwwhawai icounty.goy/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, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in o timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Amt orized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application Agency Name: Malamalama Waldorf School Program Name: Hui'Ano'Ano Parent/Child Development 12. COUNCIL AWARD WORKSHEET TABLE I: FY2015-16 PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Parents feeling supported 100% Parent satisfaction for safe/nurturing enviro 100% Increased parent and child confidence 100% Parents implementing practices in home 100% Re -enrollment in the program 100% Parent referrals 100% Other: 100% TABLE It: PROGRAM EXPENDITURES FV 15-16 Grant Request Council Award Salary and Wages 4,000 Professional Fees 1,000 Operations 1,000 Supplies 2,500 Equipment 5,000 Other. Other: Other. Other: Other: I TOTAL 13,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Malamalama Waldorf School Puna Arts in the Park Program M County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Program Agency Director: Kelley Lacks. School Director Phone No.: ( 908) 982 — not Contact Person: Kelley Lacks, School Director Phone No.: ( 808 1982 — not Mailing Address: Address. He 3 Box 13068 Address' City, ST, ZIP Kea au. HI 96749 Facility Address: Address. He 3 Box 13068 Address. City, ST, Zip Kea an HI 96749 Email Address: Kelley@hawailwaldortorg Accountant/CPA: Ron Dolan Firm (if applicable): CPA& Associates Fax No.: ( 808) 982 — Phone No.: ( 808) 935 — 7806 5433 Mailing Address: Address: 16 Railroad Ave Address: City, ST, Zip Hilo. HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds Geographical Areas To Be Served: (One or more can be checked) ❑/ Puna ❑ Hamakua ❑ North Kona South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑,/ youth ❑ Victims of crimes ✓❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page I of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 Total Program Position Count: 1 $5,200.00 $15,000.00 2. Agency Mission Statement: The mission of Malamalama Waldorf School (MWS) is to improve the quality of the educational experience by providing Waldorf Education in East Hawaii. 3. Program Description: MWS seeks to provide intersession and summer enrichment programs in East Hawaii to students grade 1-6. MWS will offer these enrichment programs during school breaks and summer. The programs are designed to encompass all students in the greater Puna area to provide them with arts and sciences educational enrichment through interactive activities, guest specialists, and fieldtrips. 4. Total Budget & Position Count: Total Program Budget: $48,200.00'' Total Program Position Count: 1 8 Total Agency Budget: $686668.00 Total Agency Position Count: 23 EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application AgencyName: Malamalama Waldorf School Program Name: Puna Arts in the Park Program FY2015-16 S. Program Funding Sources (identify all sources of funding applied to this program): F— Revenue Source FYIS-16 Estimate Tuition ($6Wsludent/week x 8 weeks), 50 students $24,00000 Hawaii County Grant $15.000.00 Other Grants (Private Foundation & Corporations) $9,200.00 TOTAL: $48,200.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Malamalama Waldorf School plans to continue increasing revenue through increased enrollment tuition to full capacity of 60 students, and through additional grant funding sources. 7. Program Objectives Using County Nonprofit Grant Program Funds: MWS objectives: 1) Enroll an average of 50 students for intersession and summer programs 2) Approximately 50 students per program day will participate in art and science instruction with local professionals 3) MWS will employ two local art/science professionals per week to provide instruction EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e-: Number ofchents served, workshops or events held, volunteer hours, etc. Desnbe, be specific) Applicant Projected Results Participation in new art experience 100% _ Participation in new science experience 100% Participation in daily exercise 100% Interaction with local artists and scientists 100% Meeting new friends 100% Parent satisfaction for safe/nurturing enviro Re -enrollment in future programs 100% 100% Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual* FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 32,000 4,800 Professional Fees 4,000 1,000 Operations 4.000 4,000 Supplies 4.400 4,200 Equipment 3.800 1,000 Other Other. Other Other Other. TOTAL 48.200 15,000 *If applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Program io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by 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: D If no conflicts exist, check here. r / "�1%�(`. rlLzLOu?I'C°It. ls'� Sign ture of Authorised Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 — 2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to final payment. 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 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 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 oaency s future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Program 11. Certification of Understanding (Page 2of2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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 lune 3011 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 hr wA �% ha a. aLmty gav/fr nonprofit-zrant 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. i Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Puna Arts in the Park Program 12. COUNCIL AWARD WORKSHEET TABLE I PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Participation in new at experience 100% Participation in new science experience 100% Participation In dally exercise 100% Interaction with local artists and scientists 100% Meeting new friends 100% Parent satisfaction for safe/nurturing enviro 100% Re enrollment in future programs 100% TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 4,800.00 Professional Fees 1,000.00 Operations 4,000.00 Supplies 4,200.00' Equipment 1,000.00 Other. --- Other. Other Other Other TOTAL 15coo.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8 of Malamalama Waldorf School Puna Off The Streets Grade Aftercare 97 0 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Malamalama Waldorf School Program Name: Puna Off The Streets Grade Aftercare Agency Director: Kelley Lacks. School Director Phone No.: (808982— 1101 Contact Person: Kelley Lacks. school Director Phone No.: ( 808) 982 — 7791 Mailing Address: Address'. HC 3 Box 13068 Address: City, ST, Zip Kea'au. H196749 Facility Address: Address: HC 3 Box 13068 Address: City, ST, Zip Kea au HI 98749 Email Address: Ke1hey@hawaiiwaldorror9 Accountant/CPA: Ron Dolan Firm (if applicable): CRAlleackolas Fax No.: ( 808) 982 — 1806 Phone No.: ( 808 ) 935 — 5433 Mailing Address: Address: 16Raoroad Ave Address: City, ST, Zip Hilo, HI 96120 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds Geographical Areas To Be Served: (One or more can be checked) ❑/ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Kau Services or Activities To Be Provided: (One or more can be checked) ❑t/ Educational concerns ❑d Youth ❑ Victims of Crimes ❑t/ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Puna Off The Streets Grade Aftercare 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 2. Agency Mission Statement: The mission of Malamalama Waldorf School (MWS) is to improve the quality of the educational experience by providing Waldorf Education in East Hawaii. 3. Program Description: MWS seeks to expand its aftercare program to include students 1-6 from neighboring schools in East Hawaii that lack a program of their own. MWS will offer this program Monday -Friday immediately following regular school hours until 5pm. The program is designed to provide a safe and nurturing place for students after school. The program is designed to continue enrichment through engaging students in interactive play, art projects, exercise, and nature exploration. MWS aftercare also offers a healthy and nutricious meal to students. MWS also seeks to increase playstrucutres and musical enhancement opportunities with the purchase of new equipment over the next 5 years. 4. Total Budget & Position Count: Total Program Budget: $32,500 00 Total Program Position Count: 1 3 Total Agency Budget: $686,66&001 Total Agency Position Count: 1 23 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Puna Off The Streets Grade Aftercare 5. Program Funding sources paentr y all sources oT Tunamg appueo to tnis program? FY15-16 Revenue Source Estimate Enrollment Fees 27,000 Hawaii County Grant 5,500 TOTAL: 32,500 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Malamalama Waldorf School plans to continue increasing revenue through increased program enrollment to full capacity. 7. Program Objectives Using County Nonprofit Grant Program Funds: MWS objectives: 1) Provide healthy and nutritious meals to students after school 2) Provide a safe and nurturing environment for students 3) Provide ongoing enrichment activities and experiences EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application Agency Name: Malamalama Waldorf School Program Name: Puna Off The Streets Grade Aftercare FY2015-16 B. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES r e.: Number of clients servedworkshops or events held, volunteer hours, etc. Oescibe, be specoh, Applicant Projected Results Students feel safe and supported _ 100% Students participate in a new experience 100% -_ Students participate in daily exercise 100% Students receive a nutritious meal 100% Students make new friends 100% Parent satisfaction for safe/nurturing gai iro _ 100 Re -enrollment in future programs . _ 100% _ Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 21,000 2000, Professional Fees 1,000 Operations 3 oo0 Supplies 4,000 2000. Equipment 3,500 1,500 Other. Other. Other: Other: Other: TOTAL 32,500 5.500,1 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Puna Off The Streets Grade Aftercare lo. 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 Hawa i'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 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. 1L -AL Si ature of Aut orized Person (spe�fy title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Puna Off The Streets Grade Aftercare it. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 final payment. 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 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 Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Puna Off The Streets Grade Aftercare 11. Certification of Understanding (rage 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 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 accented bv. 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.haevaiicounty.Rovhn-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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements Signature of Auth rized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application Agency Name: Malamalama Waldorf School Program Name: Puna Off The Streets Grade Aftercare 12. COUNCIL AWARD WORKSHEET TABLE 1: FY2O15-16 PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Students feel safe and supported 2000, Students participate in a new experience Students participate in daily exercise Students receive a nutritious meal 2000, Students make new friends 1,500 Parent satisfaction for safe/nurturing envlro Re -enrollment in future programs - TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award salary and Wages 2000, i Professional Fees Operations Supplies 2000, Equipment 1,500 Other Other Other Other: Other - — _- -_- TOTAL 5.500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 Malamalama Waldorf School Safety Albezia Removal M County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Safety Albizia Removal Agency Director: Kelley Lacks. Sohool Director Phone No.: ( 80e) 982 — 7701 Contact Person: Kelley Lacks.. School Director Phone No.: ( 808 ) 982 — 7701 Mailing Address: Address: HC 3 Bax 13068 Address: City, ST, Zip Keaau. HI96749 Facility Address: Address: HC 3 Box 13068 Address: City, ST, Zip Keaau. H196149 Email Address: Kelley@hawahwaldorfory Fax No.: ( 80e ) 982 — 1806 Accountant/CPA: Ron Dolan Phone No.: ( 808 ) 935 — 5433 Firm (if applicable): CPA&Associates Mailing Address: Address. 16aa,Iroad Ave Address'. City, ST, Zip Ha H196720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hani ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ✓❑ Educational concerns Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities [] Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Malamalama Waldorf School Program Name: Safety Albizia Removal 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 2. Agency Mission Statement: The mission of Malamalama Waldorf School (MWS) is to improve the quality of the educational experience by providing Waldorf Education in East Hawaii. 3. Program Description: Malamalama Waldorf School (MWS) resides on 20 acres in Hawaii Paradise Park. Currently, approximately 4 of those acres are cleared for existing facilities and play space. MWS seeks to remove invasive albezia trees from the remaining 16 acres over the course of 3 years. Removal of Albizia trees from the remaining 16 acres leased by MWS will improve student, road, public, and facility safety. Year one will see the removal of albizia from 8 acres bordering existing facilities and roadways. Each successive year an additional 4 acres will be removed and all cleared areas will be maintained to prevent new infestations. This submission is for stage one of this albezia eradication. 4. Total Budget & Position Count: Total Program Budget: so,00c Total Program Position Count: 1 3 Total Agency Budget: s686,668.0o Total Agency Position Count: 123 EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Safety Albizia Removal 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Hawaii County Grant 25,000 Private Funding 20,000 In Kind 15,000 Other Private Foundation and Corporation Grants 20,000 TOTAL: 80,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: MWS will continue to sedcfunding from public and private entities, to include fundraising, grant applications, and inquiry requests. 7. Program Objectives Using County Nonprofit Grant Program Funds: MWS objectives: Remove 8 acres of albizia from a 20 acre parcel Maintain cleared land to prevent new infestation Increase overall safety EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Safety Albizia Removal 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? !, PROGRAM PERFORMANCE MEASURES Applicant Projected Results p. e.. -Number of clients served, workshops or even, beld, volunteer hour, ercpescnbe be zpecijc) Clear 8 acres of albizia 100% Maintain newly cleared land 100 Prevent albizia aromh on cleared land 100% Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual• FV I5-16 Total Budget FY 15-16 Grant Req Salary and Wages 11,000 3.000 Professional Fees 60.000 18,000 Operations 3,000 1,000 Supplies 1,000 Equipment 5,000 3,000 Other Other. Other. Other. Other. TOTAL 80,000 25,000 `If applicable EXHIBIT A NONPROFIT GRANT APPLICATION Fy 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Safety Albizia Removal io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to 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. /�.l 3L, -6 Signa re of Authoriied Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Malamalama Waldorf School Program Name: Safety Albizia Removal 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 — 2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(5) 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 final payment. 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 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 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 reportusing the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Malamalama Waldorf School Program Name: Safety Albizla Removal 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, 1 (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 lune 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:/lwww.hawaucounty. ov frI 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, 2015 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 reauest and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements /L/ Cr a x si nature of Au horized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Malamalama Waldorf School Program Name: Safety Albizia Removal 1z. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Clear 8 acres of albizia 100% FY 2014-2015 Maintain newly cleared land 100 Prevent albizia growth on cleared land 100% Supplies Equipment 3,000 Other. Other. TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 3,000 FY 2014-2015 Professional Fees 18,000 Operations 1.000 Supplies Equipment 3,000 Other. Other. Other. Other Other TOTAL 25,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Mental Health Kokua Residential Rehabilitation Services M County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services Agency Director: Greg Payton Phone No.: ( 808) 737 — 2523 Contact Person: Gary Micheli Phone No.: ( 808) 331 — 1468 Mailing Address: Address: Mental Healm Kokua Address: 1221 Kapiolani Blvd.Ste 345 City, ST, ZIP Honolulu, HI 96814 Facility Address: Address: Mental Health Kokua Address: 75-166 Kalani St., Ste 103 City, ST, Zip Kailua-Kona, HI, 96740 Email Address: gmlchenQmhkhawaiiorg Accountant/CPA: Summer B. Uwono, CPA Firm (if applicable): NIA Fax No.: ( 808) 331 — 1378 Phone No.: ( 808 ) 737 — 2523 Mailing Address: Address: Mental Healm Kokua Address: 1221 Kamolani Blvd, Ste 345 City, ST, Zip Honolulu, HI 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: g io,000.00 Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua © North Kona © South Hilo © North Kohala © South Kona © North Hilo © South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor © Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 5000 $5,000.00 5000 2. Agency Mission Statement: The Mission of Mental Health Kokua (MHK) is to assist people with mental health and related challenges to achieve optimum recovery and functioning in the community. MHK provides housing, case management, and outpatient services on behalf of Hawaii citizens, and those with major mental illness and co-occurring conditions, since 1973. 3. Program Description: Our Residential Rehabilitation Services program provides community based housing to adults recovering from severe mental illness. The goal is to enable the consumer to move on to more independent living. Staff provide daily living skills training while facilitating educational, social, and recreational activities as well as linkage to community resources and assistance in finding long-term community placement. 4. Total Budget & Position Count: Total Program Budget: 1,923,4331 Total Program Position Count: 40 Total Agency Budget: 9,930,422 Total Agency Position Count: 215 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate County of Hawaii 10000 State of Hawaii — DOH 1,429,736 United Way 20,000 Program Service Fees 175,897 Donation/Other 296,700 MHK Support TOTAL: 1,923,433 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Ongoing, agency wide efforts are being made and will continue to be made to pursue additional grant funding from trusts and foundations such as the Harry and Jeanette Weinberg Foundation, G.N. Wilcox, the BOH Charitable Foundation and the Visitor Industry Charity Walk. In addition, a fund raising event to support our program and the population we serve is being planned for August 2015. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Provide residential services to 110 unduplicated consumers. 2) Limit psychiatric hospitalization to less than 3%. 3) At least 95% of consumers served are satisfied with services received.4)lmprovement in daily living skill scores upon discharge.5)Discharge to more independent housing. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.: Numberojcfieon served, workshops or events held, volunteer Fours, etc. 0esoibe, be specific) Applicant Projected Results Number of unduplicated consumers served 110 %consumers requiring psych hospitalization Less than 3% • discharged to more independent living 75% %of consumers satisfied with services 95% 30,000 Operations 381,375 425,000 Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 1,232,425 1,313,433 Professional Fees 27,801 30,000 Operations 381,375 425,000 Supplies 125,000 Equipment 30,000 10,000 Other Other. Other: Other: Other: TOTAL 1,641,601 1,923,433 10,000 'If applicable EXHIBIT A NON PROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council Staff appointed by a member of the Council ❑ The Mayor The Managing Director The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by on individual will result in measurable direct benefits accruing to the individual as apposed to benefits accruing in general to on industry. Please specify any and all mitigation measures to avoid, in factor appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here 1/20/2DIS Signature of Authorized Person Npecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation Services 11. Certification of Understanding (Page loft) I (we) have read and understood all of the 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 final payment. To register, go to http://vendDrs.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 Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit o timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of Your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation services 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at ntt[0, tn ET)rufit-grant-fowiZon or about May 30 of the year the final 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 byJune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specifytitle) (1"L/ 30 S Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Mental Health Kokua Program Name: Residential Rehabilitation services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Resant Projected Results Projected Council Proposed Projected Result Number of unduplicated consumers served 110 % consumers requiring psych hospitalization Less than 3% % discharged to more independent living 75% % of consumers satisfied with services 95% Equipment $10.000 Other: Other: TABLE It: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salaryand Wages Professional Fees Operations Supplies Equipment $10.000 Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Na Kalai Wa'a Hoea Moku Canoe Garden - Olona 111 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Canoe Garden - Olona Agency Director: Keourailani Case Phone No.: ( she) 895 — 9500 Contact Person: Keorrailani Case Phone No.: ( 808 ) 987 — 8709 Mailing Address: Address: 65-1206 Mamalahoa Hwy suite 3-11 Address: City, ST, Zip Kamuela. Hi. 96743 Facility Address: Address: 55-406 Haw, Road Address: City, ST, Zip Hawi, Hi. 96719 Email Address: keorrailanicase@nakala,waa.or9 Accountant/CPA: Firm (if applicable): Mailing Address: Address: Address: City, ST, Zip Fax No.: ( 898) W7 — 11" Phone No.: YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna © Hamakua ❑ North Kona ❑ South Hilo © North Kohala ❑ South Kona ❑ North Hilo © South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns © Youth ❑ Victims of Crimes © Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Canoe Garden - Olona 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 $6.796 FY 13-14 .25 FY 14-15 $397,4421 Total Agency Position Count: none none none 2. Agency Mission Statement: Na Kalai Wa'a provides cultural vessels (voyaging and costal canoes) to support quality educational experiences and community development and sustainability opportunities through programs that focus on marrying traditional ways of knowing and modern ways of learning. The mission of Na Kalai Wa'a is to protect, perpetuate and honor the Hawaiian traditions andpractices of wa'a (canoe) culture through the Makali'i voyaging canoe programs, for the past, present, and future generations. 3. Program Description: Hoea Moku is Na Kalai Wa a's canoe plant sustainability project. This agriculture project focuses on canoe plants found in Hawaii that sustain the canoe like hale, hau, olona, kukui, and niu; along with those plants that sustain the crew through food or la au laps au (healing plants). The project goals are to maintain a canoe garden of these plants as well as to educate our crew, students, and community on the use and maintenance of these important resources. The Hoea Moku project is unique from other ethnobotanical projects because of the lens in which the plants are studied and interacted with, that being the lens of the canoe. This lens is the unique way that Na Kalai Wa'a views the environment. It is through this lens that we develop and implement our education programs. We begin with the place of Hoea in Hawi, then the seeds that lead to the canoe plants such as the niu, hau, kukui, hala, or olona, and then the making of the parts such as the cordage or sails of the canoe. NA Kalai Wa'a has created this learning environment where community and practitioners can come to learn more about kanu wa a (canoe plants) from the plants themselves. CONTINUED ON ATTACHMENT. 4. Total Budget & Position Count: Total Program Budget: $6.796 Total Program Position Count: .25 Total Agency Budget: $397,4421 Total Agency Position Count: 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Canoe Garden - Olona S. Program Funding Sources (identify all sources of funding applied to this program): Attach additional pages, i( needed. 6. Explain what plans your agency or program has to increase revenues to support this program: NA Kalai Wa'a is not considering Hoea Moku as a commercial farm, or highly profitable venture. The focus of Hoea Moku is education and preservation of our voyaging culture. We do hope to be able to sustain our project and 'aina, however, through certain projects and possibilities. CONTINUED ON ATTACHMENT 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Educate our crew, students, and community on the propagation and production of olona by providing workshops and trainings at our Hoea property 2. Provide opportunities for crew, students, and community to participate in planting and processing the olona in order to produce cordage. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of Revenue Source FY15-16 Estimate Bakken Charitable Trust 6,796 Na K21a Wa'a property in-kind)t NA Kalai as(tools and equipment 2,50 County of awaii (pending) 44, 64 TOTAL: 65,360 Attach additional pages, i( needed. 6. Explain what plans your agency or program has to increase revenues to support this program: NA Kalai Wa'a is not considering Hoea Moku as a commercial farm, or highly profitable venture. The focus of Hoea Moku is education and preservation of our voyaging culture. We do hope to be able to sustain our project and 'aina, however, through certain projects and possibilities. CONTINUED ON ATTACHMENT 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. Educate our crew, students, and community on the propagation and production of olona by providing workshops and trainings at our Hoea property 2. Provide opportunities for crew, students, and community to participate in planting and processing the olona in order to produce cordage. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Na Kalai Wa a Program Name: Hoea Moku Canoe Garden - Olona 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.: Humber aftliern served, workshops pr events held, volunteer hours, ew, Describe, be specific) Iona workshops held at Hose 5 Student visits and service projects regarding olona 8 Crew, students, and community members will be trained to produce olona cordage 25 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 29,640 29,640 Professional Fees 6,224 6,224 Operations 5,596 Supplies 7,000 7,000 Equipment 2,500 Other: utilities (water) 1,200 Other: Property use 12,000 Other: Stipends for Olona mentors 1,200 1,200 Other: Other: TOTAL 65,360 44,064 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Na Kalai wa'a Program Name: Hoea Moku Canoe Garden - Olona io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council ❑ Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ✓❑ If no conflicts exist, check here. Milton BoardPresident Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 January 29, 2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Na Kalai wa'a Program Name: Hoea Moku Canoe Garden - Olona 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 — 2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express and be compliant prior to final payment. To register, go to htti)://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawaii grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely. complete and accurate year-end report using the template provided will impact the evaluation of your Program's or agency's future funding requests. EXHIBITA NON PROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Canoe Garden - Olona 11. Certification of Understanding (Page 2 o 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 301h 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.Pov/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, 2015 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 fundino request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. January 29, 2015 Milton ertelmann -President Keomailani Case - Sr. Resource Mgr. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Canoe Garden - Olona 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Olona workshops held at Hose 5 Student visits and service projects regarding clone 8 Crew, students, and community members will he trained to produce olona cordage 100 Supplies 7,000 Equipment Other: Stipend for Clone Mentors 1,200 Other: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 29,640 Professional Fees 6,224 Operations Supplies 7,000 Equipment Other: Stipend for Clone Mentors 1,200 Other: Other: Other: Other: TOTAL 44,064 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Canoe Garden - 01ona 3. Program Description: CONTINUED FROM PAGE 2 OF 8 In 2012, as part of the Hoea Moku Project, Na Kalai Wa'a decided to undertake the growing of and the practices of olona, one of the canoe plants that this project is dedicated to, in an effort to preserve its uses as it relates to voyaging and the canoe. To help with the olona focus on the project, Na Kzlai Wa'a developed a close relationship with Gary Eoff, a local olona enthusiast who has been growing olona in Kona for over 20 years. Gary is one of the few people in Hawaf i who still processes the olona for cordage. Olona is a shrub that grows only in Hawai i. Its bark yields fibers that are among the strongest in the world and was used to make the strongest and most pliable cordage available to early Hawaiians. Olona was the premiere cordage used for fishing line, nets, all fishing implements, weapons, adz lashing, the feathered cloaks and helmets for royalty. Now, its populations are greatly diminished and it is increasingly rare. Botanists have describe the olona population as "in decline." To ensure the preservation of the plant and its cultural uses, Na Kalai Wa'a has created a controlled environment necessary for the optimal propagation of this special plant. The grow house that is provided on the Na Kalai Wa'a property in Hawi will defend the plant from wind, intense sunlight, diseases and harmful pests. Proper maintenance includes proper soil, fertilizer, water and protection from anything harmful to the plant. Na Kalai Wa'a will be growing and propagating olona at Hoea, in Hawi, Kohala in an attempt to learn more about this rare plant and to revitalize the practices of cordage making and cordage uses. In the old days, olona required high maintenance and hard work. The person tending the olona lived with the olona plants. Cultivation and maintenance of olona was his only work. He was specialized in growing and caring for olona because this special plant needed daily monitoring. It is the same today. Olona is a very sensitive plant and with today's invasive pests and the possibilities of plant diseases, it must be closely monitored to grow successfully. The maintenance person must be trained in all aspects of growing olona. Constant care is essential in successfully growing olona today. The person hired must spend his work hours tending the olona in order to insure its successful growth and development. The grow house that is provided for the olona is a temporary structure that can be added to or reconstructed in other areas of the property in the future. The grow house will act as the "mother ship' creating a safe environment to maintain our seed bank of olona. We will utilize a cultivation room to cultivate more olona and other cordage plants that will make up the cordage gardens around the grow house and the rest of the property. �Iz;tc{-tri � z Agency Name: Na Kalai Wa'a Program Name: Hoea Moku Canoe Garden - 01on5 6. Explain what plans your agency or program has to increase revenues to support this program: CONTINUED FROM PAGE 3 OF 8 Grants and Partnerships and Donations The Hoea Moku site was a donation to our organization from Mr. Kimble Smith. We were able to begin our development of Hoes into an educational site through a one year collaboration with Kamehameha Schools `Aina Ulu Program. NKW is currently seeking future partnerships, and donations for the site as well as grants from local foundations and potentially from larger federal foundations and grant sources like the ADMINISTRATION FOR NATIVE AMERICANS (ANA) NHEA, USDA and others. Hoea Moku Products The plants grown on Hoea can produce valuable resources for community and crew, and can also be used to help raise funds to sustain Hoea Moku. Products from our Hoea gardens will include: • Native Hawaiian Raw Fibers and Finished Cordage: • `Aha (coconut sennit) and other finished fibers sell for over $10 a yard. • Skeins of Han and other raw fibers sell for about $20/bundle • Kuka'a of Lauhala (Hawaiian Hala sells for anywhere between $50-$80, a kuka'a • Other Niu Products - `Apu can be made from the coconuts, oil from the meat • Kukui Products such as'lnamona and Oil • 'Ulu Products: `Ulu kapa, `Ulu fruits, Wood for wa'a parts • Food Products such as kalo, vegetables, tea, etc. • Keiki Kana - keiki of olona,'ulu, kalo, ban and other plants from property. Na Wai Iwi Ola Ho'omana Kanaka 101 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Na Wai Iwi Ola Program Name: Ho'cmana Kanaka Agency Director: Kumu Keala Ching Phone No.: (808)640_ moi Contact Person: Kumu Keala Ching Phone No.: ( ) Mailing Address: Address: PO. eox3647 Address: City, ST, Zip Kailua-Kona, HI 96745 Facility Address: Address: Address: City, ST, Zip Email Address: kumukealaQnawaiiwiola.org Fax No.: ( ) Accountant/CPA: Lisa Fossum Phone No.: ( 808 ) 331 _ 1234 Firm (if applicable): Big Island Accounting service. LLC Mailing Address: Address: 73- 5618 Maiau street R 104 Address: City, ST, Zip Kailua-Kona, HI 96740 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hari Q North Kona ❑ South Hilo ❑ North Kohala Q South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns ❑ Youth ❑ Victims of Crimes Q Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Na Wai Iwi Ola Program Name: Ho'omana Kanaka 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FV 13-14 FY 14-15 N/A N/A N/A 2. Agency Mission Statement: Na Wai Iwi Ola (NWIO) is a multigenerational, community based foundation that perpetuates the Hawaiian culture and practices through hula protocol and ceremonies, use and study of the Hawaiian language, and by embracing the stories of our kupuna past, present, and future. NW IO will receive and hold all responsibility pertaining to any and all grant award. To achieve desired program outcomes, the components within the Ho'omana Kanaka program will be achieved through affiliation and alignment between NWIO and Ku Kamana'Ai. The mission of Ku Kamana'Ai is to perpetuate leaders on Hawaii Island through educational, cultural, and leadership development to achieve success. 3. Program Description: Ho'omana Kanaka, "empowered individuals", provides hands-on, leadership opportunities through Hawaiian cultural practices, traditional health and wellness models, utilizing mentors and practitioners of the arts in leadership. Program will provide: 1) In-house cultural educational services, 2) Services to educational institutions within the North and South Kona geographical areas; 3) Education and training in: -fitness, culture, college preparation, careertvocation mentoring, and leadership development; 4) Community festivals hosted by cultural practitioners. 4. Total Budget & Position Count: Total Program Budget: $35,000 Total Program Position Count: 20 Total Agency Budget: 1 $o Total Agency Position Count: 1 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Na Wai Iwi Ola Program Name: Ho'omana Kanaka S. Program Funding Sources (identify all sources of funding applied to this programl: Revenue Source FY15-166 Estimate Merchandise $2,000 Registration fees - 9,000 General donations/sponsorship - 2,500 In-kind services TOTAL: 816,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In addition to seeking County of Hawaii grant funds, Na Wai Iwi Ola plans to increase revenues through retail of merchandise, assessing a fee for program participants, general donations/sponsorship, along with in-kind services provided to execute this program. 7. Program Objectives Using County Nonprofit Grant Program Funds: Completing the Ho'omana Kanaka program, participants will be able to: 1) Identify themselves as holistic cultural leaders, 2) Create and establish a careerivocational, as well as a post -secondary pathway with education and mentoring support; 3) Increase level of fitness activity, 4) Increase cultural understanding and knowledge. Supportive funds will be used to provide continuation and expansion of Ho'omana Kanaka offered to North and South Kona geographical areas. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Na Wai Iwi oia Program Name: Ho'omana Kanaka 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.: Number of dien[sserveC, workshops or events held, volunteer hoary etc aezaibe, be specific.) Applicant Projected Results Pre and post assessment will show increase in 50% of participants level of proficiency in leadership, career will display increase pathway, college prep, culture, and in proficiency in fitness.- program objectives, $6,000 with a (final of 65 proficiency as noted above. Attach additional poges as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual` FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $0 "so Professional Fees Operations Supplies $6,000 $12,000 $3.450 $6,900 $3,450 $6,900 Equipment $0 $0 Other: Travel $1,800 $3,600 Other: Nutritional meals $2,800 $5,600 Other: Other: Other: TOTAL $17,500 $35,000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Na wai Iwi Ola Program Name: Ho'omana Kanaka to. 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 ❑ 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: LJ If no conflicts exist, check here. ZA (t Y �? 'T wwl 201T L— Signature of Authorized Person (spec' itle) Date EXHIBIT A NONPROFIT G RANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: NA Wai Iwi Ola Program Name: Ho'omana Kanaka 11. Certification of Understanding (page 1 of 2) 1 (we) have read and understood all of the 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. 1 (we) understand that applications will not be reviewed by County 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 final payment. 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 Hawai'i I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Na wai Iwi ala Program Name: Ho'omana Kanaka 11. Certification of Understanding (Page z of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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 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 httaj/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, 2015 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 moy result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. V I ag �nUQi Signature of Authorized Persordspkcify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Na Wai Iwi Ola Program Name: Ho'omana Kanaka 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Resant Projected Results Projected Council Proposed Projected Result Pre and post assessment will show increase in 50% of level of proficiency in leadership, career participants pathway, college prep, culture, and fitness will display Supplies increase in Equipment proficiency I-- with afinal _ of 65%. TABLE II: =FY PROGRAM EXPENDITURESequest -16 Council Award Salary and Wages $0 Professional Fees $12,000 Operations $6,900 Supplies $6,900 Equipment $0 Other: Travel $3,600 Other Nutritional Meals $5,600 Other _ Other. Other: l TOTAL $35,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8 of 8 Neighborhood Place of Puna Emergency Food Pantry 102 k"D oOp�I County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Emergency Food Pantry Agency Director: Paul Normann Phone No.: ( 808) 965 — 5550 Contact Person: Paul Nmmann Phone No.: ( 808 ) 965 — 5556 Mailing Address: Address: 16-105 Opukahaia sl. Address: City, ST, Zip Keaau, HI, 96749 Facility Address: Address: 16-1050pukahaia sl. Address: City, ST, Zip Kass , HI, 96749 Email Address: Paulgneighhomoodpiaoa.or9 Fax No.: ( 808) %5 — 5109 Accountant/CPA: aexsnn, Phone No.: ( fin) 257 — 6464 Firm (if applicable): Mailing Address: Address: 1403 Frank St Address: City, ST, Zip Honolulu, HI W816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑✓ Aged ❑ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page I of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Neighborhood Place of Puna Program Name: Emergency Food Pantry 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $25,000.00 $25,000.00 $20,000.00 2. Agency Mission Statement: The goal of the Neighborhood Place of Puna is to prevent child abuse and neglect by ensuring that families have access to the resources and skills they need to raise safe and healthy children. NPP's Mission: "Empowering families and communities in Puna by building strong foundations through healthy relationships that value each person's uniqueness." "E malama pono kakou" 3. Program Description: Neighborhood Place of Puna's Emergency Food Pantry Program, provides "on call" emergency food assistance to individuals and families living in Puna. Individuals can contact - call or drop by- Neighborhood Place of Puna, Monday through Friday, between the hours of 8am and 4pm, and request emergency food assistance. Individuals can request and receive food as much as twice a month. This past year Neighborhood Place of Puna provided Emergency Food Assitance to almost 1000 families. That's a total 3600 individuals, 1932 of which were children, who need and recived food assistance from Neighborhood Place of Puna. 4. Total Budget & Position Count: Total Program Budget: $20,000.00 Total Program Position Count: .25 Total Agency Budget: $477,000.00 Total Agency Position Count: s EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Neighborhood Place of Puna Program Name: Emergency Food Pantry S. Program Funding Sources (identify all sources of funding applied to this Program) FY25-16 Revenue Source Estimate County of Hawaii $20,000 TOTAL: $20.000 Attach additional popes, if needed 6. Explain what plans your agency or program has to increase revenues to support this program: Neighborhood Place of Puna is actively working to find resources to continue to support this important program. In FY13-14 we were fortunate to get some support from a private donor which made it possible for us to fill emergency food request on a daily basis. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objective of the emergency food pantry program is to ensure that individuals and families in Puna have access to one of the most basic of life's necessities: Food. EXHIBIT A NONPROFITGRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Neighborhood Place of Puna Program Name: Emergency Food Pantry 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i.e.: Number of dknh serve$ workshops ants Feld, etc Describe, be zpenfirJ Food Assistance namvr uvuumrvr YVYo un nacvur y. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 15,000 15,000 15,000 Professional Fees 0 0 0 Operations 2,500 2,500 2,500 Supplies 0 0 0 Equipment 0 0 0 Other: Food 2,500 2,500 2,500 Other: Other: Other: Other: TOTAL 20,000 20,000 20,000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Emergency Food Pantry io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 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. [-Ket��1i"t Id-/3OG�ji Signa re of Authorized Per -D1 rCe%r— Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Emergency Food Pantry ii. Certification of Understanding (Page 1 of z) I (we) have read and understood all of the 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 final payment. 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 resort using the template Provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page6 of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Neighborhood Place of Puna Program Name: Emergency Food Pantry 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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 301h 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 bv, 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.govlfn-noni2rofit-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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. SigKature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 ta�3a�f �— Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Emergency Food Pantry 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results I Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional COurica directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 Neighborhood Place of Puna Family Strengthening 103 ESPY County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Family strengthening Agency Director: Paul Norman Phone No.: ( 808) 965 — 555o Contact Person: paw Norman Phone No.: ( 808) 965 — 5550 Mailing Address: Address: 16.105 opukahaia St. Address: City, ST, Zip Keaau, HI, 96749 Facility Address: Address: 16-1050pukahalasl. Address: City, ST, Zip Keaau, HI, 96749 Email Address: paui*mighborhoorplace.ar9 Fax No.: ( 808) 965 — 5109 Accountant/CPA: Alex smnh Phone No.: ( 877 ) 257 — 6494 Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: City, ST, Zip Honolulu, Hi %816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑v' Puna ❑ HAmakua ❑ North Kona Q South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities ❑v' Public Health and Welfare of the People and the Environment EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $25,000.00 $25,000.00 $20,000.00 2. Agency Mission Statement: The goal of the Neighborhood Place of Puna is to prevent child abuse and neglect by ensuring that families have access to the resources and skills they need to raise safe and healthy children. NPP's Mission: "Empowering families and communities in Puna by building strong foundations through healthy relationships that value each person's uniqueness." "E malama pono kakou" 3. Program Description: Neighborhood Place of Puna's Family Strengthening Program is a child abuse and neglect prevention program. This program focuses on the five protective factors for strengthening families. The protective factors are conditions in families and communities that increase the health and well being of children and families. Research shows that these factos help us to parent effectively, even when we are under stress, and lower the incidence of child abuse and neglect. The Five Factors are: Nurturing and Atttachment, Knowledge of Child and Youth Development, Prental Resilience, Social Connections, Concrete Supports for families. The Family Strengthing Program is a free and voluntary, home based program. Because it is a voluntary program, the majority of families in the program are "self referrals." It is home based to ensure that transportation is not a barrier to receiving help. Also, being home based, NPP has an opportunity to see and work with the entire family. We see the home environment, we hear how the family communicates, and we observe the parents interactions with their children. Most importantly, we work with the whole family to address the challenges faced by the family. 4. Total Budget & Position Count: Total Program Budget: $180,00.00 Total Program Position Count: 3 Total Agency Budget: $477,000.00 Total Agency Position Count: g EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening S. Program Funding Sources (identify all sources of funding applied to this Program): Revenue Source FY15-16 Estimate State of Hawaii $132,000 Hawaii Island Untied Way $20,000 County of Hawaii $20,000 Donations $8,0)0 TOTAL: $180,000 Armen admnonat pages, p needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Neighborhood Place of Puna is a successful child abuse and neglect prevention program. We aggressively pursue a variety of funding sources to keep all of our programs funded and ensure that families have a place to turn to when they need help. However, to continue the work of preventing child abuse and neglect, we will always need government support as well as support from private funders. 7. Program Objectives Using County Nonprofit Grant Program Funds: The primary of objective of the Family Strengthening Program is to prevent child abuse and neglect. Using the Healthy Families America model, NPP works works weekly with families, in their homes, to ensure that the family is stable and has the necessary skills and resources to raise safe and healthy children. Often, when the family comes to us they are in crisis - on the verge of homelessness, lacking basic resources, or dealing with a "difficult" child. We help them work through the crisis, and then address some of the underlying issues, which may involve teaching developmentally appropriate parenting skills, budgeting, meal planning, basic life skills, healthy communication, etc. We may connect the family to professionals in the community for counseling, support, or medical assistance. We make sure that the children are in school and getting the support they need. We do a lot more as well. Each family is different and will have a "Success Plan" to address their specific needs or situation. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.: Numberofclienrs xrve$ warksM1ops or events held, volunteer Fours, etc.Oeuribe, be spedfic) Applicant Projected Results Weekly home visists to families 70 families Famiily Safety Assessment 70 families Develop Family Success Plan 70 families Successful Completion of Family Success Plan 80% of families Ages 8 Stages fro tam. wl child =<5 100% PF Survey for fam who complete Sussess Plan 100% Families free of child abuse and neglect 85% Attach additional pages as necessory. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual` FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 137,134 140,134 20,000 Professional Fees 6,409 6,409 Operations 22,648 22,648 Supplies 2,810 2,810 Equipment 0 0 Other: Direct Client Assistance 8,000 8,000 Other: Other: Other: Other: TOTAL n7,0oo 1so,a0o zo,aoo "If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Family strengthening to. 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'L Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts 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 Conflictof 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. Ecccivr_ la/iq�rY Signa re of Autho ' d Person (specify tit (�°o �t°� Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Neighborhood Place of Puna Program Name: Family strengthening 11. Certification of Understanding (Page loft) I (we) have read and understood all of the 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 final payment. 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 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 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 reportusing the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening 11. Certification of Understanding (Page 2 o 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 priorto receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 30u' 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. I ,/ F4ec.,,,\t\wG�cfG\ac S_/agPry pignature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Family Strengthening 1z. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant I Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8of8 Neighborhood Place of Puna Ongoing Lava Relief and Assistance 104 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Ongoing Lava Relief and Assistance Agency Director: Paul Normann Phone No.: ( 808) 965 — 5550 Contact Person: Paul Normann Phone No.: ( 808) 965 — 5550 Mailing Address: Address: 16-1050pukahala St. Address: City, ST, Zip Kemm, HL 96749 Facility Address: Address: 16- 105 opukahaia Sl. Address: City, ST, Zip Kraaq HI, 96749 Email Address: Paul@neighborhoodplace.org Accountant/CPA: Alex Smith Firm (if applicable): Mailing Address: Address: 1403 Frank St. Address: City, ST, Zip Honolulu, 1-1 96816 Fax No.: ( 808) 965 — 5109 Phone No.: ( an ) 257 — 6484 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL MANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑✓ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises ❑✓ Needs of the poor ❑✓ Physical/Emotional Disabilities 0 Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page l of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Ongoing Lava Relief and Assistance 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $25,OOD.00 $25,000.00 $20,000.00 2. Agency Mission Statement: NPP's Mission: "Empowering families and communities in Puna by building strong foundations through healthy relationships that value each person's uniqueness." "E malama pond kakou" 3. Program Description: Neighborhood Place of Puna is located in Puna and has been serving individuals and families in Puna since 2002. We are known and trusted in the community. Neighborhood Place of Puna's "On Going Lava Relief and Assistance Program' provides crisis case management and assistance to families affected by or potentially affected by the active lava flow. While assistance is available to all individuals and families impacted by the active lava flow, our principle focus is on medically fragile, vulnerable, or impoverished members of the Puna community. All services are provided free and on a voluntary basis 4. Total Budget & Position Count: Total Program Budget: 48,000 Total Program Position Count: 1 Total Agency Budget: 1 $477,000,001 Total Agency Position Count: g EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Ongoing Lava Relief and Assistance S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Hawaii County 30,000 Hawaii Island United Way 13,500 Donations 4,500 TOTAL: 48,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Neighborhood Place of Puna is hopeful that this is a short term program, Nevertheless, NPP has been actively soliciting donations to help families with various concrete needs and assistance: clothing, bedding, furnishings, etc. 7. Program Objectives Using County Nonprofit Grant Program Funds: The most likely impact from the active lava flow is a large displacement of households from the area below the flow. Unfortunately, there is already a shortage of affordable housing in the county. The Objectives of this program are: 1. Provide crisis case management to individuals and families in Puna 2. Assist individuals and families affected by lava in finding housing and resources 3. Coordinate assistance with other agencies providing assistance. 4. Provide support to at risk and vulnerable individuals and families that may not be able access services or are likely to "fall through the cracks." EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Ongoing Lava Relief and Assistance 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e: Nunio)clients served workshops or events held, volunteer hours, etc. Describe, be specihr) Applicant Projected Results Crisis Case Management 70 households Needs Assessment 70 households Referrals to Resources 70 households Develop Service Plan 70 households Successful Completion of Service Plan (SP) 80% of households Address Immediate Household Needs 80% of households 3 mos follow-up after SP is completed 1 D Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual` 115-16 Total Budget FY 15-16 Grant Req Salary and Wages 42,600 30,000 Professional Fees 0 Operations 0 Supplies 0 Equipment 0 Other: Direct Client Assistance 4,500 Other: Mileage Reimbursement 900 Other: Other: Other: TOTAL 48,000 30,000 "If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Ongoing Lava Relief and Assistance io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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: Q If no conflicts exist, check here. �\Kc\er I aslir SijiKature oori rson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Ongoing Lava Relief and Assistance 12. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 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 that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. 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 priorto final payment. 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 vaur program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Ongoing Lava Relief and Assistance 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 301h 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.hawaitcounty.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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. ///� Exec uvC—t�F' mow, I/aR/i5 Si Batu re of Authors rson(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Neighborhood Place of Puna Program Name: Ongoing Lava Relief and Assistance 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant I Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Addmonal council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 North Kohala Comminity Resource Center Kohala Coqui Coalition 105 copy County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: North Kohala Community Resource Center Program Name: Kohala Coqui Coalition _- Agency Director: Christine Richardson, Executive Director Phone No.: ( 808) 889 — 5523 Contact Person: Magan Solis, Associate Director Phone No.: ( 808) 689 — 5523 M ailing Address: Address: P.o. Bo.519 Address: City ST, Zip Hawi, HI 96719-0519 Facility Address: Address: 55-3393Akoni Pule Hwy. Address: CitY, ST, Zip Haw,, HI 96719-0519 Email Address: o.@uorihkohalaorg Fax No.: ( 808) 889 — 5527 Accountant/CPA: Alida Adamek, Retired CPA Phone No.: ( 808) 938 — 2200 Fi rm (if applicable): NKCRC Director 8 Treasurer Mailing Address: Address: P, o. Box 540 Address: City, ST, Zip Hawi, HI 967130540 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hari ❑ North Kona ❑ South Hilo © North Kohala ❑ South Kona ❑ North Hilo ❑ South Kandla ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑✓ Public Health and welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page I of County of Hawaii Nonprofit Grant Application FY20t5-16 Agency Name: North Kohala Community Resource Center Program Name: Kohala Coqui Coalition 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 6 wntract labor FY 14-15 $493,760! Total Agency Position Count: 1 FT/2 PT $9,600.00 $10,000 2. Agency Mission Statement: The North Kohala Community Resource Center (NKCRC) is a 13 -year-old 501(c)(3) nonprofit organization located in North Kohala, a small rural community (6,322 population) on the northern tip of the Big Island of Hawaii. The mission of NKCRC is to increase the number of successful community improvement projects in North Kohala. We meet this mission by providing training, coaching, and a 501(c)(3) umbrella to a diverse group of volunteer community project organizers. Over 120 community projects have been realized due to the support provided by the NKCRC. These collective efforts have improved our community and the lives of our citizens and illustrate the power of volunteer grass roots efforts in community development. Kohala Coqui Coalition is among the 92 projects we currently sponsor. The Coalition's mission is simple: to keep North Kohala coqui free by means of eradication, education, and prevention. 3. Program Description The Kohala Coqui Coalition was created in November 2003 shortly after a 20 -acre infestation was discovered in North Kohala. A thorough eradication program cleared all the known coqui infestations, a Coqui Hotline phone number was set up for the community to report further infestations, and a major community education program was launched. Since that time, a three -pronged approach of prevention, education and eradication has kept the coqui at bay in North Kohala. Education: includes a monthly ad in Kohala Mountain News informing of all sites reported and treated for coqui. This year we published a full-color informational flyer insert about eradication efforts to reach all PO boxholders in Kohala, and we host an information booth each year at Kohala Country Fair, Eradication: About half of our budget includes labor (spraying and mowing) and truck rental, to haul our 100 -gallon sprayer in difficult terrain. Without this, Kohala would be as infested as Hilo or Puna. Prevention: Our Coqui Hotline is available for reporting coquis. We encourage our community to buy plants from local nurseries, treat plants coming from outside Kohala, report coquis early, and make a coqui free plan before construction. 4. Total Budget & Position Count: Total Program Budget: $29 250 Total Program Position Count: 6 wntract labor Total Agency Budget: $493,760! Total Agency Position Count: 1 FT/2 PT EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: North Kohala Community Resource Center Program Name: Kohala Coqui Coalition 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate ! Community donations 7,000 County Council Contingency Funds 2,000 County of Hawaii Nonprofit Grant 20,000 Coqui boxes/Kohala Country Fair contributions 250 TOTAL: 29,250 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In 2014, District 9 Council member Margaret Wille sponsored Council Contingency funds of $2,000 to support our coqui control efforts, the only county funds the Coalition has received since early infestations on the island in 2003-04. Since a 2005 grant from Hawaii Invasive Species Council, this program has been funded solely by community donations. However, as coqui continue to spread across the island, North Kohala's exposure to coqui has increased, especially at the County Transfer Station, located next to a deep gulch and the destination of trucks from coqui-infested areas, requiring monthly mowing and 12 treatments in 2014. To date, we have treated over 200 different locations (35 new in 2014), including 30 treatments of Keokea Gulch, home of Keokea County Beach Park, at a cost of over $10,000. The Coalition is broadening its funding base by reaching out to the County and private foundations for support. We are continuing to educate the community and local groups have formed to help with eradication efforts in their neighborhoods, helping to reduce the Coalition's costs. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objective is to keep Kohala coqui free by educating our community on the problems with coquis and ways to prevent coqui infestations; providing a coqui hotline for reporting coquis; and eradicating infestations that occur. County nonprofit funds would be used for a dedicated phone line for our Coqui hotline, and storage space for equipment, including a 100 gallon sprayer, (until now these have been donated by a local nursery); contract labor costs for spraying, mowing and clearing areas for treatment (a physically demanding job that is usually done at night); a stipend for the coordinator, who has volunteered her time since the program's inception, estimated to involve about 20 hours of work per month; supplies including citric acid, lime and office supplies; equipment including personal protective equipment, truck rental, fuel and heavy equipment rental when backhoe work is required; education costs including our monthly ad with tips for prevention, flyers and booths at public events; and fiscal sponsorship fees (8% of award). EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: North Kohala Community Resource Center Program Name: Kohala Coqui Coalition S. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES n e.: Number of clients served, worksbons or events held, velunt"hn. s, etc Oesribe, be 'Pe'r".) Applicant Projected Results Number of different saes treated 40 in 2015-16 Number of treatments in total 100 in 2015-16 Educational advertisements in Kohala Mountain News 12 in 2015-16 Educational booths at Country Fair and Kohala Community Reunion 2 in 2015-16 12,500 Operations his n/a Supplies Attach additional pages as necessary. 9. TABLE II: FY 1415 PROGRAM EXPENDITURES Actual' FY 15-16 Total Budget Salary and Wages 7,417.50 8,500 Professional Fees 904.40 2,320 12,500 Operations his n/a Supplies 3,242.17 3,730 Equipment 2,483.00 4,000 Other: Education add Publications 3,157.92 3,200 2000, Other: Equipment Repairs 184.00 500 170 Other Coordinator Stipend 0.00 6,000 5,000 Other: Dedicated phone line for Hotline 0.00 300 300 Other: Storage facility rental 0.00 700 700 TOTAL 17388.99 29,250 20.000 "If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: North Kohala Community Resource Center Program Name: Kohala Coqui Coalition io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. e, f ce Cc, e r- k -r - Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: North Kohala Community Resource Center Program Name: Kohala Coqui Coalition ii. 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 allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and 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 final payment. 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. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: North Kohala Community Resource Center Program Name: Kohala Coqui Coalition tt. 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 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 hawai icounty.goy/fn- non prof it -gra 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, 2015 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 oaencv's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Cii2e 4' (C-- /-2 3 —/s Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRAN'. APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: North Kohala Community Resource Center Program Name: Kohala Coqui Coalition 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Protected Result Number of different sites treated 40 Number of treatments in total 100 Educational advertisements in Kohala Mountain News 12 Educational booths at Country Fair or public events 2 Equipment 2,500 Other Education and Publications 2,000 Other: Equipment repairs 170 TABLE II: PROGRAM EXPENDITURES FV 15-16 Grant Request Council Award Salary and Wages 6,000 Professional Fees 1,600 Operations Supplies 1,730 Equipment 2,500 Other Education and Publications 2,000 Other: Equipment repairs 170 Other: Coordinator Stipend 5,000 Other: Dedicated phone line for Hotline 300 91 Other: Storage fauliry rental 700 TOTAL 20,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8 of 8 North Kohala Comminity Resource Center North Kohala Radio 1� Go Py County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Radio Agency Director: Christine Richardson Phone No.: ( 608) 989 — 5523 Contact Person: Megan Solis Phone No.: ( eoa) e89 — 5523 Mailing Address: Address: P. o. aox 519 Address: City, ST, Zip Hasa. H196719 Facility Address: Address: 553393Akoni Pule Highway Address: City, ST, Zlp Hawi, HI 96719 Email Address: loco@nodhkohalti Fax No.: ( 808) 8e9 — 5527 Accountant/CPA: Alida Adannek, Treasurer, Retired CPA Phone No.: ( e08) 869 — 5523 Firm (if applicable): NA Mailing Address: Address: P. o. eoxeao Address: City, ST, ZiP Hawi, H196119 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑✓ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (one or more can be checked) ❑V Educational concerns © Youth ❑ Victims of Crimes © Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑Physical/Emotional Disabilities Q Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Radio 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 1415 $9,600.00 $10,000.00 2. Agency Mission Statement: The North Kohala Community Resource Center (NKCRC) is a 13 -year-old 501(c)(3) nonprofit organization located in North Kohala, a small rural community (6,322 population) on the northern tip of the Big Island of Hawaii. The mission of NKCRC is to increase the number of successful community improvement projects in North Kohala. We meet this mission by providing training, coaching, and a 501(c)(3) umbrella to a diverse group of volunteer community project organizers. Over 120 community projects have been realized due to the support provided by the NKCRC. These collective efforts have improved our community and the lives of our citizens and illustrate the power of volunteer grass roots efforts in community development. North Kohala Radio is among the 92 projects we currently sponsor. North Kohala Radio's mission is to open and operate a financially sustainable, low power, non-commercial FM radio station serving the North Kohala community. 3. Program Description: North Kohala Radio, formed in early 2014, is a group of 67 volunteers, including participants from both Kohala Middle and High schools. Our mission is to open and operate a financially sustainable, low power, non-commercial FM radio station serving the North Kohala community. The North Kohala CDP calls for a local radio station as a "huge enhancement to the community's emergency communications." Our fundamental purpose is to help strengthen community through an emphasis on inclusiveness and broad participation while providing programming delivered by local people with a local focus. We are an all -volunteer organization with no paid staff. We will provide emergency broadcasts to North Kohala as needed, and are supported by Darryl Oliveira of the Hawaii County Civil Defense Agency. We obtained a construction permit from the FCC in February 2014, along with our frequency of 96.1 FM and call sign KNKR, and are planning to open the 100 watt station no later than August 2015. We have a long term lease of our station in Hawi, and a Memorandum of Agreement for our antenna site. We ordered our on -air studio equipment on January 21, 2015. We raised $23,970 in Member Donations and $28,000 in grants in 2014. 4. Total Budget & Position Count: Total Program I Total Program Position Count: o Total Agency Budget: $493,7601 Total Agency Position Count: I FT; 2 PT EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Radio S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Member Donations $15,000 Listener Memberships $3,000 Operating Grants $40,000 Underwriting Support $6,000 TOTAL: $64,000 Attach additional pages, iif needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We expect growth in Member Donations, Listener Memberships, and Underwriting Support from businesses after we go on air in 2015. As needed, we have the capacity to do a local community event to raise funds. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our key objectives for 2015-16: 1. Complete the Station preparation, install the equipment necessary to go on air, and open the station by August 2015. 2. Introduce the Broadcasters Training Program and begin using it in 2015 to train programmers and station volunteers. 3. Meet our expense budget of $55,636 for FY 2015-16. 4. Achieve the Performance Measure targets shown in the next section. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY201 5-16 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Radio 8. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.: Number o)drena served, workshops areven[s M1el4 volun[eerhours, e[c. Oesnibe, be spen)IcJ Applicant Projected Results Volunteer and student trained broadcasters. 2015 - 25, 2016 -35 Volunteers: 2015 - 70, 2016 - 80 Emergency broadcasts with North Kohala information All alerts for North Kohala in 2015-16 Listener paid memberships at $40 each 2015 - 75, 2016 - 110 Business underwriters: 2015 - 30, 2016 - 40 Beginning in August 2015, Broadcast hours per day minimum 2015-8, 2016-12 $29,966 Attach additional pages as necessary. q_TABLE IL PROGRAM EXPENDITURES FY 1415 Actual' FY 15-16 Total Budget FV IS -16 Grant Req Salary and Wages 0 0 Professional Fees $4,459 $8,640 Operations - 0 $29,966 Supplies $190 $2,000 Equipment 0 $51,074 $20,000 Other: Insurance $2,048 $2,750 Other: Lease (Studio) $1,050 $10,056 Other Outreach $150 $1,500 other: Dues to National Federation of Community Broadcasters $225 $572 Other: Bank Charges $19 $150 TOTAL $8,142. $106,710 $20,000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Radio to. 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. Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Radio 11. Certification of Understanding (Page 1 of z) I (we) have read and understood all of the 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 final payment. To register, go to httr)://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 complywith 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 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 reportusing the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Radio 22. Certification of Understanding (Page 2of2) If awarded a grant from the County of Hawa!'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 pay mem(s). I (we) understand that failure to submit the final report within 60 days of June 30t' shall result in loss f all grantfunds received duringthe grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. (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-n on profit-grant-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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) 3'/6 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: North Kohala Community Resource Center Program Name: North Kohala Radio 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Volunteer and student trained broadcasters 2015-25.2016-35 Volunteers 2015 - 70, 2016 - 60 Emergency broadcasts with North Kohala information All alerts for N. Kohala Listener paid memberships at $40 each 2015-75, 2016- 110 Business underwriters 2015-30,2016-40 Beginning in August 2015, Broadcast hours per day minimum 2015-6. 2016-12 Other: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment $20,000 Other: Other: Other: Other Other: TOTAL $20,000 Additional Council directives re1¢ardin¢ award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 O Ka'u Kakou Family Fun Fest 107 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Kau Kakou Program Name: Family Faun Fest Agency Director: Ws Kawacni Phone No.: ( 808) 937 — 4773 Contact Person: Nadine Ebert Phone No.: ( 808) 928 — 0027 Mailing Address: Address: po uox ass ❑ North Hilo ❑ South Kohala Address City, ST, Zip Pahala, HI %777 Facility Address: Address: Aspen Center Address: Ninole Loop Road City, ST, Zip Pahala, HI %777 Email Address: ehe,moo4@nawafi.n.com Accountant/CPA: Firm (if applicable): Fax No.: ( 808) 928 — 8961 Phone No.: ( ) — Mailing Address: Address: Address: City, ST, Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: sa.000.00 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala © Ka'6 Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts ✓❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Family Fun Fest 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $6,000.00 $7,000.00 $00.00 2. Agency Mission Statement: To foster health and properity for all of K'au. 3. Program Description: The Ka'u Family Fun Fest is an annual event to offer fun, healthy activities for the our Seniors as well as our youth. We also have a parade to involve all the people and organizations of our community 4. Total Budget & Position Count: Total Program Budget: $9,200.00 Total Program Position Count: $00.00 Total Agency Budget: $9o,000.00 Total Agency Position Count: $00.00 EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: O Ka'u Kakou Program Name: Family Fun Fest S. Program Funding Sources (identify all sources of funding applied to this programl: FY15-16 Revenue Source Estimate County grant $8,00) Donations $1,200 TOTAL: $9,200 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: In 2014 we we had an adult bingo and lunch, and bouncy games, shave ice, and hot dogs for the keiki on the 4th of July. We plan to use funds raised from shave ice and hot dogs soid at various events and our recycle program to supplement county funds received. 7. Program Objectives Using County Nonprofit Grant Program Funds: To have a 4th of July event where the family gather for games for the keiki and to have bingo and lunch for adults. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Family Fun Fest 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES e.: pumne,o dre�a.:<nrce, wo.trnoApplicant p. f pzo. evenr: note, wmnrec. Hours. eta. oe:�nne, ae :o<a�ga.l Projected Results 2014 served 500 hot dogs to Me Win 550 hot dogs 2014 served 800 shave ice 850 shave ice 2014 had 80 bingo participants 90 bingo 2014 served 125 adult lunches 130 adult lunches 2014 had 50 volunteers 55 volunteers Operations $8,260 $7260 $7,260 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 1536 Grant Req Salary and Wages $00 $ob $00 Professional Fees $00 $00 $00 Operations $8,260 $7260 $7,260 Supplies $1,645 $1,940 $1,940 Equipment $00 $00 $00 Other: Other: Other. Other: Other: TOTAL $9,905 $9,200 $9,200 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Family Fun Fest io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. 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: 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. JO, A LP,,r— 27 Signature of Authorized Person (specify title Date EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: o Ka'u Kakou Program Name: Family Fun Fest t1. 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 final payment. 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 reportusing the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Family Fun Fest il. Certification of Understanding (Page 2of2) 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, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner wilt impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature Person (specify title EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Kau Kalcou Program Name: Family Fun Fest 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result 2014 served 500 hot dogs to keiki 550 but dogs 2014 served 800 shave ice to keiki 050 shave is 2014 had 80 adult bingo participants 90 bingo 2014 served 125 adult lunches 139 lunches 2014 50 volunteers 55 volunteer Other: Other: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $00 Professional Fees $00 Operations $7,280 Supplies $1,940 Equipment $00 Other: Other: Other: Other: Other: TOTAL $9,200 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 O Ka'u Kakou Ka'u Coffee Trail Race and Ohana Day MIR County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: O Ka'u Kakou Program Name: Ka'u Coffee Trail Race and Ohana Day Agency Director: ws Kawaml Phone No.: ) 808) 931 — 4773 Contact Person: Nadine Eben Phone No.: ( 808) Sze — 0027 Mailing Address: Address: Po box 365 Address: City, ST, Zip Pahala, HI 96711 Facility Address: Address: Aspen Center Address: Nimle Loop Road City, ST, Zip Pahala, HI 96777 Email Address: eter1n00.1@h.ii.rrdonn Accountant/CPA: Firm (if applicable): Fax No.: ( 808) 928 — 8961 Phone No.: ( ) — Mailing Address: Address: Address: City, ST, Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $15,000 oo Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: O Ka'u Kakou Program Name: Ka'u Coffee Trail Race and Ohana Day 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $00..00 $00.00 $00.00 2. Agency Mission Statement: Support and promote a healthy community through education and economical development opportunities that improve the quality of life in Ka'u. 3. Program Description: 5K, 10K, and half marathon races through the Ka'u Coffee Trail to promote Ka'u as an international tourist destination as well as promoting the coffee industry. Also, provide a day of outdoor physical activity for the whole family. 4. Total Budget & Position Count: total Program Budget: 1 $15,0001 Total Program Position Count: $00 Total Agency Budget: 1$90,0001 Total Agency Position Count: $oo EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Ka'u Coffee Trail Race and Ohana Day S. Program Funding Sources (identify all sources of funding applied to FY15-16 Revenue Source Estimate rni�nN arant 1 $15.000 I TOTAL: 1 $15,0001 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continue to seek donations and, while the community continues to support the efforts of O Ka'u Kakou, we have used non-specified donations to continue the programs for which we are not asking the County's help to maintain. We continue to look for new venues for fund raising and community donations to become self-sustaining. 7. Program Objectives Using County Nonprofit Grant Program Funds: To promote a healthy lifestyle through physical fitness by providing an opportunity for family participation in various activities. Also, provides an opportunity to introduce Ka'u coffee to Race participants from around the world. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Ka'u Coffee Trail Race and Ohana Day 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.- Number o)dents served, warl3liops orevenn bNd, volunteer hours, etc Oessribe, be speci)ic.J Applicant Projected Results 250 runners, kids games participants 300 runners, kids game 100 volunteers 125 volunteers 1000 volunteers hours 1250 volunteer hours 200 spectators, runner support 250 spectators $00 $00 Operations $5,700 $8,200 $8,200 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $00 $00 $00 Professional Fees Soo $00 $00 Operations $5,700 $8,200 $8,200 Supplies $6,500 $6,500 $6,500 Equipment $300 $300 $300 Other: Other: Other: Other. Other: TOTAL $12,500 $15,000 $15,000 V applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Ka'u Coffee Trail Race and Ohana Day to. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. 46lCvltO K. l`..L'YeAo� Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: O Ka'u Kakou Program Name: Ka'u Coffee Trail Race and Ohana Day 11. Certification of Understanding (Paget of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; andrecords, 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 final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii. I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report using the template provided will impact the evaluation of your program's or agency s future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Ka'u Coffee Trail Race and Ohana Day 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of 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 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 httn://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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kalcou Program Name: Ka'u Coffee Trail Race and Ohana Day 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Projected Resant Projected Results Council Proposed Projected Result 300 runners and kids games partiapants 300 125 volunteers 125 1250 volunteer hours 1250 250 spectators and runner support 250 Equipment $300 Other: Other: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $00 Professional Fees $00 Operations $8,200 Supplies $6,500 Equipment $300 Other: Other: Other: Other: Other: TOTAL $15,000 Additional Council directives re¢ardinR award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of O Ka'u Kakou Ka'u Sanitation Program 109 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Ka'u Sanitation Program Agency Director: WS Kawachi Phone No.: ( 806) 937 — 4773 Contact Person: Nadine Ebert Phone No.: ( 899) 928 — 0027 Mailing Address: Address: Po Box abs Address: City, ST, Zip Pahala, HI 96777 Facility Address: Address: Aspen Center Address: Nuala Loop Road City, ST, Zip NMI., HI %777 Email Address: ebeM004@hawaii.rr.com Accountant/CPA: Firm (if applicable): Fax No.: ( 808) 926 — 6961 Phone No.: ( ) — Mailing Address: Address: Address: City, ST, Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: SS600.00 Geographical Areas To Be Served: lone or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor © Physical/Emotional Disabilities ❑q( Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Ka'u Sanitation Program 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $7,000.00 $8,500.00 $0 2. Agency Mission Statement: To foster health and prosperity for all of Ka'u. 3. Program Description: To provide a means to keep those areas sanitary where there are no restroom facilities. 4. Total Budget & Position Count: Total Program Budget: 9,000.00 Total Program Position Count: $00.00 Total Agency Budget: $9o,000.00 I Total Agency Position Count: $00.00 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Ka'u Sanitation Program S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate County grant $8,50000 Recycle $500.00 TOTAL: $9,000.00 Attach additional pages, iif needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We have used some of our recycle money to pay for the portable toilets. We would like the County to continue helping with this programsothat we might use other donations and money received from our recycling program to fund our Senior's program, for which we are not asking for funding. We continue to look for new venues for fund raising and community donations to become self-sustaining. 7. Program Objectives Using County Nonprofit Grant Program Funds: To provide portable toilets where none currently exist at Punalu'u boat ramp, South Point fishing and visitor area, the annual Keiki Fishing Tournament (handicap toilet), and Pahala Plantation Days. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Ka'u Sanitation Program 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e. , Number of cbents served, workshop: or evens hem, wmnteer hours, etc. Describe, be scecind Applicant Projected Results 2 portable toilets at Punalu'u boat ramp 2 Portable toilets 2 portable toilets at South Point 2 portable toilets 1 he portable toilet at Fishing Tournament 1 he toilet 2 portable toilets at Plantation Days 2 portable toilets $00 $00 Operations $8,200 $9,000 $8,500 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $00 $00 $00 Professional Fees $00 $00 $00 Operations $8,200 $9,000 $8,500 Supplies $00 $00 $00 Equipment $00 Soo $00 Other: Other: Other: Other: Other: TOTAL $8,200 $8,500 $8,500 'B applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County ofHawai`i Nonprofit Grant Application FY2015-16 Agency Name: 0 Ka'u Kakou Program Name: Ka'u sanitation Program io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. one form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether 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): 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: 21 If no conflicts exist,check. here. Signature of Authorized Person (specifytit Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: o Ka'u Kakou Program Name: Ka'u Sanitation Program 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. 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 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 an 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 reportusing the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Appfication FY2015-16 Agency Name: O Ka'u Kakou Program Name: Ka'u Sanitation Program 11. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawaii, 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 specifically and explicitly indicates that the County of Hawaii is an additional insured priorto receiving any payment(s). I (we) understand thatfailure to submit the final report within 60 days of June 30" shall result in loss of all grant funds received during the grant period fmust 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) understandthere is no provision for further notification to submit the final report. Information and instructions are available at ht-,p//w w.haWaliCOLinty.gov/fri-noiiprofit-giant-formsI on or about May 30of the year the final 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. n Signature of Authorized person (specffyntle} %` EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 i 7 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kalcou Program Name: Ka'u Sanitation Program 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Provide 2 portable toilets for Punalu'u boat ramp 2 toilets Provide 2 portable toilets for South Point 2 toilets Provide 1 portable toilet for Fishing Tournament 1 hctoilet Provide 2 portable toilets for Plantation Days 2 toilet Equipment $00 other: Other: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $00 Professional Fees $00 Operations $9,000 Supplies $00 Equipment $00 other: Other: Other: Other: Other TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8 of 8 O Ka'u Kakou Punalu'u Annual Fishing Tournament 110 County of Hawai `i Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament Agency Director: ws Kawachi Phone No.: ( BOB) 931 — 6773 Contact Person: Nadine Ebert Phone No.: ( BOB ) 928 — 0027 Mailing Address: Address: Po B, 365 Address: City, ST, Zip Pahala, HI 96771 Facility Address: Address: Aspen canter Address: Ninole Loop Road City, ST, Zip Pahala, HI %777 Email Address: Fax No.: ( BOB) 928 — 8961 Accountant/CPA: Phone No.: ( ) — Firm (if applicable(: Mailing Address: Address: Address: City, ST, Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: saom oo Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑Q Educational concerns ©Youth ❑ Victims of Crimes © Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises. ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Errant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $7,000.00 $9,000.00 0.00 2. Agency Mission Statement: To foster health and prosperity for all of Ka'u. 3. Program Description: To have an annual fishing tournament for keiki ages 1 to 14 years old. 4. Total Budget & Position Count: Total Program Budget: $9,200.00 Total Program Position Count: $00.00 Total Agency Budget: $90,000.00 Total Agency Position Count: $00.00 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament S. Program Funding Sources (identify all sources of funding applied to this programl: FY15-16 Revenue Source Estimate County grant $8,00000 Donations $1,200.00 TOTAL: $s,2oo.00 Attach additionalpages, )(needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We plan to reuse our equipment from previous years. We continue to seek donations and, while the community continues to support the efforts of O Ka'u Kakou, we have used non-specified donations to continue the programs for which we are not asking the County's help to maintain. We continue to look for new venues for fund raising and community donations to become self-sustaining. 7. Program Objectives Using County Nonprofit Grant Program Funds: To promote a healthy love for the art of shore -line fishing, by providing an opportunity for family participation in a supervised fishing tournament. Each child up to the age of 14 must be accompanied by a parent or guardian in this catch and release tournament. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: O Ka'u Kakou Program Name: I unalu'u Annual Fishing Tournament S. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES 0.e.: Number of chen6 serna, worehops orewnts held, wlvnteer hours, etcaescrlbe, he spe hcf Applicant Projected Results 2014 - 310, 2015 - 294 registered fishernnen 2016 - 325 fishermen 2014 - 800, 2015 - 725 lunches and snacks 2016 - 7501unches 2014-95, 2015 - 125 volunteers 2016 - 130 volunteers 2014 - 700, 2015 - 750 volunteer hours 2016 - 775 hours $8,000 $8,000 Supplies $210 $300 $00 Equipment $775 $900 Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual- FP 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $00 $00 $00 Professional Fees $00 $00 $00 Operations $7,803 $8,000 $8,000 Supplies $210 $300 $00 Equipment $775 $900 $00 Other: Other: Other: Other: Other: TOTAL 1 $8,7881 $9,200 $s,o00 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: O Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament lo. 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. AH 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 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: Q. If no conflicts exist,check. here. 4,01 Sinature of Authorize Berson -(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kalcou Program Name: Punalu'u Annual Fishing Tournament u. Certification of Understanding (rage lofz) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records,. reporting, and fiscal accountability requirementsas 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 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 anyfacility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certifythat information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability 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 final payment. To register, go to , complete the 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 reportusing the template provided will impact the evaluation of Your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament 11. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawai i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of 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 301h shall result in loss of all grant funds received during the grant period (must be refunded to Countvl 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. r (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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. A/(rQ�,ip� TJ%u�rT Signature of Authorize - Person (specify titre) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 —27 �2615 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: o Ka'u Kakou Program Name: Punalu'u Annual Fishing Tournament 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed projected Result 2015 - registered fishermen 325 fish.. 2015 - 725 lunches 750 lunches 2015 - 125 volunteers 130 w1unfee 2015 - 750 volunteer hours n5 hours Equipment $00 Other. Other: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $00 Professional Fees $00 Operations $8,000 Supplies $00 Equipment $00 Other. Other: Other: Other: Other: TOTAL $8,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Pacific Tsunami Museum Tsunami Education Video Presentations 111 0 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education Video Presentations Agency Director: Marlene Murray Phone No.: ( 808) 935 — 0926 Contact Person: Marlene Murray Phone No.: ( 808) 935 — 0842 Mailing Address: Address: P0.60x806 Address: City, ST, Zip Hilo. H, 967214 Facility Address: Address: 130 Kamehameha Avenue Address: City, ST, ZIP Hilo. Hl 96720 Email Address: hilec@tsunami erg Fax No.: ( 808) 935 — 0842 Accountant/CPA: Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City, ST, Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Is 27 395 00 Geographical Areas To Be Served: (One or more can be checked) © Puna © Hall © North Kona ✓❑ South Hilo © North Kohala ❑✓ South Kona ✓❑ North Hilo ❑✓ South Kerala ❑/ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑,� Educational concerns ✓❑ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities I ❑� Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education Video Presentations 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $20,000 2. Agency Mission Statement: We believe that through education and awareness, no one should ever again die due to a tsunami. 3. Program Description: The Pacific Tsunami Museum will produce three (3) 30 -minute video presentations. These videos will be the main focus of student group visits to the museum and will include elements of tsunami science, the history of tsunamis on Hawaii Island and how it shaped the community, survivor stories, and safety and evacuation information. The targeted grades will include: 1. Grades 4-6 2. Grades 8-9 3. Grades 11-12 The presentations will include multi -media simulations and actual footage of tsunami events, and tsunami survivor interviews. The Executive Director will manage the project and the archivist/curator will provide the images, videos, and simulation models to the producer. All materials will be reviewed by the Scientific Advisory Committee to ensure scientific accuracy. 4. Total Budget & Position Count: Total Program Budget: 1 $27,395 Total Program Position Count: 2 Total Agency Budget: $243,739 Total Agency Position Count: 3 EXHI BIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education Video Presentations S. Program Funding Sources (identify all sources of funding applied to this program): FY15-16 Revenue Source Estimate We currently do not have the revenue sources to support this program. TOTAL: o Attach additional paces, if needed 6. Explain what plans your agency or program has to increase revenues to support this program: Since admissions, memberships dues and donations only cover out year to year expenses, we continue to pursue grants and other fund raising opportunities. 7. Program Objectives Using County Nonprofit Grant Program Funds: With over 2,000 students visiting the museum each year, their experience will be enhanced with an informative and engaging video presentation. Living on an island where ocean -based recreation is the norm, it is crucial that we educate the youth about tsunamis. The time to plan for a tsunami is now. A locally generated tsunami could occur at any time and arrive on our shores within minutes. With this educational video presentation, students will learn the causes of a tsunami, the warning signs, what to do in the case of a locally generated tsunami versus a distant tsunami, know what to do if they are at home, at school, or near the beach. Students will be instructed to take what they learn home to share with their families and to create an emergency plan. After viewing the video presentation, students and teachers will browse the museum, its exhibits and engage in interactive exhibits. The students will leave with a good understanding of the phenomena of tsunamis and know what to do the next time one occurs - because as history has proven, it isn't a matter of if, but when the next one will strike. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education Video Presentations S. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (.e.: Number of aients served, workshops or events held vowteer hours, etcaesnbe, be sect, Produce (3) video presentations for students 3 video presentations Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 1415 Actual" FY 15-16 Total Budget FY I5-16 Grant Req Salary and Wages 2307 Professional Fees 27391 Operations Supplies 1875' Equipment Other: Contract to write, review materials, act 10190 Other Contract to produce, host, film, edit 7284 Other. Contract videographer to film, edit 3000 Other: Other: TOTAL $27,395 "If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education Video Presentations io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 reoordless of whethero 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 a, 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 PersoglPecify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 1128115 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education Video Presentations 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135-2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. 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 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 Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education Video Presentations 11. Certification of Understanding (Page2of2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-farms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 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 mov result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements 1/28/15 Signature of Authorized P rs (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Pacific Tsunami Museum Program Name: Tsunami Education Video Presentations 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other. Other. Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Palekana Kai Ocean Safety, LLC Ocean Safety Education - Island Wide 112 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Ocean Safety Education - Island Wide Agency Director: Harlan Fra9as Phone No.: ( 808) 937 — 9805 Contact Person: Harlan Fragas Phone No.: ( 808) 982 — 9805 Mailing Address: Address: 980 Railroad Avenue Address: 980 Railroad Avenue City, ST, Zip Hilo, Hawaii 96720 Facility Address: Address: 989 Railroad Avenue Address: 98D Railroad Avenue City, ST, Zip Hilo, Hawaii 96720 Email Address: palekanakai®yahoo.core Fax No.: ( ) — Accountant/CPA: Hillna'i Payroll and Bookkeeping Phone No.: ( 808) — Firm (if applicable): Mailing Address: Address: P . aon 4280 Address: City, ST, Zip Hilo, Hawaii 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 620,00000 Geographical Areas To Be Served: (One or more can be checked) © Puna ❑✓ Hamakua © North Kona © South Hilo © North Kohala © South Kona © North Hilo © South Kohala © Ka'd Services or Activities To Be Provided: (One or more can be checked) Educational concerns F,-/] youth ❑ Victims of Crimes �/❑ Culture and the arts © Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBITA NONPROFIT GRANT APPLICATION FV 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Palekana Kai Ocean Safety, LLC Program Name: Ocean Safety Education - Island -Wide 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 20,000.00 $18,535.00 10,000.00 2. Agency Mission Statement: Palekana Kai Ocean Safety's mission is to educate community youth about ocean water safety while providing opportunities and alternative activities that build these young adult confidence, self-esteem, motivation and a life-long respect for the ocean and the skills needed to enjoy the ocean safely. 3. Program Description: Palekana Kai is a non-profit organization that provides ocean water safety programs such as ocean safety/awareness, ocean rescue and lifeguard training, First Aid/CPR and AED training for community and at -risk youth between the ages of 11-18. Youth receive certifications upon completion of program which may be used to find employment. The Team's experienced lifeguards voluntarily conduct ocean classes at various schools, programs and agencies island -wide. They also conduct FA/CPR/AED, oxygen administration, spinal management, bloodborne pathogens and lifeguard training for individuals of our community and for various organizations and agencies island -wide. Palekana Kai's main objective is to strive to educate, strengthen and empower our youth, families and individuals of our community to be confident and prepared to respond to an emergency situation should one occur at our beaches or recreational water sites. Activities are scheduled throughout the year. We also provide basic water awareness education and activities for our Pre-school and Kindergarten Keiki's. 4. Total Budget & Position Count: total Program Budget: 120,000.00 Total Agency Budget: 30,000.00 Total Program Position Count: lOtal Agency Position count: I 7 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2ofS County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Palekana Kai Ocean Safety, LLC. Program Name: Ocean Safety Education - Island Wide S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source Fy1S-16 Estimate The County of Hawaii non-profit grant 20,000.00 Service/Program fees 8,000.00 Donations 2,000.00 TOTAL: 30,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: At this time our program is looking into various fundraising activities. Palekana Kai is currently charging various agencies and programs a minimal fee for trainings in order to increase income and revenues to support our program. We have collaborated with various agencies and schools in order to continue assisting with at -risk and community youth, as well as those of various ages in our community. The County has generously awarded us with a $10,000.00 grant in July of 2014. These monies were used to purchase training equipment, office supplies, educational materials, certifications, rental -fees, fuel, repairs, replenish supplies, uniforms, incentives for youth and volunteers, also helped us to feed our youth who participated in programs and volunteers as well. Grant also covered our General Liability Insurance and operation expenses. These were needed in order to provide a consistent level of delivery. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1) Obtain equipment to expand training program and on and off site activities to educate youth 2) Conduct informational classes on Ocean Awareness/Safety, First Aid/CPR/AED to enable youth to be prepared to respond to an emergency situation should one occur 3) Conduct informational classes in Lifeguarding Skills, Oxygen Administration, Blood borne pathogens for community youth, various agencies, organizations and residents Island -wide. 4) Decrease number of injuries, drowning and death following an emergency situation. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Palekana Kai Ocean Safety, LLC Program Name: Ocean Safety Education - Island -Wide R. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i. or Number of clients served, workshops or events held, volunteer hours, etc. Describe, be spea)ic) Applicant Projected Results Water awareness/safety classes for youth 70+ youth First Aid/CPR/AED Training for youth 50+ youth Lifeguard/Oxygen Admin/Spinal Management 30+ youth First Aid/CPR/AED Spinal Management for Adult 40+ Lifeguard Training/Oxygen Admin/Bloodborne 40+ Youth find employment with certifications 20+ Provide rescue services for community regatta 2500+ Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 1415 Actual* FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 0 0 0 Professional Fees 720.00 860.00 860.00 Operations 1,159.11 7,500.00 7,500.00 Supplies 2,422.99 4,040.00 4,040.00 Equipment 2,346.57 7,600.00 7,600.00 Other: Other: Other: Other. Other. TOTAL 6,646.67 20,000.00 20,000.00 'If applicable EXHIBIT A NON PROFIT GRAN i APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Palekana Kai Ocean Safety, LLC Program Name: Ocean Safety Education - Island -Wide io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 o 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. O':�, Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 1/30/2015 Date Pages of S County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Palekana Kai Ocean Safety, LLC Program Name: Ocean Safety Education - Island -Wide 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. 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 o timely, complete, and accurate year-end report using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Palekana Kai Ocean Safety, LLC Program Name: Ocean Safety Education - Island -Wide 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 301h shall result in loss of all erantfunds received duringthe grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by June 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) 1/30/2015 Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Palekana Kai Ocean Safety, LLC Program Name: Ocean Safety Education - Island -Wide 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Water awareness/safety classes for youth 70- youth First Aid/CPR/AED/ Training for youth 50+ youth Lifeguard/Oxygen Admin/Spinal Management 30+ youth FirstAid/CPR/AED Spinal Management for Adult 40+ Lifeguard Training/Oxygen Admin/Bloodborne 40+ Youth find employment with cedification 20+ Provide rescue services for community regatta 2500+ TABLE II: PROGRAM EXPENDITURES FY 15-16 Giant Request Council Award Salary and Wages o Professional Fees 860.00 Operations 7,500.00 Supplies 4,040.00 Equipment 7,600.00 Other. Other. Other. Other: Other: TOTAL 20,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT 6 RANT APPLICATION FY 2014-2015 Page 8of8 Budget Details (Equipment) Project Title: Ocean Awareness Education - Island -Wide Legal Name of Entity: Palekana Kai Ocean Safety, LLC. Non-profit 501©3 Address: 980 Railroad Avenue City: Hilo State: Hawaii Zip: 96720 A. Training Equipment for FY 2015-2016 Items Unu Ince S 2,000.00 _-- _-- Unit Price QununityPrice Price Vehicles Rescue Hoard $ 900.011 2 $ 1,800.00 Infant Manikins $ 350.00 (set of4) 1 $ 350.00 Adult Water Manikin $ 1.000.00 _ _ _ 1 1 $ $ 1,000.00 100.00 Ambu for child $ 100.00 Ambu for adult $ 100.00 1 $ 100.00 UHF Radios $ 250.00 4 $ 1,000.00 VHF Radios $ _ 250.00 4 T-1 000 00 Goggles $ 25.00 10 $ 250.00 Fins $ 45.00 _ _ _ 10 $ 450.00 wards S 40.00 20 $ suit litRash T-shirts $ 15.00 511 $ 750.00 Total Training Equip S 7,600.00 B. Vehicle and Equipment Repairs/Maintenance/Fuel Items Unu Ince S 2,000.00 _-- _-- Unit PrkeQuarnitv I Price Vehicles $ 2,000.00 1 S 2,000.00 Wave Runner $ 1,500.00 1I $ 1,500.00 MaintenancelFLed $ 2.000.00 $ 2,00000 Total Maintenanm 1 20 15 $ $ 5 5500.00 C. Office Equipment Items Unu Ince S 2,000.00 _-- _-- Unit Price Quantity y Price Desk Top Con, ager $ 800.00 1 $ 800.00 Lap top $ 90000 I $ 900.110 Ink cartridges' T$ 50.00 10 $ 500.00 'rutal 1 20 15 $ $ I s 2,200.00 D. Educational and Training Materials/Manuals Items E.Insurance Itcros Ocnc,,d 1 rabila, In, Unu Ince S 2,000.00 _-- _-- Unit Price uantity 'local Price First Aid/APD Pert mamal $ B.50 40 $ 340.OU Adult FA lief Card i$ 5.00 1 40 $ 20000 First Aid Cert $ I$ 35.00 40.00 1 20 15 $ $ 700.00 600.00 Life ward manuals local IS ls4am E.Insurance Itcros Ocnc,,d 1 rabila, In, Unu Ince S 2,000.00 _-- _-- Quantity — --- Price $ 2,000.00 'local S 2,000.00 F. Professional fees Items UnitPrice Quantity Price Itookku iu $ 860.00 - $ - 86000 ntnl S N60.00 �Ibcal_ _ _ S _ 20,UUO.U0 PATCH -People Attentive to Children PATCH Training Transportation Initiative 113 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: PATCH -People Attentive to Children Program Name: PATCH Training Transportation Initiative Agency Director: Laura Bmcla Hamm Phone No.: ( 508) 550 — 3853 Contact Person: Jenny smack Phone No.: ( 808) 550 — 3851 Mailing Address: Address: 560 N. Nlmit, Hwy. 213 Address: C01 ST, Zip Honolulu, HI 96817 Facility Address: Address: 26Waianuanue Ave. Address: City, ST, Zip Hilo, HI 96720 Email Address: jschack@Patch-hl.org Fax No.: ( 808) 694 — 3851 Accountant/CPA: Carleton Wilnams Phone No.: ( 806) 531 — 10<0 Firm (if applicable): CW Asaoclatas CPAs Mailing Address: Address: 706 Bishop street Suite 1040 Address: City, ST, ZIP Honolulu, HI 96813 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: s ls000do �T Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna ✓❑ Hamakua ✓❑ North Kona ✓❑ South Hilo © North Kohala ✓❑ South Kona © North Hilo ✓❑ South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises © Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: PATCH -People Attentive to Children Program Name: PATCH Training Transportation Initiative 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 n/a () n/a 2. Agency Mission Statement: PATCH's mission is to support and improve the quality and availability of care for the young people of Hawaii. 3. Program Description: PATCH currently offers about 150 free child care workshops at various training sites across Hawaii Island. Trainings are open to care givers such as family child care, preschool and infant/toddler center staff, before and after school programs, parents, medical professionals and anyone interested in caring for children. PATCH has offices in East Hawaii serving 260 and West Hawaii serving 122 training participants. Clients skip dinner and travel (from 60-80 miles round trip) island wide to attend our evening classes, these unique challenges become barriers for individuals. Our program seeks to provide a light meal for Hilo and gas cards for Kona participants to alleviate the barriers that prevent individuals from benefiting from PATCH's free classes. Each individual that attends PATCH classes represents a family of on average 5, thus impacting 1,910 community members in a 12 month period. 4. Total Budget & Position Count: Total Program Budget: $46,786 Total Program Position Count: a Total Agency Budget: $3,465,4231 Total Agency Position Count: 138 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: PATCH -People Attentive to Children Program Name: PATCH Training Transportation Initiative S. Program Funding Sources (identify all sources of funding applied to this program) FY15-16 Revenue Source Estimate Department of Human Services (Training statewide) 418500 ( TOTAL: I 418500 Attach additional oaaes, if needed 6. Explain what plans your agency or program has to increase revenues to support this program: When the pilot year is completed we will analyze the results to see if the program enhancements had an impact on increaslrg class attendance. Our practice is to survey class participants at the end of each session and will be able to capture data related to this project. We anticipate the response will be positive. PATCH will investigate ways to continue this practice. Private funding is an option as well as operating money generated by PATCH offices in Kana and Hilo. 7. Program Objectives Using County Nonprofit Grant Program Funds: It is known that specific barriers exist which keep Hawaii County residents from participating in free PATCH training sessions. In West Hawaii we have found that folks want to attend but remote location and/or distance to the training locations hinders participation. Feedback from East Hawaii indicates lack of time for a meal becomes a deterrent. PATCH would like to remove these barriers and provide greater access to our free training classes for the residents of Hawaii County. PATCH kindly requests a $7,000 grant from the County of Hawaii for our program enhancement pilot project that would supply, 1. a light meal/pupus for E. Hawaii classes and 2. a $5 gas card for W. Hawaii class attendees. We believe this initiative has the potential to increase the skills and knowledge base of Hawaii County's residents serving the early childhood sector. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: PATCH -People Attentive to Children Program Name: PATCH Training Transportation Initiative 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.: Number o)clients serveG, workshops or events held volmreer M1ours, ea. DessribC be specific) Applicant Projected Results Clients served by East Hawaii's 75 classes Increase of 25%/class 5 per class is the average with capacity for from 5 to 8 attendees 29300 Clients served in West Hawaii's 75 classes Increase of 25%/class 5 per class is the average with capacity for [from 5 to 8 attendees Operations 10370 10370 Attach additional pages as necessary. 9. TABLE It PROGRAM EXPENDITURES FY 14-15 Actual' Pv 75-16 Total Budget F 15- lb Grantranc Req Salary and Wages W 29300 29300 Professional Fees 2428 2428 Operations 10370 10370 Supplies 4114 4114 Equipment 854 854 Other: Enhancement E. Hawaii -8 meals/class 4200 4200 Other. Enhancement W. Hawaii - 8 gas cards/class 2800 2800 Other: Other Other TOTAL 467661 53766 7000 "If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: PATCH -People Attentive to Children Program Name: PATCH Training Transportation Initiative io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 ❑ Tbo corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: PATCH -People Attentive to Children Program Name: PATCH Training Transportation Initiative ii. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. 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 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 HawaM grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete and accurate year-end reportusing the temolote provided will impact the evaluation of your program's or ogency s future fundinq requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: PATCH -People Attentive to Children Program Name: PATCH Training Transportation Initiative --- ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured priorto 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 goy/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, 2015 must be returned to the County of Hawai'i with the final report. Failu__to return these funds in a timely manner will impact the evaluation of your aoencv's future fundina reauest and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: PATCH -People Attentive to Children Program Name: PATCH Training Transportation Initiative 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages _ I Professional Fees Operations Supplies Equipment Other: Other. Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Project Vision Hawai'i Hawai'i Island Mobile Health Services 114 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Project Vision Hawai i Program Name: Hawaii Island Mobile Health Services Agency Director: E6aalneth Anna Haler Phone No.: ( 808) 282 — 2265 Contact Person: Maryellen Mender. PhD Phone No.: ( 808) 561 — 8096 Mailing Address: Address: PO hoe 23212 Address: City, ST, Zip Honolulu, Hi 96823 Facility Address: Address: 1221 Modern BIM Ste#310 Address: City, ST, ZIP Honolulu, H196814 Email Address: nrxra leylememnn Fax No.: ( ) — Accountant/CPA: Grey Wong, CPA Phone No.: (808) 222 — 4848 Firm (if applicable): Howell care Samoa: Mailing Address: Address: 1288 Ala Were BW Address: Suite 201 City, ST,Zip Hanolulu,11196814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $65,000 Geographical Areas To Be Served: (One or more can be checked) Q Puna Q Hamakua Q North Kona Q South Hilo Q North Kohala Q South Kona Q North Hilo Q south Kohala Q Ka'0 Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts Q Aged Q Victims of Health or Social Crises Q Needs of the poor Q Physical/Emotional Disabilities Q Public Health and welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Project Vision Hawai i Program Name: Hawaii Island Mobile Health Services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12.13 FY 13-14 FY 14-15 0 0 $48,500 2. Agency Mission Statement: PROJECT VISION HAWAI'I is a non-profit 501(c)3 public charity. Our mission is to enhance the quality of fife by improving vision, preventing blindness, and advancing medical knowledge through community-based research. 3. Program Description: Mobile health care for under -served population of Hawaii, providing free vision retinal eye screenings in our state-of-the-art Project Vision bus. Since beginning in 2007, Project Vision has provided free screenings to nearly 18,000 participants, detecting pathology in one or both eyes for over 40% screened inside of our mobile clinic . We have 4 programs that are summarized below. Project Vision Hawai is "Better Vision for the Keiki" project is one where we target children specifically with vision and school readiness screenings. In our "Better Vision for a Better Life" Eyeglasses for the Underprivileged Project, we provide comprehensive eye screening and prescription glasses for the uninsured and underinsured individuals - especially those who are homeless. 'WE ... a but for Health" is a wellness collaboration coordinated under Project Vision Hawaii. We provide our wellness screening events statewide, on each island to provide services in areas with access -to -healthcare issues. We define that as those who have trouble accessing health care because it is geographically difficult, too costly, or not available for other reasons. Project Vision Hawaii also has started a program working with community health centers and hospitals to screen diabetics. 4. Total Budget & Position Count: Total Program Budget: $210,000 Total Program Position Count: 4 Total Agency Budget: S528,4001 Total Agency PosRion Count: a EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Project Vision Hawai i Program Name: Hawaii Island Mobile Health Services S. Program Funding Sources (identify all sources of funding applied to this Program(: Revenue Source FY1S-16 Estimate Atherton Family Foundation 10.000 Kaiser Foundation 10.000 HMSA Foundation 15.000 State of Hawaii 30•000 Olrice of Hawaiian Affairs 40•000 Hawaii Health connector 40•0W TOTAL: 5145,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to Increase revenues to support this program: (1) We are developing a fee-for-service agreements and income stream with Community Health Centers for screening services. Our Pilot program began with with Waikiki Health Center in 2014, and that income helped us to fund additional services on the Big Island. (2) For those who do have health insurance, we can provide comprehensive eye exams through our RV program as long as we have the necessary equipment. Insurance pays, payment split between Doctor, Community Health Center and PVH. With careful cost control, this income will also help fund our free services for those with less ability to pay. (3) We have been in negotiations with various physician stakeholders over the use of the Big Island RV during weeks that we do not need it. We expect a substantial tee -for -service income stream for this availability in the future, and the RV will be able to provide a base of operations for medical research that reaches the most rural areas of the Big Island. (4) We have also offered the RV as a free resource for emergency relief in the Puna area as 7. Program Objectives Using County Nonprofit Grant Program Funds: IV. Outcomes: Given the activities and outputs accomplished during this grant period, expected outcomes are: 1) A reduction in the risk of blindness in populations who lack access to health care services 2) An increase in the number of Native Hawaii residents that are screened for vision pathologies and diabetes -related health challenges 3) More avenues for counselling, education, and access with services as needed for the most vulnerable populations. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Project Vision Hawal'i Program Name: Hawaii Island Mobile Health Services S. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES li.e.: Number oJNienasenM, wabho meventsaNa, vdunrcer Nona, nc.Oetcribe. be spttific.! Applicant Projected Results Coordinated community Events 40+ Pan nparts served with screenings 2500+ Individuals Reaeivinq Preventative Services 7500+ Participants v4th revealed patty (40%) 1000+ IMividuals that receive reading lasses 1000+ Volunteers trained 100+ Estimated Hawaii County medical costs saved I 55,000,000 + annually Attach additional pages as neceuory. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 58,000 63.000 35,000 Professional Fees 33,800 40,000 5,800 Operations 15,800 20,800 Supplies 12,000 10,000 Equipment 28.500 30.000 Other: Bus upgradesto allow retrofit 10,333 27,000 7.000 Other: Staff Travel Caste - From Oahu, and on BI 1,000 5.000 5,000 Other: Storage - Medical Records and related equip. 2,200 2,200 Other: Other: TOTAL 147,433 200,000 65,000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Project Vision Hawaii Program Name: 1o. 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 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): ❑ 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 ocwing 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 If no conflicts exist, check here. W Signature of Authorized Person (specify title) EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 (y IS Date Page 5 of 8 County of Flawai`i Nonprofit Grant Application FY2O15-16 Agency Name: Project Vision Hawai'i Program Name: Hawaii Island Mobile Health Services li. Certification of Understanding (Paget 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 final payment. To register, go tohtt / vendors.ehawah.nr,_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 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 /matt the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Project Vision Hawaii Program Name: 11. Certification of Understanding (Page2of2) 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 lune 301" 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://hawai,county.go/fn-notiprofit-grant-foron or about May 30 of the year the final 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 lune 30, 2015 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 inactions taken to recover thesefunds. By signing below, you are acknowledging that you have read and understood these requirements ( I7�'IIS Sign cur of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Project Vision Hawai i Program Name: Hawaii Island Mobile Health Services 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Coordinated Community Events - Hawaii County ao. Low Income participants served with screenings 2500+ Patients Receiving Preventative Services 7500. Patients with Critical Pathology (40%) 1000. Individuals that receive eyeglasses 1000+ Volunteers trained for health service provision 100+ Other: Staff Travel- from Oahu and to events on BI 5,000 TABLE It: PROGRAM EXPENDITURES FY 15.16 Grant Request Council Award Salary and Wages 35,000 Professional Fees 5.800 Operations Supplies 10,000 Equipment Other: Bus Upgrades - Retrofit for testing equip. 7,000 Other: Staff Travel- from Oahu and to events on BI 5,000 Other: Storage - local safe storage/madical records 2,200 Other: Other: TOTAL 65.000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 Read Aloud America RAP Programs for the Island of Hawai'i 115 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Read Aloud America Program Name: RAP Programs for the Island of Hawaii Agency Director: Jed Gaines, President Phone No.: ( eoe) 531 _ 1985 Contact Person: Beverly Heikes, Program coordinator Phone No.: ( 808 ) 938 — 9215 Mailing Address: Address: 1314 s. icing street Address: Solaro City, ST, Zip Honolulu, Hi 96814 Facility Address: Address: 99Aupmestreet Address: Suite101 City, ST, Zip Hilo, HI96720 Email Address: dgdeikes9phoo com Fax No.: ( 808) 593 _ 1984 Accountant/CPA: Allen Arakaki, CPA Phone No.: ( 808) 591 — ad60 Firm (if applicable): Allen M. Arakaki, CPA LLC Mailing Address: Address: 13145. Kingstreet Address: Smte110 City, ST, Zip Honolulu, HI 96014 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Haunt ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑ South Kona ✓❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns ❑✓Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NON PROFIT G RANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Read Aloud America Program Name: RAP Programs for the Island of Hawaii 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 $198,56200 FY 13-14 07 FY 14-15 $631,68700 Total Agency Position Count: 0 0 0 2. Agency Mission Statement: "Through the fun of reading and being read to, Read Aloud America promotes literacy, teaches strong family communication skills and builds communities of lifetime readers." The Read Aloud Program, RAP, is an innovative family program, hosted by Hawai i elementary and middle schools, which brings parents and children together for six RAP sessions during one school semester and inspires them to read. The target population to be served are families whose children attend Title I schools in Hawai is underprivileged communities where schools face such challenges as homelessness, single parent households, foster care, language barriers, special needs, and poverty. Sixty-two percent of RAP participants receive free or reduced price lunches. At RAP, families enjoy a pressure - free environment in which they learn about the importance of limiting screen time viewing such as television, video games, computer, phone, etc and replace this with increased family time through reading and reading aloud, and incorporating reading into their everyday lives. 3. Program Description: RAA's Read Aloud America Program (RAP) is an Hawaii -only literacy program offered in six evening sessions at underserved schools (Title 1) to teach parents how to develop strong communication skills with their children; teach their children to love reading for both pleasure and education, limit technology as a replacement for family interaction, and develops positive attitudes and lifelong learning skills. RAP is an evening family -based read -aloud program, hosted by public elementary or intermediate schools in some of the island of Hawai is most needy communities. It is not a "one shot" program, but rather a comprehensive program that involves classroom teachers, administrators, students and their families. The program includes a staff presentation, six to twelve classroom presentations (mini RAPS), and six early evening family RAP sessions that are completed over the course of one semester. All members of the school community are encouraged to participate, giving parents opportunities to socialize with other community members and meet teachers, school administrators, and staff in friendly social situations. Each RAP session will draw several hundred participants. Since 1999 Read Aloud America has served over 329,000 children and adults in Hawaii. No other literacy program in the nation has drawn such numbers. 4. Total Budget & Position Count: Total Program Budget: $198,56200 Total Program Position Count: 07 Total Agency Budget: $631,68700 Total Agency Position Count: 14 EXH I BIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Read Aloud America Program Name: RAP Programs for the Island of Hawaii 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Stale of Hawaii Grant In Aid Funding - 2015-16 85,055.00 aunty of HawaFi Non roti)rant - 2015-16 26, 5 0 rivate Grant,oun ations. Sc oats antl General ovations 65,155 00 TOTAL: 8196,562 00 Artach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: By developing a financial partnership with the State of Hawaii, the County of Hawaii, private foundations, schools and individuals, RAA's goal is to increase the number of school RAP programs from two to four programs during the 2015-16 school year. The County of Hawaii has a majority of state and federal designated Title I underserved schools and there is an urgent need to improve the level of literacy. Based on data from the National Center for Educational Statistics, in 2013 Hawai'i's public school students scored below the national average in almost all subject matters and grades tested, except for 4th grade math. Furhermore, in 2013 the gap in scores between the highest and lowest quintile students in reading was particularly high - 50 points for grade 4 (only 4 states have higher gaps) and 46 points for grade 8 (only two states have higher gaps). According to the Strive HI Accountability Report for 2012-13, 60% of high needs students were proficient in reading compared with 89% of non -high needs students. These statistics point to two critical issues - reading as paramount to academic success and the achievement gap between students from higher and lower income families. 7. Program Objectives Using County Nonprofit Grant Program Funds: Participating in RAP will reap many rewards for participating school communities. Families will take part in a program that motivates parents and children to read more; that offers resources and tips for reading together; and that promotes family engagement, communication amongst families and school and families, and lifetime readers. The school will find that their students are reading and listening better, and that students have a better attitude toward school. Parents will become more actively involved in the education process, strengthening the link between home and school. RAP has five goals: 1. - TO encourage families to read to children regularly and become more engage in their children's learning; 2. - TO provide resources to help families and teachers choose books and read to children; 3. - TO nurture a love of reading in parents and awaken a love of reading in their children; 4. - TO encourage families to limit technology and read; 5. - TO encourage positive family, teacher and school relationships. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Read Aloud America Program Name: RAP Programs for the Island of Hawaii 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES h.e.: Number cf1 hemi served, workshops or events held, volunteer tool etcdescribe, be spea7ic) Applicant Projected Results 24 evening RAP programs with an average attendance of 375 participants per evening grids Participants Parents report student's increased interest in voluntary reading 85% Teachers report clearly improvehome-to-schoo relations ips 75% Students report a more positive attitude toward school 70% Students decrease electronic media time in favor of reading 70% Participating families will build a Family Reading Handbook 100% Parents will commit Io reading lot ea ren at east times a week ]0 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages (Includes taxes and benefits) 98.852 0 Professional Fees 0 0 Operations 21,690 0 Supplies 2.000 500 Equipment 0 0 Other: Travel (Parent Presenter from Oahu for four programs) 14.400 3.200 Other Office/Storage Space for program supplies and operations 10.020 2.000 Other'. Transportation (Two Vans to transport to and from programs/supplies) 7200, 2,800 Other. Program (Post for 2 mailings home/Books/Incentiveaf(raining/Giveaways/ 44,400 19.852 Other: Family Handbook/RAP Up Bookhraisous Handbook/Banners/Lt, Meal 28,352 TOTAL 198,562 'If applicable EXHIBIT A NON PROFIT G RANT APPLICATION FY 2015-2016 Page 4 of 8. TABLE I: (Cont) What are the intended measurable outputs or outcomes that would be achieved with this funding? The integrity of RAP is of critical importance to Read Aloud America, and we use a variety of ways to monitor quality: 1. Participating adults fill out evaluation forms at each RAP session. 2. Participating adults and students in grades three and up complete written end-of- program surveys. 3. Families who have participated in more than one RAP program complete an additional written survey. 4. School principals and liaisons fill out written reports at the end of each program. 5. Faculty and staffat each RAP school complete an crud-of-program survey. 6. All volunteer readers turn in written evaluations at the end of the program. A Program Coordinator and Program Assistant oversee each RAP session, and the President, the Director of Program/Training, and the Director of Operations/Grants make frequent visits to program sessions to assess quality. Verbal feedback from stall; school RAP teams, parents, and volunteers is encouraged and taken into consideration. In addition, registration and attendance at each session is carefully recorded. Data reports arc shared with school administration and faculty after each session. Formal school reports, detailing survey results and presenting participants' comments, are prepared and distributed to each school. This data is compiled, analyzed, and used to evaluate all components of the program each semester. At the semester's end, Read Aloud America's Program Director compiles surety results from all schools and applies it to RAP's comprehensive program results. RAP's goals as listed in `Background and Summary" are measured through 7 objectives. RAP's success is measured by participants' responses, as stated above. Since RAP attempts to influence attitudes and habits which change slowly over time, we feel it is important to measure the feedback from families who have attended more than one RAP program. The results horn our "Returning Family Survey" show that families are internalizing RAP concepts: strengthening families, providing positive role models for youth, and developing firmer home-school relationships. Since 2002 this is what our returning family parent's saying about the RAY program? 91"/" say their children seem to like reading books more since attending RAP. 88"/o say their children are reading more. 69"/o say their families' watch less TV since attending RAP. 83"/o say their family spends more time together. 77"6, say they, they adults, read more because of RAP. 89 % say they feel more confident about reading to their children. 97"/o say RAP provides them with helpful reading information and resources. 90"A say they arc more involved in their children's learning since attending RAP. 82"/o say they are more involved with their children's school. County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Read Aloud America Program Name: RAP Programs for the Island of Hawaii io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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: 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 n confl cts Wist, check here. naN Si ature of Authoized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 January 27, 2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Read Aloud America Program Name: RAP Programs for the Island of Hawaii 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 — 2-142.1, 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 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 Hawai'i Compliance Express, and be compliant prior to final payment. To register, go to http://vendors.ehawaii.pov, complete the 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 a d will comply with the requirement to submit a year-end report to the County Council within 60 days afterlune 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 submif a timely, complete and accurate year-end report using the template provided will impact the evaluation of vour program's or ouency s future funding requests. EXHIBITA NON PROF IT GRANT APPLICATION FV 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Read Aloud America Program Name: RAP Programs for the Island of Hawaii tt. Certification of Understanding (cage 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 lune 30`b 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 littp�// hawafi ico u n ty.gov/fn - o u oft -g ra nt-fos/ on or about May 30 of the year the final 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, 2015 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 token to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. January 27, 2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Read Aloud America Program Name: RAP Programs for the Island of Hawaii 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result 24 evening RAP programs with an average attendance of 375 participants per evening 9,000 Partidpants Parents report student's increased interest In voluntary reading 85% Teachers regal clearly improved home -to -school relationships 75% Students report a more positive attitude toward school 70% Students decrease electronic media time in favor of reading dpi Participating families will build a Family Reading Handbook 100 Parents will commit to reading to their Children at least 3 times a week 70% TABLE It: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Includes taxes and benefits) 0 Professional Fees 0 Operations 0 Supplies 500 Equipment p Other: Travel (Parent Presenter from Oahu) for four programs) 3,200 O[her: Office/Storage Space for proyram supplies and operations 2000, Other. Transportation (Two vans to transport to and from programs/supplies) 2 800 Other: Program (Postage -mailings homelBooksllncentives/Training/Giveaways/PR 19,852 Other Family Hand o-k/RAP Up Book/Liaison's Ha udbook/RannersN. Meal/Print TOTAL 28,352 Additional council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Salvation Army - FIS, The Independent Living Skills - West Hawai'i 116 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army- FIS Program Name: Independent Living Skills - West Hawaii Agency Director: Pauline Pavao Phone No.: ( BOB) 959 — sass Contact Person: Denise Pacheco Phone No.: ( BOA 1981 — 0225 Mailing Address: Address: P_o. eo.5085 Address: City, ST, Zip Hilo, HI 11111 Facility Address: Address: 1766 Kinoole Street Address: City, ST, ZIP Hilo, HI 96720 Email Address: Pauline. Pavao& w.salvalionarroy.or, Fax No.: ( B08 959 — 2301 Accountant/CPA: Cary ebese9awa Phone No.: ( 808 959 — 5655 Firm (if applicable): Mailing Address: Address: POBox5085 Address: Gty, ST, Zip Hila, HI96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 535,00000 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Harl ❑, North Kona ❑ South Hilo ❑ North Kohala © South Kona ❑ North Hilo ❑ South Kerala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked( ❑ Educational concerns © youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army -FIS Program Name: Independent Living Skills - West Hawaii 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 1415 $18,750.00 $10,000.00 $20,000.00 2. Agency Mission Statement: "TO PROVIDE YOUTH WITH SKILLS FOR A HELATHY LIFE AND TO INSTILL PURPOSE, HOPE AND VISION TO YOUTH AND THEIR FAMILIES" is our mission statement and represents the philosophy we strive towards. It is our belief that in order to succeed, youth need to have a sense of belonging within their community, their culture, with their peers and most importantly with family. When achieved, opportunities come forth, involvement of the community become prevalent and the youth and family experience growth. 3. Program Description: The Independent Living Skills program is designed to help foster youth and emancipated foster youth ages 12-26 prepare for and manage the transition to productive self sufficient adulthood with a base of independent living skills. The Goals of the Independent Living Program Services is to 1) provide a comprehensive life skills based curriculum, 2) provide opportunities for foster youth to pursue higher education, vocational training, an/or employment, 3) provide linkages and resources to services in the community including: housing, health insurance,and other vital needs. For foster youth over the age of 18 and attending college, the program provides supportive services each month with the distribution of higher education vouchers, financial aid assistance, career planning, and academic counseling. 4. Total Budget & Position Count: Total Program Budget: $12603800 Total Program Position Count: s Total Agency Budget: $3,500,000.00 Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army - FIs Program Name: Independent Living Skills - West Hawaii 5. Program Funding Sources (identify all sources of funding applied to this program FY15-16 Revenue Source Estimate County of Hawaii $35,000.00 Department of Human Services $91,038.00 TOTAL: $126.038.00 Attach additional pages, if needed 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army -Family Intervention Services continuously explores funding avenues in the private, State and Federal sectors to continue and enhance program services. We annually seek grants and/or partnerships to build program services. In line with our mission and the work that we do, we do rely heavily on funding at all levels of government 7. Program Objectives Using County Nonprofit Grant Program Funds: Of the 30 youth foster youth, ages 12-26 participating in the program, 75% will successfully complete their IL program EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army - FIS Program Name: Independent Living Skills - West Hawaii 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i e.: Number o)tlienls servetl, workshops m i ven6 held, volunteer hou ; "I Desoibe, be speoficJ Applicant Projected Results Completion of ILSP 30 Participates in IL activities 20 Participates in IL plan 20 Follow up and Monitoring 30 240 Operations $23,314 $598Supplies Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual" Total Bq FY 1t648$8 Salary and Wages $69,924 $65 Professional Fees $5,584 240 Operations $23,314 $598Supplies $4820 95] Equipment Other: Other: Other: Other: Other: TOTAL $103,642 $126,038 $35,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-201.6 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army -Family Intervention Services Program Name: Independent Living Skills - West Hawaii io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 o conflict exists. NAME: John Chamness POSITION: Divisional Commander 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: 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: Ly If no conflicts exist, check here. �L= 0�0,� , I-,- Yl t S- SignAire of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army -Family Intervention services Program Name: Independent Lriwing Skills - West Hawaii 11. Certification of Understanding (page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135— 2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program($) 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 final payment. To register, go to htto://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 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 reportusing the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army- Family Intervention Services Program Name: Indeuendent Livinq Sills -West Hawaii 11. Certification of Understanding (Page z oft) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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 lune 30th shall result in loss of all grant funds received during the grant Period (must be refunded to Countvl 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 http://www.hawalicounty.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 (30%) for administrative and overhead costs. Any funds unused by June 30, 2015 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 voencv's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signatur f Authorized Person (specify title) \l,�,']1s Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army- FIS Program Name: Independent Living Skills - West Hawaii 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Completion of ILSP 30 Participates in IF activities 20 Participates in IL plan 20 Follow up and Monitoring 30 Equipment Other: Other: TABLE If: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $25,205 Professional Fees $240 Operations $8,598 Supplies $957 Equipment Other: Other: Other: Other. Other. TOTAL $a5,0on Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Salvation Army - FIS, The Positive Youth Development Prg - Kea'au 117 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army- FIS Program Name: Positive Youth Development Program-Keaau Agency Director: Pauline Pavao Phone No.: ( 808) 959 — sass Contact Person: Denise Pacheco Phone No.: ( 809 961 — 0225 Mailing Address: Address: P,o. Box sobs Address: City, ST, ZIP Hilo, HI 96720 Facility Address: Address: 1766 xmeule street Address: City, ST, ZIP Hilo. HI 96720 Email Address: Paurne,Pavao@usw,salvationarmy.org Fax No,: ( 60e J 959 — 2301 Accountant/CPA: Cary Ehesogawa Phone No.: 808 959 — 5655 Firm (if applicable): Mailing Address: Address: P.o Be,eoa5 Address: City, ST, Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: gas oo0.00 Geographical Areas To Be Served: (One or more can be checked) © Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can he checked) ❑ Educational concerns ❑� Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor [] Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRAN F APPLICATION FY 2015-2016 Page I of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army - FIS Program Name: Positive Youth Development Program-Keaau 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $31,750.00 $10,000.00 $20,000.00 2. Agency Mission Statement: "TO PROVIDE YOUTH WITH SKILLS FOR A HELATHY LIFE AND TO INSTILL PURPOSE, HOPE AND VISION TO YOUTH AND THEIR FAMILIES" is our mission statement and represents the philosophy we strive towards. It is our belief that in order to succeed, youth need to have a sense of belonging within their community, their culture, with their peers and most importantly with family. When achieved, opportunities come forth, involvement of the community become prevalent and the youth and family experience growth. 3. Program Description: The Salvation Army -Family Intervention Services -Positive Youth Development Program provides a safe and nurturing environment along with access to opportunities, experiences and services to support positive activities for youth ages 10 to 21 residing in the Keaau communities. We utilize the Botvin Life Skills Training curriculum in Department of Education and charter schools to decrease the use and abuse of alcohol, tobacco and other illicit drugs. The impact we strive to achieve is that all youth will avoid unproductive behaviors and maintain safe, healthy lifestyles. Activities during after school hours include: Cultural Awareness and Identity projects, Community Service and Learning, Sports Health and Fitness, Mentoring, Personal and Social Competence and Family Engagement. 4. iota( Budget & Position Count: Total Program Budget: $ I III 1 oo Total Program Position Count:9 Total Agency Budget: sa,500,000.00 Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army - FIS Program Name: Positive Youth Development Program-Keaau S. Program Funding Sources (identify all sources of funding applied to this program): FY15-16 Revenue Source Estimate County of Hawaii $35,000.00 Department of Human Services - Office of Youth Services $75,000.00 t $110000.00 _ TOTAL: Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The Salvation Army -Family Intervention Services continuously explores funding avenues in the private, State and Federal sectors to continue and enhance program services. We annually seek grants and/or partnerships to build program services. In line with our mission and the work that we do, we do rely heavily on funding at all levels of government 7. Program Objectives Using County Nonprofit Grant Program Funds: Of the 40 youth targeted to participate in the Prevention program. 85% will demonstrate an increase in competencies through the Botvin Life Skills Training Curriculum Of the 40 youth targeted to participate in the Prevention Program, 50% will engage in Positive youth development activities including cultural awareness and community service and learning projects. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page3 of5 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army - FIS Program Name: Positive Youth Development Program-Keaau 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (l.e: Numher of tllen[s served, workshops m even6 held volunteer how, etc Desnlbe, be spetlfic.) Completion of Botvin Life Skills Training 30 Cultural Awareness and Identity 20 Participation in Positive Alternative Act. 20 Follow up and Monitoring 40 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $36,628 $81,970 $27,241 Professional Fees $1,214 $1,080 $240 Operations $11,460 $24,550 $6,894 Supplies $3,724 $2400 $625 Equipment Other: Other: Other: Other: Other: TOTAL $53,025 $110,000 $35.000 `R applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army -Family Intervention Sevi'ces Pro ram Name: POcitie Youth Devel ooment Program -Keaau ___._� _ v io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 bgslaved regardless of whether a conflict exists. NAME: john Chamness POSITION: Divisional Commander 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: 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. L0_4� �IZ�I,s Sign I a of Authorized Person (specify title) Date ExHIBiT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army -Family Intervention Services Program Name: Positive youth Development -Keaau I 11. Certification of Understanding (page 1 of 2) 1 (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated In Article 25, Sections 2- 135 —2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and Inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to final payment. 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 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 timelvsomolete and accurate vear end reportusing the template provided will impact the evaluation of your program's or agency's future funding re guest . EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page6 ofg County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army -Family Intervention Services Program Name: Positive Youth Development - Keaau 11. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawal'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 HawaPi 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 Countvl and exclusion from future Brant 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 httl?://www, hawaiicoarty Rov/fn- non oroft-grant-fo 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, 2015 must be returned to the County of HawaYi with the final report. Failure to return these funds in P time/vmonner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. \L Ou��' — l �2 his Signa u e of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army - FIS Program Name: Positive Youth Development Program-Keaau 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Completion of Botyin Life Skills Training 30 Cultural Awareness and Identity 20 Positive Alternative Activates 20 Fallow up and Monitoring 40 Equipment Other: Other. Other: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $27,241 Professional Fees $240 Operations $6894 Supplies $625 Equipment Other: Other. Other: Other Other. TOTAL $35,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 3 of Salvation Army - FIS, The Substance Abuse Prevention Prg - Pahoa 118 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The salvation Army - FIs Program Name: substance Abuse Prevention Program-Pahoa Agency Director: Pauline Pavan © Puna ❑ Hamakua Phone No.: (floe) 959 — sass Contact Person: Denise Pacheco ❑ North Hilo ❑ South Kohala Phone No.: ( 808 ) 981 — 0225 Mailing Address: Address: P. o. Do*5085 Address: City, ST, Zip Hilo, H196720 Facility Address: Address: 1786 Klnoole Street Address: City, ST, Zip Hilo, HI 96720 Email Address: Pauline.Pavao®u,s,aalyationarmy.org Fax No.: ( 606 ) 959 — 2301 Accountant/CPA: Cary Ebesul Phone No.: ( 808 ) 959 — sass Firm (if applicable): Mailing Address: Address: P.o Bi, said, Address: City, ST, Zip Hil, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $36,000.00 Geographical Areas To Be Served: (One or more can be checked) © Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns 0 Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army - FIS Program Name: Substance Abuse Prevention Program-Pahoa 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $14,000.00 $10,000.00 $15,000.00 2. Agency Mission Statement: 'TO PROVIDE YOUTH WITH SKILLS FOR A HELATHY LIFE AND TO INSTILL PURPOSE, HOPE AND VISION TO YOUTH AND THEIR FAMILIES' is our mission statement and represents the philosophy we strive towards. It is our belief that in order to succeed, youth need to have a sense of belonging within their community, their culture, with their peers and most importantly with family. When achieved, opportunities come forth, involvement of the community become prevalent and the youth and family experience growth. 3. Program Description: The Salvation Army -Family Intervention Services- Substance Abuse Prevention Program provides a safe and nurturing environment along with access to opportunities, experiences and services to support positive activities for youth ages 7 to 17 residing in the Pahoa communities. We utilize the Botvin Life Skills Training curriculum in Department of Education and charter schools to decrease the use and abuse of alcohol, tobacco and other illicit drugs. The impact we strive to achieve is that all youth will avoid unproductive behaviors and maintain safe, healthy lifestyles. Activities during after school hours include. Cultural Awareness and Identity projects, Community Service and Learning, Mentoring, Personal and Social Competence and Family Engagement. 4. Total Budget & Position Count: Total Program Budget: $120,000.00 Total Program Position Count. e Total Agency Budget: I $3, 500,000.001 Total Agency Position Count: 55 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army - FIS Program Name: Substance Abuse Prevention Program-Pahoa 5. Program Funding Sources (identify all sources of funding applied to this program): FY15-16 Revenue Source Estimate County of Hawaii $35,000.00 Department of Health - Substance Abuse Prevention $85,000.00 TOTAL: $120,000.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program The Salvation Army -Family Intervention Services continuously explores funding avenues in the private, State and Federal sectors to continue and enhance program services. We annually seek grants and/or partnerships to build program services. In line with our mission and the work that we do, we do rely heavily on funding at all levels of government 7. Program Objectives Using County Nonprofit Grant Program Funds: Of the 40 youth targeted to participate in the Prevention program, 85% will demonstrate an increase in competencies through the Botvin Life Skills Training Curriculum Of the 40 youth targeted to participate in the Prevention Program, 50% will engage in Positive youth development activities including cultural awareness and community service and learning projects. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army - FIS Program Name: Substance Abuse Prevention Program-Pahoa 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (I. E. Number ofchems served, works hops ore vents held, ✓olun tees hours, etc. Di be spenficj Applicant Projected Results Completion of BoNin Life Skills Training 30 Cull Awareness and Identity 20 Participation in Positive Alternative Act. 20 Follow up and Monitoring 40 $1,320 $300 Operations $20,978 $35,037 $8,933 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15', Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $59,870 $80,043 $24,506 Professional Fees $4,200 $1,320 $300 Operations $20,978 $35,037 $8,933 Supplies $3,610 $3600 $1261 Equipment Other. Other Other. Other. Other: TOTAL $88,858 $120,000 $35,000 'If applicable EXHIBIT A NON PROFIT GRANT APPLICATIO N FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The salvation Army -Family Intervention services Program Name: SiLLu ante Abuse Prevention - Pahoa ■ io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'I. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: ,John Chamness POSITION: Divisional Commander 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: 5 If no conflicts exist, check here. Sig ure of Authorized Person (specify title) Date EXHIBIT A NONPROFIT CHANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army -Family Intervention Services Program Name: Substance Abuse Prevention-Pahoa 11. Certification of Understanding (Page 2 of 2) 1 (we) have read and understood all of the 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 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 Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to final payment. To register, go to http://vendors.ehawail.gov complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a era nt 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 Hawal'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 reportusing the template provided will impact the evaluation of your oroaram's or agency's future funding requests, EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army -Family Intervention Services Program Name: Substance Abuse Prevention - Pahoa 11. Certification of Understanding (Page 2 of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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 301h shall result in loss of all grant funds received during the ¢rant 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 hh>t2://www hawal'county 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, 2015 must be returned to the County of Hawaii with the final report. Fallum to return these funds in a timely manner will impact the evaluation of your agency's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. d �Iz81,5 Signal I e of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Salvation Army - FIS Program Name: Substance Abuse Prevention Program-Pahoa 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Completion of Botvin Life Skills Training 30 Cultural Awareness and Identity 20 Positive Alternative Activities 20 Follow up and Monitoring 40 Equipment Other Other: TABLE It: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $24,506 Professional Fees $300 Operations $8,933 Supplies $t 261 Equipment Other Other: Other. Other Other: - -- _ - - TOTAL $35,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Society for Kona's Education & Art (SKEA) Art Camps for Children and Teens 119 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Society for Kona's Education & Art (SKEA Program Name: Art Camps for Children and Teens Agency Director: Susan B. Hire Phone No.: ( 808) 328 — 9392 Contact Person: Susan B. Rice Phone No.: ( 888 ) 328 — 9561 Mailing Address: Address: MBox 256 Address: Cry, ST, ZIP Honaunau, Hawai WM Facility Address: Address: 845191 Marbalahoe Highway Address: City, ST, Zip Honaunau, Haw."n 96]26 Email Address: susanrce@hewai.n.mm Accountant/CPA: Enc curbs Firm (B applicable): Fax No.: ( 808) 328 — 9392 Phone No.: ( 808) 323 — 2939 Mailing Address: Address: Po box 236 Address: City, ST, ZIP Kealakekua, Hawaii%750 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: E ts,000.00 Geographiml Areas To Be served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kohala m South Kona ❑ North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns ❑ Youth ❑ Victims of Crimes Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of -&17 yV1 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Society for Kona's Education & Art (SKEA Program Name: Art Camps for Children and Teens 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 0 $3,500.00 0 2. Agency Mission Statement: With a focus on South Kona, the Society for Kona's Education and Art serves the people of Hawaii Island by providing arts and educational opportunities through programs, projects, and events that contribute to a vibrant community. Vision: Enhancing lives through creativity and knowledge. 3. Program Description: SKEA offers day camps in the visual and performing arts during the fall, spring and summer school breaks. 'Creative Magic Intensive' will be a one week magic camp, Mon-Fri.,October 5-9, 2015,for ages 10-15. Taught by professional magicians, the students will learn the techniques of magic, how to make and use props, with instruction and practice in the performing arts. This camp provides enriching and fun experiences for adolescents, an underserved group in our underserved South Kona community, Spring (1 week in March, 2016) and Summer Art Camps (2 or 3 weeks, depending on funding, in June 2016) provide a fun learning experience in the arts for out-of-school children ages 6-11. Local teaching artists offer a variety of activities such as painting, drawing, collage, music, magic, mixed media projects, pottery, dance, theatre arts, and yard games. High school students are hired and trained to act as counselors and teaching assistants;. the on-site supervisor is a DOE teacher and the teaching artists are experienced in their medium and in teaching; therefore, the quality of the teaching is high and the students are able to produce an excellent body of work that is on display during the end -of -camp gallery show and performance for friends and family. 4. Total Budget & Position Count: otal Program Budget: $34,350 Total Program Position Count: 12 part-6me Total Agency Budget: swop I Total Agency Position Count: 20 part-fime EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Society for Kona's Education & Art (SKEA Program Name: Art Camps for Children and Teens S. Program Funding Sources (identify all sources of funding applied to this programl: Revenue Source FY15-16 Estimate Hawaii state Foundation on Culture and the Arts 3,200 Kukio Community Fund 1,500 Bill Healy Foundation (20[6 Kona Brewers' Fegtval) 2,000 Hawaii Hotel Association charity Walk 650 Rotary Club of Kona Mauka (scholarships) 2,000 Tuition fees $0-$125 per student per week 10,000 TOTAL: $19,350 Attach additional pages, iif needed. 6. Explain what plans your agency or program has to increase revenues to support this program We will continue to write proposals to local foundations for support for the Art Camp program. We will put on as many weeks of art camp that we have funding for, up to six weeks per year. The funding sources listed above are sources that we have received in the past and are considered reliable, although the amounts may vary from year to year. The tuition for the camps is very reasonable, although it is still a hardship for many families; we give scholarships from our own savings and from donations (e.g., Rotary.) In this economically disadvantaged community, it is not feasible to raise the tuition. Our organization does a lot of fundraising each year to support our programs, and we will continue to do so. 7. Program Objectives Using County Nonprofit Grant Program Funds: see attached page EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of Society for Kona's Education & Art Art Camps for Children and Teens 11 Program Objectives: • Expose children ages 5-18 to the various artistic mediums- magic, visual arts, pottery, performance and drama, music -and to working artists and their methods and materials.' • Improve the students artistic and performance skills and knowledge, stimulate creative thinking and communication, and create positive self-esteem and poise through mastery and performance. • Provide meaningful work experience for teens in our community, giving our young people the opportunity to learn responsibility, cooperation, organization, as well as providing specific job skills and monetary compensation. • Provide an opportunity for adolescent students in the Magic Camp to take part in a professional magic show, the annual Magic Spectacular at the Aloha Theatre. • Increase the avaialblty of culturally enriching activities for children and yung people in our community. • Provide a safe venue for fun, healthy, and educational activity during the school breaks. • Provide opportunities for artists in our community to share their skills. I,Program Performance Measures: Attendance Records: We can accommodate up to 28 (maybe 30) children in the camp. We expect to enroll 25-30 each week of art camp (based on prior enrollments.) The Magic Camp can accommodate up to 22 students, and we expect to fill the camp, based on our prior enrollments. Written evaluations by parents and teaching artists: we distribute a one-page evaluation that we ask all parents to fill out We make an effort to get them back and we usually receive about 15- 20 each camp. Teaching artists are required to fill it out Written evaluation r eport by the Program Director- describes the activities participation, and observations on the children's level of engagement, their behaviors, etc. and the specifics of what they learned. Narrates the positives and negatives of the camp, what could be done differently, etc. Direct observation by Board and Staff- several Board members act as teaching artists, and there is usually extra staff on the premises during camps. Level of creative output by students- projects completed -the students level of engagement and focus, and whether they complete their projects. For the Magic Camp, the students level of interest and engagement can be measured by how well the learn their tricks and whether they practice at home. Photographs- we will document the activities with photos County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Society for Kona's Education & Art (SKEA Program Name: Art Camps for Children and Teens S. TABLE 1: Nnat are me mlenaeo measurame outpuu or outcomes mai wows oe acmevea mm PROGRAM PERFORMANCE MEASURES I Applicant Projected Result (ie.: NumMMdrMsserveC waksMPs aevmb M14 roWnKn Mune, etc. pesoAe, Mspe<f 1 9. TABLE II: PROGRAM EXPENDITURES FY 14.15 Actual' FY 15-16 Tool Budget FY 15516 Gran Req Salary and Wages 0 Professional Fees $17,725 $3,000 Operations $3,750 2,500 Supplies 2,225 1,500 Equipment 0 Other: Marketing 1,250 1,250 Other: registratbns, administration, bookkeeping - YO vmrt YC 3,000 1,753 Other: teen nuns (ages 16-19, tical resldeMs) 6,400 5,000 Other: Other: TOTAL $34,350 $15,000 V applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Society for Kona's Education R Art (SKEA Program Name: Art Camps for children and Teens io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel C"Allet of Interest is defined as: a substantial probability that action taken by an individual will result in measurable df e 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. wlecAwe'D%r Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 JANUMY 2Q 2016 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Society for Kona's Education & Art (SKEA Program Name: Art Camps for Children and Teens 11. 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 allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and 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($) 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 final payment. 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 imoact the evaluation of your oroorom's or agenc✓s future fundino requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Society for Kona's Education & Art (SKEA Program Name: Art Camps for Children and Teens 11. Certification of Understanding (Paget 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 lune 30 shall result in loss of all arant funds received durina the grant period (must be refunded to County) and exclusion from future grant oartidpation 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.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 lune 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in o timely manner will impact the evaluation of your agency's future fundina reauest and may result in actions token to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. ut,6,VeA�1X EXEGUC1VF- Diff Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 —10-14 , 2F5 120 G 5 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: society for Kona's Education & An (SKEA Program Name: An Camps for Children and Teens 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES I Applicant I CouncR Proposed Pnlected Results ProteRed Re It TABLE II: PROGRAM EXPENDITURES FY 1516 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives renardina award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Special Olympics Hawai'i Special Olympics Hawai'i - Easy Hawai'i Area 120 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii -East Hawaii Area Agency Director: Nar" Boaeb Phone No.: (sail) ass — 3522 Contact Person: Lisa Pana Phone No.: ( soil) aua — 4032 Mailing Address: Address: Po Box7za5 Address: City, ST, Zip Hib. Hawaii 0720 Facility Address; Address: None Address: City, ST, Zip Email Address: soeasihi®gma9.com Fax No.: ( Ma) 943 — M14 Accountant/CPA: Atamine, Oyadoman. Kosaid Phone No.: (aoa) 961 — 05M Firm (if applicable): Akamine, oyadoman, Kosaki Mailing Address: Address: 1C ",,i Sm tirsoo Address: Cty, Sr, Zip Hordulu, HawaH W14 YOU ARE RESPONSIBLE TO KEEP THEABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: s 35,000.00 Geographical Areas To Be Served: (One or more can be checked) ✓❑ Puna ✓❑ Hamakua ❑ North Kona ❑✓ South Hilo ❑ North Kohala ❑ South Kona ❑✓ North Hilo ❑ South Kohala ❑ Ka'5 Services or Activities To Be Provided: (One or more can be checked) ❑✓ Educational concerns[?] Youth ❑ Victims of Crimes ❑ Culture and the arts Z Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ✓❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii -East Hawaii Area 1. Prior Year Award of County Nonprofit Gram Program Funds: FY 12-13 FY 13-14 FY 14-15 15,000.00 $25,000.00 25,000.00 2. Agency Mission Statement: The mission of Special Olympics is to provide year mund 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 the sharing of gifts, skills and friendship with their families, other Special Olympics athletes and the community. 3. Program Description: See attached 4. Total Budget & Position Count: Total Program Budget: $142,495 Total Program Position Count: t Total Agency Budget: 1,600,000 Total Agency Position Count: to EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of Agency Name: Special Olympics Hawaii Program Name: Special Olympia Hawaii -East Hawaii Area 3. Program Description Special Olympia is a national award-winning nonprofit organization created by Eunice Kennedy Shriver in 1968 to address the neglect and disregard of individuals with intellectual disabilities. Our Special Olympia program is open to everyone with intellectual disabilities in Hawaii, regardless of the extent of their disability. People who are isolated from life experiences by a disability have little chance for the developmental growth and acquisitions of important skills that they will need to gain employment, maintain relationships and function within the community. Special Olympics believe that all people, regardless of their disability deserve to lead full, active lives, enriched with social and recreational opportunities that most of us take for granted. Unfortunately, appropriate physical education programs in the public schools and social service programs that realistically address the special needs of their population are virtually non-existent and/or very limited. The benefits for our athletes continue to be: (a) improved physical fitness and motor skills, (b) greater self-confidence, (c) a more positive self-image, (d) friendships, and (e) increased family support. We encounter these benefits in their daily lives at home, in the classroom, on the job and in the community. Our program could not happen without the help from our community volunteers. Through our program over 620 community volunteers interact with individuals with special needs. Our program is free of cost to all our athletes, special partners and coaches. All of the money raised for the East Hawaii program stays here to support our program's area budget of $142,495. Those funds will pay for all aspects of the Special Olympia program, which includes equipment, uniforms, transportation costs, family activities, our Athlete Leadership Program (ALPS) and training and professional development for our volunteers, special partners and coaching staff. Professional development and leadership training for all coaches remain a top priority in our program. Airfare of $3,000 will be needed to send 15 coaches to the certification clinic on Oahu in this upcoming year. A leadership conference will be held for coaches, volunteers, unified partners, athletes and coaching staff in which an additional $4,000 will help fund. Knowledge gained at this leadership conference will be implemented into our area program and attendees will be held accountable for sharing their learning outcomes with others in our program. This portion of the County of Hawaii grant will allow us to continue to provide our area support people the opportunity to be better for the athletes they serve by attending these trainings and development opportunities. Special Olympia East Hawaii remains one of two area programs in the state that offer a Young Athlete Program (YAP). The YAP program is for preschool -aged (2-1/2 to 5 years old) students with intellectual disabilities. The program continues to grow in several East Hawaii elementary schools, where teachers utilize the included curriculum to introduce youngsters to basic eye hand coordination activities that help to strengthen their fine and gross motor skills. With their "graduation" from YAP, athletes have a 2-3 year gap of no activity before they are eligible to participate in the regular sports programs. To allow for consistency and fluency, we are asking for $4,000 to development a Future Stars program for athletes 6-8 years old. This funding will allow our area to develop age appropriate curricular standards and benchmarks, recruit athletes, train coaches and purchase necessary equipment, supplies and uniforms. As always, Special Olympics East Hawaii's largest expense for 2015-2016 will be transportation. It is an essential part of our program that our athletes are provided an opportunity to interact and compete against people of similar athletic ability. Unfortunately, our area program is too small to be able to provide quality competition; therefore our athletes must travel to other islands to achieve that goal. The state competitions are held on O'ahu three times per year and provides many activities that our athletes to experience. Some of the activities that the athletes look forward to include dances, opening and closing ceremonies, entertainment and games, and exposure to a Healthy Athlete Program. Healthy Athlete Program provides free dental, vision, hearing, nutrition and podiatric screening. These services, which sometimes are not available to individuals with disabilities for a multitude of reasons, continue to be an essential and notably popular service provided at the state games. We remain staunch in utilizing our quota system, where a delegation will need to select a season to opt out of traveling off island. Yet, as our area continues to grow, we would like to still provide traveling and state competition experience for as many athletes as possible. We are asking for $12,000 from the County of Hawaii to help make this happen. We continue to foster our partnership with the public schools by providing an After Schools All -Stars Program. These middle schools places an equal number of special needs athletes within the school in partnerships with mainstream student athletes. Together, they train and compete in unified softball and unified basketball. Our goal is to engage and enlist at least one additional middle school to our program, so more special needs athletes can experience inclusion and acceptance, as well as, competition and friendship. We are requesting $10,000 to help fund transportation costs to get these teams to area and state competitions during the school year. A couple new area initiatives for the upcoming year include hosting a Health & Fitness Fair and a Community Awareness and Participation Event. The Health & Fitness Fair will be similar to Healthy Athlete Program, in our area for all athletes, family members, coaches, special partners and volunteers. This Health and Fitness Fair will also include a fun run/walk event, agility and balance drills, mini competitions, booths, entertainment and games. High School athletic programs and community partners will be invited to help facilitate event activities. A $4,000 allocation will help fund this event. The Community Awareness and Participation Event will target middle school and high school youth and encourage mainstream student -athletes tojoin in the campaign of "Being a Fan" and "Ending the R - Word". Our goal is to recruit middle school and high school students to be fans in the stands at our area competitions to be cheerers, clappers and high -fivers as our athletes compete. We will also strive to encourage these fans to take the pledge to stop the derogatory use of the R -word and foster Inclusion and acceptance of all special needs individuals. We are asking for $2,800 to help with costs for facilitating operations and logistics of this event. Special Olympics Hawaii -East Hawaii Area is requesting $35,000 from the County of Hawaii to help fund our Special Olympia East Hawaii program activities and events for FY 2015-2016. County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii -East Hawaii Area S. Program Funding Sources (identify all sources of funding applied to this Programl: Revenue Source FY35-16 Estimate County of Hawaii Grant $35•000 Foundations and Service Clubs $21,950 Individual Corstributom $10,000 Corporlafi Contitbutiws $3•000 Special Event $30,025 SOHi Co-op Fwd $2.600 Merchandise Sales $40,120 TOTAL: $142,495 Attach additional pages, %needed. 6. Explain what pians your agency or program has to increase revenues to support this program: See attached 7, program Objectives Using County Nonprofit Grant Program Funds: See attached EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii -East Hawaii Area 6. Explain what plans your agency or program has to increase revenues to support this program As the area director of our East Hawaii program, I am committed to the following: 1. Aggressively pursue and apply for various community grants targeting nonprofit programs such as Special Olympics 2. Organize and facilitate successful fundraisers with the potential to generate profits of $8,000 or more 3. Solicit funding assistance and contributions from community and business partners, as well as, from civic, governmental, social and sports -oriented constituents within our area Our program continues to operate in a very diverse manner in which we raise monies to support our athletes, coaches, families and volunteers. As our program grows, so do our expenses; therefore, our commitment to providing our athletes with opportunities to compete on the field and in life are that much more important and requires us to be steadfast and focused on our plans to increase revenue. 7. Program Objectives Using Count Nonprofit Grant Program Funds 1. To provide quality sports training and Olympic -type competitions in our area for 264 athletes and 120 special partners by June 2016 2. To provide sport -specific coaches training and recertification opportunities for 15 coaches by lune 2016 3. To provide professional development and leadership training opportunities for our program athletes, coaches, families, special partners and volunteers by lune 2016 4. To development curriculum for, establish and implement a Future Stars Program for special needs athletes ages 6-7 by lune 2016 5. To provide airfare transportation for 200 athletes, coaches and special partners three times a year, so that they may complete at each state competition by June 2016 6. To provide an opportunity for athletes, families, coaches, special partners and volunteers to participate in a Health and Fitness Fair, which encourages health, fitness and nutrition by lune 2016 7. To provide opportunities for middle school and high school aged students to experience involvement in an effort to foster and practice inclusion and acceptance for special needs athletes through the "Fans in the Stands' and "Spread the Word to End the Word" campaigns by June 2016 - 8. To provide an opportunity of 620 community volunteers to interact with our program athletes through June 2016 9. To continue our outreach initiatives to individuals with special needs in our East Hawaii area and provide them with unique experiences to grow and function within our community County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Special Olympics Hawaii Proom Name: Special Olympics Hawaii -East Hawaii Area S. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES rye.: Numbero7dknaserwtl wdislaps wevents he14 vdunteerhwas etc Desrdba ee spMgcl Appiicarrt Projected Results # of athletes 264 # of special Partners 8 families 220 # of volunteer, serving our program 625 # of PD and Leadership Training Opportunities 12 # of coaching Well 45 # of delegetiore 12 # of oornpea6om 110 AtMch additional pages as neceswry. Ffen:ndta PROGRAM EXPENDITURES FY 1 -15 Actual- FY 15-16 Total Budget FT 15.16 Gram Req Salary and Wages $6,500 $6,500 0 Professional Fees 0 0 0 Operations $47,006 $49,945 0 Supplies 0 0 0 Equipment 6 $2,966 $4,000 Other:Airfve Mer school AllStara $10,000 $10,000 $10,000 Other: Airfare Athletes to attend competitions $72.000 $60.250 $12,000 Other: PD g Leadership Training $3.500 $7.000 $7,000 Other: Health g Fitness Fair 0 $1.000 $4.000 Other: community Awareness g Partiapation Evert 0 $2.800 $2,800 TOTAL $1a9,o00 $142,495 $05,000 rrappnooie EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii -East Hawaii Area io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel conflict of Interest is defined as: a substantial probability that action taken by an Individual will result in measurable direct benefits accruing to the individual as opposed to bemfts 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 'Y1'fSl cunt K4/ W 4 I kjO Sign ture o uthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii -East Hawaii Area 11. Certification of Understanding (Page 1 of 2) 1(we) have read and understood all of the 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. 1(we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and 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 ngtt 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 Expres& and be compliant prior to final payment. To register, go to http,//vendom.ehawaii.g 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 reauirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall Indude an explanation of the public benefits derived from the awarding of the gram (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by county of Newall grant funds, and 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 impactthe evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii -East Hawaii Area 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawari 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 30v' shall result in loss of all grant funds received during the grant period Imust be refunded to County) and exclusion from future gram 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.hawalicoun!y.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, 2015 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 aaenc✓s future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. �t�GiS, C�.tri.t e10 c a 1 R L5 sl nature Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Special Olympics Hawaii Program Name: Special Olympics Hawaii -East Hawaii Area 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURESI Projected Results I Projected Rewtt TABLE If: PROGRAM EXPENDITURES Fy 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives reeardina award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Special Olympics Hawai'i - West Hawai'i SOWH - General Fund 121 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Special Olympics Hawaii -West Hawaii Program Name: SOWH - GENERAL FUND Agency Director: NANCY SOTTELO Phone No.: ( boa) 943 - Seas Contact Person: DENISE LINDSEY Phone No.: ( We) 345 — 433 Mailing Address: Address: P.o. sox 39,35, Address: City, ST, Zip KEAUHOU-KONA. Al W739 Facility Address: Address: P. o. BOX 3295 Address: City, Sl, Zip HONOLULU, HI 96W1 Email Address: d..ex( bigislan wri Fax No.: ( 801 322 — 3,198 Accountant/CPA: Akarnme, oyado ri a Kosad Phone NO.: (roe) 941 — 500 Firm (if applicable): Ak.,re, oyadwaad a Koseki, CPAs, o,c. Mailing Address: Address: 1440Kal>iaari Brod. Address: Surae M9W CItY.ST,LP A.W lo,HI 96814 YOU ARE RESPONSIBLE TO KEEP THF ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANYCHANGES Amount of Request for County Nonprofit Grant Program Funds Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua © North Kona ❑ South Hilo © North Kohala © South Kona ❑ North Hilo © South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts © Aged © Victims of Health or Social Crises ❑ Needs of the poor © Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Special Olympics Hawaii - West Hawaii Program Name: SOWH - GENERAL FUND 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 1415 12000.00 $15,000.00 15000.00 2. Agency Mission Statement: The mission of Special Olympics is provide year-round sports training and athletic competition in a variety of Olympic -type sports for children and adults with intellectual disabilities (formerly called mental retardation), giving them continuing opportunities to develop physical fitness, demonstrate courage, experience joy and participate in a sharing of gifts, skills, and friendship with their families, other Special Olympics athletes and the community. 3. Program Description: Special Olympics is an organization that unleashes the human spirit through the transformative power and joy of sports everyday on every island throughout our state. Through work in sports, health education and community building, Special Olympics is addressing inactivity, injustice, intolerance and social isolation by encouraging and empowering people with intellectual disabilities (ID) which leads to a more welcoming and inclusive society. Special Olympics West Hawai'i is an accredited program under Special Olympics Hawai'i. All money raised by Special Olympics West Hawai'i stays right in West Hawai'i for our athletes and program. 4. Total Budget & Position Count: Total Program Budget: saes oo Total Program Position Count: 150 Total Agency Budget: i0sa3ea.00 Total Agency Position Count: 3950 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Special Olympics Hawaii -West Hawaii Program Name: SOWH - GENERAL FUND S. Program Funding Sources (identify all sources of funding applied to this programl: Revenue Source FY15-16 Estimate Bench P1ess 8 Deatllitl com titlon 1000.00 ZUMBA then 3000.00 Fishing Tournament Kona Marathon Aid Station __500000 700.00 Roberts Hawaii Bus Pull 300000 _ Underpants Run thm Multisrollsoom 5500.00 Golf Tournament 3500.00 TOTAL: 21700.00 Atfoch ad)t onal pages, if needed_ 54t' 417QGdil Yl3_ir-T el 6. Explain what plans your agency or program has to increase revenues to support this program: Special Olympics West Hawaii will continue with our partnerships of the ongoing fundraisers that we have. We will be adding a Golf Tournament this year. We hope to increase the participants in our fundraisers which in turn will be more money raised for our local program. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our biggest cost is Air Fare to neighbor islands, as you know. The majority of our County Grant goes towards that. Of the projected Grant amount of $15,000.00 we plan to use about three quarters of those funds to fly our athletes, coaches and Unified Partners to the neighbor islands for competition and some of the funds goes for our coaches training. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County ofHawai`i Nonprofit Grant Application FY2015-16 Agency Name: SOe cr Al 0L'14Vcr Program Name: Sow li— 6e e l : u n0 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate County of Hawaii Grant _ Visitor Industry Charity Walk Cop on Top _ 7500.00 20000 p0 Corporate & Individual donations _ 5000.00 Hawaii Community Foundation Grant _ _ ]000.00 Torch Run T -Shirt Sales 4000.00 Ironman Grant7000.00 TOTAL: (pS DOOJ Attach additional pages, if needed 6. Explain what plans your agency or program has to increase revenues to support this program: 7. Program Objectives Using County Nonprofit Grant Program Funds: EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Special Olympics Hawaii -West Hawaii Program Name: SOWH - GENERAL FUND S. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES numx.o70ienattrve4.w hoer or .&, Mid, rWwrerrMurz, mc. o,orae,xspergrcl Applicant Projected Results 50 Special Olympias Athletes Kana to HNL $1000000 6 Special Olympics Coaches Kona to HNL $1200.00 6 Special Olympm Coaches to clinics HNL $1200.00 Bus Transportaticni to Hilo for Area Games $900.00 Area Game for Island wide Softball tournamen $600.00 Area Games for Island wide Bocce 8 Soccer $900.00 55200.00 13000.00 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget Fr 15-16 Grant Req Salary and Wages 13100.00 13800.00 Professional Fees 0.00 0.00 Operations 55400.00 55200.00 13000.00 Supplies 9500.00 9000.00 2000.00 Equipment 9000.00 asoo.00 Other: 285o0J 785.00 Other: Other: Other: Other: TOTAL 8728500 87285.oO 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: SPec,.a l OL,1„ „ P cS Program Name: -F� n0 io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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: If no conflicts exist, check here. —)0-ja `p `fir" c Fo Signature of'Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Special Olympics Hawaii -West Hawaii Program Name: SOWH - GENERAL FUND 11. 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 allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expend!ng/oversight agency) full, free, and unrestricted access and authority to examine and 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 final payment. 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 (wel 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 reportusino the template provided will impact the evaluation of your oroarom's or agenc✓s future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Speed CDLcj"zcs 11G,�n;:-W�7 1J r.•;� Program Name: Sa-a rt— C�err. t -F�-,,.o 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30`h 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. f (we) understand there is no provision for further notification to submit the final report. Irformation and instructions are available at - - -- - - - 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 lune 30, 2015 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 fundina request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Special Olympics Hawaii -west Hawaii Program Name: SOWN -General Fund u. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result 50 Spatial Olympia Athletes air fere Kana to HNL 1000ow S Special Olympia Coaches air fare Kona to HNL 1200.00 B Special Oh/mPics Coaches to Coaches Clinic HNL 12000.00 Full day round trip Bus Transport Kona to Hilo 900.00 Etpenses Area Games Island Wide SoREall Toumamen 900.00 Expenses Area Games, Island Wide Bacca&somer tourn 900.00 Other: Full day round by Bus Transport to Hilo 9M.00 TABLE 11: PROGRAM EXPENDITURES FY 15.16 Grant Request Council Award Salary and Wages Professional Fees Operations 1/D000 Supplies Equipment Other: hr fare State centers for Athletes & Coaches 12400,00 Other: Full day round by Bus Transport to Hilo 9M.00 Other: Other: Other: TOTAL 15000.W Additional council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 20142015 Page 8 of Teach For America - Hawai'i Hawai'i Island Teacher Programming 122 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Teach For America- Hawaii Program Name: Hawaii Island Teacher Programming Agency Director: nn Baldemor (One or more can be checked) Phone No.: ( 808) 258 — 4438 Contact Person: JR Fujimoto South Hilo Phone No.: ( 808 ) 295 — 5410 Mailing Address: Address: 500 At. Were Boulevard F.I Ka'u Address- Suite 3400 City ST, Zip Honolulu HI 96813 Facility Address: Address. 75-170 Hualalu Road Address'. Suite D216 A City, ST, Zip Kailua-Kona HI 06740 Email Address: jit[ raldemor@teaohforamenca. or9 Fax No.: ( 808) 538 — 3793 Accountant/CPA: Grant Thronton LLP Phone No.: 212 1599 — 0100 Firm (if applicable): Mailing Address: Address: 6s6Tmm Avenue Address: 13th Floor City, ST, Zip New York, NY 10017 4011 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds Services or Activities To Be Provided: (One or more can be checked) ❑,� Educational concerns W1 Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 Geographical Areas To Be Served: (One or more can be checked) 7 Puna 71 Hamakua © North Kona South Hilo Q North Kohala✓❑ South Kona ❑� North Hilo Q South Kohala F.I Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑,� Educational concerns W1 Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Teach For America- Hawaii Program Name: Hawaii Island Teacher Programming 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $0.00 $0.00 $0.00 2. Agency Mission Statement: Teach For America's mission is to enlist, develop, and mobilize a group of our nation's most promising future leaders to grow and strengthen the movement for educational equity. Our vision is that one day, all children in this nation will have the opportunity to attain an excellent education. On Hawaii Island, we recruit and train a diverse group of educators—many of whom are Native Hawaiian, Kama'Aina and have ties to Hawaii Island, who have also demonstrated strong leadership and achievement— to ensure that our keiki growing up in high -need communities on Hawai'i Island are prepared to enter college or a career upon high school graduation. This school year, we have 63 full-time, highly qualified teachers working in 24 of our most under -served public schools across all three complex areas. Our corps member teachers bring to their work the conviction that with high expectations and culturally -relevant support, all of our keiki can achieve at the highest levels. 3. Program Description: Our program fills a key need on Hawaii Island and without it, the DOE tells us that 9% of teaching positions would be left vacant at the start of the school year and occupied by substitutes. Our teachers accept hard -to -fill positions and commit to maximizing students' potential through leadership and rigorous learning experiences. Last year, our leachers collectively made 1.2 years of growth with students, surpassing the average growth that is expected to occur in a single school year. Our teachers are supported by four full-time staff on Hawai'i Island, including two coaches who conduct monthly classroom visits and student -data analysis to identify student growth and areas for improvement. We also develop teachers through monthly professional development, during which they attend content -based workshops. Additionally, we are committed to developing culturally responsive educators through our Hawaii Island Huaka'i Program, because we believe that our teachers will have a deeper impact on student achievement if they are grounded in the culture of Hawaii. This cultural development incorporates three place -based huaka'i and a capstone Wilke for teachers to showcase the impact of their own development on student growth. 4. Total Budget & Position Count: Total Program Budget: 535,a]9 Total Program Position Count: a' FTE Total Agency Budget: 5.415,906 Total Agency Position Count: 21 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Teach For America -Hawaii Program Name: Hawai'i Island Teacher Programming 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY35-16 Estimate Connection Charter (School Partnership) 5,000 Kua O Ka La Charter (School Partnership) 10,000 Private Donors (Individual gifts) 15,000 Roberts Foundation 170,000 TOTAL: $200,000 Attach additional pages, ifneeded. 6. Explain what plans your agency or program has to increase revenues to support this program Teach For America Hawaii depends upon the generous donations of foundations, grant programs, and private individuals to support its work. Our Hawai'i Island program began in 2009 and as such, still heavily relies on the TFA Oahu and mainland branches to subsidize funding necessary for operations. In the last two years, we have placed a heavy emphasis on Hawaii Island project sustainability by seeking local funding sources. We have also prioritized building community relations by joining the Kona-Kohala Chamber of Commerce and attending Rotary Club meetings. We believe we can increase revenue by 1) renewing past grants and foundation donations as well as seeking new opportunities, 2) investing more heavily in grass-roots fundraising in order to become funded by local companies and individuals and 3) partnering with the DOE and other education development organizations, including charter schools, which would provide for alternative funding sources. 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding will be used to cover some costs of our Hawai'i Island program to provide experiences and supports necessary for our teachers to be culturally -responsive and transformational educators for students. On Hawaii Island, we have the following three main objectives: 1) to maximize our teachers' impact on student achievement by having 80% of teachers make more than average growth or subject mastery with students, as measured by rigorous school, state, or national assessments; 2) to recruit a diverse corps of teachers that reflect the backgrounds of our students on Hawaii Island. This year, 30% of our corps is kama'aina and our goal for next year is that 35% will identify as such; and 3) to develop alumni leaders of our program in order to drive systemic change in the educational landscape. Our goal is to have twenty-five alumni in leadership roles within education in Hawai'i. Funding from Hawai'i County would concentrate support towards our first objective of maximizing impact on student achievement on Hawaii Island by supporting the 4 full-time staff and 5 part-time coaches' who are charged with supporting teacher impact on student learning. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Teach For America -Hawaii Program Name: Hawaii Island Teacher Programming 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES tle.rN.rrb,a/cbenh served,..,k1hrd orevents h,ld, Ii—s r hr., eec oesvme he sneaflcl Applicant Projected Results Student achievement results on assessments 80% above avrg. growth Student Impact 2,835 students Classroom observations and data analysis Monthly feedback Hdike culturally responsive portfolio 100% teachers pass He'ike Showcase 100 cmnty members Volunteer hours 700 Is cmnty service Principal survey _ 75% adv avrg impact Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Taal Budget FY 15-16 Grant Req Salary and Wages 158638 301,070' 5.000 Professional Fees Operations 76,950 219.409 Supplies Equipment Other. Part-time staff (Instructional Mentors) 8,225 15.000 5.000 Other Other Other'S&W supports 4 FTE on Hawaii Island and some Other: Oahu staff that supports operations part-time TOTAL 243,813 535479 10,000 9f applicable EXHIBIT A NONPROFITGRANT APPLICATION FY 2015-2016 Page 4 of 8 TEACHFORAMERICA 8. Program Performance Measures • Student Achievement results: Our goal is that 80% of corps member teachers will make mare -than -average student growth or subject mastery as measured by rigorous assessments (usually school assessments, state assessments, or nationally recognized assessments). • Student Impact: Each of our 63 teachers reaches an average of 45 students every school year. Therefore, our teachers are working with and impacting nearly 3,000 students on a daily basis throughout each school year. • Classroom observations and feedback: Our instructional coaches on staff will directly observe and debrief with teachers on a monthly basis to determine effectiveness of lessons on student learning. Also discuss student data and determine course of action to meet above-average student growth at the end of the year. • Ho' ike portfolio: This is graded on a 4 -point rubric by part-time staff mentors and is an essential component of our teacherslicensing process. We analyze the degree to which our teachers incorporate culture -based education in their classroom instruction through submission of this culturally responsive teaching portfolio. We ask our teachers on surveys to reflect on a) the degree to which they have grown in culture -based education and b) their connection to Hawai' i. Students also provide feedback on a lesson to determine its effectiveness and relevance. Ho'ike Showcase: At the end of the school year, our first-year teachers who have completed the portfolio will invite students, families, and community members to celebrate the school year and share their reflections on the culturally -responsive teaching strategies they have acquired and their impact on student learning. Our goal is for at least 100 community members, including students and families, to attend in order to share in this celebration of learning and student impact. Volunteer Hours: All of our 63 teachers and 4 staff members on Hawai' i Island partake in service learning during our Huaka' i experiences, as well as during other community days throughout the year. Our goal is to have our corps members complete at least 700 collective hours of community service in the communities where they also teach. We have volunteered at the Keauhou ahupua' a, Kohanaiki and O' oma shorelines, and in Kawaihae working on the wa' a with the crew of the Makali' i, though organizations and places for which we volunteer may change in the future. Principal Survey: At the end of every school year, we ask Hawai' i Island school principals to fill out surveys about the Teach For America teachers at their schools. On surveys given to school principals at the end of last school year, 100% reported that as compared to other beginning teachers, our teachers are as effective if not more effective. Seventy-two percent of principals rated Teach For America teachers' impact on student achievement as "above average'. Our goal this year is for at least 75% of principals to report this. County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Teach For America -Hawaii Program Name: Hawaii Island Huaka'i Programming io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as. a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest. ❑✓ If no conflicts exist, check here. I �0 ac?5 Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Teach For America- Hawaii Program Name: Hawaii Island Teacher Programming 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 — 2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. 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 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. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Teach For America- Hawaii Program Name: Hawaii Island Huaka'i Programming 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period 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 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, 2015 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 fundino request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. %d6)fa015 Signature of Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FV 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Teach For America- Hawaii Program Name: Hawaii Island Teacher Programming 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Student achievement results on assessments 80%abv avrg Student Impact 2,895 stents Classroom observations and data analysis Monthly He ike culturally responsive portfolio 100%pass Hdike Showcase 100 cmnly Volunteer hours 700 Principal Survey 75%abv avrg TABLE 11: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 5.000 Professional Fees Operations Supplies Equipment Other. Part-time teacher coaches 5,000 Other. F Other .—�-I — Other Other TOTAL 10000 Additional Council directives regarding award: EXHIBIT B NONPROFIT G RANT APPLICATION FY 2014-2015 Page 8 of The Arc of Hilo Client Computer -Learning Center 123 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The arc of Hilo Program Name: Client Computer -Learning Center Agency Director: Michael E. Gleason Phone No.: ( 808) 935 — 8534 Contact Person: Debbie Perkins Phone No.: ( 808 ) 935 — 8534 Mailing Address: Address: 1099 Nlaianuenue Ave. Address: City, ST, Zip Hilo, HI 96720 Facility Address: Address. same Address: City, ST, Zip Email Address: debbleperkms@haoarc erg Fax No.: ( 808) 934 — 7714 ACCountant/CPA: iM, Are Fukuhara. CPA, MBA Phone No.: ( 808) 961 — 5532 Firm (if applicable): Mailing Address: Address. 45 Pohako sl. Address 1,,1,1112 City. ST, Zip Hilo. HI YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $25,00000 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑ Hamakua ❑ North Kona Z South Hilo ❑ North Kohala ❑ South Kona North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns Z Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑✓ Victims of Health or Social Crises ✓❑ Needs of the poor Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: The Arc of Hilo Program Name: Client Computer -Learning Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $25,125 - _ $2,77000 $20,000 2. Agency Mission Statement: The mission of The Arc of Hilo is to improve the quality of life for people with developmental and other disabilities who reside on Hawaii through educational, vocational, and skill training as well as employment and residential opportunities. 3. Program Description: The Arc's Adult Day Health Program is in desperate need of upgrading outdated computer systems (both hardware & software), and installing wi-f access at our facility. Technology is a necessary gateway that most people take for granted today. However, for the disabled person who cannot afford it, a computer can be vital to provide a sense of independence. Along with this independence, comes the capability for even severely disabled people to earn a living. With the help of computer devices & advanced software, many disabled people can be just as competitive and/or creative as anyone else. For example, accommodations such as compact keyboards, voice recognition, & audio/visual software will allow our clients an entry into the world of cyberspace & job creation. A multi -media lab, with large screen capabilities, can offer opportunities for group interfacing, practice interviews, editing, & recording accomplishments. The ability to share information, events & news through the widespread use of e-mail, Twitter, Facebook, & chat programs are ideally suited for some clients because they don't require a person to hear or speak. Communication is one of the main keys to socialization, which is of vital importance to the client's ability to mainstream, make friends, & improve self-worth. 4. Total Budget & Position Count: Total Program Budget: $3i 6,932 Total Program Position Count: t t Total Agency Budget: $3.7M Total Agency Position Count: tot EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Arc of Hilo Program Name: Client Computer -Learning Center S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source Fy1S-16 Estimate Mclnerny Foundation (BOH)', Pending $10,000 _ The Arc of Hilo Fundraising Campaign: Pending $2000 TOTAL: ... $12,000 Attach additional pages, if needed, 6. Explain what plans your agency or program has to increase revenues to support this program: We will continue to foster our many relationships with both ethnic and area -based organizations serving the disabled population throughout the Big Island. We are experimenting with social media and web outreach to inform the community of the opportunities we provide, and as interest grows, more clients will come to The Arc. Through our programs and services, we promote Hawaii Island as a place of abundance; inspiring those seeking creative outlets for artistic expression; and encouraging those interested in gaining independence through employment, Revenues will increase due to The Arc's imminent expansion of the Job Training and Creation Center, slated to open in the Spring of 2015. The goal of the Learning Lab is to implement systems that would allow the agency to increase the quality of care for its clients with developmental disabilities, and accommodate and support organizational growth. Continued fund raising efforts will be earmarked for this project. 7. Program Objectives Using County Nonprofit Grant Program Funds: The Arc of Hilo believes that the future outlook for people with handicaps is excellent. Computers have & are giving disabled people a powerful tool for achieving independence in their daily lives. A multi -media program can be an excellent means of learning new job skills, and improving writing and math abilities. By using creative software for graphic design, video editing, or music recording, clients are able to turn their own personal interests and forms of expression into potential career opportunities, which is naturally fun and motivating. Computer access gives participants the ability to immerse themselves into a world that might otherwise be unavailable. Computers level the playing field by creating an environment where physical disabilities do not inhibit communication. They can tap into practical, disability -related information or converse with other disabled people. Exploring the internet, with individualized instruction, provides multi -sensory experiences & a sense of accomplishment. For the first time in their lives, many disabled people find themselves able to belong somewhere, a virtual community where they can be swept along by daily events, as in any community. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Arc of Hilo Program Name: Client Computer -Learning Center 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES is e.: Number of clients served workshops or events held, volunteer hours, etc aescnbe, be sh,,ficf Applicant Projected Results Clients served 30+ Individualized training workshops 20-25 Career skills _ 50 Artistic expression 100 i 100% 30% Communication skills Entrepenurial skills Operations Attach additional pages os necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual= FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $258.574 $4000 Professional Fees $1,413 Operations $77,454 Supplies $4,119 Equipment _ Other Computers/Monitors (8) $12.000 Other Will access points, extenders $1000 Other. Computer interface software Other Office Chairs 8 desks (8) Other Program Activities $4500 $3500 $8,5401 TOTAL $350,100 $25000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Arc of Hilo Program Name: Client Computer -Learning Center io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION' May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined asa 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. /112 ZI !J Sighdture of Authorized Person (specify title) / Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agent y Name: The Arc of Hilo Program Name: Client Computer -Learning Center ii. 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, 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, 1 (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. 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 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 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 yearend report using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Arc of Hilo Program Name: Client Computer -Learning Center ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30`h 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-fornis/ on or about May 30 of the year the final 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, 2015 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 ooencv's future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 /zf/S" Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: The Arc of Hilo Program Name: Client Computer -Learning Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees IOperations Supplies Equipment Other Other Other: Other Other. TOTAL Additional Council directives re¢ardin¢ award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Three Ring Ranch Extern ships/Internships/Mentoring 124 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Three Ring Ranch Program Name: Externships/Intemships/mentodng Agency Director: Ann Goody PhD Phone No.: ( 808) 331 — 8778 Contact Person: Ann Goody PhD Phone No.: ( MB) 331 — 8778 Mailing Address: Address: 75A09 Keaolanl De Address: City, ST, Zip K.N."ore HI 96740 Facility Address: Address: same Address: City, ST, Zip Email Address: a rimals&veenngmntlhorg Fax No.: ( 866) 365 — 5097 Accountant/CPA: Bill Hauser Phone No.: ( 702) 248 — 2814 Firm (if applicable): The Taxman Mailing Address: Address: 871comnadocenmrormo9 Address: City, ST, ZIP HerMerson W 89052 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $16,000.00 Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua North Kona © South Hilo © North Kohala © South Kona © North Hilo [?] South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Three Ring Ranch Program Name: Extemships/Intemships/mentoring 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14.15 0 $0.00 0 2. Agency Mission Statement: Our mission is to positively impact the environment while educating Hawaii's children about their place in the natural world. We assist in the development of an environmentally responsible generation of youth while caring for exotic animal residents. 3. Program Description: A. Residential internships for pre -vet and veterinary students at 3RR. Summer programs x 2, one 4 weeks and a second one lasting 8 weeks, three students at a time. Special preference always given to Hawaii student applicants. Applicants from BI given highest status. B. Extemships x 2 for fouth year vet students. Preference to Hawaii residents or vet students who plan on practicing in Hl. C. High school residential internships (3 week program) for Hawaii senior high school youth to prepare them for careers in any science field. Three students at a time. BI students receive highest preference. 0. Youth (BI) Afterschool Mentorship program, 4 hours 2 x week, also on all school breaks. 2015 budget figures quoted below. 0 paid employees at 3RR, all volunteer staff. Positions for these programs, 6 total. For entire 3RR facility 40+ 4. Total Budget & Position Count: Total Program Budget: $35,0001 Total Program Position Count: o Total Agency Budget: I $94,4001 Total Agency Position Count: I 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Three Ring Ranch Program Name: Externships/lntemships/mentoring 5. Program Funding Sources (identfty all sources of funding applied to this Programl: Revenue Source FY15-16 Estimate Hawaii Island United Way 4,500 Kukro Fund 5,000 3RR In -Kind, curator time 8,500 County of Hawaii Grant funds - pending 16,000 TOTAL: 35,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We continue to seek support for all of our educational programs via private patrons, grants and through our own donor base. New PR & marketing plan is in the works for 2015 and hopefully will result in branding that will attract financial support. We are joining the Hawaii Visitors and Convention Bureau. But we must keep specific time frames free of tours for the Internships. The goal is to boost income on times free of internships to further balance need of income verses time for internships. 7. Program Objectives Using County Nonprofit Grant Program Funds: Our goals are to maintain 2014 educational program numbers (A, B & D) and increase high school student mentoring (C). Thus we intend to offer more programs for Hawaii youth who hope to enter higher level educational programs on Oahu and the mainland. We feel that this will increase the numbers of graduates returning to practice in Hawaii. We offer a program like no other in Hawaii. With County Nonprofit funds we can dedicate the time to the students so that our focus 100% during their time with us this compensates for our lost revenue during those hours. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Three Ring Ranch Program Name: ExtemshipsAntemships/mentoring 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.r NumberoR4enuserve4, worksMps osevenn M1eW, rolunteer M1wns, etc. Desnibe, be specific) Applicant Projected Results Residential internship (vet and prevet) 6 students, 6 weeks Fxtemships 4th year vet students 2 students, 4-6 weeks High School Residential internships 6 students 4 weeks ARerschool mentorships 25-30 students 32 week 0 0 Operations 4054 4500 0 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages 0 0 0 Professional Fees o 0 0 Operations 4054 4500 0 Supplies 0 0 0 Equipment 2242 2500 2000 Other: foocuutilifies 5878 7,000 7000 Other: surgery (mobile vet van and clinics) 1127 2700 2000 Other: loss of tour income 9500 9500 Other: projected program expansion costs 8800 5,000 Other: TOTAL 22791 35000 16,000 elf applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Three Ring Ranch Program Name: Extemshipsllntemships/mentoring io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Ann Goody POSITION: Curator May have a conflict or potential conflict of interest, including anyfamilial 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 or 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. Signature of ALittardied Person (specify title) 7'1Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Three Ring Ranch Program Name: Extemships/Intemships/mentoring it. Certification of Understanding (Pagel of z) I (we) have read and understood all of the 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 final payment. 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. com lete and accurate ear -end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Three Ring Ranch Program Name: Extemships/Intemships/mentoring 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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 30'^ shall result in loss of all grant funds received during the grant period (must be refunded to Countyl 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.hawailcounty.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, 2015 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 fundina reauest and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements Signature of A th ' ed Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Three Ring Ranch Program Name: Extemships/Intemships/mentodng 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Residential Internships (vet and pre -vet) 6 x 8 w Externships (4th yr vet students) 2x4 -6.M High school residential internships 6 x 4 wks Afterschwl memors 25-30 x 32 Equipment 2000 Other: food & utilities 7000 Other: surgery, mbile vet van s dinics 2000 TABLE 11; PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 0 Professional Fees 0 Operations 0 Supplies 0 Equipment 2000 Other: food & utilities 7000 Other: surgery, mbile vet van s dinics 2000 Other: loss of tour income 0 Other: projected Program expansion costs 5.000 Other: TOTAL 16000 Additional Council directives reeardine award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Three Ring Ranch Fence Replacement 125 COFI il I County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Three Ring Ranch Program Name: Fence replacement Agency Director: Ann Goody PhD Phone No.: ( 809) 931 — 8778 Contact Person: Ann Goody PhD Phone No.: ( 808 ) 331 — 8]]8 Mailing Address: Address: 75-809 Keaolanl De Address: City, ST, Zip Kailua-Kone H196740 Facility Address: Address sama Address: City, ST, Zip Email Address: animals®threeringrancn erg Fax No.: ( 866) 365 — 5097 Accountant/CPA: Bol Hauser Phone No.: ( 702 ) 248 — 2814 Firm (if applicable): The Tasman Mailing Address: Address: 871 Coronado Center or #200 Address: City, ST, Zip Henderson NV 89052 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: s9,000.00 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua ❑ North Kona ❑ South Hilo ❑ North Kerala ❑J South Kona ❑ North Hilo ❑ South Rol la ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) Q Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page I of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Three Ring Ranch Program Name: Fence replacement 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 0 MOO 0 2. Agency Mission Statement: Our mission is to positively impact the environment while educating Hawaii's children about their place in the natural world. We assist in the development of an environmentally responsible generation of youth while caring for exotic animal residents. 3. Program Description: Aging fences must be replaced to keep the animals and humans safe. Originally put up in 1998 these fences meet or exceed all HI state regulations for the species we house however the weather in Hawai'i rusts the wire and t posts creating an unsafe situation over time. Our fences must stay secure and capable of retaining all of our residents safely with out injury. They must secure the facility and prevent human trespassing. Fences also keep predators out and with the endangered species we house for education this is essential. Replacement of internal and external fences is necessary in 2015. 4. Total Budget & Position Count: Total Program Budget: 13,547 Total Program Position Count: 0 Total Agency Budget: 94,400 Total Agency Position Count: 0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Three Ring Ranch Program Name: Fence replacement 5. Program Funding Sources (identify all sources of funding applied to this program): FY35-16 Revenue Source Estimate County of Hawaii grant funds - pending 9,000 Three Ring Ranch capitol project funds 4547 TOTAL: 13,547 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: This is a major capitol expenditure for 3RR. We have been saving towards the project for the past 4 years but have not met the bid amount from KIIK Services. Keone Iranon is able to provide the best price we can find for quality work. We have been increasing our income producing tours, applying for capitol grants and soliciting donations from our regular supporters. This project cannot wait but needs to be completed in 2015 to meet safety standards for all Global Federation of Animal Sanctuary (GFAS) accredited facilities such as 3RR. 7. Program Objectives Using County Nonprofit Grant Program Funds: Replace external and part of the internal fences to keep animal residents and humans as safe as possible. Prevent all fence related animal injury, prevent human trespassing, prevent predator from harming residents, prevent animal escape. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Three Ring Ranch Program Name: Fence replacement 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i.e.: Numbera)dienrs served, wmFshope , events held, volunteer M1ours, etc aesdbe, be sOeofiU Applicant Projected Results Fences are replaced as planned 100% Animals safe from injury on old fences 100% Humans safe from animal escape 100 Professional Fees 0 0 0 Operations 0 0 0 Attach additional pages as necessary, 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages o 0 0 Professional Fees 0 0 0 Operations 0 0 0 Supplies 0 0 0 Equipment 0 0 0 Other: Fencing material and installation service 0 13547 9,000 Other: Other Other: Other: TOTAL 13547 9,000 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Three Ring Ranch Program Name: Fence replacement it 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 o conflict exists. NAME: Ann Goody, PhD POSITION: Curator 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 asa 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 Authorize on (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Three Ring Ranch Program Name: Fence replacement ii. Certification of Understanding (Page t of 2) 1 (we) have read and understood all of the 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 programs) 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 final payment. 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 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 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 reportusing the template provided will impact the evaluation of your program's or oger 5 future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Three Ring Ranch Program Name: Fence replacement 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 30" shall result in loss of all grant funds received during the grant period (must be refunded to Countvl 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.hawailcounty.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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. 2 �lz) Signature of Authoriz d P rson (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Three Ring Ranch Program Name: Fence replacement 1z. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Fences are replaced as planned 100 animals safe from injury on old fences 100% Humans safe from animal escape �00� Supplies 0 Equipment 0 Other: /encing material and installation service 9,000 Other: TABLE 11: PROGRAM EXPENDITURES FV 15-16 Grant Request Council Award Salary and Wages 0 Professional Fees 0 Operations 0 Supplies 0 Equipment 0 Other: /encing material and installation service 9,000 Other: Other: Other Other: TOTAL 9,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8 of Uhane Pohaku Na Moku O Hawaii, Inc. Palehua Farm Project 126 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku O Hawaii, Inc. Program Name: Palehua Farm Project Agency Director: Kawlkayahiro Phone No.: ( 808) 341 — 1490 Contact Person: Karachi Ryder Phone No.: ( 806 ) 382 — 8744 Mailing Address: Address: 279 Hakelau Place Address: City, ST, Zip Honolulu, HI 96825 Facility Address: Address: Paled -da Farm Address: Wood Valley Road City, ST, Zip cabala, HI 96777 Email Address: kawlkae08Q9manmon, Accountant/CPA: Adhur K. Kuwahara Firm (if applicable): Mailing Address: Address: 1350 south King Street, suite 209 Address: City, ST, Zip Honolulu, HI 96914 Fax No.: ( ) — Phone No.: ( 868) 942 — 7789 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: 876,975.00 Geographical Areas To Be Served: (One or more can be checked) ❑] Puna © Hamakua✓❑ North Kona © South Hilo © North Kohala © South Kona Q North Hilo © South Kohala Ka'u Services or Activities To Be Provided: (One or more can be checked) Educational concerns © youth ❑ Victims of Crimes © Culture and the arts © Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku O Hawaii, Inc. Program Name: Palehua Farm Project 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 o $o.o0 0 2. Agency Mission Statement: Our mission is to foster and encourage a deep appreciation, integrating the ahupua'a concept, of the Hawaiian mindset, through cultural arts, hula, mo'olelo and chant traditions, cultural site protection, maintenance, and restoration that promotes Hawaiian values, language and practices while embracing our living environment which truly defines ones culture. 3. Program Description: The Palehua Farm Project will work with at -risk youth between the ages of 10-25, island wide, on our farm located in Pahala. The Palehua Farm Project is a pu'uhonua compass, with our kupuna as the foundation, that enlightens our youth service projects with a working farm in progress. Three acres of mamaki tea and taro are in the process of being cultivated with 25 acres to be developed, hence the need for this grant. Our food production will focus on the traditional food plants of the Hawaiian diet. Medicinal tea plants, like the mamaki, koko'olau, olena, awa and uhaloa will also be planted and produced. With the kupuna as our teachers, the youth will learn the medicinal and health benefits of these teas. Through this project they will be able to share the knowledge learned with their families and community. All planting of fruit and organic mulch will also add to the farm's natural environment. The youth will also take part In the cultivation of dry and wet land taro and learn the methods of taro farming. The production of poi will occur once their taro is ready to harvest. Cultural food sustainability is what we want to teach our youth and their families. 4. Total Budget & Position Count: Total Program Budget: $76,975.00 Total Program Position Count: Total Agency Budget: $668,197.001 Total Agency Position Count: a EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku O Hawaii, Inc. Program Name: Palehua Farm Project 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate State of Hawaii Grant in Aid $610,037.00 Tha Salvation Army Family Intervention services $50,400.00 Hawaii Community Foundation - 0 i Grant $7,760.00 TOTAL: $668,197.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program As Uhane Pohaku Na Moku O Hawaii, Inc. (Uhane) has re -located our agency to Hawaii Island in February of 2014, the agency is about teaching our youth to be good stewards of the land and ocean. Learning, on land and in the ocean, by the use of traditional Hawaiian cultural strategies, is the foundation we try to teach our youth. This format also increases our participants caring, health, and wanting to become responsible for the ling term sustainability of the project. Our operation is based out of Pahala, in Ka'u, where we have access to 3 acres, total of 25 acres with long term usage, of land that the youth are learning farming methods of mamaki tea, taro, sweet potato, banana and other fruits and vegetables. Uhane is applying for grants from the State, County and private foundations to get the infrastructure in place to allow the farm to grow and produce basic staples to feed our youth and their families. The surplus can be sold to the community to build revenue. We intend to develop acreage in the near future to enhance our economic base. 7. Program Objectives Using County Nonprofit Grant Program Funds: There will be two sets of impact measures identified for this project. The first set of measures will show the restoration of natural resources (aina) to the point of productivity, and the restoration of Native Hawaiian cultural values to participants involved. The second impact measures will focus on the youth participants knowledge, attitudinal, and behavioral changes made. Also Included will be participants "well-being", a model which identifies five domains for youth to succeed in school, and progress to post -secondary training/education. The project Is designed to accomplish the following: - to facilitate social bonding of youth in the project to each other, staff and kupuna; - to appreciate the fragile relationships between the'aina (land), flora and fauna; - to develop self-esteem and confidence in relation to learning and education; - to develop a sense of usefulness through contribution (community service learning); - to earn responsible citizenship and feel a sense of respect for self, others and community; - to learn and understand cultural food sustainability. EXHIBIT A NONPRON r GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku O Hawaii, Inc. Program Name: Palehua Farm Project S. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES h e.: Number ofcllents serwe, workshops or events held, wlunteer hours, e[c oes"he, be speclficf Applicant Projected Results 1. Of the 50 youth served, 80%, will gain a 40 youth sense of respect and ownership to the are $271,238.00 $29,875.00 while increasing their academic skills. 2. Of the 50 youth served, 80%, will develop 40 youth and sustain relationships with our kupuna. $13,000.00 3. Of the 50 youth served, 80%, will 40 youth increase their self esteem and self identity. Equipment Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual* FY 15-16 FY 15-16 Total Budget Grant Req Salary and Wages 0 $271,238.00 $29,875.00 Professional Fees $13,000.00 Operations $13,000.00 Supplies $45,160.00 $17.500.00 Equipment $202,300.00 $16,600.00 Other. insurance $6,749.00 Othermotor vehicle lease/purchase $129,750.00 Other: Other: Other: TOTAL $668,197.00 $76,975.00 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku 0 Hawaii, Inc. Program Name: Patehua Farm Project io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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: YA",a POSITION: lex,-vup,ee¢w 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 on 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. Signature of Authorized Plerson (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku O Hawaii, Inc. Program Name: Palehua Farm Project 11. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 2S, 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 final payment. 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 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 Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit o timely, complete and accurate year-end report using the template provided will impact the evaluation of your program's or agency s future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Ohane Pohaku Na Moku 0 Hawaii, Inc. Program Name: Palehua Farm Project 22. 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 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.hawalicounty.gov/­fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements Signature of Authorize erson (speci title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku 0 Hawaii, Inc. Program Name: Paiehua Farm Project 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result 1. Of the 50 youth served, 80%, will gain a sense 40 youth of respect and ownership to the aina while $13,000.00 increasing academic skills. 2. Of the 50 youth served, 80%, will develop and 40 youth sustain positive relationships with kupuna $16,600.00 3. Of the 50 youth served, 80%, will increase 40 youth their self esteem and self identify. Other: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $29,875.00 Professional fees $13,000.00 Operations Supplies $17,500.00 Equipment $16,600.00 Other: Other: Other: Other: Other: TOTAL $76,975.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Uhane Pohaku Na Moku O Hawaii, Inc. Reforestation of Makakupu Gulch in Ka'u 127 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku 0 Hawaii, Inc, Program Name: Reforestation of Makakupu Gulch in Ka'u Agency Director: Kawika Yahirc Phone No.: ( 606) sal — 1490 Contact Person: Kawahi Ryder Phone No.: ( 606) see — 6744 Mailing Address: Address: 279 Hakalau Place Address: City, ST, Zip Honolulu, HI 96625 Facl l ity Address: Address: Makakupu Gulch Address: Wood Valley Road City, ST, Zip Peru] , HI 96777 Email Address: kawika806@9rnu[c0m Fax No.: Accountant/CPA: Arthur K. Kuwahara Phone No.: ( aoa 1942 — 7769 Firm (if applicable): Mailing Address: Address: 1350 south King Street, suite 209 Address: City, ST, Zip Honolulu, HI 96914 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: g 79,482.00 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna ❑✓ Hamakua [North Kona © South Hilo Q North Kohala © South Kona © North Hilo 0 South Kohala © Ka'0 Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth ❑ Victims of Crimes © Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page Iof8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku O Hawaii, Inc, Program Name: Reforestation of Makakupu Gulch in Ka'u 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 1 FY 13-14 FY 14-15 0 $0.00 0 2. Agency Mission Statement: Our mission is to foster and encourage a deep appreciation for the Hawaiian cultural arts through hula traditions and cultural site protection, maintenance, and restoration that promotes Hawaiian values, language and practices. 3. Program Description: Our project will work with at -risk youth, ages 10-25 years of age, island wide, to help restore and preserve an ahupua'a in Ka'u. The project is two fold. The first is the mauka, Paauau ahupua'a. This will include the reforestation and restoration of the Makakupu dry stream bed in Wood Valley. We will take out invasive species and plant native Hawaiian plants that have medicinal use as well as traditional use as in the hula and crafts. The plan is to educate our youth on conservation and be able to share this with the Ka'u community. Eventually the Makakupu dry stream bed can become an eco -tourist site with educational trail tours of our native plants and their uses. The second ahupua'a we will work on is, makai. This is the Ninoole-Hllo'e fishponds in the Punalu'u ahupua'a. This is the first phase of a bigger project. We will remove all of the vegetation growing over the fishponds that include grass and mix brush. Once the vegetation is cut down, we can look at planting coastal plants. 4. Total Budget & Position Count: Total Program Budget: $79,482.00 Total Program Position Count: 1 1 Total Agency Budget: 1 $668,197,001 Total Agency Position Count: e EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku O Hawaii, Inc, Program Name: Reforestation of Makakupu Gulch in Ka'u S. Program Funding Sources (identify all sources of funding applied to this programl: Revenue Source FY1S-16 Estimate State of Hawaii Grant in Aid $610,037.00 The Salvation Army Family Intervention Services $50,400.00 Hawaii Community Foundation - O'io Project $7,760.00 TOTAL: $668,197.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program As Uhane Pohaku Na Moku O Hawaii, Inc. (Uhane) has re -located our agency to Hawaii Island in February of 2014, the agency is about teaching our youth to be good stewards of the land and ocean. Learning, on land and in the ocean, by the use of traditional Hawaiian cultural strategies, is the foundation we try to teach our youth. This format also increases our participants caring, health, and wanting to become responsible for the long term sustainability of the project. Our operation is based out of Pahala, in Ka'u, where we have access to 3 acres, total of 25 acres with long term usage, of land that the youth are learning farming methods of mamakl tea, taro, sweet potato, banana and other fruits and vegetable. Uhane is applying for grants from the State, County and private foundations to get the infrastructure in place to allow the farm to grow and produce basic staples to feed our youth and their families. The surplus can be sold to the community to build revenue. We intend to develop acreage in the near future to enhance our economic base. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives are to appreciate the fragile relationships between the flora, fauna, and'aina (land); to develop confidence and self esteem in relation to learning and education; to develop a sense of usefulness through contribution (community service learning); to earn responsible citizenship and feel a sense of respect for self, others and community; to increase participants pro -social behaviors through on-going involvement and participation of programs and services that perpetuate the Hawaiian culture. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Pdge 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku O Hawaii, Inc, Program Name: Reforestation of Makakupu Gulch in Ka'u 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES in s, Number of clients served, workshops ar events held, valunteerbaurs, ehDescribe, be specific) Applicant Projected Results 1. Of the 50 youth Served, 80%, will 40 youth complete 96 hours of project activities. 0 2. Of the 50 youth served, 80% will 40 youth demonstrate increase skills and proficiencies that perpetuate the Hawaiian culture. 3. Of the 50 youth served, 80%, will show 40 youth improvement of positive pro -social behaviors 5,500 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES 114-15 Ac[uaN 115-16 Total Budget fy 15-16 Grant Req Salary and Wages 0 271,238 31,382 Professional Fees Operations 13,000 5,500 Supplies 45,160 33,433 Equipment 202,300 5,850 Other. insurance 6,749 3,317 Other motor vehicle lease/purchase 129,750 Other: Other: Other: TOTAL 668,197 79,482 If applicable EXHIBIT A NONPROFIT GRANT APPLICATION 12015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: uhane Pohaku Na Moku G Hawaii, Inc. Program Name: Reforestation of Makakupu Gulch in Ka'u 10. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, reaordless of whether a conflict exists. NAME: KAwin Yw+tiR POSITION: Exe���,✓c Dr«,r<-taq 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 wilt 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 factor appearance, any conflicts or potential conflicts of interest: dIf no conflicts exist, check here. Signature of Authori d Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku O Hawaii, Inc, Program Name: Reforestation of Makakupu Gulch In Ka'u 11. 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 2S, 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. 1 (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability 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 final payment. To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawaii I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku 0 Hawaii, Inc. Program Name: Reforestation of Makakupu Gulch in Ka'u 11. Certification of Understanding Nage 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.hawailcounty.goy/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, 2015 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 token to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Autho zed Persorrfspecify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku O Hawaii, Inc, Program Name: Reforestation of Makakupu Gulch in Ka'u 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result 1. Of the 50 youth served, 80%, will complete 96 40 youth l hours of project activities. Operations 2, Of the 50 youth served, 80%, will demonstrate 40 youth Supplies increase skills and proficiencies that perpetuate FE the Hawaiian culture. Other. insurance 3. Of the 50 youth served, 80%, will show 40 youth Other. improvement of positive prosocialbehaviors. Other TABLE II: PROGRAM EXPENDITURES FY 15-16 Council Award Salary and Wages Professional Fees Operations 13,317 Supplies Equipment Other. insurance Other. Other Other: Other: TOTAL 79,482 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 Uhane Pohaku Na Moku O Hawaii, Inc. The Opelu I'a Project IM County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku O Hawaii, Inc, Program Name: The Opelu I'a Project Agency Director: Kawikavaniro Phone No.: ( 808) 341 — 1499 Contact Person: Kawehi Ryder Phone No.: ( e08 ) 382 — 8744 Mailing Address: Address: 279 Hakelau Place Address: City, ST, Zip Honolulu, HI 96825 Facility Address: Address: 82-6130 Mamalahoa Highway Address: City, ST, Zip Captain Cook, HI 96704 Email Address: kawika908®gPi mom Fax No.: ACCO u ma in t/C PA: Art K. Kuwahara Phone No.: ( 008) 942 — 7789 Firm (if applicable): Mailing Address: Address: 1350 south King sleet. Site 209 Address: City, ST, Zip Honolulu, HI 96814 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $76.299.00 Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua✓❑ North Kona ❑ South Hilo ❑ North Kohala © South Kona ❑ North Hilo ❑ South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth ❑ Victims of Crimes © Culture and the arts © Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku 0 Hawaii, Inc, Program Name: The Opelu I'a Project 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 0 fTotal Agency Budget: $ss8,i s7.00 2. Agency Mission Statement: Our mission is to foster and encourage a deep appreciation for the Hawaiian cultural arts through hula traditions and cultural site protection, maintenance, and restoration that promotes Hawaiian values, language and practices. 3. Program Description: In keeping with the Kuamo'o mindset which begins with the vertabra that joins us with the past so in our sharing we become a link with the future, we will attempt to embrace our kupuna who holds the traditions of opelu fishing that are now aged and land bound, yet willing to pass on this traditional knowledge in our project focus area of Keauhou to Honaunau. We have started the process of phase I by receiving $7760.00 from the Hawaii Community Foundation, O'io Project, to focus on the process of drying fish types identified as opelu, akule, ahi and aku. In phase 2, with this grant, we are focusing on identified fishermen in the Kona district, that are wanting to pass the tradition on. We will continue the dry fish process, but will now teach the youth how to catch the fish with the use of the upena (net) to catch opelu and eventually boat fishing. The youth will learn the food bait process (palu). They will cultivate the taro and pumpkin that is used for fish food. The youth will document the research, data archive and mo'olelo with these kupuna opelu fishermen. They will study the seasons, currents and timelines of the opelu. Our end result is to do a video documentation of kupuna teachers and the overall project. 4. Total Budget & Position Count: Total Program Budget: $76,299co Total Program Position Count: t fTotal Agency Budget: $ss8,i s7.00 Total Agency Position Count: e EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku O Hawaii, Inc, Program Name: The Opelu I'a Project 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate State of Hawaii Grant in Aid $610,037.00 The Salvation Army Family Intervention Services $50,400.00 Hawaii Community Foundation - old Project $7,760.00 TOTAL: $666,197.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program As Uhane Pohaku Na Moku O Hawaii, Inc. (Uhane) has re -located our agency to Hawaii Island in February of 2014, the agency is about teaching our youth to be good stewards of the land and ocean. Learning food sustainability, on land and in the ocean, by the use of traditional methods, is one of the foundations we try to teach our youth. Our operation is based out of Pahala, where we have use of 25 acres of land that the youth are learning farming methods of mamaki tea, taro, sweet potato, banana and other fruits and vegetable. Uhane is applying for grants from the State, County and private foundations to get the infrastructure in place to allow the farm to grow its own to feed our youth and their families. The surplus can be sold to the community to build revenue. 7. Program Objectives Using County Nonprofit Grant Program Funds: The objectives are to produce a healthy food product that has a traditional cultural lineage, an economic development product combined with market research and strategies that can integrate with academic success, and learning to be responsible and accountable such as: understanding costs and breakdown, ie. paying the electric and water usage costs. Most of all we want to learn from the keepers of the traditions, our kupuna. We want to document their knowledge of opelu fishing and pass it on to our youth, this generation. From the hands on work with the kupuna, to classroom learning of the studies of the fish and ocean, our hope is that some of our youth will take an interest in the vocation and will want to become an opelu fisherman and be able to keep the tradition going. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku O Hawaii, Inc, Program Name: The Opelu I'a Project 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Number of then¢ served, workshops prevents held, voWnteerhouo, etc Oescribc, be speci)ic) Applicant Projected Results 1. Of the 50 youth served, 80%, will 40 youth complete 120 hours of project activities. 0 2. Of the 50 youth served, 80% will write a 40 youth journal including research, data and mo'olelo 3. Of the 50 youth served, 80% will 40 youth understand the value of our cultural food sustainability. 6,500 Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual* FY 15-16 Total Budget FY 1516 Grant Req Salary and Wages 0 271,238 31,382 Professional Fees 12,000 Operations 13,000 6,500 Supplies 45,160 8,100 Equipment 202,300 8,500 Other: insurance 6,749 3,317 Other: motor vehicle lease/purchase 129,750 6,500 Other: Other: Other: TOTAL 668,197 76,299 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: uhane Pohaku Na Moku 0 Hawaii, Inc. Program Name: The Opelu I'a Project io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: KAWIy.A '/A"I n POSITION: G,elae--m 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 substontiol proboblliry that action token 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 Author;116cl Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku O Hawaii, Inc, Program Name: The Opelu I'a Project 11. Certification of Understanding (rage 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, 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 final payment. 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 reportusing the template provided, will impact the evaluation of your progrom's or aoencv's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku 0 Hawaii, Inc. Program Name: The Opetu Ira Project 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result In loss of all grant funds received during the grant period !must be refunded to County) and exclusion from future Brant 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 httr)://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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Author! r Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Uhane Pohaku Na Moku O Hawaii, Inc, Program Name: The Opelu I'a Project 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result 1. Of the 50 youth served, 80%, will complete 120 40 youth hours of project activities. 12,000 2. Of the 50 youth served, 80%, will write a 40 youth Journal Including research, data and mo'olelo. 8,100 3. Of the 50 youth served, 80%, will understand 40 youth the value of our cultural food sustainability. 3,317 Othermotor vehicle lease/purchase 6,500 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 31,382 Professional Fees 12,000 Operations 6,500 Supplies 8,100 Equipment 8,500 Other. insurance 3,317 Othermotor vehicle lease/purchase 6,500 Other. Other: Other TOTAL 76,299 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Volunteer Legal Services Hawaii Hawai'i County Community Legal Access Project 129 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Community Legal Access Project Agency Director: Mel D. Acosta Phone No.: ( 808) 522 — e,678 Contact Person: Michelle D. Acosta Phone No.: ( 808) 522 — p 678 Mailing Address: Address: 545 Queen Street suite loo Address: City, ST, Zip Honolulu, Hawaii 96813 Facility Address: Address: 545 Queen Street, Suite 100 Address: City, ST, Zip Honolulu, Hawaii 96813 Email Address: michelle@v1sh org Fax No.: ( 808) 524 — 2147 Accountant/CPA: Jeffrey Lee Phone No.: ( eo8 ) 734 — 1921 Firm (if applicable): choo, osada a Lee CPAs Inc. Mail i ng Address: Address: 113612th Avenue, #240 Address: City, ST, ZIP Honolulu, Hawaii 96816 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑./ Aged ❑ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities d❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 Geographical Areas To Be Served: (One or more can be checked) ❑✓ Puna Z Hamakua ❑✓ North Kona © South Hilo 0 North Kohala ❑Q South Kona ❑ North Hilo © South Kohala ❑✓ Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes ❑ Culture and the arts ❑./ Aged ❑ Victims of Health or Social Crises ❑✓ Needs of the poor ❑ Physical/Emotional Disabilities d❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Community Legal Access Project 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 0.00 $5,000.00 $15,000.00 2. Agency Mission Statement: Volunteer Legal Services Hawaii (VLSH) is dedicated to ensuring that poverty is not a barrier to accessing quality civil legal services. VLSH has been delivering on its mission of providing pro bono civil legal services to individuals and families who are in direst need of access to justice. Today, in collaboration with various community partners, the organization provides the framework and administrative support for volunteer attorneys to handle a variety of civil matters through programs responsive to the community's unmet legal needs. VLSH reaches out to and serves those least able to access legal services due to socio-economic and geographic barriers. The diverse needs of this target population are met with a continuum of services through legal advice clinics, self-help assistance, and referrals to volunteer attorneys for direct representation. 3. Program Description: There are four main activities under this program, all of which aim to increase the availability of legal services for individuals and families in Hawaii County who are experiencing civil legal issues affecting their basic quality of life: housing, employment, self-care, and family relations. 1. The 4 Family Law Legal Workshops/Clinics in West Oahu will provide legal advice and brief services to Individuals and families with family law related matters including: divorce; child custody, support and visitation; guardianships and adoptions; 2. The 4 Ka'u Legal Clinics will bring much needed services to the very rural areas of Hawaii County. These clinics will build on the pilot clinic conducted in September 2014 wherein 13 individuals were serviced with initial advice and counsel and further referred for pro bono services through VLSH's core pro bono program. 3. The Senior Legal Check -Up is a propose project through the HMSA Foundation to provide low-income seniors in Hilo access to legal information and services regarding legal and health planning. 4. Core legal services will continue to be offered to Hawaii County residents. 4. Total Budget & Position Count: Total Program Budget: $ss,000.00 Total Program Position Count: 4 Total Agency Budget: $700,000.00 Total Agency Position Count: 11 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Community Legal Access Project 5. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate FY 2015-2016 State Grant -in -Aid Funds (pending) HMSA Foundation (pending) $29,900.00 $7,500.00 VLSH In -Kind $2,000.00 TOTAL: $39,400.00 Attach addltlonal pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: VLSH plans to diversify sources of revenue to support legal services for the County of Hawaii residents to include the following: 1. Foundations: Recently, VLSH applied for funds from the Hawaii Medical Service Association (HMSA) Foundation to fund a project to meet the legal needs of the elderly population in West Hawaii in the amount of $7,500.00. If awarded, funds would be made available in June 2015. VLSH will continue to actively seek out funding to support expanded services to Hawaii County. 2. VLSH is submitting an application for funding to the State Grant -in -Aid in conjunction with this application for overall program support. 3. Private Donations: At present, the majority of private donations come from attorneys licensed to practice in the State of Hawaii at approximately $100,000.00 per year. A portion of these funds go to support overall program operations. 7. Program Objectives Using County Nonprofit Grant Program Funds: Funding will support targeted legal services to a total of 350 Hawaii County low and moderate income, elderly, and rural residents through the following activities for the grant period: a. 4 Self -Help Family Law Clinics in East Hawaii serving at least 20 individuals b. 4 Legal Clinics in Ka'u serving at least 30 individuals in rural West Hawaii c. 4 Senior Legal -Checkups in West Hawaii reaching at least 200 low and moderate income seniors with legal information and estate planning services (advance health care directives) d. At least 100 Intake services provided throughout the grant period for placement with pro bono attorneys for legal advice, limited scope, and full representation services. EXHIBITA NO NPROFIT GRANT APPLICATION FY 2015-2016 Page 3of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Community Legal Access Project 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Number gfchentsservee, workshops or events held, volunteer hours, to Describe, he epeclfl.) Applicant Projected Results 4 Self -Help and Legal Advice Family Law Clinics 20 services provided 4 Legal Clinics in Ka'u regarding various civil legal issues 30 services provided 4 Senior Legal Check -Up Workshops - Outreach and Direct Services 200 reached 100 serviced 12 months of overall Intake Services and referral to core services 100 services $1,000.00 $1,000.00 Operations $1,000.00 $1,000.00 Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual` FY I5-16 Total Budget FY 15-16 Grant Req Salary and Wages $37,000.00 $23,000.00 Professional Fees $1,000.00 $1,000.00 Operations $1,000.00 $1,000.00 Supplies $400.001 $200.00 Equipment Other Inter -Island Travel (airfare and ground transportation for staff 8x) 0.00 $2,400.00 Other: Printing of service brochures and event flyers $500.00 Other: Volunteer Refreshments and Appreciation Tokens for Clinic and Workshop $500.00 Other: Venue fees and Insurance $2,000.00 Other. TO 400.001 $30,600.00 -If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: volunteer Legal Services Hawaii Program Name: Hawaii County Community Legal Access Project io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: ❑✓ If no conflicts exist, check here. le" / 13 'lz-z' C? U i'Y 41 nature of AJ g zed Person (specify title) Date EXHIBITA l NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Community Legal Access Project li. 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 programs) 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 Hawa i'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express, and be compliant prior to final payment. 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 Hawa i'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 reportusinq the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: volunteer Legal Services Hawaii Program Name: Hawaii County Community Legal Access Project 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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 300° 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.Kov/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, 2015 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 fundina request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements Si nature of Authork�erson(specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Volunteer Legal Services Hawaii Program Name: Hawaii County Community Legal Access Project 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result 4 Self -Help and Legal Advice Family Law Clinics in West Hawaii 120 services 4 Legal Clinics in Ka'u 30 services $1,000.00 4 Senior Legal Check -lip Workshops 200 reached $1,000.00 Intake and Referral to Core Pro Bono Services: ad,rc, brief services, full representation 100 services $200.00 Equipment 0.00 Other: Inter -island Trave! $2,400.00 Other: Printing of service brochures and event flyers $500.00 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $23,000.00 Professional Fees $1,000.00 FY 2014-2015 Operations $1,000.00 of Supplies $200.00 Equipment 0.00 Other: Inter -island Trave! $2,400.00 Other: Printing of service brochures and event flyers $500.00 Other: Volunteer refreshments and appreciation tokens for clinic and workshops $500.00 ! Other: Venue fees and Insurance $2,000.00 Other: TOTAL 1, $30,600.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Waikoloa Dry Forest Initiative Waikoloa Future Foresters 130 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Waikoloa Dry Forest Initiative Program Name: Waikoloa Future Foresters Agency Director: .ion Lawson Phone No.: ( 808) 49a — 2208 Contact Person: 30o Lawson Phone No.: ( 808) e9a — 2208 Mailing Address: Address: W3729 wa Hoaoa Pl Address: City, ST, Zip Waikoloa, 1196738 Facility Address: Address: Co., Road Address: City, ST, Zip Waikoloa, HI 98738 Email Address: ien®wafkoloadryloresLorg Fax No.: ( eo8) 883 — 9988 Accountant/CPA: N/A Phone No.: ( ) — Firm (if applicable): Mailing Address: Address: Address: City, ST, Zip YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can he checked) ❑ Puna ❑ Wmakua ❑ North Kona ❑ South Hilo ❑ North Kohala ❑ South Kona ❑ North Hilo © South Kohala ❑ Ka'0 Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns © Youth ❑ Victims of Crimes © Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Waikoloa Dry Forest Initiative Program Name: Waikoloa Future Foresters 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 2. Agency Mission Statement: Waikoloa Dry Forest Initiative (WDFI) is a 501(c)(3) non-profit made up of a small group of citizens dedicated to forest conservation and education. Our mission is to preserve, protect and restore a remnant native Hawaiian dry forest ecosystem through land management, outreach, education and grass roots advocacy. We believe that educating our community about the importance of dryland forests and environmental conservation is essential for the success of our restoration projects and will lead to a better stewardship of our natural resources. 3. Program Description: The Waikoloa Future Foresters program is an educational program for children that meets in the forest preserve weekly or bi-weekly. The purpose of the Waikoloa Future Foresters program is to provide an opportunity for joyful learning; a safe, positive, hands-on, diverse and fun educational program where the kids can be active, outdoors and help to shape the lessons and activities. The Waikoloa Future Foresters program focuses on Hawaiian dryland forest ecology and we offer a dynamic lesson plan throughout the year that incorporates science, Hawaiian culture, traditional practices, conservation, land stewardship and more. We strive to provide children with different perspectives and ideas and do so by including experts and practitioners into our program and going on excursions to different sites. Field trips are a really important part of the program because we get kids out of Waikoloa and into other important places in which they can learn, discuss mauka-makai connections and understand the broader conservation context that the Waikoloa Dry Forest Preserve fits into. 4. Total Budget & Position Count: Total Program Budget: I s18,5oo.00 Total Program Position Count: 2 Total Agency Budget: $109,700A0 Total Agency Position Count: 2 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Waikoloa Dry Forest Initiative Program Name: Waikoloa Future Foresters 5. Program Funding Sources (identify all sources of funding applied to this programl: Revenue Source FYIS-16 Estimate Annual Campaign (Individual Donors) $3000.00 DLNR Forest Stewardship Program $2500.00 Young Brothers $500.00 WDFI $2500.00 TOTAL: $8500.00 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program The Waikoloa Future Foresters program is an ongoing program that is dear to our organization. We continue to seek funding for improving the program but are dedicated to the continuation of the program. We have partial funding for outreach and education coordination, some of which is allocated to the Future Foresters, through 2018 and expect that we will be able to obtain funds from donors who value environmental education to continue the program after that. WDFI is currently developing long-term financial sustainability plan which includes sales, memberships, recycling programs, evening seminars and widening our donor base. We are working hard to cultivate support and gaining momentum in our community and aim to rely less heavily on grants over time. It is important that we raise funds for our kid's programs such as the Future Foresters program without charging fees because we want to keep the program open and free to all of our participants. 7. Program Objectives Using County Nonprofit Grant Program Funds: The 20-30 children who participate in the Waikoloa Future Foresters 2015 program will be introduced to a wide variety of concepts and activities related to native ecosystems, Hawaiian culture and conservation. The Waikoloa Future Foresters do real applied science in the field and learn from professionals, scientists, and practitioners who serve as role models and mentors for young people. We expect to deepen their connection with their environment and teach them valuable lessons in stewardship, science and culture. We believe that educating the youth will lead to a more informed and stewardship -minded community of adults. We also believe that the children will take the lessons that they learn in the program home to parents, siblings and friends and have a positive influence on their behaviors and understanding of trees in their yards, parks, cities and forests. We hope that cultivating interest native forests during childhood will help guide our community toward better environmental practices and placing a higher value on native trees in our urban and wild areas. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Waikoloa Dry Forest Initiative Program Name: Waikoloa Future Foresters 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES fi.e.: Number oleiienrz served, workshops or events beta, rolun[eer Hours, erc nesrnbe, be zpxificJ Applicant Projected Results Number of children participating 30 Number of meetings held 25 Number of field trips 4 Number of camp trips 2 Volunteer hours served 160 Operations Attach additional pages as necessary. 9. TABLE It: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages $14,000.00 $16,000.00 $10,000.00 Professional Fees Operations Supplies $854.00 $2,000.00 Equipment Other: Transportation $500.00 Other: Other: Other: Other: TOTAL $14,854.00 $18,500.00 310,000.00 'If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Waikoloa Dry Forest Initiative Program Name: Waikoloa Future Foresters io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as o substantial probobility 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 r,AI;,U�K Sign ure ckAuthorized Person (specify title)T D� ate EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Waikoloa Dry Forest Initiative Program Name: Waikoloa Future Foresters 11. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 final payment. To register, go to http://vendars.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 aaencv's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Waikoloa Dry Forest Initiative Program Name: Waikoloa Future Foresters 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of 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 30°M1 shall result 4, 1.sc of all grant funds received during the grant period (must be refunded to County) and exclusion from f„ture 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 Int �n v, w,j n s yn,-_t p, arl 1 on or about rOav 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes _ect fn, —i-- 11nN.1 in, costs. Any funds unused by June 30, 2015 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 By signing below, you are acknowledging that you have read and understood these requirements. NONPROFIT GRANT APPLICATION FV 2015-2016 Page 7 of 8 >Igrioture bf: Authorizeo e,sun (speoly title) Mace NONPROFIT GRANT APPLICATION FV 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Waikoloa Dry Forest Initiative Program Name: Waikoloa Future Foresters 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Number of children participating W Number of meetings held 25 Number of field trips 4 Number of camp trips 2 Volunteers Nice hours served 160 Other: Other: TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages $10,0(10.00 Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL $10,000.00 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 West Hawaii County Band Friends Music and Equipment Fund 131 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund Agency Director: tarry artistic, Phone No.: ( ) — Contact Person: Llsa Archuleta Phone No.: ( 898 ) 936 — 38,19 Mailing Address: Address: WHCB Friends Address: PO Box 5058 City, ST, Zip Keilus-Kona, HI 96745 Facility Address: Address. Address: City, ST, Zip Email Address: maestrolisa@yahoo com Fax No.: Accountant/CPA: valence smith Phone No.: ( 808) 929 — 8000 Firm (if applicable): Kau Business servmes, LLP Mailing Address: Address: P.o. Box6239 Address: City, ST, Zip Ocean View, Hl 96]3] YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: u� Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Harri © North Kona ❑ South Hilo © North Kohala © South Kona ❑ North Hilo © South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes © Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 ___ I $8,100.00 $5,000.00 2. Agency Mission Statement: The primary and specific purpose for the West Hawaii County Band Friends shall be to support morally and financially, promote, assist and enhance the County Band in West Hawaii. 3. Program Description: This program will help to purchase sheet music sets with instrument parts and conductor score to assist the Band in its compliance with Parks and Recreation's goal of sight-reading 20 new compositions a year. The purchase of file cabinets will ensure good condition of the sheet music sets. The purchase of new uniform shirts will promote a more professional appearance and will enable the new members to have the same shirts as the core members. The purchase of monthly color programs will support audience enrichment, marketing of the non profit and promotion of the County's ongoing commitment to culture and the arts. Total Rudoet K Position Count: Total Program Budget: 9,000 Total Program Position Count:0 Total Agency Budget: 24.000 Total Agency Position Count: e EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund 5. Program Funding Sources (identify all sources of funding applied to this program): FY1S-16 Revenue Source Estimate Hawaii International Billfish Tournament 400 Ironman Corporation 300 Private Individuals 200 TOTAL: 900 Attach additional pages, irf needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our organization plans to apply for more grants and to market private individuals' opportunity to make a charity contribution to the program. 7. Program Objectives Using County Nonprofit Grant Program Funds: The program will help the Band be in compliance with Parks and Recreation sight-reading goals, the purchase of file cabinets will protect the current and future sheet music library, the new uniforms will promote a professional appearance and the purchase of concert programs with enhance the audience appreciation for the music and composers. All these help to create a professional and enriching experience for the audience. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund 8. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES n e.: Number of clients serves, workshops or events held, volunteer hours, etca¢snibe, be specific) Applicant Projected Results The Band will be able to sight read at least _ Compliance with County 20 new compositions. The music library will goals. Larger and be protected. The number of concerts more diverse audiences will be increased. 400 400 Operations 675 675 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual" FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages Professional Fees 400 400 Operations 675 675 Supplies 500 500 Equipment Other: Uniforms 4000 3500 Other Cabinets 970 970 Other: Sheet music 2400 2000 Other: Postage 55 55 Other TOTAL 9000 8100 9f applicable EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Program Name: io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 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): ❑ 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: Z( If no conflicts exist, check here. signature of uthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135-2-142.1, 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 final payment. 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 reportusing the template provided will impact the evaluation of your progrom's or ogencv's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Program Name: 11. Certification of Understanding (Page2of2) 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 lune 3011 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 lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. ZIA Signature Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii County Band Friends Program Name: Music and Equipment Fund 12. COUNCIL AWARD WORKSHEET TABLE 1: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other. Other: Other: Other. - Other: - - TOTAL --al a vuncn ci rectiyes re¢aralnE award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 West Hawai'i County Band Friends Volunteer Musicians Fund 132 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii County Band Friends Program Name: volunteer Musicians Fund Agency Director: tarry Boucher Phone No.: ( ) — Contact Person: rasa Archuletta Phone No.: ( 808) 936 — 3849 Mailing Address: Address: WHCB Friends Address'. P.O. Box5o58 City, ST, Zip Kailua-Kona, HI 96745 Facility Address: Address: Address: City, ST, Zip Email Address: maestrohsa@yahoo com Fax No.: ( ) — Accountant/CPA: Meleana smith Phone No.: ( 868) 929 — 8000 Firm (if applicable): Kau Business service¢. LLP Mailing Address: Address: P, o. So. 6239 Address: City, ST, Zip Ocean View, HI 96737 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua © North Kona ❑ South Hilo © North Kohala © South Kona ❑ North Hilo © South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth ❑ Victims of Crimes © Culture and the arts ❑ Aged ❑ Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii County Band Friends Program Name: volunteer Musicians Fund 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 13,250 $15,000.00 $15,000.00 2. Agency Mission Statement: The primary and specific purpose for the West Hawaii County Band Friends shall be to support morally and financially, promote, assist and enhance the County Band in West Hawaii. 3. Program Description: This program helps the volunteer musicians by providing them with an honorarium to defray the cost of gas to travel to a rehearsal or performance. The musicians donate their time and talent to augment the ten member County -paid group and sometimes as for financial assistance for travel. 4. Total Budget & Position Count: Total Program Budget: is,000 I Total Program Position Count: 0 Total Agency Budget: 24,0001 Total Agency Position Count: s EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii County Band Friends Program Name: volunteer Musicians Fund 5. Program Funding Sources (identify all sources of funding applied to this program) FY15-16 Revenue Source Estimate TOTAL: Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: Our organization plans to apply for more grants and to market private individuals' opportunity to make a charity contribution to the program. 7. Program Objectives Using County Nonprofit Grant Program Funds: The program will provide the ten member County paid musicians an opportunity for more complete coverage of music parts and a bigger more professional sound. The program will encourage more musicians to volunteer when their travel needs are met. The program helps to create a professional and enriching experience for the audience and supports the County's commitment to culture and the arts. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii County Band Friends Program Name: volunteer Musicians Fund 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES I, Number of lkln6 served, workshops or 111,6 held, volunteer hours, erc. Describe, be specific) Applicant Projected Results The Band will be able to perform every month Compliance with County at its concert series at Hale Halawai. The goals. Larger and program will increase the number of more diverse audiences musicians available to perform. More concerts per year Operations Attach additional pages as necessary. 9. TABLE If: PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-I6 Total Budget FY 15-16 Grant Req Salary and Wages Professional Fees Operations Supplies Equipment Other: Honorarium 15,000 15,000 Other: Other Other: Other: TOTAL 15,000 15,000 "If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Y 41.E Cak 1 cds Agency Name: W l�iuv.�• �j Program Name: 1/6/,6n fc� M1,y7c4a .S., d io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be 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 ❑ 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: lvf� If no conflicts exist, check here. signature of uthorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii County Band Friends Program Name: volunteer Musicians Fund 11. 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, 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 final payment. 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 reportusing the template provided, will impact the evaluation of Your program's or agency's future fundino requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: 2JOSf Program Name: Vaiu y {ems r f47ugif -' 11. Certification of Understanding (Page z of z) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii County Band Friends Program Name: volunteer Musicians Fund 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Protected Resul[s Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other. Other. Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 West Hawai'i Community Health Center (WHCHC) Adult Dental for Under -served 133 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii Community Health Center (WHCHC) Program Name: Adult Dental for Under -served Agency Director: Richard TaaRe, CEO Phone No.: (808)326— 3878 Contact Person: Natasha Ala. Assn. Directorof Developments Marketing Phone No.: ( 808 ) 326 — 5629 Mailing Address: Address: 75-5751 Kuakmi H,vy, suite 203 Address: City, ST, Zip Kailua-Kona, HI 96740 Facility Address: Address: 75-5751 Kuakmi Hwy.. suite 104 Address. City, 5T, Zip Kailua-Kona, HI 96740 Email Address: nala®westhawaiichaorg Fax No.: ( 808) 327 — 1939 Accountant/CPA: Nishihama s Kishida, CPAs, INC. Phone No.: ( 808) 524 — 2255 Firm (if applicable): Mailing Address: Address: Amencan savings Bank Tower Address: 1001 Bishop Street., Suite 1700 City, ST, Zip Honolulu, 111 96813-3696 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua © North Kona ❑ South Hilo ❑ North Kohala © South Kona ❑ North Hilo © South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts © Aged ❑ Victims of Health or Social Crises © Needs of the poor © Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page Iof8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii Community Health Center (WHCHC) Program Name: Adult Dental for Under -served 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $10,000.00 $10,000.00 $10,000.00 2. Agency Mission Statement: The mission of West Hawaii Community Health Center (WHCHC) is to make quality, comprehensive and integrated health services accessible to all, regardless of their ability to pay. Services are culturally appropriate and promote community well-being through the practice of malam pono. WHCHC was established as a non-profit 501 (c) 3 entity in November 2003. In January 2005 WHCHC first opened it's doors to serve the public and one year later, in 2006, WHCHC received its Federally Qualified Health Center (FQHC) status, paving the way for a cost-effective approach to delivering health care to the under -served and uninsured in our community. 3. Program Description: Since 2009, West Hawaii Community Health Center has provided emergency dental services to adults at the Friendly Place, a homeless shelter in Kailua-Kona, where many patients were always asking for restorative care, so they could keep their teeth. Mid -summer of 2015, the adult dental program will move to the new WHCHC — Kealakehe facility, and for the first time comprehensive dental care (preventative and restorative) will be offered to adults. A keiki dental program will also be incorporated into this new facility. Services offered, which begin with a comprehensive dental exam, range from $64 - $154 and will be in high demand by the uninsured, low-income and homeless populations, as there is a very limited number of private dental offices that provide care to these patients. 4. Total Budget & Position Count: Total Program Budget: $578,201 Total Program Position Count: 5.4 FTE Total Agency Budget: $11,416,737 1Total Agency Position Count: 106 79 Fre EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii Community Health Center (WHCHC) Program Name: Adult Dental for Under -served S. Program Funding Sources (identify all sources of funding applied to this orograml: Revenue Source FY15-16 Estimate WHCHC Adult Dental Kealakehe - Medicaid Reimbursment $152,390 WHCHC Adult Dental Kealakehe - Self -Pay Reimbursment $70,280 WHCHC Adult Dental Kealakehe - Private Insurance Reimbumment $80,603 State of Hawaii - POS $6,740 TOTAL: $310,013 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program WHCHC anticipates a revenue gap in the new adult dental clinic due to the fact that Medicaid does not cover preventative dental treatments, and it is estimated that only roughly 20% of WHCHC's projected patients will have private dental insurance, thus, nearly 80% of all adult dental reimbursement will come from the a self -pay reimbursement program. The self -pay program reimbursement is income based and thus most patients will be eligible to self -pay under the value of the service they receive. To increase revenues, WHCHC will adjust the self -pay reimbursement schedule to increase the patients contribution for services. WHCHC staff will also consult patients regarding their eligibility for dental insurance plans. 7. Program Objectives Using County Nonprofit Grant Program Funds: Hawaii county Nonprofit Grant funds will be used to cover the gap in the actual cost of providing comprehensive (preventative and restorative) dental services to adults who are uninsured, low-income and/or homeless. Medicaid only covers adult emergency care, not preventative or restorative care, thus, creating a gap in the actual costs from what it is taken in. WHCHC projects that approximately 80% of its adult dental patients will need financial assistance to pay for their dental services. It is projected that approximately 423 patients would be covered by this $30,000 request. Providing restorative oral health care for the most under -served population will benefit society through lowering health care costs, promotion of health, and reduction of morbidity associated with oral health problems. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii Community Health Center (WHCHC) Program Name: Adult Dental for Under -served 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i. e.: r✓umbe. oJdientsservee, workshops or events hem, volunteerhours, em oeuribe, be specific.) Applicant Projected Results Number of days open to serve patients 5 Days Number of Total Adult Patient Visits 2,650 Patient Visits Number of Medicaid Patient Vista 778 Patient Visits Number of Self -Pay Visits 1,300 Patient Visits Number of Private Insurance Visits 572 Patient Visits Operations N/A $34,720 $30,000 Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 14-15 Actual- FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages N/A $443,787 0 Professional Fees N/A $65,000 0 Operations N/A $34,720 $30,000 Supplies N/A $34,694 0 Equipment N/A N/A N/A Other. Other: Other. Other: Other: TOTAL $578,201 $30.000 `If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii Community Health Center (WHCHC) Program Name: Adult Dental for Under -served to. 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. Signature of Authorize Pers specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 January 19, 2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii Community Health Center (WHCHC) Program Name: Adult Dental for Under -served 11. 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, 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 final payment. 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 Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBITA NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii Community Health Center (WHCHC) Program Name: Adult Dental for Under -served 11. Certification of Understanding (Page 2 of 21 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 301h 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 oft his 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorit d Perso , pecify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 January 19, 2015 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii Community Health Center (WHCHC) Program Name: Adult Dental for Under -served 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results I Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other: TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 West Hawaii Community Health Center (WHCHC) WHCHC Medical Van Renovation 134 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii Community Health Center (WHCHC) Program Name: WHCHC Medical Van Renovation Agency Director: Richard TaaHe, CEO Phone No.: ( 808) 326 — 3878 Contact Person: Lauren Avery. Director of Development& Marketing Phone No.: ( 808 ) 331 — 6472 Mailing Address: Address: 15-5751 Kaakim Hwy. Suite 203 Address: City, ST, Zip Kailua-Kona, HI 96740 Facility Address: Address: ]5-5]51 Kuakini Hwy., Suite 104 Address: City, ST, Zip Kailua-Kona. HI 96740 Email Address: Iavery@westhawaAchcorg Fax No.: ( 808) 327 — 1939 Accountant/CPA: Nishihama 8 Kishida, CPAs.. INC. Phone No.: ( 8061 524 — 2255 Firm (if applicable): Mailing Address: Address: American Savings Bank Tower Address: 1001 Bishop Street, Suite 1700 City, ST, Zip Honolulu, HI 96813-3696 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) ❑ Puna ❑ Hamakua © North Kona ❑ South Hilo ❑ North Kohala © South Kona ❑ North Hila © South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts © Aged ❑ Victims of Health or Social Crises © Needs of the poor © Physical/Emotional Disabilities © Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii Community Health Center (WHCHC) Program Name: WHCHC Medical Van Renovation 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $10,000.00 $10,000.00 $10,000.00 2. Agency Mission Statement: WHCHC was established as a non-profit 501 (c) 3 entity in November 2003. In January 2005 WHCHC first opened it's doors to serve the public and one year later, in 2006, WHCHC received its Federally Qualified Health Center (FQHC) status, paving the way for a cost-effective approach to delivering health care to the under -served and uninsured in our community. The mission of West Hawaii Community Health Center is to make quality, comprehensive and integrated health services accessible to all, regardless of their ability to pay. Services are culturally appropriate and promote community well-being through the practice of malam pono. 3. Program Description: WHCHC currently offers emergency dental services at a Dental Van located at The Friendly Place Homeless Shelter. With the opening of the new WHCHC Kealakehe dental clinic in July 2015, the dental services offered at the Dental Van will be transfered to the new facility and the van will be converted to provide primary medical services. WHCHC will expand the number of days primary medical services are offered for the homeless and under -served, as well as take the Medical Van to locations where hard -to -reach and under -served people live and work - such as farmworkers and Marshallese. 4. Total Budget & Position Count: Total Program Budget: $25,000 Total Program Position count: NIA Total Agency Budget: $tfats,7s7 Total Agency Position Count: tos7s FTE EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii Community Health Center (WHCHC) Program Name: WHCHC Medical Van Renovation S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FYIS-16 Estimate WHCHC Opperating Budget $5,000 J. K. Luke (Hawaii National Bank) $5,000 County of Hawaii $15,000 TOTAL: $25,000 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: The medical van renovation will only require money identified in the Program Expenditures totaling $25,000. With money secured from current projected revenue sources identified above, WHCHC will complete the Medical Van renovation and will not need to pursue other funding sources. 7. Program Objectives Using County Nonprofit Grant Program Funds: WHCHC's primary objective is to provide medical and behavioral health care to 200 individuals (roughly 500 patient visits) who have not had access to health care. The target population includes; the homeless, farmworkers working in coffee and mac -nut fields, and others with limited or no transportation. Many people receiving Medicaid, or who are uninsured, face transportation barriers that prevent them from receiving health care. WHCHC will equip a Medical Van for the purpose of improving access for this population. This refurbished Medical Van will allow medial staff to travel to remote locations where patients live and work, providing much needed preventative care to patients in an effort to reduce the probability of costly emergency care. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii Community Health Center (WHCHC) Program Name: WHCHC Medical Van Renovation 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES (i. e.: Number oJcli served, workshops or events held, volunteer hovrs, etc. describe, be speQicf Applicant Projected Results Number of days open to serve patients 1-2 Days Number of Total Patient Visits 500 Patient Visits Number of Self -Pay or Medicaid Patient Vista - 95% 475 Patient Visits Number of Insured Patient Visits - 5% 25 Patient Visits Number of Medical Visits 300 Medical Visits Number of Behavior Health Visits 200 Behavior Health Visits N/A N/A Attach additional pages as necessary. 9. TABLE II: PROGRAM EXPENDITURES FY 1415 Actual- FY 15-16 Total Budget FY 15-16 Grant Req Salary and Wages N/A N/A N/A Professional Fees N/A $2,500 0 Operations N/A N/A N/A Supplies N/A $4,000 0 Equipment N/A $6,000 $5,000 Other: Tires, Engine Repairs N/A $2,500 0 Other: Interior van renovation (install wall, cabinets, doors, electrical) N/A $10,000 $10,000 Other: Other: Other: TOTAL $25,000 $15,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii Community Health Center (WHCHC) Program Name: WHCHC Medical Van Renovation to. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: 0 If no conflicts exist, check here. Signature of Authoriz d Pe (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 January 19 2015 Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii Community Health Center (WHCHC) Program Name: WHCHC Medical Van Renovation 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 — 2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. 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 (wel understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after June 30 of the contractual year for which the grant was awarded. The report, using the template provided, shall include an explanation of the public benefits derived from the awarding of the grant (focusing on specific, measurable outcomes), a complete accounting of all expenditures supported by County of Hawai'i grant funds, and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: West Hawaii Community Health Center (WHCHC) Program Name: WHCHC Medical Van Renovation 11. Certification of Understanding (Page 2of2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 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.hawalicounty.gov/fn-nonprofit-grant-forms/ on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposes stated in the application, except for a maximum ten percent (10%) for administrative and overhead costs. Any funds unused by lune 30, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized pefson (specify title) January 19, 2015 Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: West Hawaii Community Health Center (WHCHC) Program Name: WHCHC Medical Van Renovation 12. COUNCIL AWARD WORKSHEET TABLE I: Applicant Council Proposed PROGRAM PERFORMANCE MEASURES Projected Results I Projected Result TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other: Other: Other: Other: Other. TOTAL Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of Yeshua Outreach Center, Inc Yeshua Outreach Center 135 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Yeshua Outreach Center, Inc Program Name: Yeshua Outreach Center Agency Director: Paa r Lonn carmicnael Phone No.: ( eoa) 96s — s w Contact Person: Andrea Miday Phone No.: ( 868) 966 — 6489 Mailing Address: Address: P.o. B.. ls9a Address: City, ST, Zip Keaau, HI 96749 Facility Address: Address: 161592Pah.ku Cede Address: City, ST, Zip Keaau, H196149 Email Address: sndreemiday@yahoo.aorn Fax No.: ( BOB) 966 — 6112 Accountant/CPA: Cardee Fam..d Phone No.: ( aha) 9e2 — 39M Firm (if applicable): slralegy By N.m Mailing Address: Address: P.O.Box4130 Address: City, ST, Zip Hilo, HI96T26 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OFANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: (0116019 Geographical Areas To Be Served: (One or more can be checked) ❑V Puna i Hamakua I North Kona Q South Hilo J North Kohala South Kona North Hilo —] South Kohala (__ Ka9 Services or Activities To Be Provided: (One or more can be checked) Q✓ Educational concerns ❑✓ youth Victims of Crimes J Culture and the arts ❑✓ Aged ❑✓ Victims of Health or Social Crises Q✓ Needs of the poor Q✓ Physical/Emotional Disabilities ❑✓ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page l of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Yeshua Outreach Center, Inc. Program Name: Yeshua Outreach Center 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 0$45,000.0 Total Agency Budget $$67,500.00 2. Agency Mission Statement: Our mission is to bring healing and wholeness to individuals, families, and our community by turning lives around through quality, Christ -centered prevention and intervention programs, in a safe and caring environment, with emphasis on mentoring, and a strong anti-drug and alcohol message. We are dedicated to developing wholeness in mind, body, and spirit; building character and teaching respect; and enabling stronger and healthier individuals, families, and community. 3. Program Description: We currently serve and mentor over 150 youth and adults per week in our programs, open to all ages, which include a fitness gym with supervision, boxing, Kempo Karate, and a Friday Night Youth program that provides youth in the community with a safe place to go on Friday nights, dinner, mentorship, supervised high interest activities, and transportation. In reaching out to our community, we provide community classes on life skills, divorce care, nutrition, and addiction recovery, with a goal of lowering recidivisim rates. We are partnering with Red Cross and Hawaii County Civil defense and have activated a Red Cross shelter on-site for community victims of the lava flow and future emergencies. We are partnering with Hawaii Youth Business Center, offering on-site business skills development classes. We will be partnering with HawCC to offer their ICAN college -prep curriculum on-site, and with the DOE to offer GED classes on-site. We are partnering with Hawaii Youth Challenge in supporting at -risk youth. We are partnering with Teen Challenge Hawaiian Islands supporting those in the community suffering from addictions. We are dedicated to making a positive difference in our community. ._1 n...1.,e• a u..eirb.n rnnnt- Total Program Budget: 166.500 Total Program Position Count: 2.0 Total Agency Budget 166,5001 Total Agency Position Count: 2.0 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Yeshua Outreach Center, Inc. Program Name: Yeshua outreach center Fnndine Sources lidentlfv all sources of funding applied to this programl: Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We have significantly increased our exposure to and interaction with the community, and will continue to do so through partnerships with Hawaii Community College, Hawaii Youth Business Center, Hawaii Youth Challenge, the DOE Adult Community School, Teen Challenge Hawaiian Islands, Red Cross and Hawaii County Civil Defense, Hilo Interfaith, and more, and with our series of free community service classes, along with the concomitant growth of the church, we hope to realize an increased awareness of our programs, and increased membership and fees, donations, in-kind support, sales of goods, and volunteer base, to include local business support. With equipment we have purchased over this FY, and what we look to buy during FY 15-16, we will expand our fitness gym to a full service 6 day/week fitness center- the only one of its kind in Puna, serving over 50,000 people, thus realizing a significant increase in membership. We have established a grant writing Capability, which will lead to an increase in grant awards. Our goal is self-sustainment within three years. 7. Program Objectives Using County Nonprofit Grant Program Funds: We will continue to purchase supplies and equipment to expand and improve the fitness center, with the goal of phasing in a full service fitness center over the coming fiscal year, the only one of its kind in Puna District. We will improve and provide facility and supply support across all of our programs, to include new programs, i.e. the Red Cross Shelter, and the GED program. We will increase our community outreach in offering free and low cost classes and services to the community, and special events. We will utilize an active marketing effort to ensure increased awareness of our programs in the community, and increased membership enrollment and community participation. We will offer scholarships to those who cannot afford membership tuition. We will provide travel support for those participants who qualify for competition on other islands, and similar opportunities. We will continue to research and develop new programs, as well as establish new partners to meet the needs of our community (e.g. anger management classes, disaster relief counseling for both adults and children in partnering with BISAC and Southern Baptist Relief). EXHIBIT A NONPROFIT GRANT APPLICATION N2015-2016 Page 3 of fY15-16 Revenue Source Estimate County of Hawaii Grant Request 67,500 Tuition from membershl Iregishm - 5,000 3,000 Special events 5,000 Cash donations 1'000 Salad gods _ Sure Foundation wages 25,000 Sure Foundalion facility use 60'000 TOTAL: 166,500 Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program: We have significantly increased our exposure to and interaction with the community, and will continue to do so through partnerships with Hawaii Community College, Hawaii Youth Business Center, Hawaii Youth Challenge, the DOE Adult Community School, Teen Challenge Hawaiian Islands, Red Cross and Hawaii County Civil Defense, Hilo Interfaith, and more, and with our series of free community service classes, along with the concomitant growth of the church, we hope to realize an increased awareness of our programs, and increased membership and fees, donations, in-kind support, sales of goods, and volunteer base, to include local business support. With equipment we have purchased over this FY, and what we look to buy during FY 15-16, we will expand our fitness gym to a full service 6 day/week fitness center- the only one of its kind in Puna, serving over 50,000 people, thus realizing a significant increase in membership. We have established a grant writing Capability, which will lead to an increase in grant awards. Our goal is self-sustainment within three years. 7. Program Objectives Using County Nonprofit Grant Program Funds: We will continue to purchase supplies and equipment to expand and improve the fitness center, with the goal of phasing in a full service fitness center over the coming fiscal year, the only one of its kind in Puna District. We will improve and provide facility and supply support across all of our programs, to include new programs, i.e. the Red Cross Shelter, and the GED program. We will increase our community outreach in offering free and low cost classes and services to the community, and special events. We will utilize an active marketing effort to ensure increased awareness of our programs in the community, and increased membership enrollment and community participation. We will offer scholarships to those who cannot afford membership tuition. We will provide travel support for those participants who qualify for competition on other islands, and similar opportunities. We will continue to research and develop new programs, as well as establish new partners to meet the needs of our community (e.g. anger management classes, disaster relief counseling for both adults and children in partnering with BISAC and Southern Baptist Relief). EXHIBIT A NONPROFIT GRANT APPLICATION N2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Yeshua Outreach Center, Inc. Program Name: Yeshua Outreach center 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES lie, : Numberofc1wim served, smrbhops orevenn heK volunteer hours, etc. Desnlbe, be specific) Applicant Projected Results Establish full service fitness center membership base 100 Deliver USA Boring-sancfioned amateur and similar community special evems 6 Increase event attendance at special events by 20% 650 _ Increase boxing, weightlif8ng, YOC youth and Karate weekly attendance by 20% _ 170 Increase community partners by 20% 12 . Increase overall community outreach by 20% 600 Inc ase commun4 service classes by 20% 10 Attach additional pages as necessary. 9. TABLE IL• PROGRAM EXPENDITURES Fr lass Actual• FY 15-16 Total audget w 15-18 Grant Ray Salary and Wages 27.077 33.000 8,000 Professional Fees 13,278 14,000 4,000 Operations 51,240 65,000 2,000 Supplies 7,038 10,000 B,SOo Equipment 12,235 34.500 34,500 Other: Travel 1,140 5,000 5,000 Other Special Events (e.g. boxing, drug awareness, disaster relief support) 1,100 5,000 5,000 Other: Other: _— TOTAL 123,108 166,500 67,500 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Yeshua Outreach Center, Inc. Program Name: Yeshua Outreach Center io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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 beneflts 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) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 / -ate-Is Date Page 5 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Yeshua Outreach Center, Inc. Program Name: Yeshua Outreach Center 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 2S, 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 final payment. 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 Hawa'i I (w) understand and will comply with the reouirement 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 reportusing the template provided, will impact the evaluation of your program's or agency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of 8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: Yeshua outreach Center, Inc. Program Name: Yeshua outreach center 11. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 301M1 shall result in loss of all grant funds received during the grant period Imust be refunded to Countyl and exclusion from future grant partidpetion 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_.gov/fn-nonprofit-grant-formsZ on or about May 30 of the year the final 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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements Signature of Authorized Person (specify title) /- ).>-rS Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: Yeshua Outreach Center, Inc. Program Name: Yeshua Outreach Center 12. COUNCIL AWARD WORKSHEET TABLE I: PROGRAM PERFORMANCE MEASURES ApplicantCouncil es Prolectetl Results Proposed Projected ResRlt Establish full service lioness center membership base t 00 Deliver USA Boxing -sanctioned amateur and similar community special events a Increase event attendance at special events by 20% 650 Increase boxing, weightlifting, YOC youth and Karate weekly attendance by 20% 170 Increase community partners by 20% 12 Increase overall community ou reach by 20% 600 Increase community service Gasses by 20% 10 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 8,000 Professional Fees 4,000 Operations 2,500 Supplies 8,500 Equipment 34,500 Other: Travel 5,000 Other: Special events (e.g. boxing, drug awareness, disaster relief support) 5,000 Other: Other: Other: TOTAL 67,500 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8 of 8 YWCA Hawaii Island Healthy Start Program - Home Visiting 136 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Program - Home Visiting Agency Director: Kathleen Mccilvray, CEO Phone No.: ( 808) 930 — 5702 Contact Person: Andy Kahai, CREo/Progrann Director Phone No.: ( 808) 930 — 5727 Mailing Address: Address: 1382 Kilauea Avenue Address: City, ST, Zip Hilo Hawaii 96720 Fad Ey Address: Address: 1382 Kilauea Avenue Address. City, ST, Zip Hilo. Hawaii 96720 Email Address: akahuii@ywcahawauisland org Fax No.: ( 808) 961 — 9140 Accountant/CPA: Taketa, Iwata, Hard 8 Associates Phone No.: ( 908 ) 935 — 5404 Firm (if applicable): Cemaed Rubrn Ann nun tents Mailing Address: Address: 101 Aupuni street, suite 139 Address: City, ST, Zip Hilo, Hawaii 96720-4260 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: $ 25,000.00 Geographical Areas To Be Served: (One or more can be checked) © Puna © Hari ❑ North Kona © South Hilo ❑ North Kohala ❑ South Kona ✓❑ North Hilo ❑ South Kohala ❑ Ka'a Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑( Youth ❑✓ Victims of Crimes ❑ Culture and the arts ❑ Aged © Victims of Health or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ✓❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page l of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA of Hawai'i Island Program Name: Healthy Start Program - Home Visiting 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $42,500.00 $30,000.00 $10,000.00 2. Agency Mission Statement: YWCA Hawaii Island is dedicated to eliminating racism, empowering women and promoting peace, justice, freedom and dignity for all. The YWCA Hawaii Island was first organized in Hilo in 1919 and was established as a 501 (c)(3) non-profit organization in 1965. Throughout our history, the YWCA Hawaii Island has offered valuable programs and activities for the benefit of women, children and their families. We work to maintain the National YWCA's goals and objectives by fulfilling our local community's needs. 3. Program Description: The subject of this proposal will be funding to support the enrolling of 20 additional mothers and pregnant women into the YWCA of Hawai'i Island Healthy Start Home Visiting Program, an accredited Healthy Families America (HFA) site, which provides home visiting services in the Hilo and Puna areas on the island of Hawai'i (Census tracts 201-211). The target population to be served includes pregnant women and families of newborns (within the first three (3) months of life). Families may remain in the program until the target child is three (3) years old. HFA is a signature program of Prevent Child Abuse (PCA) America that has been providing home visiting services for more than 20 years. Expectant and new parents have common questions about their child's development. HFA connects with families through community partners like hospitals and pediatricians to find the answers to their questions, meeting within the familiarity and convenience of the family's own home. In April 2014, the YWCA's home visiting program was accredited by HFA as a provider of high quality HFA home visiting services. (See Attachment A - 3. Program Description: continued) 4. Total Budget & Position Count: Total Program Budget: $386,000.00 Total Program Position Count: 7.05 Fre Total Agency Budget: $2.923,857.761 Total Agency Position Count: 60 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency [Name: YWCA of Hawaii Island Program Name: Healthy Start Program - Home visiting S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate Stale of Hawaii. Department of Health, HHVN Grant $350,000.00 Trust and Foundations $10,00000 Contributions and Donations $1,000.00 County of Hawaii $25,000.00 _ _ TOTAL: $386,000M Attach additional pages, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program The YWCA's home visiting program has been funded since 1989 by the State of Hawai'i, Department of Health to provide services to families in East Hawai'i on the island of Hawai'i. By demonstrating effectiveness in terms of outcome measures, the YWCA operates a highly efficient program with well-trained seasoned staff who has successfully delivered services in East Hawaii for years. Families, referral sources, other community organizations and businesses alike recognize this program in the community as a valuable service. (See Attachment B - 6. Explain what plans your agency or program has to increase revenues to support this program: continued) 7. Program Objectives Using County Nonprofit Grant Program Funds: The County Nonprofit Grant funds will be used to support the Healthy Start Program's commitment to building a culture of quality within its home visiting program. The goals of the program are to: 1) Improve maternal/newborn health, 2) Reduce child injuries, abuse, neglect or maltreatment and reduce emergency department visits, 3) Improvements in school readiness/achievement, 4) Reduce crime or domestic violence; 5) Improve family economic self-sufficiency; and 6) Provide coordination and referrals for other community resources and supports. (See Attachment C - 7. Program Objectives Using County Nonprofit Grant Program Funds: continued) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA of Hawaii Island Program Name: Healthy start Program - Home visiting 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i. e.: Number of direct served, workshops or events held, volunteer hours, etc. Oemol e, be speciccf See Attachment D - 8 Table IContinued as necessary. 9. TABLE II: PROGRAM EXPENDITURES 114-15 Actual* FY 15-16 Total Budget 115-16 Grant Req Salary and Wages $307,920 18,897 $289,265 10,008 $14,470 550 Professional Fees Operations 63,251 55,034 7,130 Supplies 8,332 6,693 350 Equipment o a 0 Other: Indirect cost 1,600 0 2,500 Other. Other Other. Other: TOTAL $400,000 $361,000 $25,000 "If applicable EXHIBIT A NONPROFITGRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA of Hawaii Island Program Name: Healthy Start Program - Home Visiting io. ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of 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: Karen Teshima POSITION: Executive Assistant 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 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. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION Fy 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: YWCA of Hawai'i Island Program Name: Healthy start Program - Home visiting 11. Certification of Understanding (Page 1 of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 — 2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawai'i Compliance Express, and be compliant prior to final payment. 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 ggencV s future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6 of County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: YWCA of Hawai'i Island Program Name: Healthy Start Program - Home Visiting ii. Certification of Understanding (Page z of 2) If awarded a grant from the County of Hawai'i, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawai'i is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 30th shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.liawailcountV.goy/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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 7 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA of Hawai'i Island Program Name: Healthy Start Program - Home Visiting TABLE I: 12. COUNCIL AWARD WORKSHEET PROGRAM PERFORMANCE MEASURES Applicant Council Proposed Projected Results I Projected Result I See Attachment E - 12. Table I: Continued TABLE II: PROGRAM EXPENDITURES FV 15-16 Grant Request Council Award Salary and Wages $14,420.00 Professional Fees Operations 550.00 7,130.00 Supplies 350.00 _ Equipment 0 Other: Indirect Cost 2,500.00 Other. Other: Other: Other: TOTAL $25, 000.001 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FV 2014-2015 Page 8of8 YWCA of Hawaii Island Healthy Start Home Visiting Program County of Hawai'i Nonprofit Grant Application FY 2015-16 Exhibit A — Nonprofit Grant Application Attachment A — 3. Program Description: continued Attachment A— 3. Program Description: continued 3. Program Description: The subject of this proposal will be funding to support the enrolling of 20 additional mothers and pregnant women into the YWCA of Hawaii Island Healthy Start Home Visiting Program, an accredited Healthy Families America (HFA) site, which provides home visiting services in the Hilo and Puna areas on the island of Hawaii (Census tracts 201-211). The target population to be served includes pregnant women and families of newborns (within the first three (3) months of life). Families may remain in the program until the target child is three (3) years old. HFA is a signature program of Prevent Child Abuse (PCA) America that has been providing home visiting services for more than 20 years. Expectant and new parents have common questions about their child's development. HFA connects with families through community partners like hospitals and pediatricians to find the answers to their questions, meeting within the familiarity and convenience of the family's own home. In April 2014, the YWCA's home visiting program was accredited by HFA as a provider of high quality HFA home visiting services. A copy of the accreditation letter is included. The YWCA's community based, culturally sensitive home visiting program offers services provided by Para -professional and Professional staff who live in and are familiar with the geographic areas and the population they serve. The staff are culturally sensitive to non- western values and behavior, able to interpret client problems within a cultural context, and skilled in developing culturally appropriate interventions tailored to an individual family. The YWCA's home visiting program has been funded since 1989 by the State of Hawai i, Department of Health to provide services to families in East Hawai'i on the island of Hawai i. By demonstrating effectiveness in terms of outcome measures, the YWCA operates a highly efficient program with well-trained seasoned staff who have successfully delivered services in East Hawaii for years. This program is recognized in the community as a valuable service by families, referral sources, other community organizations and businesses alike. It has a proven track record of cooperative efforts with other agencies such as East Hawaii MCHB, Public Health Nursing Branch, Hilo Medical Center, WIC, Bay Clinic, Easter Seals, University of Hawaii, as well as, numerous Obstetricians and Pediatricians. The YWCA operates the only home visiting program of its kind in East Hawai i. It has the only home based program focused specifically on pregnant women and families with newborns. In addition, other programs do not offer the frequency of visits and/or the comprehensiveness and intensity of services that are necessary to address at -risk families' multifaceted needs. Page 1 of 1 Prevent Child Abuse Amctica '-S SlIAk wuba,h Awnuc IU"Moor Chlcago_11 61614 a 1' ,61 i i 1 1, 1 212.929.596^_ @.r R.�U.�1M19.91Gh1tPhlI3UOf� April 21, 2014 Mr. Andrew Kahili, Program Manager �y��,,,.....I.. Healthy Families Hawaii �n.ma M,enn YWCA Hawaii Island u... 1382 Kilauea Avenue m,nml, un„,, Hilo, Hawai'i 96720 `”"nihil ,leu Dear Mr. Kahili: cnr;n„N e,,,,,.i ��/ m,..r�„ un.N It is with great pleasure that we inform you that the Healthy Families Hawai'i site has been accredited by Healthy Families America as a provider of high quality HFA home visiting services. This accreditation is effective through March 31, 2018. h.,nwu The Healthy Families America (HFA) accreditation process is designed to identify individual sites and multi -site systems that have achieved high standards for c.:..: nI performance and a commitment to quality. HFA is proud to grant Healthy Families A11k, D” hl nun Hawal'i accreditation. r en, ha�.,.n ..... Uuun nrul.11.n.- Prevent Child Abuse America is honored to be associated with you and your colleagues. We wish you the very best in your continuing service to families in your nIhnj,1 ri��ri��i� community. i� %I Inn,,, „.1,1, Congratulations on your achievement! 6, \I I ,uei James M. Hmurovich President 8 CEO Pn.Wnrnr d CL'O p � L,m.vI Ilnnu v„d, 4 �idirt (/ �Niceiun S6i(rmrur n p, u. n1 11.1 111111L I'll it 1, 1 Cydney M. Wessel, MSW nr National Director of Healthy Families America YWCA of Hawaii Island Healthy Start Home Visiting Program County of Hawai'i Nonprofit Grant Application FY 2015-16 Exhibit A — Nonprofit Grant Application Attachment B — 6. Explain what plans your agency or program has to increase revenues to support this program: continued Attachment B-6. Explain what plans your agency or program has to increase revenues to support this program: continued 6. Explain what plans your agency or program has to increase revenues to support this program: The YWCA's home visiting program has been funded since 1989 by the State of Hawai'i, Department of Health to provide services to families in East Hawai'i on the island of Hawai'i. By demonstrating effectiveness in terms of outcome measures, the YWCA operates a highly efficient program with well-trained seasoned staff who has successfully delivered services in East Hawai'i for years. Families, referral sources, other community organizations and businesses alike recognize this program in the community as a valuable service. Due to the tough economic times and the reduction in funding resources, the program needs seek out various funding streams in order to maintain the status of services our East Hawaii families. Over the years, this program has been awarded funding from the County of Hawaii and othertrust and foundations. In addition to the funding sources listed in section five of this proposal the program will be submitting proposals requesting for funding to organizations such as the Hawaii Community Foundation, the O'Neill Family Foundation, the Office of Hawaiian Affairs, the Queen Emma Foundation, and other local businesses that support funding for children and youth. Page 1 of 1 YWCA of Hawaii Island Healthy Start Home Visiting Program County of Hawai'i Nonprofit Grant Application FY 2015-16 Exhibit A — Nonprofit Grant Application Attachment C — 7. Program Objectives Using County Nonprofit Grant Program Funds: continued Attachment C - 7. Program Objectives using County Nonprofit Grant Program Funds: continued 7. Program Objectives using County Nonprofit Grant Program Funds: continued The County Nonprofit Grant funds will be used to support the Healthy Start Program's commitment to building a culture of quality within its home visiting program. The goals of the program are to: 1) Improve maternal/newborn health, 2) Reduce child injuries, abuse, neglect or maltreatment and reduce emergency department visits, 3) Improvements in school readiness/achievement, 4) Reduce crime or domestic violence; 5) Improve family economic self-sufficiency; and 6) Provide coordination and referrals for other community resources and supports. As part of the grant funded by Health Resources and Services Administration (HRSA) through the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program, information about families enrolled in the program will be collected through record review, administering standardized measures, and questions asked during home visits. While a majority of the information is already being collected within the current home visiting program, a few additional standardized measures and questions are being added. The program will use the Hawaii Data Toolkit Guide issued by the State of Hawai'i Department of Health, which provides the basic information about each of the standardized measure instruments and guidance on how to best administer the instrument and question to obtain the most consistent information families enrolled in the program. Information will be collected from the following standardized measures: 1. Pregnancy Risk Assessment Monitoring System(PRAMS)— Tobacco questionnaire 2. Pregnancy Risk Assessment Monitoring System (PRAMS) - Breastfeeding questionnaire 3. Reported suspected maltreatment (allegations) 4. Reported substantiated maltreatment 5. First time victim of maltreatment 6. Infant Toddler Home Observation for Measurement of the Environment (HOME) 7. Ages and Stages Questionnaire 3`0 Edition (ASQ-3) 8. Ages and Stages Questionnaire Social -Emotional (ASC -SE) 9. Edinburgh Postnatal Depression Scale (EPDS) 10. Women's Experience with Battering Scale (WEBS) aka Relationship Assessment Tool The information collected from these instruments will be used to: 1) Strengthen and improve the program and activities carried out with enrolled families, 2) Improve coordination of services for at - risk families, and 3) identify and provide comprehensive services to improve outcomes for families who reside in East Hawai i. Research from the Johns Hopkins University Children's Center tell us that families who are involved in a home visiting program had an avoidance to child abuse and neglect behaviors, reduced hospitalization from trauma and conditions, and improved protective factors for their children. The researchers found that mothers with higher levels of depression were up to three (3) times more likely to severely physically assault their children than those with little or no depression. Mothers with no partner and those in violent relationships were up to six (6) times more likely to severely assault their children compared to those in nonviolent relationships. Physical assault varied over time, with 2 -year- olds incurring the highest risk of abuse. Infants born small for their gestational age were nearly six (6) times as likely to be physically abused as normal weight babies. Mothers who were depressed, who used illegal drugs, who did not have a partner or who were involved in violent relationships were at increased risk of mental abuse of their children. Page 1 of 2 Attachment C - 7. Program Objectives using County Nonprofit Grant Program Funds: continued The study team found no significant difference between the groups in terms of mothers' desire for and use of community services available. But home visitors often able to recognize parental risks and linked families with community resources. Researchers did observe a reduction in poor mental health among mothers being visited by programs; a modest reduction in maternal problem alcohol use and repeated incidents of physical violence from a partner in some of the families; and a modest impact in preventing abuse and neglect. Page 2 of 2 YWCA of Hawai'i Island Healthy Start Home Visiting Program County of Hawai'i Nonprofit Grant Application FY 2015-16 Exhibit A — Nonprofit Grant Application Attachment D-8. Table: continued Attachment C-8. Table l: continued B. Table I: continued What are the intended measurable outputs of outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (l. e.: Number oftlients served workshops or events held, volunteer hours, etc Describe, be specific) 100% Enroll an additional 20 mothers and pregnant women into the program Identify the number of women smokers (including e -cigarettes) at intake 100% and who report decreased smoking by one year post enrollment Ensure enrolled women receive their post partum examination within 3 100%' months from delivery Provide breastfeeding screening and monitoring at birth up until the 100% children is 6 months old. Ensure all enrolled families receive birth spacing education within 6 100% months post enrollment and annually Enroll all enrolled mothers are screened for depressive symptoms within 100% 6 months post enrollment and annually Ensure all enrolled children receive the recommended schedule of 100% immunization Ensure all enrolled families have a medical home and not using the 100% emergency room as their primary medical care provider Ensure all enrolled families have health insurance coverage for parent(s) 100% and child(ren) Ensure all enrolled families will NOT HAVE A CONFIRMED report of child 100% abuse and neglect within 6 months post enrollment and annually Ensure all enrolled children are screened for suspected developmental 100% delays within 6 months post enrollment and annually Ensure all enrolled women are screened for Domestic Violence within 6 100% months post enrollment and annually (Women's Experience with Battering (WEB) scale) Ensure all enrolled women with active Domestic Violence occurring have 100% a safety plan 100% Monitor the average income of enrolled adult caregivers( at intake and annually Monitor the number of hours month spent by caregiver(s) in education 100%', program (Such as school, college, workforce development training, etc) at intake and annually Monitor and track enrolled families request and receipt of referral to 100% community resources. (WIC, Housing, SNAP, Early Intervention Services, etc) Page 1 of 1 YWCA of Hawai'i Island Healthy Start Home Visiting Program County of Hawai'i Nonprofit Grant Application FY 2015-16 Exhibit A — Nonprofit Grant Application Attachment E — 12. Table: continued Attachment E - 12. Table I: continued 12. Council Award Worksheet -Table I: continued PROGRAM PERFORMANCE MEASURES Applicant Projected Council Projected Results Result Enroll an additional 20 mothers and pregnant women 100% into the program _ Identify the number of women smokers(including e- 100% cigarettes) at intake and who report decreased smoking by one year post enrollment _ Ensure enrolled women receive their post partum 100% examination within 3 months from delivery Provide breastfeeding screening and monitoring at birth 100% up until [he children is 6 months old. Ensure all enrolled families receive birth spacing 100% education within 6 months post enrollment and C annually Enroll all enrolled mothers are screened for depressive 100% symptoms within 6 months post enrollment and annually Ensure all enrolled children receive the recommended 100% schedule of immunization Ensure all enrolled families have a medical home and 100% _ not using the emergency room as their primary medical care provider 100% Ensure all enrolled families have health insurance coverage for parent(s) and child(ren) 100% Ensure all enrolled families will NOT HAVE A CONFIRMED report of child abuse and neglect within 6 months post enrollment and annually Ensure all enrolled children are screened for suspected 100% developmental delays within 6 months post enrollment and annually Ensure all enrolled women are screened for Domestic 100% Violence within 6 months post enrollment and annually (Women's Experience with Battering (WEB) scale) Page 1 of 1 YWCA Hawai'i Island Sexual Assault Support Svcs. 137 County of Hawaii Nonprofit Grant Application FY2015-16 Facility Address: Address: 1382 Kilauea Avenue (1)AND Address: 75-5706 Hanama Place. Suite #202 (2) City, ST, Zip Hilo, HI 96720 (1) and Kulua Kona, HI 96740 (2) Email Address: Idavis@ywcahawarisland.org Fax No.: ( 818) 961 — 9140 Accountant/CPA: Phone No.: ( 808) 935 — 5404 Firm (if applicable): Takete Iwato Hera a Associates LI -C Mailing Address: Address: Hilo Lagoon Centre Association Address: 101 Aupuni Street,#139 City, ST, Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua Q North Kona © South Hilo © North Kohala © South Kona © North Hilo © South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth © Victims of Crimes ❑ Culture and the arts E] Aged ® Victims of Hea lth or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 Island UJCOP LJ Agency Name: YWCA of Hawaii Program Name: sexual Assault support services Agency Director: Kathleen McGilvray, CEO Phone No.: (808)935— 7141x112 Contact Person: Lorraine Davis, COO Phone No.: BOB() 962 — 3877x 162 Mailing Address: Address: 1382 Kilauea Avenue Address: City, ST, Zip Hilo. HI 96120 Facility Address: Address: 1382 Kilauea Avenue (1)AND Address: 75-5706 Hanama Place. Suite #202 (2) City, ST, Zip Hilo, HI 96720 (1) and Kulua Kona, HI 96740 (2) Email Address: Idavis@ywcahawarisland.org Fax No.: ( 818) 961 — 9140 Accountant/CPA: Phone No.: ( 808) 935 — 5404 Firm (if applicable): Takete Iwato Hera a Associates LI -C Mailing Address: Address: Hilo Lagoon Centre Association Address: 101 Aupuni Street,#139 City, ST, Zip Hilo, HI 96720 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna © Hamakua Q North Kona © South Hilo © North Kohala © South Kona © North Hilo © South Kohala © Ka'u Services or Activities To Be Provided: (One or more can be checked) ❑ Educational concerns ❑ Youth © Victims of Crimes ❑ Culture and the arts E] Aged ® Victims of Hea lth or Social Crises ❑ Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 1of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support services 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $36,250.00 $60,000.00 $30,000.00 2. Agency Mission Statement: YWCA of Hawaii Island is dedicated to eliminating racism, empowering women, and promoting peace, justice, freedom and dignity for all. The YWCA of Hawai'i Island (YWCA), first organized in Hilo in 1919, has offered valuable programs and activities for the benefit of women, children and their families. The YWCA was established as a 501(c)(3) non-profit organization in 1965 and has been a partner agency of the Hawai'i Island United Way (HIUW) since 1979. It belongs to a national organization consisting of 300 YWCA Associations across the U.S. with 2.6 million members. Employing over 60 full-time and part-time staff, the YWCA offers a variety of services to people of all ages, from newborns to senior citizens, throughout the island of Hawai'i. 3. Program Description: The YWCA Sexual Assault Support Services (SASS) Program works to reduce the incidence of sexual assault and disability to those who have been victimized. Services include the only 24/7 sexual assault crisis line on the island which includes crisis response and stabilization and opportunities to enter into the YWCA SASS Program for a variety of supportive services. The advocates who answer the crisis line can accompany a victim to the hospital for a forensic exam, and in the case of a minor, will meet the family at the Children's Justice Center to stay with the family during a forensic interview. Additionally, the Advocate is available to support the victim and family when they interact with law enforcement and prosecutors. The YWCA SASS Program also offers clinical services which includes counseling for the victim and immediate family. The clinician will also accompany the victim and family to court to help prevent the re -traumatizing the victim and family during court proceedings. SASS also offers training and educational opportunities to schools, professionals and service providers on the effects of sex assault. All services are provided at no cost to the victim or their family. 4. Total Budeet & Position Count: Total Program Budget: 403,952 Total Progam rPosition Count: 16 Total Agency Budget: 2,923.857 Total Agency Position Count: 60 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault Support Services S. Program Funding Sources (identify all sources of funding applied to this program): Revenue Source FY15-16 Estimate State of Hawaii Department of the Attorney General through Sex Abuse Treatment Center 308,034 Victim's of Crime Act through the Hawaii County Office of the Prosecuting Attorney (not secured) 22,000 County of Hawaii Nonprofit Grant Application (not secured) 60,000 Fundraising _ 10,000 TOTAL: 400,064 Attach additional pages, iJneeded. 6. Explain what plans your agency or program has to increase revenues to support this program The agency is taking a multi -pronged approach to securing additional funds. The program is also seeking funds from Hawaii Island United Way, the Hawaii Community Foundation and other Hawaii based organizations who have supported the YWCA. In addition, grant applications are made to funders with like-minded missions and objectives, for example the national AIIState Insurance Foundation, The YWCA is also partnering with different service groups to obtain funding. These groups include the Kiwanis Club, Rotary Clubs and the Lion's Club. The YWCA is also working with community groups to collaborate on group activities and therefore, leverage funds to provide awareness and services. An example of this would be UH -Hilo and Tutu's House in Waimea for a film screening of a documentary surrounding sexual assault. Finally, the YWCA hosts an annual fundraiser, Walk a Mile in Her Shoes, and the monies raised from this event go directly into the SASS program. 7. Program Objectives Using County Nonprofit Grant Program Funds: 1. The SASS program would continue to provide the only sex assault crisis line and core services to victims of sexual assault and their families throughout the entire island of Hawaii. 2. Purchase gas cards to provide to clients living in outer areas where travel to Hilo and/or Kona would be a hardship. This assistance allows them to continue in therapy. This FY there were no funds and clients left the program because of the expenses to travel to therapy. 3. Other funds will be used to support on-call and on-call back-up stipends to staffing at a rate of $2.50/hour and $1.67/hour, respectively. 4. Funds would be used to support the building of Phase II of the phone/database system which has allowed the program to stream -line their processes, provide information and support to clients quickly, eliminate substantial paperwork and "go green." Phase I has been completed for Crisis portion of the program and Phase II will incorporate Crisis with Clinical so all services are cohesive, responsive, and paperless. EXHIBIT A NONPROFITGRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA of Hawaii Island Program Name: Sexual Assault support Services 8. TABLE I: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES he, Number o)dients served, workshops or events held, volunteer hours, etc Describe, be specific) Applicant Projected Results Fully trained personnel are available to assess and respond to callers on the crisis line. 100% of the calls to the line will be taken Fully trained personnel are available to provide crisis intervention/stabilization face to face 150 clients will be served Fully trained therapists will crevice therapeutic services to victims and their families 2040 hours of therapy will be provided The final phases of the clinical database will be compared Database is fully functional and operating 29,286 20,000 Operations 32,043 32,396 9,550 Attach additional pages as necessary. Q TARI F II - FY PROGRAM EXPENDITURES 14-15 Actual* FV 15-18 Total Budget FV 15-16 Grant Req Salary and Wages 254,752 295,835 17,685 Professional Fees 39,635 29,286 20,000 Operations 32,043 32,396 9,550 Supplies 1,281 1,025 515 Equipment 0 Other: Occupancy 24,455 13,450 6,000 Other: Travel 4,204 4,350 249 Other: Indirect 47,582 52,644 6,000 Other: Other: TOTAL 409,952 428,986 60,000 *If applicable EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA of Hawaii Island Program Name: sexual Assault support services ro. 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: Karen Teshima POSITION: Board Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check al I 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 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. Signal re of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5 of 8 County of Hawai'i Nonprofit Grant Application FY2O15-16 Agency Name: YWCA of Hawaii Island Program Name: sexual Assault support services 11. Certification of Understanding (Paget of 2) I (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135 —2-142.1, Hawai'i County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County (the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawai'i Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express. and be compliant prior to final payment. To register, go to http // dors 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 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 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 aaencv s future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA of Hawaii Island Program Name: sexual Assault support services tt. Certification of Understanding (Page 2of2) 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 lune 30t' shall result in loss of all grant funds received during the grant period (must be refunded to County) and exclusion from future grant participation for a minimum of one year or until a written report is submitted to, and accepted by, the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at htto //www.hawaiicouniy.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 lune 30, 2015 must be returned to the County of Hawai'i with the final report. Failure to return these funds in a timely manner will imaoct the evaluation of your agenc✓s future funding request and may result in actions taken to recover these funds. By signing below, you are acknowledging that you have read and understood these requirements. v Signal re of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA of Hawaii Island Program Name: sexual Assault support services 12. COUNCIL AWARD WORKSHEET TABLE!: r. PROGRAM PERFORMANCE MEASURES Applicant Projected Results Council Proposed Projected Result Fully trained personnel are available to assess and respond to callers on the crisis line. 100% calls taken Fully trained personnel are available to provide crisis intervention/stabilization face to face 150 clients served Fully trained therapists will provide therapeutic services to victims and their families 2040 hours provided The final phases of the clinical database will be completed oatabsee operational Equipment Other: occupancy 6.000 Other: Travel 4,350 TABLE II: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages 1,685 Professional Fees 20,000 Operations 9,550 Supplies 515 Equipment Other: occupancy 6.000 Other: Travel 4,350 Other: Indirect 6,000 Other: Other: .. -- TOTAL 60,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8 YWCA Hawai'i Island YWCA Developmental Preschool County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA Hawaii Island O ®c C V p \, Ll Program Name: YWCA Developmental Preschool Agency Director: Kathleen Mccilvray, CEO Phone No.: ( 808) 935 — 6067 Contact Person: Lissa Van Kralingen Phone No.: (808)935— 7141 Mailing Address: Address: YWCA Hawaii Island Address: 1382 Kilauea Ave. City, ST, Zip Hilo, HI 96720 Facility Address: Address: 145 Ululani Street Address: City, ST, Zip Hilo, H196720 Email Address: Wnkolingen@ywaahsoan,all org Fax No.. (808)935 — 5150 Accountant/CPA: Takata, Iwata, Har. &Associates Phone No.: ( 808) 935 — 5404 Firm (if applicable): cemacd Pubic AccourdaMs Mailing Address: Address: fol Aupuni street, sane 139 Address: City, ST, Zip Hilo, HI 96720-4260 YOU ARE RESPONSIBLE TO KEEP THE ABOVE INFORMATION CURRENT AND TO PROMPTLY NOTIFY THE FINANCE DEPARTMENT AND COUNCIL OF ANY CHANGES Amount of Request for County Nonprofit Grant Program Funds: Geographical Areas To Be Served: (One or more can be checked) © Puna © Harri ❑ North Kona © South Hilo ❑ North Kohala ❑ South Kona © North Hilo ❑ South Kohala ❑ Ka'u Services or Activities To Be Provided: (One or more can be checked) © Educational concerns © Youth ❑ Victims of Crimes ❑ Culture and the arts F-1 Aged ❑ Victims of Health or Social Crises © Needs of the poor ❑ Physical/Emotional Disabilities ❑ Public Health and Welfare of the People and the Environment EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page Iof8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name, YWCA Hawaii Island Program Name: YWCA Developmental Preschool 1. Prior Year Award of County Nonprofit Grant Program Funds: FY 12-13 FY 13-14 FY 14-15 $13,750 $10,000.00 $8,000 2. Agency Mission Statement: YWCA Hawaii Island is dedicated to eliminating racism, empowering women and promoting peace, justice, freedom and dignity for all. The YWCA Hawaii Island was first organized in Hilo in 1919 and was established as a 501 (c)(3) non-profit organization in 1965. Throughout our history, the YWCA Hawaii Island has offered valuable programs and activities for the benefit of women, children and their families. We work to maintain the National YWCA's goals and objectives by fulfilling our local community's needs. 3. Program Description: The YWCA Developmental Preschool is nationally accredited through the National Association for the Education of Young Children and licensed by the Department of Human Services to care for 115 children ages 2 years to 5 years. We provide breakfast, lunch, and an afternoon snack daily, which are nutritionally balanced , portion controlled meals, at no additional costs to the families we serve thanks to our participation in the USDA Child and Adult Care Food Program. The food program, since its inception, has been supplemented by grants from the Hawaii County Non Profit Grant, Hawaii Island United Way, and the Walmart Foundation State Giving Program. Our teachers and support staff use the Creative Curriculum for teaching. Our program operates year round providing childcare continuity for families and our hours of operation are 7:00 am - 5:15 pm. Children are enrolled based on space availability and 68% of our families are living at or below the Federal Poverty Guidelines. 4. Total Budget & Position Count: Total Program Budget: $874,282 Total Program Position Count: 19 Total Agency Budget: 2,923,857.76 Total Agency Position Count: 60 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 2 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA Hawaii Island Program Name: YWCA Developmental Preschool .., c.,ndine sedir�ec (identify all sources of funding applied to this program): ......b....... _.._...e ___. ___,-____.,— _ FYIS-16 Revenue Source Estimate $15,000 Hawaii Island United Way $772,503$3,000 Program service Fees Special Events (fund raisers) USDA Child and Adult Care Food Program _ $60,000 $10,000 Activity fees $8,000 Trusts 8 Foundations $10,000 Government & Other grants _ TOTAL: $878,503 Attach additional Poges, if needed. 6. Explain what plans your agency or program has to increase revenues to support this program In 2012, the preschool started an Annual Family Fun Fair to help increase revenues for the preschool. We actively applied for grants through the Samuel N. and Mary Castle Foundation, the Walmart State Giving Program, and the Hawaii Island United Way. We have applied for and received Weinberg Grants through the Rotary Club of Hilo and the Kiwanis Club of East Hawaii. Our last tuition increase was in August 2012 and the increase was approximately 1.7% for one age group and 4% for the other age group, resulting in all students paying the same monthly tuition of $625. In January of each school year, we plan for the next school year and make the necessary adjustments to meet our budgetary needs/expenses. We will need to revisit our tuition structure for the 2015/2016 school year. We are currently providing Early Childhood Education and extended childcare for approximately $2.81 per hour for each child. 7. Program Objectives Using County Nonprofit Grant Program Funds: This current school year, children have been withdrawn from school, and parents have been requesting financial assistance due to loss of employment and/or a reduction in financial assistance from DHS. We also have great grandparents requesting financial assistance, most who are on a fixed income, paying for preschool as they are now the primary caregiver of the child. Our limited funding streams allow for short term tuition assistance of one to two months. In reviewing the different situations our families are facing we have encountered the following: it may take 3 or 4 months to secure new employment, it could take 6 months to a year to gain legal custody of child or children, or they need financial assistance of $25 to $150 every month to enroll their child in preschool. Throughout the school year, parents are made aware of financial assistance opportunities that they may qualify for and they are encouraged to apply for those opportunities even if it outcome will be that they may end up attending another school. The goal is that all children have an opportunity to participate in an early childhood education program. EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 3 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA Hawaii Island Program Name: YWCA Developmental Preschool 8. TABLE 1: What are the intended measurable outputs or outcomes that would be achieved with this funding? PROGRAM PERFORMANCE MEASURES Applicant Projected Results (i. e.: Number o)clients served, workshops rr events held, valunteerhaurs, eta. Describe, be specift ) FY 15-16 Grant Req financial assistance due to loss/change in 95% off applicants wil employment will receive funds Families experiencing a reduction or loss of 95% off applicants wil public or private assistance will receive funds Families experiencing events that places a 95% off applicants it short term strain on family finances will receive funds Supplies 3,750 Attach additional pages as necessary. n TAmc u. PROGRAM EXPENDITURES FY 14-15 Actual' FY 15-16 Totalaudget FY 15-16 Grant Req Salary and Wages 521,875 547,969 Professional Fees 3,322 3,488 Operations 368,548 390,222 Supplies 3,750 4,125 Equipment 1,650 1,815 other: Tuition Assistance 17,640 20,000 15,000 Other: Other: Other: Other TOTAL 916,785 947,619 15,000 EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 4 of County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA Hawaii Island Program Name: YWCA Developmental Preschool to. 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: Karen Teshima POSITION: Executive Assistant 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: o 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. t� (��- C ll—zc/S Signa re of Authorized Person (specify title) Date EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Page 5of8 County of Hawaii Nonprofit Grant Application FY2O15-16 Agency Name: YWCA Hawaii Island Program Name: YWCA Developmental Preschool tt. Certification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the 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 final payment. 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 of aaency's future funding requests. EXHIBIT A NONPROFIT GRANT APPLICATION FV 2015-2016 Page 6of8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA Hawaii Island Program Name: YWCA Developmental Preschool ii. Certification of Understanding (Page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability ($1,000,000 general liability, $50,000 each occurrence) must be provided to the county of Hawai'i Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of lune 301h 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 gov/fn-nonprofit-gra t -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, 2015 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. By signing below, you are acknowledging that you have read and understood these requirements. Signature of Authorized Person (specify title) EXHIBIT A NONPROFIT GRANT APPLICATION FY 2015-2016 Date Page 7 of 8 County of Hawaii Nonprofit Grant Application FY2015-16 Agency Name: YWCA Hawaii Island Program Name: YWCA Developmental Preschool 12. COUNCIL AWARD WORKSHEET MEASURES pplicant Projected Results Council ProposedERFCE Projected Resultsista losslchange in 95%of appset APROGRAM"MEASURESProjected will receiveerienuction or loss of 95%of apps.ic or sistance will receiveerients that places a 95%of appsm stily finances will receive Other: Ao c n: PROGRAM EXPENDITURES FY 15-16 Grant Request Council Award Salary and Wages Professional Fees Operations Supplies Equipment Other, Tuition Assistance 15,000 Other: - Other: Other. - TOTAL 15,000 Additional Council directives regarding award: EXHIBIT B NONPROFIT GRANT APPLICATION FY 2014-2015 Page 8of8